Download Syncope

Syncope
Priya Victor M.D
Introduction
► Syncope
is defined as transient loss of
consciousness and postural tone
► Accounts for 3% of all ER visits and 6% of
all hospital admissions
► Could be the manifestation of benign
neurocardiogenic or the first manifestation
of an occult lifethreatening condition
Objective
► To
determine the utility of various diagnostic
tests in the evaluation syncope
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CT scans
Echo
EKG
Holter monitor
EEG
Tilt table test
Methods
► Retrospective
study
► 100 patients from the RCRMC ER admissions
with a diagnosis of syncope were identified
► Chart review was performed with attention
to the cause of syncope, investigations and
results of further testing.
Results of CT scans
1%
39%
60%
Negative CT scan
Old changes
Acute changes
Echo cardiogram
11%
1%
88%
Negative Echo
Insignificant changes
Significant changes(AS)
EKG
15%
1%
84%
Normal
Significant changes
Insignificant
Other tests
► 24
hr holter monitor two were done, both
normal.
► One adenosine cardiolyte – normal.
► One ETT – normal.
► Two tilt table test , both were positive for
hypotension.
► One dobutamine stress test – normal.
Causes of syncope
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vasovagal
Orthostatic hypotension
Hypoglycemia
Secondary to medications
Sick sinus syndrome
Symptomatic bradycardia
PSVT
BPV
Iron defi anemia
Seizures
Afib with RVR
Neck mass
Unknown etiology
23
9
6
3
2
2
2
1
1
1
1
1
48
Discussion
► Of
patients visiting ER with syncope: (Alboni et al
JACC 2001;37:1921)
Cardiac (often arrhythmia) 23%
Neurally mediated 58%
Neuro-psychiatric 1%
Unexplained 18%
► Of patients with cardiac syncope, 24%
subsequently develop Sudden Death (Kapoor,
Medicine (Baltimore) 1990;69:160)
Approach
► Accurate
diagnosis of etiology is possible from
history, examination, basic lab & ECG in 2/3 of
patients.
► 􀂃 Of those who require detailed work-up:
Clinically targeted: Dx. Reached by work-up in
73%
Not targeted: Dx. Reached by work-up in 25%
(Sarasin et al Am J Med 2001;111:177)
► 􀂃 Work-up depends on duration of
symptoms,frequency of attacks, known preexisting disease, and age of the patient.
Neurologic testing
►􀂃
EEG (Hyperventilation, Sleep-deprived,
Nasopharyngeal)
► 􀂃 Brain CT / MRI
► 􀂃 Carotid Duplex
Some test is done in over half pts with syncope
Rarely useful, except in very well-selected cases
Pires et al. Arch Int Med
2001;161:1889
CONCLUSION
► Of
all the tests performed, EKG was of
greatest yield.
► The most common etiology was vasovagal.
► Even though vasovagal syncope was a
common diagnosis , the tilt table test was
only ordered for a minority of patients.
CONCLUSION
► Of
currently available diagnostic tests, the
initial clinical history provides the greatest
yield.
► A broad range of specialized tests can be
performed for patients with syncope whose
initial history and physical examination do
not provide a diagnosis.