Syncope 2011

Syncope 2011: 

Syncope 2011

Sources: 

American Family Physician Up To Date ACEP 2007 Syncope Guidelines 2009 European Society of Cardiology guidelines Sources

Goals: 

Learn the 3 most common causes of syncope Identify the most helpful clinical features to find the etiology of the common syncope Understand the diagnostic criteria for common types of syncope Understand the clinical indications for advanced syncope testing and hospital admission Learn two syncope decision rules Goals

Syncope:Definition: 

Loss of consciousness Rapid onset Transient Loss of postural tone Recovery Spontaneous Complete Usually prompt Syncope:Definition

Where syncope fits in: 

Where syncope fits in

Syncope: Overview: 

Decreased cerebral perfusion is the common endpoint 1/3 of the population will have an episode Incidence increases after age 70 Loss of cerebral perfusion “homeostasis” Chronic disease Aging and autonomic reflexes Too many toxins (medications) Syncope: Overview

Syncope: Most Common Identified Causes: 

1. Reflex ( neurally mediatied ) Syncope 2. Orthostatic Hypotension Syncope 3. Cardiac Syncope Neurologic Syncope is < 1%! After age 70: OH is #1 Unknown cause 18-34% in literature Heterogeneous group 5% one year mortality 69% dxs made on initial eval and only 25% afterwards Syncope: Most Common Identified Causes

Reflex syncope types: 

Vasovagal Mediated by emotional distress Mediated by orthostatic stress Situational Cough GI (swallow, postprandial, defecation) Post exercise Micturition (old guys and big prostates) Carotid sinus syncope (goes up with age) Reflex syncope types

Reflex syncope: helpful hints: 

Prodrome No hx of heart disease Long history ( yrs ) of recurrent syncope Unexpected stimulus: sight, sound, injury Prolonged standing Hot crowded places Nausea or vomiting Meals Carotid sinus pressure: head turn, tight collar After exertion +/- slow fall Reflex syncope: helpful hints

Orthostatic Hypotension Syncope: 

Primary Autonomic Failure Parkinson’s Disease, Lewy body dementia Secondary autonomic failure DM, amyloidosis, spinal cord injury Drug induced For fun and addiction (alcohol) Iatrogenic BP meds Antidepressants Diuretics Analgesics (opiates) Volume Depletion Orthostatic H ypotension Syncope

OH Syncope: Helpful Hints: 

After standing up (first AM syncope) New meds Old diseases Standing after exertion Prolonged standing in hot crowded places Documented hypotension at the event Positive orthostatic testing shortly after Positive hemoccult testing SBP drops at least 20, DBP 10mm Hg OH Syncope: H elpful H ints

Cardiovascular Syncope: 

Arrhythmia Bradycardia Sinus node malfunction AV conduction system disease Device malfunction Tachycardia Supraventricular Ventricular Structural Disease Cardiac valvular disease (AS) Hypertrophic cardiomyopathy (30%) Cardiac masses Pericardial disease Acute Coronary Syndrome (very rare!) Cardiovascular Syncope

Cardiac Syncope: Helpful Hints: 

Past cardiac disease Abnormal structural exam AS murmur (usually critical!) Murmur with valsalva Family Hx of sudden death During exertion or while at rest Trauma Palpitations before syncope M ale Cardiac Syncope: H elpful Hints

Cardiac Syncope: Helpful Hints: 

ECG findings Bifasicular block QRS > = 0.12 sec Second or third degree heart block Asymptomatic inappropriate bradycardia (<50) Sinus pause > 3s Non-sustained VT Prexcited QRS Abnormal QT intervals Early repolarization RBBB with ST elevation V1-3 Q waves suggestive of MI Cardiac Syncope: Helpful Hints

All together: 

All together

Confounding Conditions: 

Seizures Atypical seizures can have no motor activity Cerebral hypoperfusion can cause brief tonic/ clonic like motor activity Seizure patients almost always have a postictal period Incontinence can be helpful “ Polytrauma ” can be helpful Aura can be helpful 5-15% of undifferentiated syncope Confounding Conditions

Confounding Conditions: 

Metabolic disorders Hypoglycemia, hypoxia, hyperventilation Slower onset with historical clues Intoxication Slow onset/slow resolution Vertebrobasilar TIA Vertigo sxs Falling without LOC Anaphylaxis (insect venom and IV meds) Confounding Conditions

Initial Evaluation of all new episodes of syncope: 

History Physical Examination Vital Signs (including orthostatic measurements) Cardiovascular exam Neurologic exam Hemocult as indicated 12 lead ECG with rhythm strip Other labs as history indicates to r/o confounding conditions Initial Evaluation of all new episodes of syncope

Thinking about hospitalization……: 

Short-term high risk criteria Severe cardiac structural dx or CAD CHF Low LVEF Previous MI Arrhythmia Risks Syncope during exertion or supine Palpitations with syncope Family Hx of SCD High risk ECG (see previous slides) Co-morbidities Anemia Metabolic disturbances Thinking about hospitalization……

Other Testing: 

Carotid sinus massage Patients > 40 yrs old NO TIA or stroke for 3 mos NO carotid bruits Diagnostic if: Syncope Asystole > 3 sec SBP falls > 50 mm Hg Review criteria and technique Other Testing

Other testing: Orthostatic challenge: 

Active Standing (AS) Must be lying supine for at least 5 minutes Measure BP at least each minute for at least 3 minutes (< 4/min) Manual cuff is preferred >= 20 mmHg SBP/>=10mmHg DBP/ SBP < 90mmHg Still counts if asymptomatic Tilt Testing (TT) Other testing: Orthostatic challenge

Orthostatic syndromes: 

Test Result Classic OH (AS or TT) >= 20 mm Hg SBP or 10 mm Hg DBP with in 3 min Initial OH (AS) Immediate > 40 mm Hg SBP Recovery in 30 sec Vasovagal syncope Normal resp with fall in venous return with bradycardia and vasodilitation (TT ) Delayed OH (TT) Slow progressive decrease in SBP w/o bradycardia Delayed OH with reflex syncope (TT) Postural Orthostatic Tachy Syndrome (POTS) (TT) Severe orthostatic intolerance HR > 30 or > 120 with BP stability Orthostatic syndromes

Other testing: 

ECG monitoring ECG abnormalities are common and so is syncope (not causal) ECG is helpful when: Syncope occurs with an arrhythmia Syncope occurs without an arrythmia Exceptions > 3 sec ventric pause in Mobitz II 2nd or third degree HB Rapid prolonged paroxysmal SVT or VT Types of monitoring Inhospital : 16% yield for HR patients Holter (24-48 hr ): 1-3% yield, may ID pts who need EPS External Event Recorders Better than Holter Once a month or more frequent Implantable loop recorders (18-24 months) Other testing

Mobitz II second degree heart block: 

Mobitz II second degree heart block

Other Testing: 

Echocardiography Suspicion of structural heart disease Diagnostic findings for syncope Severe aortic stenosis Obstructive tumor or thrombus Cardiac tamponade Aortic dissection Congenital anomaly of the coronary arteries Other Testing

Other Studies: 

EPS Pts with ischemic heart disease and syncope and clinical susp of arrhythmia BBB with failure of noninvasive tests to find disease Can have 50% yield REMEMBER to skip EPS: LVEF <= 30% + MI = ICD LVEF <= 35% + NYHA II or III = ICD Exercise Testing Syncope during or shortly after exerise ECHO first Positives: Syncope with ECG changes or severe hypotension Mobitz II or 3 rd degree AV block Hypotension during exercise and under 40 yo consider: Left main dx and hypertrophic cardiomyopathy Older patients with hypotension with exercise: autonomic failure Can be helpful for QT syndromes Other Studies

Syncope Decision Tools: 

Syncope Decision Tools

Syncope Decision Tools: 

San Francisco Rule Risk factors SBP < 90 SOB ECG: not SR or new changes CHF Hct < 30% Serious outcomes in 30 days No risk factors: 0.3% One or more: 15% There has been some difficulty with external validity for this rule Syncope Decision Tools

Syncope Decision Tool for admission: 

ROSE rule (Risk stratification Of Syncope in the E dept ) B BNP > 300 Bradycardia < 50 bpm R Rectal with occult blood A Anemia with Hgb <= 9.0 C Chest pain with syncope E ECG with Q wave (not lead III) S Oxygen sat <= 94% on RA Sensitivity and specificity for one month adverse out comes: 87% and 66% Negative predictive value : 98.5% BNP alone predicted 8/9 deaths Syncope Decision Tool for admission

Definitive diagnostic criteria for syncope: 

Vasovagal syncope can be diagnosed if syncope is precipitated by emotional or orthostatic stress and has a typical prodrome Situational syncope can be diagnosed if syncope occurs during or after triggers OS can be diagnosed if it occurs after standing up and OH is documented Arrhythmia related syncope Persistent sinus brady <40 bpm when awake or > 3 s pauses Mobitz II second or third degree AV block Alternating left and right BBB VT or rapid paroxysmal SVT Nonsustained polymorphic VT + QT interval dx Device malfunction with cardiac pauses Cardiac ischemia syncope with ECG evidence of acute ischemia Cardiovascular syncope when there is atrial myxoma , severe AS, pulmonary HTN, PE, or acute aortic dissection Definitive diagnostic criteria for syncope

Flow diagram: 

Flow diagram

Treatment of Syncope: 

Treatment of Syncope

Reflex syncope treatment: 

Reflex syncope treatment

PCM: 

Physical Counterpressure Maneuvers Isometric Leg crossing/ grip /arm tensing Increases BP during prodrome or presyncope Can reduce syncope about 40% PCM

Orthostatic Hypotension Treatment: 

Orthostatic Hypotension Treatment

Treatment of Syncope from Cardiac Arrhythmias: 

Treatment of Syncope from Cardiac Arrhythmias

Treatment of Syncope from Cardiac Arrhythmias: 

Treatment of Syncope from Cardiac Arrhythmias

Indications for ICD in patients with syncope and high risk of sudden cardiac death: 

Indications for ICD in patients with syncope and high risk of sudden cardiac death

Driving and Syncope: 

Driving and Syncope

Carotid Sinus Massage: 

Continuous ECG and intermittent BP monitoring IV access, O2 and crash cart 10 sec each side supine and erect Carotid Sinus Massage

Relevant ECGs: 

Relevant ECGs

Question #1: 

The most common types of syncope are: A. Neurogenic, Orthostatic, and Cardiovascular B. Arrhythmia, Anemia, and Ischemia C. Reflex, Orthostatic, and Cardiac D. Hypoglycemic, Hypoxic, and IronCitic Question #1

Question #2: 

All ED patients with syncope should receive: A. Tilt table testing B. an ECG C. EPS studies D. Cardiac catheterization Question #2

Question # 3: 

All of the following are echocardiographic diagnostic criteria for cardiac syncope EXCEPT: A. Cardiac tamponade B. High grade Aortic Stenosis C. Aortic dissection D. low LVEF Question # 3