Evaluation and Management of Syncope

1. Evaluation and Management of Syncope

2. Syncope Definition: Sudden transient loss of conciousness and postural tone with subsequent spontaneous recovery.

3. Syncope - Epidemiology 1% of hospital admissions 3% of ER visits 6% annual incidence in the elderly Upto 50% of young adults have history of isolated LOC Annual cost $800 M (1999) Clin Electrophysiol 22:1386,1999

4. Syncope - Prognosis Highest mortality in patients with cardiac cause Neurally mediated syncope/ medication induced syncope did not increase mortality Soteriades ES, et al: N Eng J Med 347:878, 2002

5. Causes of Syncope Vascular ( 58 � 62 % ) : Reflex mediated, orthostatic, anatomic Cardiac ( 10 � 23 % ): Arrhythmias, anatomic Neurologic/cerebrovascular* ( 0.5 � 5 % ) Metabolic/drugs ( 0 � 2 % ) Psychogenic* ( 0.2 � 1.5 % ) Syncope of unknown origin ( 14 � 18 % )

6. Differential Diagnosis of Syncope

7. Syncope - Clinical Features Suggestive of Specific Causes

8. Syncope � Clinical Features Suggestive of Specific Causes (cont�d )

9. Syncope � Clinical Features Suggestive of Specific Causes ( cont�d )

10. Diagnostic Tests for Syncope

11. Diagnostic Tests for Syncope (cont�d)

12. Syncope � Indications For Hospitalization Presence of heart disease ECG suggestive of arrhythmic syncope in: WPW, long QTc, SSS, AV block, VT, Brugada syndrome, RV dysplasia Syncope with severe injury Syncope during exercise Family h/o sudden cardiac death

13. Sinus Arrest on Holter Monitor

14. Syncope � Loop Event Recorder

15. Implanted Loop Event Recorder

16. Wide Complex Tachycardia � Loop Event Monitor

17. Head Up Tilt Table Testing

18. Neurally Mediated Syncope Also known as vasovagal syncope. Syncope in the absence of structural heart disease is most likely neurally mediated. Head-upright tilt test maximizes venous pooling, sympathetic activation and circulating catecholamines. Most vasovagal episodes involve both cardioinhibition (drop in heart rate) and vasodepressor response (drop in BP).

19. Case # 1 A 20 year old female presents with recurrent near syncope and syncope preceded by nausea, sweating and gradual �tunnel vision�usually after prolonged standing. The ECG and ECHO are normal. What would be the next step? A: Tilt table test

21. Electrophysiologic Testing in Syncope Sinus node function: prolonged sinus node recovery time Abnormal AV conduction: ?HV interval, infra His block Inducibility of sustained VT Inducibility of rapid SVT with symptoms, hypotension

22. Guidelines for EP Testing in Syncope Class I: General agreement Patients with structural heart disease and unexplained syncope Class II: Less certain, but accepted Patients with recurrent unexplained syncope without structural heart disease and a negative tilt test Class III: Not indicated Patients with known cause of syncope in whom treatment will not be guided by EP testing

23. Drugs Affecting Sinus Node Function Antiarrhythmic Drugs Amiodarone Flecainide, propafenone, sotalol Quinidine, disopyramide, procainamide Antihypertensives (Sympatholytic) Alpha-methyldopa, reserpine, clonidine Beta-Blockers Miscellaneous Cimetidine, Lithium, Phenytoin

24. Sinus Node Recovery Time � 1 of 2

25. Sinus Node Recovery Time � 2 of 2

26. Electrophysiologic Recording of AV Block ( 1 of 2 )

27. Electrophysiologic Recording of AV Block ( 2 of 2 )

28. Neurally Mediated Syncope Precipitating factors: prolonged standing, dehydration, alcohol, diuretics, vasodilators. Sit/lie down at onset of symptoms, cross the legs and tense them together if sitting. Salt supplementation and fluids. Isometric arm, leg counterpressure. Moderate aerobic and isometric exercise. Tilt training.

29. Therapy of Neurocardiogenic Syncope

30. Pharmacologic Therapy of Neurally Mediated Syncope Despite the widespread use of drug therapy, none of these pharmacologic agents have been demonstrated to be effective in large prospective randomized clinical trials. A small study has reported the efficacy of midodrine. Metoprolol, propranolol and nadolol are no more effective than placebo.

31. Syncope - Prognosis Highest mortality in patients with cardiac cause Neurally mediated syncope/ medication induced syncope did not increase mortality Soteriades ES, et al: N Eng J Med 347:878, 2002

32. Suggested Strategies for Syncope Management

33. Syncope:May be a harbinger of sudden cardiac death Evaluation � purpose is to determine if pt is at increased risk for death Identify pts with underlying heart disease (ischemic CM, non-ischemic CM, HCM), myocardial ischemia, WPW, genetic diseases (long-QT syndrome, Brugada Syndrome), catecholaminergic polymorphic VT

34. AHA/ACCF Scientific Statement on the Evaluation of Syncope

35. AHA/ACCF Scientific Statement on the Evaluation of Syncope, continued�

36. Diagnostic Evaluation of Syncope

37. Case # 2 65 year old male with h/o inferior wall myocardial infarction 1 year ago presents with rapid palpitation and syncope. An ECG shows SR and old IWMI. A 2D echo shows LVEF 40% with inferoapical dyskinesis. Coronary angiography reveals totally occluded RCA with collaterals. What is the next step? Answer: Electrophysiologic study.