Download Syncope

Syncope
What we will discuss?
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Background
information
Evaluation of syncope
Treatment of certain
causes of syncope
Useful, practical
items
Definition
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Sudden and brief loss of consciousness
Associated with loss of postural tone
Recovery is spontaneous
A symptom and not a disease
Scope of the problem
Occurs in 3-37% of general population
 6% annual incidence amongst elderly
residents of long-term care institutions
 3.5% of all ER visits
 1-6% of all hospital admissions
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Is it syncope?
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Presyncope
Dizziness
Vertigo
Drop attacks
Seizures
Cardiac arrest
Pathophysiology
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Sudden decrease in or brief cessation of
cerebral blood flow and nutrient delivery (seen
in all forms)
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Mechanisms:
- Decrease in cardiac output, including loss of preload, mechanical
outflow obstruction, and arrhythmias
- Loss of vascular resistance, often by neurocardiogenic reflex
mechanisms
- Focal or generalized decrease in cerebral perfusion caused by
cerebrovascular disease
- Causes in which cerebral blood flow is essentially normal, such as
hypoglycemia, hypoxia, and seizures
Neurocardiogenic reflex mechanisms
Causes of Syncope
More causes of syncope
Causes of Syncope
Kapoor, W. N. N Engl J Med 2000;343:1856-1862
Diagnosing the cause
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History is key
Presence of structural heart disease
Physical exam
EKG
The findings from this initial assessment will
guide your evaluation.
Historical aspects
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Number of episodes
Associated symptoms/Prodrome
Preceding events
Witnessed appearance
Recovery or postevent period
PMHx/Family hx/Medications
More on history
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Number of episodes
- Single episode or multiple episodes over many years vs. multiple
episodes over a short period time
Associated symptoms/Prodrome
- Dyspnea, angina, focal neurologic abnormalities
- Nausea, warmth, pallor, lightheadedness, diaphoresis
Preceding events
- Coughing, eating, drinking cold liquid, urinating, defecating, exertion
Recovery or postevent period
- Persistence of nausea, pallor, diaphoresis
- Significant neurologic changes or confusion
Other historical features
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Age
- Young vs. elderly
Position
- Supine vs. standing
Duration of symptoms
- Brief vs. prolonged
Injury
- Tongue biting
- Important to determine if syncope places individuals or
others at risk
Preexisting medical conditions
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Psychiatric illness
Diabetes mellitus
- Orthostatic hypotension secondary to autonomic neuropathy
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HTN
- Antihypertensive medications can result in syncope
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Presence of heart disease
Importance of heart disease
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Only independent predictor of
cardiac cause of syncope
(sensitivity 95%, specificity
45%)
Most important factor for
predicting risk of death and
likelihood of arrhythmias
Increased risk of death
regardless of the cause of
syncope
Obtaining information from Cardiology
Can page EKG tech (800-308-5890)
 Make copies of old EKG’s, echo reports,
cath reports, clinic SF600’s (before CHCSII)
 If you are in the Cardiology clinic, can
obtain this information from front desk area,
record/storage room (code to door is 7843)
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Physical examination
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Vital signs
Heart rate, Orthostatics, RR
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Cardiac exam
Systolic murmurs and physiologic maneuvers
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Neuro exam
Focal signs, mental status
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Carotid sinus massage
Carotid sinus massage
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Each carotid palpated and auscultated for
presence of bruits (test not performed in those
with evidence of carotid artery disease)
Pressure applied to one carotid sinus for 2-3 secs
with vigorous/circular movements
Done with simultaneous EKG monitoring
Positive test if there is pause for > 3 secs
Use cautiously in elderly patients
EKG findings
Sinus bradycardia
 AV nodal disease (2nd or 3rd degree heart
block)
 Bundle branch and/or fascicular block
 Prolonged QT interval
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Presence of EKG findings does not prove causality unless
findings are captured during actual event/symptoms.
Other EKG findings
Prolonged QT syndrome
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www.torsades.org
Diagnostic Tests
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Basic laboratory tests
- Leads to specific cause in 2-3% of patients
Echocardiogram
Stress testing
Ambulatory monitoring or continuous-loop event monitor
Electrophysiologic studies
Tilt table testing
Neurologic testing
Psychiatric evaluation
Echocardiogram
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May diagnose underlying
structural heart disease
(LV dysfunction,
hypertrophic
cardiomyopathy,
significant aortic stenosis)
Stress testing
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Frequently obtained
in patients with
cardiac disease
Useful in patients
with exertion-related
syncope or exerciseinduced arrhythmias
Testing for arrhythmias
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Symptoms occurring with arrhythmias occur in
4% of patients in studies using Holter monitoring.
Event recorders require the patient to activate the
unit to have the rhythm stored at the time of
symptoms.
Intermittent loop recorders can store several
minutes of recording if the unit has the ability.
Event recorders and Holter monitors can be
ordered via CHCS
Ordering monitoring devices
 Ordered in CHCS
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Under consult procedure to cardiology
- Holter or event monitor
Specify in consult amount of time for event
monitor (# of weeks)
Make sure you have a correct address on patient
because event monitor is mailed to them.
Implantable loop recorders
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Placed in subcutaneous pocket, usually in left pectoral
region
Can store about 45 minutes of retrospective
electrocardiographic recording
Can record automatically or be activated by the patient
after an event
Usually reserved for recurrent syncope in whom diagnosis
remains uncertain
Diagnostic yield between 25-40% during a period 8-10
months
Monitoring devices
Electrophysiologic studies
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Yield depends on whether
there is structural heart disease
or abnormal findings on EKG
Among patients with heart
disease, ~ 21% have inducible
ventricular tachycardia and
34% have bradycardia (14%
with multiple diagnoses)
In patients with abnormal
EKG’s, ~ 3% have inducible
ventricular tachycardia and
19% have bradycardia
Poor sensitivy/specificity for
bradyarrhythmias
Tilt table testing
 Used for diagnosis of neurocardiogenic or
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vasovagal syncope
Positive test is one where a hypotensive episode
is provoked that reproduces a patient’s symptoms
Specificity of negative test on passive tilt at
angles between 60-70 degrees is close to 90%
Sensitivity of test is uncertain because of no gold
standard
Tilt table test protocol
 Variety of protocols have been described
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Angle of tilt (60-90 degrees)
Duration of tilt (10-60 minutes)
Patient monitored in supine position for five minutes, then
placed in head-up tilt position
Second tilt can be performed with isoproterenol infusion if
patient asymptomatic during first tilt (nitrates are another
agent used)
Carotid massage can be performed with test
Indications for Tilt-Table Testing
Grubb, B. P. N Engl J Med 2005;352:1004-1010
Demonstration of the Use of a Tilt Table
Grubb, B. P. N Engl J Med 2005;352:1004-1010
Neurologic testing
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EEG
- May be helpful to rule out seizures/epilepsy
- Provides diagnostic information in < 2% of cases of syncope
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Head CT scan
MRI
Carotid doppler ultrasound
CT angiography
Psychiatric evaluation
 Generalized anxiety disorder, panic disorder, and
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major depression may cause syncope by
predisposing patients to neurally mediated
reactions.
Fainting is a known manifestation of somatization
disorder.
Alcohol and drug dependence/abuse may also
lead to syncope.
Useful hints on the wards
 Fall precautions
- Protocol: yellow armband, bed alarm, side rails up, offer
toileting q2 while awake/qhs/qAM, frequent reorientation
PRN
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Seizure precautions
Telemetry monitoring
- Speak to in person or call using hotline phones to
telemetry tech for any events
- Also a telemetry chart that you can look at
Treatment
 Neurocardiogenic
- Avoidance of predisposing factors
- Patient should be instructed to lie down at onset of prodromal
symptoms
- Isometric contractions of arm and leg muscles, intense hand gripping
- Increased fluid and salt intake
- Tilt training (standing for 10-30 minutes each day against a wall)
- Pharmacologic agents (beta-blockers, fludrocortisone, midodrine,
SSRI’s)
- Permanent cardiac pacing
Treatment
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Orthostatic hypotension
- Volume replacement in those with intravascular
volume depletion
- Discontinuing or reducing doses of drugs
- In cases of autonomic failure, increasing intake
of salt and fluid, use of waist-high support
stockings and abdominal binders
- Fludrocortisone or midodrine
Treatment
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Neurologic causes
- Antiseizure medications for seizure disorder
- Surgical intervention for severe carotid artery
disease
Psychiatric causes
- Psychiatric referral
- Medications (antidepressive, anxiolytic)
Treatment for cardiac causes
 Ventricular arrhythmias
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- Antiarrhythmic therapy, ICD placement, radiofrequency
ablation, electrophysiologic guided surgery
Bradycardia due to conduction abnormalities
- Pacemaker placement (sinus node dysfunction, high
grade AV block,)
Severe aortic stenosis
- Aortic valve replacment
Hypertrophic cardiomyopathy
- Beta blockers or CCB’s, RV pacing, myomectomy,
mitral valve replacment
Pacemakers/ICD
References
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Kapoor W. N. Primary Care: Syncope. N Engl J Med 2000;
343:1856 1862, Dec 21, 2000.
Grubb B. P. Neurocardiogenic Syncope. N Engl J Med 2005;
352:1004-1010, Mar 10, 2005.
Olshansky B. Evaluation of the patient with syncope. UpToDate
2005.
Olshansky B. Pathogenesis and etiology of syncope. UpToDate
2005.
Olshansky B. Mangement of the patient with syncope. UpToDate
2005.
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