Download Approach to SYNCOPE - Texas Tech University Health Sciences

Approach to
SYNCOPE
Rey Vivo, MD
Department of Internal Medicine
Texas Tech University Health Sciences Center
Case 1
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74M with no documented cardiovascular disease drove himself to the ED
after falling at home 3 hours ago. He had been feeling well and was
preparing to play tennis when he suddenly collapsed in his bathroom. He
did not recall any dizziness, blurring of vision, palpitations or chest pain
preceding the event and regained consciousness spontaneously. He could
not say how long he was out but remembered that he was shaving before
the incident. Vital signs and physical exam were within normal. ECG and
CT scan of the head were unremarkable. What is the most likely
explanation?
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•
•
•
A.
B.
C.
D.
Vasovagal syncope
Carotid sinus syncope
Situational syncope
Seizure
Objectives
• Define syncope
• Differentiate causes
• Plan a diagnostic approach
• Know indications for admission
Causes of Syncope
Carotid sinus massage
Tilt-table test
Case 2
•
59F with long-standing diabetes mellitus on insulin therapy presents to the
office with episodic fainting. She said the episodes began 1 month ago and
have been occurring more frequently. She initially felt light-headed upon
standing only; lately, she had become dizzy after meals and has been
witnessed by her daughter to have fainted upon getting up and after eating.
The episodes last few seconds and resolve spontaneously. On exam:
supine BP 145/90, HR 70; standing BP 132/75, HR 90, associated with
light-headedness. Both feet are insensate on monofilament testing. The
rest of her PE, including neurologic evaluation, was normal. Random
glucose: 230 mg/dL. ECG showed sinus rhythm with non-specific ST wave
changes. What is the most the most likely diagnosis?
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•
•
A.
B.
C.
D.
Coronary artery disease
Hypoglycemia
Reflex-mediated syncope
Orthostatic hypotension
Orthostatic hypotension
Case 3
•
Cerebrovascular
Differential diagnosis
• Vertigo
• Coma
• Drop attacks
• Dizziness
• Sudden cardiac death
Syncope vs. Seizure
• 15-90% of syncopal patients exhibit limb jerking or myoclonic
activity, predominantly arrhythmic jerking of UE and LE
Pallor
Cyanosis
Prodromal sweating
Mouth frothing, tongue biting
Palpitations, nausea
Sleepiness post-event
Provocation
Unconsciousness > 5 mins.
Best discriminatory symptom is post-ictal confusion
favoring seizures
Case 4
•
68F is brought to the ED after a witnessed loss of consciousness at home.
She could not recall the incident but woke up without confusion. Her son
narrated that she was raking leaves in the backyard before she collapsed.
She added that she had been experiencing chest pressure on heavy
exertion but has otherwise been active. PE revealed normal vital signs; S1,
indistinct S2, grade III/VI mid-systolic murmur loudest at the R 2nd ICS
radiating to the neck; clear lungs; unremarkable neurologic exam. ECG is
shown:
An echo confirmed the diagnosis which is severe. She is
anxious about her condition and wants everything done to get well. What is
the next most appropriate step?
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•
•
•
A.
B.
C.
D.
Surgery
Coronary angiography
Medical therapy
Reassurance
EKG
Brugada syndrome
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Defined in 1992 by brothers Pedro and Josep
Brugada in J Am Coll Cardiol
Rare condition associated with sudden cardiac death (SCD) or ventricular
fibrillation/polymorphic VT in structurally normal hearts
Mean age of presentation: 35-40 years; male predominance (notably in SE
Asia where it is endemic)
Familial with autosomal dominant inheritance
Clinical presentation: syncope or SCD is most common initial event;
typically occurs in sleep or in early morning
ECG criteria: ST segment elevation in V1-V3 with characteristic RBBB
pattern
Defect in sodium channel gene (SCN5A) on chromosome 3
Lifetime risk of SCD
Consider ICDs; refer for genetic counseling
Indications for Echo
Figure. Decision Pathway for Ordering Transthoracic Echocardiography
Figure from MKSAP 14
Case 5
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80M
Pacemaker
Recommendations for Permanent Pacing in Acquired Atrioventricular Block in
Adults
• Third-degree and advanced second-degree AV block at any anatomic level,
associated with any one of the following conditions:
– Bradycardia with symptoms (including heart failure) presumed to be due to AV
block. Arrhythmias and other medical conditions that require drugs that result in
symptomatic bradycardia.
– Documented periods of asystole greater than or equal to 3.0 seconds or any
escape rate less than 40 bpm in awake, symptom-free patients
• Second-degree AV block regardless of type or site of block, with associated
symptomatic bradycardia.
Recommendations for Permanent Pacing in Sinus Node Dysfunction
• Sinus node dysfunction with documented symptomatic bradycardia, including
frequent sinus pauses that produce symptoms. In some patients, bradycardia is
iatrogenic and will occur as a consequence of essential long-term drug therapy of a
type and dose for which there are no acceptable alternatives.
• Symptomatic chronotropic incompetence.
ACC/AHA/NASPE 2002 Guidelines
Take home points
• Syncope is (1) sudden transient LOC with (2)
spontaneous recovery
• Thorough history can largely differentiate from other
conditions
• Causes range from benign to life-threatening (recall: 4
categories); important to rule out cardiac and
cerebrovascular causes
• Tailor additional testing to initial evaluation
Thank you