Download Syncope

My Chest Hurts and I Passed
Out!
Ryan Johnson, M.D.
Arizona Pediatric Cardiology
Consultants
Chest Pain in Adolescents
• Very common
• More that 650,000 physician visits per year in
patients 10-21 y/o
• Second only to heart murmur among referrals
to pediatric cardiology
• 98% of the time it has nothing to do with the
heart
Non-Cardiac Chest Pain
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Musculoskeletal
Pulmonary
Gastrointestinal
Psychosocial
Other
Musculoskeletal
• Chest wall pain (costocondritis)
– most common cause (15-31%)
– sharp/stabbing pain, upper-mid sternum, lasts for few
seconds to minutes and often worse with deep breaths
– frequently reproducible with palpation over costosternal
joint(s)
– always self limited, can have intermittent exacerbations
Muskuloskeletal
• Tietze syndrome
– Localized inflammation of costochondral,
costosternal or costoclavicular joint
– Positive history of recent URI (? Coughing related)
– Swelling, warmth and tenderness of single joint
Muskuloskeletal
• Trauma/exercise
– Gymnastics, weightlifting, football, wrestling
– Up to 2% of cases
– Ask the question
Muskuloskeletal
• Precordial Catch “Texidor Twinge”
– Intense, sudden onset, sharp pain over left lower
sternal border to apex
– Occurs at rest or during mild activity
– Exacerbated by inspiration
– Thought to be associated with poor posture and
pinched nerve
Muskuloskeletal
• Treatment
– Reassurance, Reassurance, Reassurance
– “you are not having a heart attack”
– Self limited
– Can reoccur
– Warm compress
– NSAID Tid for 1 week
Pulmonary
• Asthma
– 2 to 11% of cases
– Weins et.al Pediatrics 1992 – PFTs during treadmill
testing of children with chest pain revealed 75%
with evidence of asthma
• Pulmonary embolism
– Intense chest pain with hypoxemia
• Sickle Cell
– Acute chest syndrome
Gastrointestinal
• GERD (gastroesophageal reflux)
– 8% of cases
– Burning type pain in epigastric to sub-sternal area
– ? Bitter taste in mouth
– H2 blockers or PPI
• Cholecystitis
• Esophageal stricture, foreign body
Psychosocial
• Anxiety
– Anxiety attack, panic attack
– Generalized pressure to sharp pain often
accompanied by shortness of breath
– history of recent social stressors or life changes
• Hyperventilation
– Often associated with anxiety
– SOB, dizziness and paresthesias
Other
• Breast related
– 1-5% of cases
– Mastitis, fibrocystic disease, pregnancy
• Hepes Zoster/Shingles
– Burning type pain in a dermatomal pattern
Cardiac Chest Pain
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Inflammatory
Structural heart disease
Coronary artery abnormalities
Other
Inflammatory
• Pericarditis/myocarditis
– Most common type of cardiac chest pain, but
accounts for <5% of cases
– Post infectious (cocksakie virus)
– Sharp retrosternal pain, radiates to left shoulder,
aggravated by supine position
– Tachycardia/hypotension with myocarditis
– Treatment = ibuprofen, steroids in rare cases, +/pericardiocentesis
Structural Heart Disease
• Cardiomyopathy (dilated and hypertrophic)
• LVOT obstruction (aortic stenosis, subaortic
stenosis and supravalvar aortic stenosis
• Pain commonly associated with exercise
• Harsh ejection murmur usually found on exam
Coronary Artery Abnormalities
• Congenital anomalies: ALCAPA, ALCA
• Acquired: Kawasaki disease, post surgical
(arterial switch, Ross procedure)
• Heart transplant
• Familial Hypercholesterolemia?
• Squeezing, tightness, pressure associated with
exertion
Other Cardiac
• Aortic dissection (Marfan, Ehlers-Danlos)
• Pulmonary Hypertension (Primary or
Secondary)
• Drugs (cocaine, methamphetamine,
marijuana)
Syncope
• Greek synkoptein “to cut short” or “cessation
• William Harvey first describes vasovagal
response during phlebotomy (1628)
• Definition: Transient loss of conciousness and
muscle tone with sponaneous recovery
resulting from inadequate cerebral perfusion
Syncope
An Alternative Mechanism For
Death by Crucifixion, Clinical
Medicine, Ethics and Philosophy
of MedicineIssueVolume 73,
Number 3 / August
2006CategoryArticlePages282289Online DateTuesday, January
29, 2008
Prevalence
• At least 15% of children between ages 8 – 18
years
• Unusual before age of 6 years except in
seizure disorders, breath holding spells
History
• Position (supine, sitting or standing)
• Activity (Δ position, after urination, exercise)
• Predisposing factors (warm place, prolonged standing, fear,
pain, neck movements)
• Onset of attack: palpitations, SOB, n/v, blurred vision, dizzy
• Attack: fall (slump or kneel over), skin color, duration of
LOC, movements
• End of attack: N/V, confusion, skin color, injury, chest pain,
palpitations, incontinence
• Medications
• Diet
• Bathroom patterns
• First attack, last attack and how many total
Orthostatic Intolerance Syncope
• Cardioinhibitory (vasovagal, neurocardiogenic,
simple, neurally mediated)
• Cardiodepressor (vasodepressor,
dysautonomia)
• Postural Orthostatic Tachycardia Syndrome
(POTS)
Cardioinhibitory Syncope
• Uncommon before age 10 years
• Prodrome of dizziness, nausea, pallor,
flushing/diaphoresis, palpitations, blurry/dark
vision, headache
• Less than 1 min of LOC
• Common in am, hot shower, prolonged
standing, fright, pain, blood, crowded places,
after prolonged exercise (stopped)
Cardioinhibitory syncope
• Upright posture causes pooling of blood in LE
• Decrease in venous return causes transient
hyperdynamic ventricle
• Cardiac C fibers (mechanoreceptors) activate
causing parasympathetic response resulting in
bradycardia, peripheral vasodilation and
hypotension
• Abrupt decrease in BP and HR ± asystole
Vasodepressor Syncope
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Wide age range
Prodrome of dizziness only
Less than 1 min LOC
Common in dehydration, prolonged standing,
prolonged bed rest
• Guillain-Barre’ Syndrome, Complex regional
pain syndrome
Vasodepressor Syncope
• Upright posture with venous pooling
• Inappropriate or inadequate vasomotor
response causing hypotension with little heart
rate response
• Decrease in blood pressure with blunted HR
response
POTS
• Common in adolescent females
• Venous pooling with sympathetic discharge
• Dizziness, palpitations, nausea, exercise
intolerance, chronic fatigue (syndrome)
• Defined as increase in HR ≥ 30 bpm or HR ≥
120 bpm in first 10 min after standing/upright
POTS
• Upright posture with venous pooling
• Large sympathetic discharge resulting in
significant tachycardia ± hypotension
Work Up
• Family History: epilepsy, sudden death/SIDS,
cardiomyopathies, early adult heart disease
• Social History: substance abuse, family
stressors, psychiatric disorders
• Physical Exam: usually normal (neuro,
orthostatic vitals, murmur)
• Labs: BMP, CBC, UA, thyroid
• EKG: heart block, LQTS, WPW, ARVC, Brugada
Tilt Table Test
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Used for: unexplained, recurrent, treatment failures
Reproduces neurally mediated reflex
Patient supine for 10-45 minutes prior to test
Patient is tilted head-up at 60-70 degree for 20-45
minutes
Can drug challenge (isoproterenol, nitroglycerin,
edrophium) if passive phase negative
False-positive: 10%
NO sensitivity known d/t no “gold standard” for
diagnosis of neurally mediated syncope
Early studies showed angle < 60 = loss of sensitivity,
>80= loss of specificity
Treatment
• Increase in fluid and salt intake
• Support hose
• Recognition of prodrome and aborting
episode by lying down
• Medications: fludrocortisone, midodrine, beta
blockers, SSRI
• reassurance
When to refer
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Multiple episodes
Atypical story
Abnormal EKG
Murmur
Family history of sudden death
Provider comfort level