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Syncope

Syncope. Joseph P. Ornato , MD, FACP, FACC, FACEP Professor & Chairman, Department of Emergency Medicine. Syncope – A symptom, not a diagnosis. Self-limited loss of consciousness and postural tone Relatively rapid onset Variable warning symptoms

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Syncope

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  1. Syncope Joseph P. Ornato, MD, FACP, FACC, FACEP Professor & Chairman, Department of Emergency Medicine

  2. Syncope – A symptom, not a diagnosis • Self-limited loss of consciousness and postural tone • Relatively rapid onset • Variable warning symptoms • Spontaneous, complete, and usually prompt recovery without medical or surgical intervention Underlying mechanism is transient global cerebral hypoperfusion. Brignole M, et al. Europace, 2004;6:467-537.

  3. Syncope Neurally-mediated reflex syndromes Orthostatic hypotension Cardiac arrhythmias Structural cardiovascular disease Disorders Mimicking Syncope With loss of consciousness (i.e., seizure disorders, concussion) Without loss of consciousness, i.e., psychogenic “pseudo-syncope” Classification of Transient Loss of Consciousness (TLOC) Real or Apparent TLOC Brignole M, et al. Europace, 2004;6:467-537.

  4. Neurally- Mediated Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary • 3 • Bradyarrhythmia • Sinus node dysfunction • AV block • •Tachyarrhythmia • VT • SVT • Long QT syndrome • 1 • Vasovagal syndrome • Carotid sinus syndrome • • Situational • Cough • Post- Micturition • 2 • Drug-induced • • Autonomic nervous system failure • Primary • Secondary • 4 • Acute myocardial ischemia • Aortic stenosis • Hypertrophic cardiomyopathy • Pulmonary hypertension • Aortic dissection Causes of true syncope Unexplained Causes = Approximately 1/3

  5. Syncope mimics • Acute intoxication (e.g., alcohol) • Seizures • Sleep disorders • Somatization disorder (psychogenic pseudo-syncope) • Trauma/concussion • Hypoglycemia • Hyperventilation Brignole M, et al. Europace, 2004;6:467-537.

  6. Impact of syncope • 40% will experience syncope at least once in a lifetime1 • 1-6% of hospital admissions2 • 1% of emergency department visits per year3,4 • 10% of falls by elderly are due to syncope5 • Major morbidity reported in 6%1(fractures, motor vehicle crashes) • Minor injury in 29%1(lacerations, bruises) 1Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27. 2Kapoor W. Medicine. 1990;69:160-175. 3Brignole M, et al. Europace. 2003;5:293-298. 4 Blanc J-J, et al. Eur Heart J. 2002;23:815-820. 5Campbell A, et al. Age and Ageing. 1981;10:264-270.

  7. Impact of syncope: costs • Estimated hospital costs exceeded $10 billion1 • Estimated physician office expenses exceeded $470 million2 • Over $7 billion is spent annually in the US to treat falls in older adults4 1Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27. 2OutPatientView v. 6.0. Solucient LLC, Evanston IL. 3Farwell D, et al. J Cardiovasc Electrophysiol. 2002;13(Supp):S9-S13. 4Olshansky B. In: Grubb B and Olshansky B. eds. Syncope: Mechanisms and Management. Futura. 1998:15-71.

  8. 73%1 71%2 60%2 Impact of syncope: Quality of life Percent of Patients 37%2 Anxiety/Depression Alter DailyActivities RestrictedDriving ChangeEmployment 1Linzer M. J Clin Epidemiol. 1991;44:1037. 2Linzer M. J Gen Int Med. 1994;9:181.

  9. Syncope mortality • Low mortality vs. high mortality • Neurally-mediated syncope vs. syncope with a cardiac cause Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347(12):878-885. [Framingham Study Population]

  10. Diagnostic objectives • Distinguish true syncope from syncope mimics • Determine presence of heart disease • Establish the cause of syncope with sufficient certainty to: • Assess prognosis confidently • Initiate effective preventive treatment

  11. Diagnostic plan • Initial Examination • Detailed patient history • Physical exam • ECG • Supine and upright blood pressure • Monitoring • Holter • Event • Insertable loop recorder (ILR) • Cardiac Imaging • Special Investigations • Head-up tilt test • Hemodynamics (cardiac cath) • Electrophysiology study Brignole M, et al. Europace, 2004;6:467-537.

  12. Detailed patient history • Circumstances of recent event • Eyewitness account of event • Symptoms at onset of event • Sequelae • Medications • Circumstances of prior events • Concomitant disease, especially cardiac • Pertinent family history • Cardiac disease • Sudden death • Metabolic disorders • Past medical history • Neurological history • Syncope Brignole M, et al. Europace, 2004;6:467-537.

  13. Initial exam • Vital signs • Heart rate • Orthostatic blood pressure change • Cardiovascular exam: Is heart disease present? • ECG: Long QT, pre-excitation, conduction system disease • Echo: LV function, valve status, hypertrophic cardiomyopathy • Neurological exam • Carotid sinus massage • Perform under clinically appropriate conditions preferably during head-up tilt test • Monitor both ECG and BP Brignole M, et al. Europace, 2004;6:467-537.

  14. Specific conditions • Neurally-mediated • Vasovagal Syncope (VVS) • Carotid Sinus Syndrome (CSS) • Cardiac arrhythmia • Tachy-brady syndrome • Long QT syndrome • Torsade de pointes • Brugada syndrome • Drug-induced • Structural cardio-pulmonary disease • Orthostatic

  15. Neurally-mediated reflex syncope • Vasovagal syncope (VVS) • Carotid sinus syndrome (CSS) • Situational syncope • Post-micturition • Cough • Swallow • Defecation • Blood drawing, etc.

  16. Vasovagal syncope • Most common form of syncope • 8% to 37% (mean 18%) of syncope cases • Depends on population sampled • Young without structural heart disase, ↑ incidence • Older with structural heart disease, ↓ incidence

  17. 60° - 80° Tilt table test • Useful as diagnostic adjunct to confirm vasovagal syncope • Useful in teaching patients to recognize prodromal symptoms Brignole M, et al. Europace. 2004;6:467-537.

  18. Etiology Drug-induced (very common) Diuretics Vasodilators Primary autonomic failure Multiple system atrophy Parkinson’s Disease Postural Orthostatic Tachycardia Syndrome (POTS) Secondary autonomic failure Diabetes Alcohol Amyloid Orthostatic hypotension

  19. Hypersensitive carotid sinus syndrome • Syncope clearly associated with carotid sinus stimulation is rare (≤1% of syncope) • CSS may be an important cause of unexplained syncope/falls in older individuals Kenny RA, et al. J Am Coll Cardiol. 2001;38:1491-1496. Brignole M, et al. Europace. 2004;6:467-537. Sutton R. In: Neurally Mediated Syncope: Pathophysiology, Investigation and Treatment. Blanc JJ, et al. eds. Armonk, NY: Futura;1996:138.

  20. Method1 Massage, 5-10 seconds Don’t occlude Supine and upright posture (on tilt table) Outcome 3 second asystole and/or 50 mmHg fall in systolic BP with reproduction of symptoms = Carotid Sinus Syndrome Absolute contraindications2 Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months Complications Primarily neurological Less than 0.2%3 Usually transient Carotid sinus massage (CSM) 1Kenny RA. Heart. 2000;83:564.2Linzer M. Ann Intern Med. 1997;126:989. 3Munro N, et al. J Am Geriatr Soc. 1994;42:1248-1251.

  21. Other diagnostic tests • Ambulatory ECG • Holter monitoring • Insertableloop recorder (ILR) • Tilt table test • Includes drug provocation (NTG, isoproterenol) • Cardiac catheterization • Electrophysiology study (EPS) Brignole M, et al. Europace, 2004;6:467-537.

  22. Heart monitoring options OPTION 10 Seconds 12-Lead 1 day Holter Monitor Event Recorders(non-lead and loop) 7-30 days Up to 14 Months ILR 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 TIME (Months) Brignole M, et al. Europace, 2004;6:467-537.

  23. Diagnostic yield of various tests

  24. Neurological tests • EEG • Head CT Brignole M, et al. Europace. 2004;6:467-537.

  25. Cardiac syncope • Includes cardiac arrhythmias and structural heart disease • Often life-threatening • Suspect if syncope exercise-induced • May be warning of critical CV disease • Tachy and brady arrhythmias • Myocardial ischemia, aortic stenosis, pulmonary hypertension, aortic dissection • Assess culprit arrhythmia or structural abnormality aggressively • Initiate treatment promptly

  26. Syncope due to cardiac arrhythmias • Bradyarrhythmias • Sinus arrest, exit block • High grade or acute complete AV block • Can be accompanied by vasodilatation (VVS, CSS) • Tachyarrhythmias • Atrial fibrillation/flutter with rapid ventricular rate (eg, pre-excitation syndrome) • Paroxysmal SVT or VT • Torsade de pointes

  27. Factors contributing to sudden death likelihood • Cardiovascular pathology • Coronary artery disease • Severe left ventricular dysfunction • Cardiomyopathy • Hypertrophic cardiomyopathy • Arrhythmogenic right ventricular cardiomyopathy • Congenital heart disease, especially coronary artery anomalies • Valvular heart disease • Cardiac pacemaker andconducting system disease • Hereditary channelopathies (Sudden Arrhythmic Death Syndrome (SADS)) • Brugada syndrome • Early repolarization syndrome (ERS) • Long QT syndrome (LQTS) • Short QT syndrome (SQTS) • Catecholaminergic polymorphic ventricular tachycardia (CPVT)

  28. Importance to emergency physicians • Often present as recurrent syncope or brief seizures in children or young adults before sudden death occurs • May have young relatives who have had sudden death • ECG findings are often diagnostic • Effective preventive treatment is available (ICD) • Astute emergency physician may be the ONLY healthcare provider who can make the diagnosis and prevent tragic loss of a young life

  29. Brugada syndrome • Male predominance • Autosomal dominant • Common in Asians • 40-60% prevalence of life-threatening ventricular arrhythmias and SCD • Presents as syncope • Downsloping ST-segment elevation in ECG leads V1–3

  30. Early repolarization syndrome (ERS) • Type I – 43% ↑ in SCD • Male predominance • 1-2% of adults • Normalizes with exercise • Type II – no ↑ in SCD

  31. Long Q-T syndrome Hereditary • Autosomal recessive (Jervell Lange-Nielsen syndrome) with hereditary nerve deafness • Autosomal dominant (Romano Ward syndrome w/out deafness) • Syncope, VF, SCD Bazett Formula QTc = 0.35-0.44 at HR= 60 Acquired causes • Hypocalcemia • Hypokalemia • Hypomagnesemia • Ischemia • Anorexia • CNS pathology • QT-prolonging drugs (www.azcert.org)

  32. Short Q-T syndrome Acquired causes • Hypercalcemia • Hyperkalemia • Acidosis • Systemic inflammatory syndrome • Myocardial ischemia • Increased vagal tone Hereditary • Autosomal dominant • Atrial fibrillation • Syncope, VF, SCD • Early repolarization inferolateral leads in 65%

  33. Exercise-related syncope • Anomalous L coronary artery off the pulmonary artery • Hypertrophic cardiomyopathy • Severe aortic stenosis • Catecholaminergic polymorphic ventricular tachycardia • Hereditary defect in myocardial calcium handling • Stress-related syncope, VF, SCD • ECG – unexplained sinus bradycardia at rest • 50% carry a diagnosis of epilepsy before correct diagnosis established

  34. Conclusion • Syncope is a common symptom with many causes • Deserves thorough investigation and appropriate treatment • Clinical decision (observation) unit at VCU is an appropriate location to initiate the evaluation

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