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Approach to SYNCOPE Rey Vivo, MD Department of Internal Medicine Texas Tech University Health Sciences Center Case 1 • 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? • • • • 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? • • • • 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? • • • • A. B. C. D. Surgery Coronary angiography Medical therapy Reassurance EKG Brugada syndrome • • • • • • • • • 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 • 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