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Syncope. David Robertson February 9, 2007. Objectives. Recognize and treat: Severe orthostatic hypotension (AF) Postural tachycardia syndrome (POTS) Neurally mediated syncope (NMS). Cardiovascular Continuum. AF. POTS. NMS. Normotension. Labile HBP. HBP. Bradycardia/hypotension
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Syncope David Robertson February 9, 2007
Objectives • Recognize and treat: • Severe orthostatic hypotension (AF) • Postural tachycardia syndrome (POTS) • Neurally mediated syncope (NMS)
Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans Orthostatic tachycardia ~500,000 Americans Orthostatic hypotension ~100,000 Americans
Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans asymptomatic Orthostatic tachycardia symptomatic ~500,000 Americans Orthostatic hypotension ~100,000 Americans
Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans Orthostatic tachycardia ~500,000 Americans Orthostatic hypotension Severe Dysautonomias ~100,000 Americans
Severe Dysautonomia: Therapy • FIRST LINE: • Water (+40 mmHg!) • Food (-30mmHg!) • SECOND LINE: • Physical Maneuvers • Exercise (in water) • THIRD LINE: • Fludrocortisone + Salt • Pressor Drugs (midodrine)
Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans Mild Dysautonomias Orthostatic tachycardia ~500,000 Americans Orthostatic hypotension ~100,000 Americans
Postural Tachycardia SyndromePOTS • Upright symptoms without hypotension • Upright tachycardia (>30 bpm rise) • 500,000 Americans: usually young women • Antecedent infection; surgery; pregnancy • Many causes • Tx: low dose (10 mg tid) propranolol
Neuropathic POTS Hyperadrenergic POTS Normal 200 HR (bpm) 50 200 BP(mmHg) 0 60 Tilt Angle 0
Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans Mild Dysautonomias Orthostatic tachycardia ~500,000 Americans Orthostatic hypotension ~100,000 Americans
Neurally Mediated SyncopeNMS Transient loss of consciousness with loss of postural tone followed by recovery
Syncope Emotional Dysautonomia Viral Swallowing Standing Arrhythmia
Hypotension and Sinus Arrest During Venipuncture 100 BP (mm Hg) 80 60 40 20 ECG 5 10 15 20 25 30 35 40 45 50 0 Time (sec)
Tilt-Induced Bradycardia EKG BP HR Tilt
Syncope: The Problem • Loss of consciousness is common • Long differential diagnosis • Most benign; some fatal • Treatment requires diagnosis
Syncope and its Risk OTHER CAUSES CV DISEASES A cardiac etiology conveys risk Wishwa Kapoor et al.NEJM1983; 309: 197
Why Do We Faint ? Blood/Injury/Fear Pain, blood, medical procedures, fright After minutes or hours of upright posture Generally standing or quiet sitting Worse in heat or warm stuffy rooms Probably related to tilt test syncope Within 30 seconds of arising from sitting or lying Probably increased conductance in muscle bed Can occur with starting to walk after quiet standing At or immediately after peak heavy exercise
Syncope: Common Symptoms Frequent symptoms or signs Nausea Diaphoresis Pallor Fatigue Myoclonic twitches Frequent presyncopal spells Improvement on lying down
Syncope Rate in Young Adults 12-48 % (usually no medical attention)
Syncope • 3-5% of all ER visits (35% admitted) • Syncope 1o diagnosis: 1-6% of admits • 1,000,000 new patients evaluated yearly • Prevalence: 0.7% in young; 6.0% in old • Tends to be young women and old men
Syncope Impact • Recurrent syncope ~ Rheumatoid arthritis • Maybe home schooling • Maybe lose your job • Maybe injury: Falls 4th cause of death • Pacemaker may make you uninsurable
Neurally Mediated Syncope • Recurrent (>3) syncope • No cardiac lesion • Especially in young • Rarely life-threatening • Most gradually improve
Case 1 • 21 year old woman • Syncope during choir practice
No W/U Required • If syncope has an obvious cause • If there is no cause for concern • But if in clinic: H&P plus ECG
The History • Complete Description • Other illnesses (virus?) • Type of Onset • Duration of Attacks • Posture • Associated Symptoms • Sequelae • Prolonged fatigue is almost universal
Case 2 • 21 year old woman • Syncope during basketball competition
Evaluation of Syncope I • Is there structural heart disease ? • Hx • PE • ECG • Echo • Monitoring (loop recorder)
Case 3 • 21 year old woman • Syncope during class • Father died suddenly at 34
Evaluation Of Syncope II • Tilt-Table Test • EP (Electrophysiological) Study • But……only BP, HR during spontaneous syncope is definitive.
Tilt Table Test • Widely used but rarely helpful to patients • Demonstrates what fainting feels like • 20% of normal subjects test positive • Positive test doesn’t mean the patient has NMS • Negative test doesn’t mean patient does not have NMS
Positive Tilt Test • Hemodynamics • Hypotension • Bradycardia • Reproduction of Symptoms • Syncope • Pre-syncope
Normal Subjects Syncope Patients 13 %* 24-75 % Tilt-Table Test: Positivity *but ~30% of normals positive at Vanderbilt MEV PetersenHeart2000; 84: 509
Therapy of Syncope • No drug or device proven helpful • Rate-drop pacemaker • Drugs sometimes employed: • Propranolol • Fludrocortisone • SSRIs • Midodrine • Water?
16 oz Water: Effect on Tilt Tolerance 45 30 Orthostatic Tolerance (min) 15 0 Water No Water