Download here - Boston University Medical Campus

Diagnosis and Management of
Syncope
Robert Helm, M.D.
Assistant Professor of Medicine
Boston University School of Medicine
August 2013
Case 1
53 year-old obese gentleman with diabetes, hypertension and
hyperlipidemia who presented with syncope. This occurred
after working at the boat yard on a very hot day. He was taking
a break and drinking a cold slurpee, when he suddenly felt pins
and needles in his neck, peri-oral numbness, and tingling of his
forehead. As he was calling for wife, he lost consciousness and
fell to the ground. According to his wife, he was unconscious
for about a minute and his entire body was quivering. Upon
regaining consciousness, he was confused and disoriented.
His wife reports that he was cold, clammy, and very
diaphoretic. He sustained some minor bruising of left shoulder
but no head injuries.
Case 1
No prior syncope but two weeks ago he did a “pirouette”
due to sudden brief episode of lightheadedness and loss of
balance. He did not lose consciousness. He consulted
with his internist, who found relative low blood pressure
(100/54 mmHg) and reduced his Lisinopril by half (40 to 20
mg daily). His blood sugars have been well controlled.
Case 1
Past Medical History
Diabetes (HgBA1C 5.8)
Hypertension
Hyperlipidemia
? myocardial infarction
Obstructive sleep apnea
Allergies
None
Medications
Cardizem cd 120 mg daily
Lisinopril 20 mg daily
Lantus 40 units at night
Social History
Novalog 12 units with meals
Non-smoker
Aspirin 81 mg daily
No alcohol or drugs
Lasix 80 mg daily
Simvastatin 80 mg at night
Family History
Fenofibrate 134 mg daily
Mother had MI at 60
Percocet 5/325 mg as needed for pain
Brother died suddenly at 48
Viagra 100 mg – last used 2 days prior
Nitroglycerin 0.4 mg SL – never used
Review of system
Negative. Good functional
capacity.
Case 1
Physical examination
BP 124/62 mmHg. Not orthostatic. Normal carotid
palpation and auscultation. Normal cardiovascular exam.
Bruised right hip.
Laboratory
BUN 27 ng/dl Creatinine 1.47 ng/dl. Electrolytes and blood
count normal.
Echocardiogram – normal 1 month ago.
Case 1
Case 1
Admitted for 24 hour observation and hydration.
Diagnosis: “Vaso-vagal syncope”
Poll
The correct statement is:
A. The patient has been correctly diagnosed.
B. The patient should be referred for urgent pacemaker.
C. The patient should be referred for electrophysiologic
study.
D. The patient should be referred for 30 day event
recorder.
E. The patient should be referred for tilt-table study.
Case 2
61 year old gentleman with history of cocaine use who
presented with syncope. “He was in kitchen making
Thanksgiving dinner and developed lightheadedness. He
sat on a step stool and the next thing he remember is being
on the floor and his son calling his name. He felt like he
couldn’t move. The kitchen was really hot and and he had
missed lunch. He reports using cocaine “months ago”.
Case 2
Past Medical History
none
Allergies
None
Social History
history of cocaine
Medications
None
Family History
no premature CAD or SCD
Review of system
Negative.
Case 2
Physical examination
BP 145/91 mmHg. Not orthostatic. Normal carotid
palpation and auscultation. Normal cardiovascular exam.
Minor bruise on elbow.
Laboratory
BUN 26 ng/dl Creatinine 1.1 ng/dl. Electrolytes and blood
count normal.
Case 2
Poll
The correct next step is:
a.
b.
c.
d.
Check toxicology screen. If positive then
attribute syncope to cocaine use.
Continuous-loop event monitoring.
Increase fluid intake and reassure patient.
Electrophysiology study to assess for inducible
e.
f.
g.
h.
i.
j.
Tilt-table study.
Implant loop recorder (ILR).
Echocardiogram.
B and then D if event monitoring is negative.
B and then F if event monitoring is negative.
G and if ejection fraction is < 35% then D
VT
Why is syncope a difficult problem?
• Physiologic response to a wide variety of medical conditions
• By definition it is a transient condition
• Occurs with unpredictable and random pattern
• Difficult to establish definitive “diagnosis”
• “Another patient with syncope….”
• History from patient may not be reliable.
Amnesia for Loss of Consciousness in
Carotid Sinus Syndrome
Falls
(n=34)
Syncope
(n=34)
P value
5.1
5.4
0.42
Right Positive CSM
24 (71%)
29 (85%)
0.92
CSM positive upright
20 (59%)
9 (26%)
0.24
LOC during CSM
22 (64%)
15 (44%)
0.144
Amnesia for LOC
21 (95%)
4 (27%)
<0.001
Mean max asystole (s)
Perry S, et al: J Am Coll Cardiol 2005;45:1840
Causes of Syncope
Neurally mediated reflex syncopal syndromes
Vasovagal (common) faint
Carotid sinus syndrome
Situational faint
Acute hemorrhage
Cough, sneeze
Gastrointestinal stimulation (swallow, defecation,
visceral pain)
Micturition (postmicturition)
Postexercise
Other (e.g. brass instrument playing, weightlifting,
postprandial)
Glossopharyngeal and trigeminal neuralgia
Orthostatic
Primary autonomic failure syndromes (e.g. pure
autonomic failure, multiple system atrophy,
Parkinson’s disease with autonomic failure)
Secondary autonomic failure syndromes (e.g.
diabetic neuropathy, amyloid neuropathy)
Volume depletion
Hemorrhage, diarrhea, Addison’s disease
Cardiac arrhythmias as primary cause
Sinus node dysfunction (including
bradycardia/tachycardia syndrome)
AV conduction system disease
Paroxysmal supraventricular and ventricular
tachycardias
Inherited syndromes (e.g. long QT syndrome,
Brugada syndrome, short QT, arrhythmogenic
dysplasia)
Implanted device (pacemaker, ICD) malfunction
Drug-induced proarrhythmias
Structural cardiac or cardiopulmonary disease
Cardiac valvular disease
Acute myocardial infarction/ischemia
Obstructive cardiomyopathy
Atrial myxoma
Acute aortic dissection
Pericardial disease/tamponade
Pulmonary embolus/pulmonary hypertension
Cerebrovascular
Vascular steal syndromes
Classification of Syncope
Common and benign
Orthostatic
Neurocardiogenic
Common and not so benign
Sinus node dysfunction, carotid sinus hypersensitivity
Paroxysmal AV block
Less common, lethal
Ventricular tachycardia, ventricular fibrillation
Torsade de pointes
Everything else
Emergency Visits with Syncope
European Society of Cardiology Guidelines
465 patients
Number
Percent
Neurally mediated
309
66
Orthostatic
Hypotension
46
10
Cardiac Arrhythmias
53
11
Cardiovascular
21
5
Unknown
11
2
Non-syncopal attack
25
5
Cause
Brignole M, et al. European Heart Journal 2006;27:76-82
Neurally - mediated
Reflex syncope
Vasovagal
Carotid sinus hypersensitivity
Situational
Post-exercise
Glossopharyngeal and trigeminal
neuralgia
Orthostatic syncope
Primary autonomic failure
Secondary autonomic failure
Volume depletion
Drugs and alcohol
Reflex Mechanism - Bezold Jarisch
Trigger
Venous return
BP
Vagal
efferent
Small ventricle
HR
Reflex
Sympathetic
tone
Wall stretch
Inotropy
Contractility
Arterial
tone
Syncope
C-fibers
Vagal
afferent
Vasodilation
BP
Sympathetic
withdrawal
BP
Chang-Sing P. Cardiol Clinics. 1991;9(4):641-651
When is History and Physical Sufficient
• Young patient with single presentation or clear
situational dependency
• Normal physical examination
• Normal ECG
• No significant injury
• Low risk occupation
What about the rest of the patients?
History & physical exam including CSM
ECG
Tilt table test
Echocardiogram
Electrophysiology study
Holter monitor / Event recorder / Implantable Loop
Recorder (ILR)
Neurological evaluation
Psychiatric evaluation
Role of history in differentiating NMS from
cardiac syncope
341 patients
Warm Place
Abdominal Discomfort
Weakness
Feeling warm
Awareness about to
faint
Yawning
Syncope while
standing
Nausea
Feeling tired
Standing in one place
Vomiting
Feeling cold
Lightheadedness
Prodrome
History > 4 yrs
Alboni P, et al: J Am Coll Cardiol 2001;37:1921-28
Role of history in differentiating NMS from
cardiac syncope
341 patients
Abdominal Discomfort
Standing in one place
Feeling cold
History > 4 yrs
Alboni P, et al: J Am Coll Cardiol 2001;37:1921-28
Role of history in differentiating NMS from
cardiac syncope
191 patients with cardiac disease
Warm Place
Abdominal Discomfort
Weakness
Feeling warm
Awareness about to
faint
Yawning
Syncope while
standing
Nausea
Feeling tired
Standing in one place
Vomiting
Feeling cold
Lightheadedness
Prodrome
History > 4 yrs
Alboni P, et al: J Am Coll Cardiol 2001;37:1921-28
Role of history in differentiating NMS from
cardiac syncope
191 patients with cardiac disease
History > 4 yrs
Alboni P, et al: J Am Coll Cardiol 2001;37:1921-28
Case 2
53 year-old obese gentleman with diabetes, hypertension and
hyperlipidemia who presented with syncope. This occurred
after working at the boat yard on a very hot day. He was taking
a break and drinking a cold slurpee, when he suddenly felt pins
and needles in his neck, peri-oral numbness, and tingling of his
forehead. As he was calling for wife, he lost consciousness and
fell to the ground. According to his wife, he was unconscious
for about a minute and his entire body was quivering. Upon
regaining consciousness, he was confused and disoriented.
His wife reports that he was cold, clammy, and very
diaphoretic. He sustained some minor bruising of left shoulder
but no head injuries.
Case 2
ECG – Abnormal conduction
Prolonged PR / heart blocks
Functional
Short PR
Structural
Bundle
Vagal
tonebranch blocks
AV nodal or His Purkinje fibrosis
AV node
Medications
Long QT
His
Short QT
Mitral annular calcification
Infiltrative
Genetic
AH
HV
Intra-cardiac recording
PR interval
What about the rest of the patients?
History & physical exam including CSM
ECG
Tilt table test
Echocardiogram
Electrophysiology study
Holter monitor / Event recorder / Implantable Loop
Recorder (ILR)
Neurological evaluation
Psychiatric evaluation
Tilt table test
Tilt Table Response consistent with NMS
Pretest
1 min
12.5 min
Recovery
ECG
Syncope
Blood
Pressure
(mmHg)
Tilt
HR (BPM)
BP (mmHg)
0
77
115/70
70
94
125/80
70
40
55/30
0
46
98/55
Sra JS. Ann Intern Med. 1991;114:1013-1019.
Echocardiogram
• Strongly consider for all patients
• Screen for hypertrophic cardiomyopathy
• Stratification for EP study
Ejection fraction < 30% - meet criteria for ICD
35-50% - test for inducibility of VT
Electrophysiology Study
• Risk stratification of ventricular arrhythmias – assess
for inducibility
• It is poor at diagnosing bradycardic arrhythmias
• It is highly sensitive for tachycardias.
Holter Monitor
Yield: Arrhythmia with symptoms = 2%
Symtoms without arrhythmia = 15%
Gibson TC et al Am J Cardiol 1984;53:1013-17
Comparison of Loop Recorders versus
Holter Monitor (COLAPS)
Sivakumaran S, et al. Am J Med 2003;115:1-5
Event recorder in patient with syncope
Implantable Loop Recorders (ILR)
ILR
Automatically detects
bradycardia
Records rhythm at
tachycardia
time of trigger
asystole
Patient
Assist Device
ILRs
Example tracing from ILR
ILR in unexplained syncope
with normal conventional work-up
Tachycardia
Asystole /
bradycardia
11%
No arrhythmia
56%
33%
Diagnostic yield: 35%
(175/506 patients)
Brignole et al. Europace 2009;11,671-687
Suspect Pacemaker malfuction
1. EKG
2. Interrogate pacemaker – check lead integrity with
provocative maneuvers
3. Chest X-ray
Importance of Interrogating PPM or ICD
Atrial lead
Ventricular lead
2
Right ventricular lead
Atrial lead
Syncope – red flags
A.
B.
C.
D.
E.
Syncope resulting in injury
Syncope during exercise
Syncope in the supine position
Suspected or known structural heart disease
ECG abnormality
Pre-excitation (WPW)
Long QT
Bundle-branch block
HR<50 bpm or pauses > 3 seconds
Mobitz I or more advanced heart block
Documented tachyarrhythmia
Myocardial infarction
F. Family history of sudden death
G. Frequent episodes (>2 per year)
H. Implanted pacemaker or defibrillator
I. High risk occupation (bus driver, pilot etc.)
Case 1 - review
Discharged after 24 observation with diagnosis of “Vaso-vagal syncope”
2 days later…
Witnessed collapse while seated.
Episode of syncope with complete heart block noted on telemetry.
Dual chamber pacemaker implanted.
Discharged home the next day.
Case 1
Suspected or known structural heart disease - prior MI
Abnormal EKG – trifasicular block
Family history of sudden death – brother died at 45
Frequent episodes – “pirouette” 2 weeks prior
Case 2 - review
Discharged after 24 observation with diagnosis of “Vaso-vagal syncope”
3 month later..
Cardiac arrest at home and successfully defibrillated but prolonged down
time.
Had slow neurologic recovery.
ICD implanted for secondary prevention.
Case 2
Test questions
Which of the following historical findings are useful for
predicting neurally-mediated syncope in patients with heart
disease and recurrent syncope?
a.
b.
c.
d.
e.
Feeling warm.
Awareness of being about to faint.
Recovery duration lasting longer than 60 minutes.
Confusion during recovery.
Time (years) between first and last syncopal
episodes.
Which of the following historical findings are useful for
predicting neurally-mediated syncope in patients with heart
disease and recurrent syncope?
a.
b.
c.
d.
e.
Feeling warm.
Awareness of being about to faint.
Recovery duration lasting longer than 60 minutes.
Confusion during recovery.
Time (years) between first and last syncopal
episodes.
An 80 year-old frail woman presents to you after falling while
ambulating to the bathroom at night. This is the second time
she has fallen in the last month. Echocardiogram shows
diastolic dysfunction and moderate mitral annular
calcification. ECG is essentially normal with exception of
first degree AV block. After her first fall one month ago, she
was told by her physician that she needs to use a cane and
to rise slowly out of bed. Her daughter is very concerned
and wants a second opinion. You recommend which of the
following:
a. Discontinuing evening dose of Lasix.
b. Tilt-table study to diagnosis the etiology of
falls and reassure her daughter.
c. Electrophysiologic test to assess for
bradyarrhythmias.
d. Continuous-loop event monitoring.
An 80 year-old frail woman presents to you after falling while
ambulating to the bathroom at night. This is the second time
she has fallen in the last month. Echocardiogram shows
diastolic dysfunction and moderate mitral annular
calcification. ECG is essentially normal with exception of
first degree AV block. After her first fall one month ago, she
was told by her physician that she needs to use a cane and
to rise slowly out of bed. Her daughter is very concerned
and wants a second opinion. You recommend which of the
following:
a. Discontinuing evening dose of Lasix.
b. Tilt-table study to diagnosis the etiology of
falls and reassure her daughter.
c. Electrophysiologic test to assess for
bradyarrhythmias.
d. Continuous-loop event monitoring.
A 16 year-old girl presents to you after a syncopal event
while playing field hockey on an unusually hot day. She
was running when she developed profound lightheadedness
just prior to losing consciousness. Upon regaining
consciousness, she was diaphoretic and confused to
surroundings. She felt nauseated for the rest of the day.
She has no cardiac history and her exam is unremarkable
except for mild orthostasis. Her EKG is normal. You
recommend which of the following:
a. Genetic testing for long QT channelopathy.
b. Continuous-loop event monitoring.
c. Increasing fluid intake and reassure parents.
d. Refer to electrophysiology.
e. Tilt-table study.
A 16 year-old girl presents to you after a syncopal event
while playing field hockey on an unusually hot day. She
was running when she developed profound lightheadedness
just prior to losing consciousness. Upon regaining
consciousness, she was diaphoretic and confused to
surroundings. She felt nauseated for the rest of the day.
She has no cardiac history and her exam is unremarkable
except for mild orthostasis. Her EKG is normal. You
recommend which of the following:
a. Genetic testing for long QT channelopathy.
b. Continuous-loop event monitoring.
c. Increasing fluid intake and reassure parents.
d. Refer to electrophysiology.
e. Tilt-table study.