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SYNCOPE
Module #3
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
981320 UNMC
Omaha, NE 68198-1320
[email protected]
Web: geriatrics.unmc.edu
402-559-7512
PROCESS
Series of 3 modules and questions on
Etiologies, Evaluation, & Management
Step #1 Power point module with voice
overlay
Step #2 Case-based question and answer
Step # 3 Proceed to additional modules or
take a break
EVALUATION
Etiologies:


The evaluation requires:
Comprehensive approach
Step-wise progression to first rule out the
most lethal causes (i.e. cardiac) and then
next progressing to the other etiologies as
indicated
EVALUATION
First Step
First step:
History
H &P*,
EKG,
Labs
Suggested
(CBC, electrolytes,
glucose, BUN/Cr. Ca+
and SaO2, cardiac
enzymes)
Precipitant
Activities
Prodrome
Medications
Witnesses
Comorbid conditions
What to ask?
Characteristics of the Three Classes of
Syncope
Phase
Cardiac
arrhythmia
Vasovagal
Seizure
Prior to
event
-Any position
< 5 secs warning
-Precipt. absent
-Palpitations rare
-Aborted with lying flat
-Precipt. present
-Nausea
-Visual changes
-Any position
-May have a
warning or
prodrome
During
event
-Flaccid
-Absent pulse
-Blue, ashen skin
-Incontinence rare
-Motionless, relaxed
tone
-Slow, faint pulse
-Pale, color skin
- Pupils dilated, reactive
-Rigid tone
-Pulse: rapid
 BP
-Tonic eye
deviation
-Frothing
Recovery
-Rapid, complete
-Fatigue after event
-No retrograde amnesia
-Diaphoresis & nausea
-Slow recovery
-Disorientation
-Focal neuro.
findings
EVALUATION
Physical
-orthostatic BP & pulse
(lying, sitting &
standing 1 & 3 min.)
-pulmonary
-cardiac
-neurologic exams
First Step1
History
(from patient and witness)
will give diagnosis 50% of
the time
Physical
will give diagnosis 20% of
the time
EVALUATION First Step2,3
LAB:
BMP
CBC
Gave diagnosis for
what % of
patients?
2-3% of patients
EKG
Gave diagnosis for 5%
of patients
BUT
Often gave clue to dx:
e.g. (old MI, BBB,
arrhythmias)
EVALUATION
additional steps4
Echocardiography yields
unsuspected findings in----- <
10% of patients
(should be performed pre stress test,
if patient has exertional syncope to
r/o cardiac obstruction; eg septal
hypertrophy)
EVALUATION
additional steps5
FOR Patients with
Structural cardiac abnormalities*
* structural heart. Dz: (CAD, CHF, Valve dz, cong. hrt dz)
or
EKG abnormalities
(old MI, BBB, arrhythmias, conduction syst. dz)
who have:
Ischemic symptoms
Perform:
Exercise or Pharmacologic Stress Testing
EVALUATION
additional steps6
If added:
Ambulatory ECG (Holter) gave:
correlation of arrhythmia with symptoms 4% of the
time
 absence of arrhythmia with symptoms 17% of the
time
(79% of pts. had no arrhythmia or brief arrhythmia)

Note: 72 hr ambulatory monitoring did not increase yield for
symptomatic arrhythmias over 24 hr monitoring
EVALUATION
additional steps
Ambulatory loop recorders or Event
monitors (“King of Hearts”): (11)
 in patients able to operate recorder gave
diagnosis 25% of time
 in patients unable to operate recorder
consider implantable loop recorder
EPS:
Electrophysiologic studies7
Indications
High yield patients:


structural heart disease with unexplained syncope
detection of arrhythmias in ischemic heart disease
Detect arrhythmias by:
via by EKG, cardiac monitoring or Holter or Event
monitoring
Significant findings:

NSVT, Sinus Brady, 3 degree Heart Block, BiFasicular BBB
EPS meta-analysis
Ann Intern Med 1997;127:76-86
Patients with:
EPS yield:
history of
Structural
heart Disease
21% demonstrated ventricular tachycardia (VT)
34% demonstrated bradycardia*
(N=406)
Abn EKG
(i.e.
conduction
abnormalities)
with “normal
hearts”
Total diagnostic yield:
50% in patients with OHD
(14% patients had both VT and bradycardia)
3% demonstrated VT
19% demonstrated bradycardia*
*EPS has low sensitivity and specificity for bradycardia
1% VT
10% bradycardia
(i.e.
absence of structural Total diagnostic yield:
heart disease)
(N= 219)
10% in patients without OHD
EVALUATION



additional steps
If added:
CT(head) or EEG
yielded diagnosis in only---- 4% of pts
(12)
(these tests are rarely helpful unless neurologic
signs or symptoms are present)

all patients with positive scans had focal
neurologic signs or witnessed
seizure)
EVALUATION
If added:
Head-up tilt table test
(HUTT):
Indications:
-suspect vasovagal
or
-unexplained syncope in
those not suspect or
ruled out for cardiac
cause
additional steps8
when added to above
evaluation, these tests
gave diagnostic yield to
total of
 .60-76% of patients
 Specificity 90%
 Sensitivity 66%
Caveat
What is false positive rate?
 Can have false
positives: positive tilt
table in 10% of the
elderly population

* Tilt table testing
The Technique

1st Passive testing:




Technique
fasting
serial BP’s in various tilt
positions up to 60
degrees with patient
standing still
2nd Isoproteronol
infusion:


Technique:
as above plus infusion of
isoproteronol
Positive:

demonstrates drop in
BP> 20 mm Hg
and

symptom
reproduction
Review
Definition
List the consequences
Describe the aging
physiology that
predisposes to
syncope
List the causes
Describe the evaluation
Sudden LOC
Mortality high in cardiac
Baroreceptor,
 B receptors,
Volume
 MM tone
P-A-S-S O-U-T
R/o cardiac first
H &P, EKG, Labs
How to remember the causes?
“Mnemonics”
 P-A-S-S O-U-T
The following mnemonic reviews the etiologies of
syncope, and pertinent data on each:
P
A
S
S
ressure (hypotensive causes) O utput (cardiac)/O2 (hypoxia)
rrhythmias
U nusual causes
eizures
T ransient Ischemic Attacks
ugar (hypo/hyperglycemia)
& Strokes, CNS dz’s
The End of Module three on
9
Evaluation of Syncope
Request “Syncope Pearls” summary card from
402.559.3964
or [email protected]
Post Test

(10)
A 75-year-old woman has chronic congestive heart
failure with normal systolic function. Current medications
are furosemide and an angiotensin-converting enzyme
(ACE) inhibitor. While sitting in a chair approximately 1
hour after eating breakfast and taking her medications,
she suddenly loses consciousness and falls to the floor.
On examination at the hospital, her pulse rate is 68 per
minute and blood pressure is 160/72 mm Hg. A grade
3/6 midsystolic murmur is heard at the left sternal
border and radiates to the carotid arteries. There are
good carotid upstrokes and no carotid bruits. Complete
blood cell count, serum electrolytes, cardiac enzymes,
electrocardiogram, and chest radiograph are normal.
One day later, blood pressure is 104/70 mm Hg 1 hour
after breakfast. Which of the following is the most
appropriate next step?
Which of the following is the most appropriate
next step?
A. Order Doppler echocardiography.
B. Encourage the patient to drink two cups
of coffee (250 mg of caffeine) each
morning.
C. Discontinue furosemide.
D. Discontinue the ACE inhibitor.
E. Prescribe fludrocortisone, 0.1 mg orally
every morning.
Answer: C Discontinue furosemide.
This patient has postprandial hypotension, which
could be exacerbated by hypotensive
medications taken with breakfast. Diuretics have
been shown to exacerbate postprandial and
orthostatic hypotension, probably because of
their preload-reducing effects. In one study,
furosemide withdrawal improved postprandial
hypotension in elderly patients with heart failure
and preserved systolic function.

Doppler echocardiography probably would confirm
reduced early diastolic ventricular filling and normal left
ventricular function, which are characteristic of diastolic
heart failure. This will not change the treatment
approach, however. It is possible but unlikely that the
systolic murmur represents aortic stenosis or
hypertrophic cardiomyopathy. Even if present, these
probably are not hemodynamically significant, given the
normal physical findings and electrocardiogram. Caffeine
has been effective in ameliorating postprandial
hypotension in some patients, but tolerance develops
rapidly. ACE inhibitors may improve postprandial
regulation of blood pressure. Fludrocortisone is useful for
chronic orthostatic or postprandial hypotension, but it is
relatively contraindicated in patients with heart failure
because it causes sodium retention.
Post Test #2 (10)


You are called to see an 80-year-old nursing-home
resident with Alzheimer’s disease, reflux esophagitis, and
glaucoma who suddenly lost consciousness and fell to
the floor at 9:00 am while sitting in the dining room
beginning his breakfast. He was noted by his nurse
during morning rounds to be more lethargic than usual,
not engaging in his usual pacing behavior before
breakfast. At 8:00 am he received docusate, omeprazole,
and timolol eye drops. After his collapse the patient
spontaneously regained consciousness while lying on the
floor and was diaphoretic. There were no other
symptoms. On examination by the nurse, his supine
blood pressure was found to be 168/92 mm Hg, heart
rate was regular at 96 per minute, respiration rate was
28 per minute, and axillary temperature was 37.7°C
(99.8°F).
What is the most likely diagnosis?
What is the most likely diagnosis?
A. Postprandial hypotension
B. Arrhythmia
C. Pneumonia
D. Neurally mediated syncope
E. Acute myocardial infarction
Answer; C. Pneumonia

Syncope in the elderly patient is often the atypical
manifestation of diseases or situations that may not be
expected to result in loss of consciousness. Pneumonia is
a common cause of syncope in the elderly patient,
possibly as a result of hypoxemia, dehydration, or
altered cardiovascular reflexes. In this case there are
several signs consistent with this diagnosis. First, the
patient was lethargic during morning rounds, suggesting
that there was an occult illness. Also, during the nurse’s
examination he had a relatively high heart rate and
respiration rate, suggesting the presence of an acute
respiratory illness. His axillary temperature of 37.7°C
(99.8°F) corresponds to an oral temperature of 38.2°C
(100.8°F).

Although the patient was eating a breakfast meal,
postprandial hypotension usually does not occur until 30
to 45 minutes after the meal. The fact that he was
receiving ophthalmic timolol drops might predispose him
to a bradyarrhythmia; however, his heart rate was 96 per
minute following the event. Certainly an arrhythmia is
possible, but this would present acutely and would not
be associated with lethargy earlier in the morning. The
diagnosis of neurally mediated syncope is less common
in the elderly patient but does occur; usually this is
preceded by a prodrome of nausea, abdominal
discomfort, diaphoresis, or a stressful situation. Finally, it
is possible that an acute myocardial infarction
precipitated syncope; however, in the setting of lethargy,
fever, and tachypnea in a nursing-home patient without
prior cardiovascular disease, this diagnosis is less likely
than pneumonia. End
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6th Edition (Pompei P, Murphy JB, eds.), New York: American Geriatrics Society, Chapter
23, pp168-173, 2006.
2. Kapoor WN. Current evaluation and management of syncope. Circulation 2002 Sep
24;106(13):1606-9.
3. Linzer M, Yang EG, Estes NA, et al. Diagnosing syncope. Part 1: Value of history, physical
examination, and electrocardiography. Ann Int Med 1997; 126:989-996
4. Recchia D, Barzilai B. Echocardiography in the evaluation of patients with syncope. J Gen
Intern Med 1995 Dec;10(12):649-55.
5. Kapoor WN. Syncope. N Engl J Med 2000 Dec 21; 343(25):1856-62.
6. Bass EB, Curtiss EL, ArenVC, et al. The duration of holter monitoring in patients with
syncope. Is twenty-four hours enough? Arch Int Med 1990;150(5):1073-1078.
7. Menozzi C, Brignole M, Garcia-Civera R, et.al. Mechanism of syncope in patients with heart
disease and negative electrophysiologic test. Circulation 2002 Jun 11; 105(23):2741-5.
8. Natale A. Akhtar M, Jazayeri M, et.al. Provocation of hypotension during head-up tilt
testing in subjects with no history of syncope or presyncope. Circulation 1995 Jul
11;92(1):54-8.
9. Bush D. Syncope. In: Geriatric Review Syllabus: A Core Curriculum in Geriatric Medicine,
5th Edition (Cobbs EL, Duthie EH, Murphy JB, eds.), Malden, MA: Blackwell Publishing for
the American Geriatrics Society, Chapter 24, pp 165-169, 2002
10. Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500
Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
11. Bush D. Syncope. Geriatric Review Syllabus, sixth edition,, chapter 23, page 171
12. Linzer M., Yang EH. Et. al. Diagnosing syncope; part one: value of history, physical exam, a
nation and electrocardiography. Annals Int Med, June 15, 1997; 126:99-996
References