Download Syncope and The Older Patient

Syncope and The Older Patient
Debra L. Bynum, MD
Division of Geriatric
Medicine
Pretest…
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1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac
etiology for syncope
2. History: 75 year old man reports presyncopal symptoms that occur while he is
driving backwards out of his driveway in the morning. This suggests …
3. History: an 80 year old man reports an episode of syncope that occurred after
doing arm exercises for a rotator cuff injury. This suggest…
4. The only independent predictor of a cardiac etiology of syncope is a past history
of …
5. ____ is a neurodegenerative disease characterized by profound autonomic
insufficiency and parkinsonian features on exam
6. An 82 year old man presents with postural hypotension, an idiopathic peripheral
neuropathy, significant proteinuria and your attending orders a rectal biopsy to look
for____
7. Name 3 causes of “situational syncope”
8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus
massage c. orthostatic hypotension d. all of the above
Pretest: bonus question
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Sudden cardiac death in young men
(originally described in young asian men)
associated with this sign on EKG is known as
what syndrome?
Syncope: Definition
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Sudden and temporary loss of
consciousness with inability to maintain
postural tone, followed by spontaneous
recovery
Causes of Syncope
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Neurally Mediated (up to 58% in some
series)
Orthostatic/postural
Cardiac arrhythmia (20-25%)
Structural cardiac or pulmonary causes
Cerebrovascular or psychiatric (1%)
Unknown (18-30%)
Syncope in the Elderly
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Usually multifactorial
Often confounded by findings (orthostasis
and carotid hypersensitivity common and
may be found and yet not be the cause…)
Prevalence up to 25% in nursing home
population over age 70
Higher pretest probability of cardiac disease
or arrhythmia
Importance of History and PE
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Up to 70% of patients in prospective studies
had probable cause identified based upon
history, physical exam and ecg
The History…
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History of Heart Disease
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The ONLY independent predictor of cardiac cause
(sens 95%, spec 45%)
Absence of heart disease up to 97% specific to
rule out cardiac etiology (good NPV)
The History
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Position
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Presyncopal symptoms
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Supine: cardiac until proven otherwise
Upon sitting/standing: orthostasis
Prolonged standing: venous pooling/orthostasis/vasovagal
Presence suggests vasovagal, but does not rule out arrhythmia
Lack of suggests arrythmia (up to 65% with sudden syncope)
Dyspnea (Pulmonary embolus)
Focal neurologic symptoms (TIA, seizure)
Seizure like activity (including loss of bowel and bladder
control, tongue bite, postictal state)
The history…
Recovery period
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Situational syncope (vasovagal)
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Instant: arrythmia
Feeling hot and nauseated: vasovagal
Confusion/lethargy: postictal
Cough
Swallow (cold liquid)
Micturition (urination)
Defecation
Exertional
– Ventricular tachyarrhythmia
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Aortic stenosis or HOCM
Pulmonary Hypertension
The history…
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Prior “faint” 1-4 years prior suggest vasovagal
Age
Medications
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Tricyclic antidepressants
Nitrates
Alpha adrenergic antagonists
Diuretics
Injury (facial suggests arrhythmia)
Postprandial (vagally mediated)
Specific Causes and Treatment
Options for Syncope
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Postural Hypotension
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Drop in systolic blood pressure of over 20
Medications
Autonomic Insufficiency
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No reflex tachycardia
Shy-Drager (multiple systems atrophy)
Primary autonomic failure
Parkinson’s Disease
Diabetes
Aging
Amyloid
Volume Loss
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Dehydration
Blood loss
Autonomic Insufficiency and
Orthostatic Hypotension
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Treatment Options
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Review of medications
Avoid volume depletion
Arising slowly
Tensing crossed legs while standing
Dorsiflex feet or handgrip prior to standing
Thigh high Jobst stockings (decreases venous pooling)
Avoid prolonged standing (venous pooling)
Increased salt diet
Smaller meals to avoid postprandial drop in BP
Fludrocortisone
Midodrine (alpha 1 adrenergic agonist)
Phenylephrine (not usually used in older patients)
Fluoxetine
Mechanical Cardiac Causes
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Obstruction to LV outflow
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Aortic Stenosis
HOCM
Left atrial myxoma
Mitral Stenosis
Obstruction to pulmonic flow
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Pulmonic stenosis
Pulmonary HTN
PE (can also have vasovagal type syncope associated with
smaller PEs)
Right atrial myxoma
Other Mechanical Cardiac Causes
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Large MI with LV dysfunction
CHF
Tamponade
Aortic dissection
Cardiac Arrhythmias
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Bradycardia
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Sick sinus syndrome
2nd or 3rd degree AV block
Pacemaker malfunction
Tachycardia
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Ventricular tachycardia
Ventricular fibrillation
SVT
If you see atrial fibrillation, think sick sinus syndrome as
potential cause of syncope…
Brugada Syndrome
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Triad
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RBBB pattern in right precordial leads
Transient/persistent ST elevation in v1-v3
Sudden cardiac death
Structurally normal heart
Association with young and healthy men from southeast asia who
present with sudden cardiac death
Brugada sign may be asymptomatic
High risk of sudden cardiac death in those who have syncope or
family history of sudden death (Indication for AICD based upon
observational data)
Brugada Sign
Implantable Cardioverter-Defribrillator
Guidelines
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AICD indicated for patients with spontaneous
Vtach with underlying heart disease or in
patients with normal heart when vtach not
amenable to other treatments
AICD guidelines
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Ischemic Cardiomyopathy
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LVEF <30%
At least 1 month after MI and 3 months after revascularization
MADIT-II trial
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Multicenter Automatic Defibrillator Implantation Trial
5.6% ARR in mortality over 4 years
Results support prophylactic AICD, but not considered cost wise
Based upon subset analysis, Current recommendation in those
with QRS >120 ms
Unclear result: those with ICDs had 5% absolute increased risk of
hospitalization for CHF (19% vs 14%): ?artifact, ?due to living
longer?, ?detrimental
AICD guidelines…
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Syncope in patients with advanced structural
heart disease
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High risk of sudden cardiac death
Inducible Vtach with structural heart disease
Inducible Vtach with normal heart that is not
amenable to ablation therapy
Subclavian Steal Syndrome
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Proximal subclavian artery stenosis
Decreased blood flow to distal subclavian artery worsened with
exertion of arm
Blood from vertebral artery on opposite side goes to basilar artery and
then down ipsilateral vertebral artery, away from brainstem, to serve as
collateral for arm
Usually asymptomatic
Atherosclerosis
Symptoms of vertebrobasilar insufficiency (dizziness, vertigo, diplopia,
nystagmus)
Rare to have permanent neurological deficits
Diagnosis with dopplers, MRA
Treatment: surgical revascularization, stents
Cerebrovascular Disease
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Less common cause of true syncope
Vertebrobasilar disease (presyncope)
Drop Attacks
Vasovagal/Neurocardiogenic syncope
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Situational Syncope
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Micturition
Defecation
Cough
Swallow
Recurrent Neurocardiogenic Syncope
Posprandial
The FAINT
Vasovagal Syncope
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Presyncopal symptoms
Setting (procedure, pain, anxiety)
Prior history
Neurally Mediated Syncope
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Cardiac sensory receptors in LV stimulated
by stretch
Increased neural discharge to vasomotor
center in medulla
Increased parasympathetic tone and
decreased sympathetic activity
Sudden bradycardia and hypotension
Recurrent Neurocardiogenic Syncope
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Upright posture lead to pooling of blood in lower extremities
Decreased venous return
Normal response: reflex tachycardia and forceful LV contraction
and vasoconstriction
Susceptible individuals: activation of mechanoreceptors triggers
reflex bradycardia and hypotension
Response triggered by forceful LV contraction with prolonged
standing or with increased catecholamines (anxiety, fear, panic,
pain)
Treatment of Recurrent
Neurocardiogenic Syncope
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Medications
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Paroxetine
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Midodrine
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Alpha adrenergic agonist
Small studies
Fludrocortisone
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Only agent shown effective in RCT
No good study
Beta blockers
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Often used, mixed evidence in studies
Pacemakers in the treatment of
Recurrent Neurocardiogenic Syncope
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3 large RCTs of permanent pacing
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North American Vasovagal Pacemaker Study (VPS-1)
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Vasovagal Syncope International Study
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Patients with over 6 episodes, positive tilt table test with
significant bradycardia
Significant decrease in recurrence with pacer (HR .087)
5% recurrence with pacemaker vs 61% without (19 patients)
Syncope Diagnosis and Treatment Study
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Pacemaker vs atenolol
93 patients: 4.3% recurrence vs 26%
Pacemakers and neurocardiogenic
syncope:
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Problems with trials…
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Small numbers of patients
Not blinded
Highly selected patients
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Patients had profound bradycardia on tilt table testing
and multiple episodes
Pacers and neurocardiogenic
syncope…
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Bottom line:
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May benefit patients with recurrent episodes of
clear neurally mediated syncope, associated with
significant bradycardic response, who have a
decreased QOL otherwise (injuries, driving, etc)
Carotid Sinus Hypersensitivity
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?Role of Carotid Sinus Massage
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Some recommend if no bruits, recent MI, cva or history of vtach
?monitor
Positive response: 3 sec pause
In literature, but most cardiologists would not recommend
High yield of carotid massage in elderly (up to 40% over the
age of 75 may have a positive response), but not specific in
identifying this as the cause of syncope (PPV not known)
History: syncope/presyncope with turning neck, backing up in
car, wearing tight collar
Evaluation of Syncope
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When a cause of syncope is identified,
history and physical lead to etiology in up to
85% cases
The only independent predictor of a cardiac
cause of syncope is the presence of
underlying heart disease (95% sens, only
45% spec)
Orthostasis
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May be confounder in older patients
Up to 25% of older patients may have
orthostasis when tested, the presence of
orthostasis may be true, true and unrelated…
The ECG
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Prolonged QT
Bradycardia, AVN disease, MI, HOCM,
Brugada
Only 2-10% will have diagnostic abnormality
Up to 50% of patients with syncope have
abnormal EKG
Greatest use in NPV (negative predictive
value) of NORMAL ECG
The Holter Monitor
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24-48 hours continuous ECG
No added yield with 72 hours
Low yield unless frequent symptoms
Up to 70% of Holter studies negative for diagnosis
One series: only 5% of studies had arrhythmia that
correlated with symptoms
Probably good NPV if symptoms documented with
benign rhythm
Event or Loop Monitors
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Higher yield than holter (up to 55% positive
yield of symptom-arrhythmia correlation in
some series)
Problem with patient education and ability to
activate monitor correctly (25% of patients
have difficulty)
May be especially problematic in the very
elderly or those with dementia
Implantable Loop Recorder
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Prolonged monitoring for those with syncope
of unclear etiology despite workup, especially
for those in whom cardiac etiology is
suspected
Several small studies suggest that in very
selected patients, may increase yield of
diagnosis to almost 85%
Other Cardiac Tests
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Echo
Exercise or Functional Tests
EP studies
Most useful when history or physical
suggests specific further testing to be done…
Tilt Table Testing…
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Passive or Isoproterenol
Test: patient held in upright position at 40-90 degrees and
observed for symptoms and hypotension or bradycardia
Passive testing: sensitivity of 70%, specificity of 90-100%
Isoproterenol: only 55% specificity
Overall little to add to history and PE; lack of sensitivity with
passive testing and lack of specificity with induced testing limits
usefulness of test…
Lab tests…
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The basics (anemia)
?BNP: some studies report usefulness as a marker for cardiac
cause of syncope: sensitivity of 82% and specificity of 92%,
Likelihood ratios of pos and neg tests probably not more useful
than pretest probability of underlying heart disease based upon
history and physical exam
CK, MB and Troponins
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More useful if positive (greater PPV) than neg
One series: up to 10% nursing home patients presenting with
syncope had positive enzymes…
The Least Useful Tests…
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CT head with negative neurological exam
EEG with no neurological symptoms
Carotid Artery Dopplers (useful for evaluation
of CVA or TIA, not useful for evaluation of
syncope without vertebrobasilar
symptoms…)
The Older Patient
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Positive tests that are more common in the elderly
and not necessarily the cause of the syncope:
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Orthostasis
Positive carotid massage
Positive tilt table testing
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Up to 54% of older patients with syncope may have positive
test…
Positive test in 10% of asymptomatic elderly!
Algorithm for diagnosing syncope
Linzer, M. et. al. Ann Intern Med 1997;127:76-86
Summary of Charges for Diagnostic Tests in Syncope*
Linzer, M. et. al. Ann Intern Med 1997;127:76-86
Summary
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Syncope in the older patient usually multifactorial
Tailor tests based upon history and physical exam
Elderly more likely to have positive tests that may be
confounders…
Elderly more likely to have underlying heart disease
and higher pretest probability of a cardiac etiology
Use algorithms in older, complicated patients with
great caution!!!
Back to the Pretest…
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1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac
etiology for syncope
2. History: 75 year old man reports presyncopal symptoms that occur while he is
driving backwards out of his driveway in the morning. This suggests …
3. History: an 80 year old man reports an episode of syncope that occurred after
doing arm exercises for a rotator cuff injury. This suggest…
4. The only independent predictor of a cardiac etiology of syncope is a past history
of …
5. ____ is a neurodegenerative disease characterized by profound autonomic
insufficiency and parkinsonian features on exam
6. An 82 year old man presents with postural hypotension, an idiopathic peripheral
neuropathy, significant proteinuria and your attending orders a rectal biopsy to look
for____
7. Name 3 causes of “situational syncope”
8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus
massage c. orthostatic hypotension d. all of the above
Answers to Pretest…
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1. NPV
2. Carotid Hypersensitivity
3. Subclavian steal syndrome
4. Cardiac history
5. Multiple Systems Atrophy (shy-drager)
6. amyloid
7. micturition, defecation, cough, swallow
8. all of the above
9. bonus: brugada syndrome
Selected References
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Benditt DG, VanDjjk JG, Sutton R. Syncope: Curr Prob Cardiol 2004; 29(4): 152-229
Epstein AE. An update on implantable cardioverter-defibrillator guidelines. Curr Opin
Cardiology 2004; 19(1): 23-25
Littman L et al. Brugada syndrome and Brugada sign. Am Heart J 2003; 145(5): 768-778
Raj S, Sheldon RS. Role of pacemaker in treating neurocardiogenic syncope. Curr Opinion
Cardiol 2003; 18: 47-52
Gregoratos G, Cheitlin MD, Conill A. ACC/AHA guidelines for implantation of cardiac
pacemakers and antiarrthythmia devices: executive summary: a report of the American
College of Cardiology/Am Heart Assoc Task Force on Practice Guidelines. Circulation.
1998; 97: 1325-1335
Connolly SJ et al. The North American Vasovagal Pacemaker Study. J Am Coll Cardiol
1999; 33: 16-20
DiGirolamo et al. Effects of paroxetine on refractory vasovagal syncope. J Am Coll Cardiol
1999; 33: 1227-30
Sutton R et al. Dual chamber pacing in the treatment of neurally mediated tilt-positive
cardioinhibitory syncope (VASIS). Circulation 2000; 102: 294-299
Selected References…
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Krahn Ad et al. Use of the implantable loop recorder in
evaluation of patients with unexplained syncope
Kapoor WN. Current evaluation and management of syncope.
Circulation 2002; 106: 1606
Alboni P et al. Diagnostic Value of history in patients with
syncope. J Am Coll Cardiol 2001; 37: 1921
Kapoor et al. Evaluation and outcome of patients with syncope.
Medicine 1990; 69: 160
Linzer et al. Diagnosing syncope: part I. Ann Int med 1997;
126:989
Linzer et al. Diagnosing syncope: part II. Ann Int Med 1997;
127: 76