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Mini-Meds 2009
Syncope
Christopher Hillis
Class of 2009
Michael G. DeGroote School of
Medicine
Disclosures
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I am not an MD (just yet)
I was told you like jokes and cases, so
watch out.
Financial contributions have been received
from Ontario Taxpayers… and I am very
grateful.
This powerpoint is not fancy.
VOLUNTEERS NEEDED!
Syncope – A Symptom, Not a
Diagnosis
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Self-limited loss of consciousness and postural tone
Relatively rapid onset
Variable warning symptoms
Spontaneous, complete, and usually prompt recovery without
medical or surgical intervention
Underlying mechanism is
transient global cerebral hypoperfusion.
Brignole M, et al. Europace, 2004;6:467-537.
Classification of Transient Loss of
Consciousness (TLOC)
Syncope
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Neurally-mediated reflex
syndromes
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Orthostatic hypotension
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Cardiac arrhythmias
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Structural cardiovascular disease
Brignole M, et al. Europace, 2004;6:467-537.
Disorders Mimicking
Syncope
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With loss of consciousness, i.e.,
seizure disorders, concussion,
stroke
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Without loss of consciousness, i.e.,
psychogenic “pseudo-syncope”;
Cases
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Syncope or not?
Scary or not?
Guy walks into a bar…
Mechanisms of Syncope
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global cerebral hypoperfusion
interruption of sympathetic outflow
increased vagal tone
other mechanisms -edema, cerebral
autoregulation, central serotonin pathways
CO = SV X HR
BP = CO X PVR
The Common Faint
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the nucleus tractus solitarius of the brainstem is
activated directly or indirectly by the triggering
stimulus, resulting in simultaneous enhancement of
parasympathetic nervous system (vagal) tone and
withdrawal of sympathetic nervous system tone.This
results in a spectrum of hemodynamic responses
 REST
& DIGEST beats up FIGHT or
FLIGHT
Parasympathetic
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cardioinhibitory response:
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drop in heart rate
drop in blood pressure that is significant enough
to result in a loss of consciousness
Sympathetic
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vasodepressor response
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drop in blood pressure without much change in
heart rate
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
A Diagnostic Puzzle
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History
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Syncope?
Cardiac?
Which pattern?
Physical
Diagnostic Tests
Reassess
Repeat
Pepsi Challenge - NEJM 1999
A 72-year-old man with recurrent dizziness, confusion, and syncope
reported that cold, carbonated beverages caused him to feel strange,
dizzy, and confused and might have triggered several episodes over a
one-year study period. A carotid Doppler study, 24- hour Holter monitor,
cranial MRI scan, CT scan, and echocardiogram were unremarkable.
An EEG showed diffuse slowing. Phenytoin was given but provided no
improvement. Another internist evaluated the patient's condition and
ordered a ETT and another MRI scan, which were negative. A
cardiologist was consulted, and the results of a tilt-table test and
coronary angiography were normal. After this evaluation, the patient
drank a carbonated beverage while driving and wrecked his car. The
patient was referred to me for further evaluation, and he gave the same
history. Because the episodes were initiated reproducibly with cold,
carbonated beverages, a can of Pepsi was given to the patient to drink
while he was being monitored with an electrocardiograph. Abrupt
bradycardia and hypotension developed, along with the patient's usual
symptoms. Carotid-sinus massage was negative.
History
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Circumstances of recent event
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Circumstances of more remote events
Concomitant disease, especially cardiac
Pertinent family history
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Eyewitness account of event
Symptoms at onset of event
Sequelae - what happened after?
Medications
Cardiac disease
Sudden death
Metabolic disorders
Past medical history
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Neurological history
Syncope
History
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Prodrome
Associated symptoms
Activity prior to event
Position of patient
Witnesses
Duration; rate of recovery
Trauma?
“He went right funny”
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70% experience a prodrome
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Pallor, diaphoresis
Nausea or vomiting
Faintness, dizziness
Blurring/dimming vision, constriction of visual
fields, paralysis of voluntary lateral gaze, EOM
fixed
Yawning, ringing in ears
Parasthesias
Red Flags
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Chest pain
Dyspnea
Back pain
Palpitations
Focal CNS deficits
‘worst headache ever’
Stable? Proceed with exam:
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Vital signs
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Cardiovascular exam: Is heart disease present?
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Heart rate
Orthostatic blood pressure change
ECG: Long QT, pre-excitation, conduction system disease
Echo: LV function, valve status, HCM
Neurological exam
Carotid sinus massage
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Perform under clinically appropriate conditions preferably
during head-up tilt test
Monitor both ECG and BP
Orthostatic Vitals
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Recumbent for 5 minutes prior
Stand at least 2 minutes
Significant changes include
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Systolic ↓ 20 mm Hg
Diastolic ↓ 10 mm Hg
Heart rate ↑ 30 bpm
High false positive rate in elderly (drop but
asymptomatic)
Other Diagnostic Tests
Blood
Work
Ambulatory ECG
Holter monitoring
 Event recorder
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Intermittent vs. Loop
Head-Up
Tilt (HUT)
Electrophysiology Study (EPS)
Brignole M, et al. Europace, 2004;6:467-537.
Neurological Tests:
Rarely Diagnostic for Syncope
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EEG, Head CT, Head
MRI
May help diagnose
seizure
Brignole M, et al. Europace. 2004;6:467-537.
Head-Up Tilt Test (HUT)
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Protocols vary
Useful as diagnostic
adjunct
in atypical syncope
cases
Useful in teaching
patients
to recognize prodromal
symptoms
Not useful in assessing
treatment
Brignole M, et al. Europace. 2004;6:467-537.
60° - 80°
Treatment
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Scary? REFER!! Urgently or emergently
Educate to avoid triggers / postures
Removing offending agent
Treat cardiac arrhythmia / valve lesion
Cases!
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Syncope?
Pattern:
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Reflex
Orthostatic
Cardiac (arrhythmia)
Cardiac (structural)
Case 1*
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Case 1 (#22): A 23 yo man with GERD and
“blacking out” while swallowing
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden,
MA. 2006.
Cases!
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Syncope?
Pattern:
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Reflex
Orthostatic
Cardiac (arrhythmia)
Cardiac (structural)
Case 1
Giada F, Raviele A. Swallow syncope associated with asystole. In: Syncope Cases. Garcia-Civera R, BaronEsquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 62.
Case 2*
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Case 2 (#42): A 20 yo man with
lightheadedness and LOC shortly
(5-10 sec) after standing.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
Cases!
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Syncope?
Pattern:
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Reflex
Orthostatic
Cardiac (arrhythmia)
Cardiac (structural)
Case 4
van Dijk N, Harms MPM, Wieling W. Initial orthostatic hypotension as a cause of syncope in an adolescent. In:
Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura,
Malden, MA. (2006) p. 118
Orthostatic Hypotension
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Etiology
Drug-induced (very
common)
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Diuretics
Vasodilators
Primary autonomic failure
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Multiple system atrophy
Parkinson’s Disease
Postural Orthostatic
Tachycardia Syndrome
(POTS)
Brignole M, et al. Europace, 2004;6:467-537.
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Secondary
autonomic failure
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Diabetes
Alcohol
Amyloid
Treatment Strategies for
Orthostatic Intolerance
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Patient education, injury avoidance
Hydration
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Sleeping with head of bed elevated
Tilt training, leg crossing, arm pull
Support hose
Drug therapies
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Fluids, salt, diet
Minimize caffeine/alcohol
Fludrocortisone, midodrine, erythropoietin
Tachy-Pacing (probably not useful)
Brignole M, et al. Europace, 2004;6:467-537.
Case 3*
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Case 3 (#86): a 48 yo smoker with discomfort
and dizziness while driving, and falls to
ground after exiting the car (who then drove
to the hospital).
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
Cases!
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Syncope?
Pattern:
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Reflex
Orthostatic
Cardiac (arrhythmia)
Cardiac (structural)
Case 8
Sanchez Gonzalez A, Fournier Andray JA, Ballesteros Pradas SM, Diaz de la Llera LS, Villa Gil-Ortega M.
Syncope as an isolated manifestation of left main coronary artery occlusion. In: Syncope Cases.
Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA.
(2006) p. 247.
Thank-you!
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[email protected]
Questions
Comments/concerns
Offers of paid
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engagements :)