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Syncope
A work up for Internists and Hospitalists
Philip Dittmar
January 31, 2014
• I have no conflicts of interest to disclose.
Syncope
• The current state in healthcare
• Classification of syncope
• Costs of a “typical” work up
• Ways to provide “High Value Cost Conscious
Care”
Syncope
• Transient loss of consciousness due to
transient global cerebral hypoperfusion
characterized by rapid onset, short duration,
and spontaneous complete recovery.
Moya A, Eur Heart J 2009
What we want to know?
• What caused it to happen?
• Will it happen again?
• Is this a sign of other things?
• Is it deadly?
What we do know…
• 40% of the adult population has experienced a
syncopal episode1
• 1% of ER visits2
– Up to 5% of admissions
• Annual healthcare costs estimated at $2.4bn2
– Cost per inpatient work up $5,400
1
Soteriades ES, N Engl J Med 2002
2 Sun BC, Am J Cardiol 2005
What we do know…
• Incidence and rate of hospitalization increases
with age
1
Soteriades ES, N Engl J Med 2002
What does this do to our patients?
Functional impairment on par with RA, chronic low back
pain, and depressive disorders.
80%
70%
60%
50%
40%
30%
20%
10%
0%
Change ADLs
Limit Driving
Change
Employment
Linzer M, J Clin Epidemiol 1991
Syncope
• The current state in healthcare
• Classification of syncope
• Costs of a “typical” work up
• Ways to provide “High Value Care”
Symptom not a Diagnosis
• Cardiac syncope
– Arrhythmia
– Structural heart disease
• Non-cardiac syncope
– Neurally-mediated syncope
– Orthostatic hypotension
• Non-syncope
– Epilepsy, concussion, psychogenic pseudosyncope
Cardiac Syncope
• Arrhythmia
– Bradycardia
• Sick sinus, atrioventicular block
– Tachycardia
• Ventricular tachycardia, supraventricular tachycardia, WolffParkinson-White
– Long QT syndrome, Brugada syndrome
• Structural
– Aortic stenosis, mitral stenosis
– Hypertrophic obstructive cardiomyopathy
– Ischemia
Non-Cardiac Syncope
• Neurally-mediated syncope
– Vasovagal
– Carotid sinus
– Situational – cough, sneeze, micturition
• Orthostatic hypotension
– Drug induced
– Autonomic nervous system failure
Non-Syncope
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Epilepsy
Concussion
Psychogenic pseudosyncope
Acute intoxication
Hypoglycemia
Sleep disorders
Overall Survival with Syncope
Soteriades ES, N Engl J Med 2002
Causes of syncope by age
Parry SW, BMJ 2010
Syncope
• The current state in healthcare
• Classification of syncope
• Costs of a “typical” work up
• Ways to provide “High Value Cost Conscious
Care”
Our patient
• 65-year-old man with history of CAD s/p stent
with syncope. He does not recall any
prodrome, but stated that symptoms started
after walking across his living room. His wife
was in another room and heard him crash into
the coffee table. She noted some jerking
movements prior to his return to full
alertness. Wife called 911.
What we do (on day 0)
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Thorough history with witness statement
Physical examination
ECG with telemetry
CBC, CMP, Troponin, CXR, Transthoracic Echo
CT Head
Urinalysis with Toxicology
• Cost: >$1,500
https://www.healthcarebluebook.com/
What we do (on day 1)
•
•
•
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•
Stress test
Carotid doppler
MRI/MRA
EEG
CTA chest
TSH, lipids, Hgb A1C
• Additional cost for testing: >$4,250
https://www.healthcarebluebook.com/
…and on day 2
• Left heart catheterization
• Send home with a Holter monitor
• Could add an addition cost of: $7,0001
• Testing could reach: >$12,500
• Average cost in US per syncope-related
hospitalization: $54002
• Average length of stay: 2.7 days
1
https://www.healthcarebluebook.com
2 Sun BC, Am J Cardiol 2005
Syncope
• The current state in healthcare
• Classification of syncope
• Costs of a “typical” work up
• Ways to provide “High Value, Cost Conscious
Care”
How can we do this better?
• Syncope. Cost-effective patient workup.
– Radack KL, Postgrad Med 1986.
• A cost effective approach to the investigation
of syncope: relative merit of different
diagnostic strategies
– Simpson CS, Can J Cardiol 1999.
AHA/ACCF Statement on the
Evaluation of Syncope – 2006
Expert Concensus
Strickberger, SA, Circ & J Am Coll Cardiol 2006
New Concepts in the
Assessment of Syncope.
JACC 2012
Brignole M, J Am Coll Cardiol 2012
How do we assess risk?
Parry SW, BMJ 2010
Calgary Syncope Symptom Score
Is there a history of bifascicular block,
asystole, SVT, or diabetes?
-5
Blue during faint?
-4
First episode when age 35 or older?
-3
Do you remember anything while
unconscious?
-2
Lightheaded spells or fainting with
prolonged sitting or standing?
+1
Diaphoresis or warm feeling prior to
faint?
+2
Lightheaded spells or fainting with pain
or in medical settings?
+3
Vasovagal syncope if the total point score is ≥ -2
Excludes patients with known cardiomyopathy or myocardial
infarction
Sheldon R, Eur Heart J 2006
Red Flags – San Fran Syncope Rule
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Congestive heart failure history
Hematocrit < 30%
EKG changes
Shortness of breath
Systolic Blood Pressure < 90 mm Hg at triage
• No to all = Low risk for serious outcome at 7 days
Quinn J, Ann Emerg Med 2004
OESIL Risk Score
• Abnormal ECG
• History of
cardiovascular disease
• Lack of prodrome
• Age > 65
12 month all cause mortality:
• 0% - score 0
• 0.6% - score 1
• 14% - score 2
• 29% - score 3
• 53% - score 4
Colvicchi F, Eur Heart J 2003
Recap of Risk Factors
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Age
Known cardiac disease
Abnormal ECG
Lack of prodrome
Associated chest pain or shortness of breath
Syncope Evaluations in the Elderly
• Retrospective Review
from 2002-2006 at Yale
• 2106 syncope admits,
aged ≥65
• Admission or discharge
diagnosis of syncope
• Syncope Etiology:
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Unknown 47%
Vasovagal 22%
Orthostasis 13%
Arrhythmia 12%
Dehydration 8%
Other cardiac causes 4%
Situational 3%
>1 Etiology 9%
Mendu ML, Arch Intern Med 2009
Diagnostic Yield in Older Patients
Test
Obtained
Abnormal
Affected Dx
Etiology
Management
ECG
2081 (99)
438 (21)
147 (7)
72 (3)
153 (7)
Telemetry
2001 (95)
314 (16)
212 (11)
95 (5)
245 (12)
Enzymes
1991 (95)
108 (5)
31 (2)
9 (0.5)
29 (1)
Head CT
1327 (63)
138 (10)
28 (2)
7 (0.5)
28 (2)
TTE
821 (39)
516 (63)
35 (4)
13 (2)
36 (4)
Postural BP
808 (38)
230 (28)
142 (18)
122 (15)
202 (25)
Carotid US
267 (13)
122 (46)
2 (1)
2 (0.8)
6 (2)
EEG
174 (8)
68 (39)
2 (1)
1 (0.6)
2 (1)
Head MRI
154 (7)
46 (30)
20 (13)
3 (2)
19 (12)
Stress Test
129 (6)
53 (41)
13 (10)
2 (2)
12 (9)
Mendu ML, Arch Intern Med 2009
Diagnostic Yield in Older Patients
Test
Obtained
Abnormal
Affected Dx
Etiology
Management
ECG
2081 (99)
438 (21)
147 (7)
72 (3)
153 (7)
Telemetry
2001 (95)
314 (16)
212 (11)
95 (5)
245 (12)
Enzymes
1991 (95)
108 (5)
31 (2)
9 (0.5)
29 (1)
Head CT
1327 (63)
138 (10)
28 (2)
7 (0.5)
28 (2)
TTE
821 (39)
516 (63)
35 (4)
13 (2)
36 (4)
Postural BP
808 (38)
230 (28)
142 (18)
122 (15)
202 (25)
Carotid US
267 (13)
122 (46)
2 (1)
2 (0.8)
6 (2)
EEG
174 (8)
68 (39)
2 (1)
1 (0.6)
2 (1)
Head MRI
154 (7)
46 (30)
20 (13)
3 (2)
19 (12)
Stress Test
129 (6)
53 (41)
13 (10)
2 (2)
12 (9)
Mendu ML, Arch Intern Med 2009
Test
Cost per test result affecting
management
EEG
$32,973
Head CT
$24,881
Cardiac Enzymes
$22,397
*Troponin I alone
$4,818
Carotid Ultrasound
$19,580
Head MRI
$8,678
Stress Test
$8,415
Echo
$6,272
ECG
$1,020
Telemetry
$710
Postural Blood Pressure
$17
Mendu ML, Arch Intern Med 2009
What is NOT helpful?
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EEG
Head CT
Cardiac Enzymes
Carotid US
EEG and Syncope
• Myoclonic jerks associated with true syncope
– Can be mistaken for seizure activity
• Ictal asystole is a rare but severe complication
of epileptic seizures
• 828 patients admitted for presurgery video
EEG monitoring between 2003-2013.
– 9 (1.08%) had ictal asystole
– Lasting 13 +/- 7 seconds
– Mostly asymptomatic
Nguyen-Michel VH, Epilepsia 2014
Head CT and Syncope
• Of 293 ED syncope patients, 113 underwent CT head
– 5% had abnormal head findings
• 2 with subarachnoid hemorrhage
• 2 with cerebral hemorrhage
• 1 with stroke
• Abnormal CTs associated with:
– Focal neurological findings, headache, or trauma
• Only half of patients undergoing CT had any
neurological findings, headache, trauma above the
clavicles, or coumadin use.
Grossman SA, Intern Emerg Med 2007
Cardiac Enzymes and Syncope
• Troponin unlikely to be beneficial unless other
signs or symptoms point to MI.
• Copeptin – surrogate marker for Vasopressin
– Studied in Acute Myocardial Infarction
– Small studies have found increased levels in
patients with positive head up tilt test.1
1
Lagi A, Int J Clin Pract 2013
Carotid US and Syncope
• Choosing Wisely Recommendation #2:
– Don’t perform imaging of the carotid arteries for
simple syncope without other neurologic
symptoms.
Langer-Gould AM, Neuro 2013
What does work?
• Thorough history with collateral information
from witness
• Physical examination
• Postural blood pressure
• ECG
• Cost = $435
https://www.healthcarebluebook.com/
Take a good history!
• “5 Ps”
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Precipitants
Prodrome
Palpitations
Position
Post-event phenomena
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Appearance
Abnormal Movements
Eyes open or closed
Mental State
Incontinence/Tongue
Biting
• Chronic medical issues
• Family history of SCD
Parry SW, BMJ 2010
ECG and Telemetry
• ECGs are relatively cheap and informative
• Structural Heart Disease
– Q-waves (infarct)
– ST segment changes (ischemia)
• Conduction System Disease
– Bundle branch block
– Atrioventricular (AV) block
• Electrical Disease
– Wolff-Parkinson-White (WPW) syndrome
– Brugada syndrome
– Long QT syndrome
Marine JE, J Electrocardiol, 2013
Outpatient ECG Monitoring
• Holter Monitor – daily syncopal episodes
• Event Recorder – weekly syncopal episodes
• Implantable Loop Recorder – monthly
syncopal episodes
Postural Blood Pressure
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Have the patient lie supine for 10 minutes
Measure blood pressure and pulse
Have the patient stand
Inquire about symptoms
Repeat blood pressure after 1 and 3 minutes
• Classical Orthostatic Hypotension is defined by:
– Drop in SBP >20 mm Hg or DBP >10 mm Hg within 3
minutes of standing
Carotid Sinus Syncope
• Carotid Sinus Massage
– 10 second sequential (right then left) with patient
supine and erect
• Hypersensitivity defined by:
– Ventricular pause lasting >3 seconds
– Fall in systolic BP >50 mm Hg
• Carotid Sinus Syncope define by hypersensitivity
in the presence of syncope
Post - H&P, ECG, and Postural BP
• You should be able to answer:
– Syncope or not?
– Etiology determined based on the above?
– High risk of cardiovascular events or death?
Echocardiogram and Syncope
• Echo is helpful to confirm or refute suspicion
of cardiac disease after the basics
• Not indicated for syncope without suspicion of
cardiac disease
– Must have 2nd diagnosis
Advanced Cardiac Testing
• Stress testing and Left Heart Catheterization
– If concern for ischemia
• EP study
– If concern for tachyarrhythmia
• Tilt test
– For diagnostic dilemma or if it will affect
treatment
Tilt Table Testing
• An effective technique for providing direct
diagnostic evidence indicating susceptibility to
vasovagal syncope
• Utilizes a drug-free tilt lasting 45 minutes and
pharmacologic provocation (Isoproterenol)
• Monitor heart rate and blood pressure
– Positive test with provocation of neurally-mediated
hypotension or bradycardia (or both)
Benditt DG, JACC, 1996
General Concepts
• Perform a comprehensive history and physical examination
using evidence based tools
• Routinely obtain an ECG
• Utilize EEG, Head CT, or MRI only with clinical suspicion of
focal neurological deficit or seizure
• Consider Holter, event recorder, or implantable loop
recorders if an arrythmia is suspected, depending on
frequency of events
• Utilize cardiac imaging only with clinical suspicion of
structural or valvular heart disease
• Perform invasive EP study only with clinical suspicion of a
tachyarrhythmia
• Obtain a Tilt test only for diagnostic dilemma and if it will
affect treatment and/or outcome
Do’s and Don’ts
• Do every time:
– H&P, ECG, Postural Blood Pressure
• Try to avoid:
– EEG, Cardiac Enzymes, Head CT, Carotid US
• Other testing as indicated based on findings
– Try to avoid the shot gun approach
Bibliography
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Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version 2009): the task
force for the diagnosis and management of syncope of the European Society of Cardiology (ESC). Eur Heart J 2009;30:2631-71.
Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, et al. Incidence and prognosis of syncope. N Eng J Med 2002;347:878-85.
Sun BC, Emond JA, Camargo CA Jr. Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol 2005;95:668-71.
Linzer M, Pontinen M, Gold DT, Divine GW, Felder A, Brooks WB. Impairment of physical and psychosocial function in recurrent syncope. J Clin
Epidemiol 1991;44:1037-43.
Rosanio S, Schwarz ER, Ware DL, Vitarelli A. Syncope in adults: systematic review and proposal of a diagnostic and therapeutic algorithm. Int J Cardiol
2013;162(3):149-57.
Parry SW, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ 2010;340:c880.
https://www.healthcarebluebook.com/
Radack KL. Syncope. Cost-effective patient workup. Postgrad Med 1986;80(8):169-76.
Simpson CS, Krahn AD, Klein GJ, Yee R, Skanes AC, Manda V, Norris C. A cost effective approach to the investigation of syncope: relative merit of
different diagnostic strategies. Can J Cardiol 1999;15(5):579-84.
Strickberger, SA, Benson DW, Biaggioni I, Callans DJ, Cohen MI, Ellenbogen KA, et al. AHA/ACCF scientific statement on the evaluation of syncope:
from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the
Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the
Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 2006;113(2):316-27.
Brignole M, Hamdan MH. New concepts in the assessment of syncope. J Am Coll Cardiol 2012;59(18):1583-91.
Sheldon R, Rose S, Connolly S, Ritchie D, Koshman ML, Frenneaux M. Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur
Heart J 2006;27(3):344-50.
Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term
serious outcomes. Ann Emerg Med 2004;43(2):224-32.
Colvicchi F, Ammirati F, Melina D, Guido V, Imperoli G, Santini M, et al. Development and prospective validation of a risk stratification system for
patients with syncope in the emergency department: the OESIL risk score. Eur Heart J 2003;24:811-9.
Mendu ML, McAvay G, Lampert R, Stoehr J, Tinetti ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med
2009; 164(14):1299-1305.
Nguyen-Michel VH, Adam C, Dinkelacker V, Pichit P, Boudali Y, Baulac M, et al. Characterization of seizure-induced syncopes: EEG, ECG, and clinical
features. Epilepsia 2014;55(1):146-55.
Grossman SA, Fischer C, Bar JL, Lipsitz LA, Mottley L, Sands K, et al. The yield of head CT in syncope: a pilot study. Intern Emerg Med 2007;2(1):46-9.
Lagi A, Cuomo A, Veneziani F, Cencetti S. Copeptin: a blood test marker of syncope. Int J Clin Pract 2013;67(6):512-5.
Langer-Gould AM, Anderson WE, Armstrong MJ, Cohen AB, Eccher MA, et al. The American Academy of Neurology’s top five choosing wisely
recommendations. Neurology 2013;81(11):1004-11.
Marine JE. ECG features that suggest a potentially life-threatening arrhythmia as the cause for syncope. J Electrocardiol 2013;46(6):561-8.