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SYNCOPE
Tim Evans
July 30, 2014
Syncope Background
• Syncope Podcast—Steve Carroll, DO
• Syncope—Saklani P, Circulation. 2013;127:1330-1339
• Clinical Policy: Critical Issues in the Evaluation and Management of
Adult Patients Presenting to the Emergency Department with
Syncope—ACEP Clinical Policies Subcommittee, Ann Emerg Med.
2007;49:431-444
• AHA/ACCF Scientific Statement on the Evaluation of Syncope: From
the American Heart Association Councils on Clinical Cardiology, etc,
Circulation. 2006;113:316-327
A PROSPECTIVE EVALUATION AND FOLLOW-UP OF
PATIENTS WITH SYNCOPE—Kapoor WN, et al: N Eng J Med 1983;
309: 197-204
• Results
• 204 patients evaluated and followed for up to more than one year—
97 patients never found to have an etiology of syncope identified
• Tests performed
• Labs in every patient—no cause for syncope found
• ECG in every patient—12 causes for syncope found,
• Sinus bradycardia (2)
• Complete heart block (3)
• Pacemaker malfunction (1)
• MI (2)
• Sinus pause (1)
• V Tach (3)
A PROSPECTIVE EVALUATION AND FOLLOW-UP
OF PATIENTS WITH SYNCOPE
• Results (continued)
• Tests performed
• Prolonged electrocardiographic monitoring—190 patients, 29 causes for
syncope found
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Sinus pauses greater than 2 seconds (8)
Symptomatic sinus bradycardia (1)
V Tach (14)
A fib (2)
Symptomatic SVT (2)
Mobitz II AV block (2)
• Electrophysiologic Studies—23 patients, 3 inducible V Tach patients
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identified
Cardiac cath—25 patients, 5 with aortic stenosis, 2 with pulmonary
hypertension
Cerebral angiography—11 patients, 2 with subclavian steal
EEG—101 patients, 3 with abnormalities, 1 perhaps causing seizures
CT scan head—65 patients, no cause of syncope found
A PROSPECTIVE EVALUATION AND FOLLOW-UP
OF PATIENTS WITH SYNCOPE
• Diagnostic Studies that Determined Cause of Syncope
• H+P—52
• ECG—12
• ECG monitoring—29
• Electrophysiologic studies—3
• Cardiac cath—7
• Cerebral angiography—2
• EEG--1
A PROSPECTIVE EVALUATION AND FOLLOW-UP
OF PATIENTS WITH SYNCOPE
Cardiovascular Cause for
Syncope—53 patients
• V Tach—20
•
• Sick Sinus—10
•
• Aortic Stenosis—5
•
• SVT—3
• Complete heart block—3
• Bradycardia—2
• Mobitz II AV block—2
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• MI—2
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• Pulm HTN—2
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• PE—1
• Pacer malfunction—1
• Carotid Sinus Syncope—1
• Aortic Dissection--1
Non-cardiovascular Cause for
Syncope—54 patients
Situational Syncope—15
Orthostatic Syncope—14
Vasodepressor Syncope—10
Drug Induced—6
TIA—3
Seizure—3
Subclavian Steal-2
Conversion--1
Deaths During the Follow up Period
Cardiovascular
cause (N=53)
Non
cardiovascular
cause (N=54)
Unknown Cause
(N=97)
Sudden Death
11
2
3
Non sudden
cardiovascular
death
2
0
0
Death due to
other underlying
diseases
3
4
3
Mortality at 12
months
30
12
6.4
•The only difference
between syncope and
sudden death is that in
one you wake up.
Detailed Patient history
• Circumstance of recent
event
• Eyewitness account
• What was patient doing at
time of event?
• Symptoms at onset of
event—was there a
prodrome?
• Position during event
• Sequelae
• Circumstance of prior
events
• Past Medical History
• Cardiac
• Neurologic
• Family History
• Cardiac
• Sudden Cardiac Death
• Medications
Drugs Commonly implicated in Syncope
• Antihypertensives
• Antipsychotics
• Beta Blockers
• Antidepressants
• Cardiac glycosides
• Phenothiazines
• Diuretics
• Antidysrhythmics
Antiparkinsonism
• Nitrates
Alcohol
Cocaine
Physical Exam
• Vital signs
• Orthostatic hypotension
• Cardiovascular exam—murmurs? Heart failure?
• Neurologic exam—focal deficits?
• Evidence of trauma?
• Carotid Sinus Massage
Risk Stratification tools for syncope
• Bottom Line—no single decision rule is sufficiently
sensitive or specific to use in the ED
• But not useless—provide framework for clinical decision
making
Decision Rules
• Martin and Kapoor—history of arrhythmias, abnormal ecg,
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hx of chf, age>45
San Francisco Syncope Rule—CHESS-hx chf, hct < 30,
ecg with changes or non-sinus rhythm, sbp<90, sob
Osservatorio Epidemiolgicalao sulla Sincope nel Lazio
(OESIL)—age>65, hx cardiovascular dx, syncope without
prodrome, abnormal ecg—if 2 positive increased risk of
sudden death
Risk Stratification of Syncope in ED (ROSE)—bnp>300,
brady <50, gi blood, anemia, cp, O2 sat <94—if one
positive admit
Boston Syncope Criteria-signs and symptoms of cad,
cardiac hx, persistent abnormal vital signs in ED, volume
depletion, conduction abnormalities, valvular heart disease
by history or exam
Evaluation of Guidelines in Syncope Study (EGSYS)—
abnormal ecg, heart disease, palpitations before syncope,
syncope with effort or supine, no prodrome, no precipitants
High Risk Criteria
• Abnormal ECG—Bundle branch block or ivcd,
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bradycardia or 1st degree block in absence of beta
blockers or physical training, short PR, short or long
QT, ischemia, infarction
Suspicion of structural heart disease –hx or
signs/symptoms of MI, CHF, valvular heart disease
SOB
Syncope during exertion or with recumbency
SBP < 90
HCT < 30
Family hx of sudden cardiac death—particularly if
under age 50
Advanced age
Brugada Syndrome
Wolff Parkinson White
Syncope--Summary
• Do thorough H+P—this is where the diagnosis
will be made
• Do an ECG—look for the obvious and the not so
obvious—infarcts, abnormal intervals, right heart
strain
• Limit labs—HCG in fertile females, not much else
• Don’t do CT unless abnormal neuro or looking for
traumatic injury
Is it true syncope?
Transient LOC with return to baseline neurologic function
Yes
History, examination,
investigation of other
symptoms, ECG
No
(e.g.seizure, stroke, head trauma, other)
Appropriate
management
Diagnosis
established?
Yes
No
Syncope with
clear cause
Unexplained
syncope
Risk
stratification
Serious
cause?
High-risk
Criteria*
Appropriate
management; admission
Cardiac syncope

Arrhythmia

Myocardial infarction

Pericardial effusion

Pulmonary embolism

Neurologic syncope

Subarachnoid hemorrhage

Subclavian steal syndrome

Transient ischemic attack
Significant hemorrhage

GI/GU/Gyn bleed

Trauma
Low risk
and asymptomatic
Likely discharge
Neurocardiogenic/vasovagal

Vasomotor syncope

Carotid hypersensitivity

Situational syncope
Medication related
Orthostatic hypotension
Admission for evaluation and cardiac
monitoring
*High-risk criteria:

Abnormal ECG

Suspicion of structural heart
disease, especially a history of
CHF

HCT <30

Shortness of breath

SBP <90 mmHg

Family history of sudden
cardiac death

Advanced age**
**There is no discrete age limit, and
other factors such as cardiovascular
risk play a greater role; age <45
appears to clearly be low risk if no
other factors are present
Discharge with follow-up