Syncope and The Older Patient

Syncope and The Older Patient Debra L. Bynum, MD Division of Geriatric Medicine

Pretest… • 1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope • 2. History: 75 year old man reports presyncopal symptoms that occur while he is driving backwards out of his driveway in the morning. This suggests … • 3. History: an 80 year old man reports an episode of syncope that occurred after doing arm exercises for a rotator cuff injury. This suggest… • 4. The only independent predictor of a cardiac etiology of syncope is a past history of … • 5. ____ is a neurodegenerative disease characterized by profound autonomic insufficiency and parkinsonian features on exam • 6. An 82 year old man presents with postural hypotension, an idiopathic peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____ • 7. Name 3 causes of “situational syncope” • 8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus massage c. orthostatic hypotension d. all of the above

Pretest: bonus question • Sudden cardiac death in young men (originally described in young asian men) associated with this sign on EKG is known as what syndrome?

Syncope: Definition • Sudden and temporary loss of consciousness with inability to maintain postural tone, followed by spontaneous recovery

Causes of Syncope • Neurally Mediated (up to 58% in some series) • Orthostatic/postural • Cardiac arrhythmia (20-25%) • Structural cardiac or pulmonary causes • Cerebrovascular or psychiatric (1%) • Unknown (18-30%)

Syncope in the Elderly • Usually multifactorial • Often confounded by findings (orthostasis and carotid hypersensitivity common and may be found and yet not be the cause…) • Prevalence up to 25% in nursing home population over age 70 • Higher pretest probability of cardiac disease or arrhythmia

Importance of History and PE • Up to 70% of patients in prospective studies had probable cause identified based upon history, physical exam and ecg

The History… • History of Heart Disease • The ONLY independent predictor of cardiac cause (sens 95%, spec 45%) • Absence of heart disease up to 97% specific to rule out cardiac etiology (good NPV)

The History • Position • Supine: cardiac until proven otherwise • Upon sitting/standing: orthostasis • Prolonged standing: venous pooling/orthostasis/vasovagal • Presyncopal symptoms • Presence suggests vasovagal, but does not rule out arrhythmia • Lack of suggests arrythmia (up to 65% with sudden syncope) • Dyspnea (Pulmonary embolus) • Focal neurologic symptoms (TIA, seizure) • Seizure like activity (including loss of bowel and bladder control, tongue bite, postictal state)

The history… Recovery period • Instant: arrythmia • Feeling hot and nauseated: vasovagal • Confusion/lethargy: postictal • Situational syncope (vasovagal) • Cough • Swallow (cold liquid) • Micturition (urination) • Defecation • Exertional • Ventricular tachyarrhythmia • Aortic stenosis or HOCM • Pulmonary Hypertension

The history… • Prior “faint” 1-4 years prior suggest vasovagal • Age • Medications • Tricyclic antidepressants • Nitrates • Alpha adrenergic antagonists • Diuretics • Injury (facial suggests arrhythmia) • Postprandial (vagally mediated)

Specific Causes and Treatment Options for Syncope • Postural Hypotension • Drop in systolic blood pressure of over 20 • Medications • Autonomic Insufficiency • No reflex tachycardia • Shy-Drager (multiple systems atrophy) • Primary autonomic failure • Parkinson’s Disease • Diabetes • Aging • Amyloid • Volume Loss • Dehydration • Blood loss

Autonomic Insufficiency and Orthostatic Hypotension • Treatment Options • Review of medications • Avoid volume depletion • Arising slowly • Tensing crossed legs while standing • Dorsiflex feet or handgrip prior to standing • Thigh high Jobst stockings (decreases venous pooling) • Avoid prolonged standing (venous pooling) • Increased salt diet • Smaller meals to avoid postprandial drop in BP • Fludrocortisone • Midodrine (alpha 1 adrenergic agonist) • Phenylephrine (not usually used in older patients) • Fluoxetine

Mechanical Cardiac Causes • Obstruction to LV outflow • Aortic Stenosis • HOCM • Left atrial myxoma • Mitral Stenosis • Obstruction to pulmonic flow • Pulmonic stenosis • Pulmonary HTN • PE (can also have vasovagal type syncope associated with smaller PEs) • Right atrial myxoma

Other Mechanical Cardiac Causes • Large MI with LV dysfunction • CHF • Tamponade • Aortic dissection

Cardiac Arrhythmias • Bradycardia • Sick sinus syndrome • 2nd or 3rd degree AV block • Pacemaker malfunction • Tachycardia • Ventricular tachycardia • Ventricular fibrillation • SVT • If you see atrial fibrillation, think sick sinus syndrome as potential cause of syncope…

Brugada Syndrome • Triad • RBBB pattern in right precordial leads • Transient/persistent ST elevation in v1-v3 • Sudden cardiac death • Structurally normal heart • Association with young and healthy men from southeast asia who present with sudden cardiac death • Brugada sign may be asymptomatic • High risk of sudden cardiac death in those who have syncope or family history of sudden death (Indication for AICD based upon observational data)

Brugada Sign

Implantable Cardioverter-Defribrillator Guidelines • AICD indicated for patients with spontaneous Vtach with underlying heart disease or in patients with normal heart when vtach not amenable to other treatments

AICD guidelines • Ischemic Cardiomyopathy • LVEF <30% • At least 1 month after MI and 3 months after revascularization • MADIT-II trial • Multicenter Automatic Defibrillator Implantation Trial • 5.6% ARR in mortality over 4 years • Results support prophylactic AICD, but not considered cost wise • Based upon subset analysis, Current recommendation in those with QRS >120 ms • Unclear result: those with ICDs had 5% absolute increased risk of hospitalization for CHF (19% vs 14%): ?artifact, ?due to living longer?, ?detrimental

AICD guidelines… • Syncope in patients with advanced structural heart disease • High risk of sudden cardiac death • Inducible Vtach with structural heart disease • Inducible Vtach with normal heart that is not amenable to ablation therapy

Subclavian Steal Syndrome • Proximal subclavian artery stenosis • Decreased blood flow to distal subclavian artery worsened with exertion of arm • Blood from vertebral artery on opposite side goes to basilar artery and then down ipsilateral vertebral artery, away from brainstem, to serve as collateral for arm • Usually asymptomatic • Atherosclerosis • Symptoms of vertebrobasilar insufficiency (dizziness, vertigo, diplopia, nystagmus) • Rare to have permanent neurological deficits • Diagnosis with dopplers, MRA • Treatment: surgical revascularization, stents

Cerebrovascular Disease • Less common cause of true syncope • Vertebrobasilar disease (presyncope) • Drop Attacks

Vasovagal/Neurocardiogenic syncope • Situational Syncope • Micturition • Defecation • Cough • Swallow • Recurrent Neurocardiogenic Syncope • Posprandial • The FAINT

Vasovagal Syncope • Presyncopal symptoms • Setting (procedure, pain, anxiety) • Prior history

Neurally Mediated Syncope • Cardiac sensory receptors in LV stimulated by stretch • Increased neural discharge to vasomotor center in medulla • Increased parasympathetic tone and decreased sympathetic activity • Sudden bradycardia and hypotension

Recurrent Neurocardiogenic Syncope • Upright posture lead to pooling of blood in lower extremities • Decreased venous return • Normal response: reflex tachycardia and forceful LV contraction and vasoconstriction • Susceptible individuals: activation of mechanoreceptors triggers reflex bradycardia and hypotension • Response triggered by forceful LV contraction with prolonged standing or with increased catecholamines (anxiety, fear, panic, pain)

Treatment of Recurrent Neurocardiogenic Syncope • Medications • Paroxetine • Only agent shown effective in RCT • Midodrine • Alpha adrenergic agonist • Small studies • Fludrocortisone • No good study • Beta blockers • Often used, mixed evidence in studies

Pacemakers in the treatment of Recurrent Neurocardiogenic Syncope • 3 large RCTs of permanent pacing • North American Vasovagal Pacemaker Study (VPS-1) • Patients with over 6 episodes, positive tilt table test with significant bradycardia • Significant decrease in recurrence with pacer (HR .087) • Vasovagal Syncope International Study • 5% recurrence with pacemaker vs 61% without (19 patients) • Syncope Diagnosis and Treatment Study • Pacemaker vs atenolol • 93 patients: 4.3% recurrence vs 26%

Pacemakers and neurocardiogenic syncope: • Problems with trials… • Small numbers of patients • Not blinded • Highly selected patients • Patients had profound bradycardia on tilt table testing and multiple episodes

Pacers and neurocardiogenic syncope… • Bottom line: • May benefit patients with recurrent episodes of clear neurally mediated syncope, associated with significant bradycardic response, who have a decreased QOL otherwise (injuries, driving, etc)

Carotid Sinus Hypersensitivity • ?Role of Carotid Sinus Massage • Some recommend if no bruits, recent MI, cva or history of vtach • ?monitor • Positive response: 3 sec pause • In literature, but most cardiologists would not recommend • High yield of carotid massage in elderly (up to 40% over the age of 75 may have a positive response), but not specific in identifying this as the cause of syncope (PPV not known) • History: syncope/presyncope with turning neck, backing up in car, wearing tight collar

Evaluation of Syncope • When a cause of syncope is identified, history and physical lead to etiology in up to 85% cases • The only independent predictor of a cardiac cause of syncope is the presence of underlying heart disease (95% sens, only 45% spec)

Orthostasis • May be confounder in older patients • Up to 25% of older patients may have orthostasis when tested, the presence of orthostasis may be true, true and unrelated…

The ECG • Prolonged QT • Bradycardia, AVN disease, MI, HOCM, Brugada • Only 2-10% will have diagnostic abnormality • Up to 50% of patients with syncope have abnormal EKG • Greatest use in NPV (negative predictive value) of NORMAL ECG

The Holter Monitor • 24-48 hours continuous ECG • No added yield with 72 hours • Low yield unless frequent symptoms • Up to 70% of Holter studies negative for diagnosis • One series: only 5% of studies had arrhythmia that correlated with symptoms • Probably good NPV if symptoms documented with benign rhythm

Event or Loop Monitors • Higher yield than holter (up to 55% positive yield of symptom-arrhythmia correlation in some series) • Problem with patient education and ability to activate monitor correctly (25% of patients have difficulty) • May be especially problematic in the very elderly or those with dementia

Implantable Loop Recorder • Prolonged monitoring for those with syncope of unclear etiology despite workup, especially for those in whom cardiac etiology is suspected • Several small studies suggest that in very selected patients, may increase yield of diagnosis to almost 85%

Other Cardiac Tests • Echo • Exercise or Functional Tests • EP studies • Most useful when history or physical suggests specific further testing to be done…

Tilt Table Testing… • Passive or Isoproterenol • Test: patient held in upright position at 40-90 degrees and observed for symptoms and hypotension or bradycardia • Passive testing: sensitivity of 70%, specificity of 90-100% • Isoproterenol: only 55% specificity • Overall little to add to history and PE; lack of sensitivity with passive testing and lack of specificity with induced testing limits usefulness of test…

Lab tests… • The basics (anemia) • ?BNP: some studies report usefulness as a marker for cardiac cause of syncope: sensitivity of 82% and specificity of 92%, Likelihood ratios of pos and neg tests probably not more useful than pretest probability of underlying heart disease based upon history and physical exam • CK, MB and Troponins • More useful if positive (greater PPV) than neg • One series: up to 10% nursing home patients presenting with syncope had positive enzymes…

The Least Useful Tests… • CT head with negative neurological exam • EEG with no neurological symptoms • Carotid Artery Dopplers (useful for evaluation of CVA or TIA, not useful for evaluation of syncope without vertebrobasilar symptoms…)

The Older Patient • Positive tests that are more common in the elderly and not necessarily the cause of the syncope: • Orthostasis • Positive carotid massage • Positive tilt table testing • Up to 54% of older patients with syncope may have positive test… • Positive test in 10% of asymptomatic elderly!

Algorithm for diagnosing syncope Linzer, M. et. al. Ann Intern Med 1997;127:76-86

Summary of Charges for Diagnostic Tests in Syncope* Linzer, M. et. al. Ann Intern Med 1997;127:76-86

Summary • Syncope in the older patient usually multifactorial • Tailor tests based upon history and physical exam • Elderly more likely to have positive tests that may be confounders… • Elderly more likely to have underlying heart disease and higher pretest probability of a cardiac etiology • Use algorithms in older, complicated patients with great caution!!!

Back to the Pretest… • 1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope • 2. History: 75 year old man reports presyncopal symptoms that occur while he is driving backwards out of his driveway in the morning. This suggests … • 3. History: an 80 year old man reports an episode of syncope that occurred after doing arm exercises for a rotator cuff injury. This suggest… • 4. The only independent predictor of a cardiac etiology of syncope is a past history of … • 5. ____ is a neurodegenerative disease characterized by profound autonomic insufficiency and parkinsonian features on exam • 6. An 82 year old man presents with postural hypotension, an idiopathic peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____ • 7. Name 3 causes of “situational syncope” • 8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus massage c. orthostatic hypotension d. all of the above

Answers to Pretest… • 1. NPV • 2. Carotid Hypersensitivity • 3. Subclavian steal syndrome • 4. Cardiac history • 5. Multiple Systems Atrophy (shy-drager) • 6. amyloid • 7. micturition, defecation, cough, swallow • 8. all of the above • 9. bonus: brugada syndrome

Selected References • Benditt DG, VanDjjk JG, Sutton R. Syncope: Curr Prob Cardiol 2004; 29(4): 152-229 • Epstein AE. An update on implantable cardioverter-defibrillator guidelines. Curr Opin Cardiology 2004; 19(1): 23-25 • Littman L et al. Brugada syndrome and Brugada sign. Am Heart J 2003; 145(5): 768-778 • Raj S, Sheldon RS. Role of pacemaker in treating neurocardiogenic syncope. Curr Opinion Cardiol 2003; 18: 47-52 • Gregoratos G, Cheitlin MD, Conill A. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrthythmia devices: executive summary: a report of the American College of Cardiology/Am Heart Assoc Task Force on Practice Guidelines. Circulation. 1998; 97: 1325-1335 • Connolly SJ et al. The North American Vasovagal Pacemaker Study. J Am Coll Cardiol 1999; 33: 16-20 • DiGirolamo et al. Effects of paroxetine on refractory vasovagal syncope. J Am Coll Cardiol 1999; 33: 1227-30 • Sutton R et al. Dual chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope (VASIS). Circulation 2000; 102: 294-299

Selected References… • Krahn Ad et al. Use of the implantable loop recorder in evaluation of patients with unexplained syncope • Kapoor WN. Current evaluation and management of syncope. Circulation 2002; 106: 1606 • Alboni P et al. Diagnostic Value of history in patients with syncope. J Am Coll Cardiol 2001; 37: 1921 • Kapoor et al. Evaluation and outcome of patients with syncope. Medicine 1990; 69: 160 • Linzer et al. Diagnosing syncope: part I. Ann Int med 1997; 126:989 • Linzer et al. Diagnosing syncope: part II. Ann Int Med 1997; 127: 76

Syncope and The Older Patient