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Syncope Low Back Pain of Cardiology!!

Syncope Low Back Pain of Cardiology!!. Win K. Shen, MD Professor of Medicine Mayo Clinic College of Medicine Chair, Cardiovascular Diseases Mayo Clinic Arizona ACC Florida, 2014. DISCLOSURE. Relevant Financial Relationship(s) None Off Label Usage None. Low Back Pain???.

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Syncope Low Back Pain of Cardiology!!

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  1. SyncopeLow Back Pain of Cardiology!! Win K. Shen, MD Professor of Medicine Mayo Clinic College of Medicine Chair, Cardiovascular Diseases Mayo Clinic Arizona ACC Florida, 2014

  2. DISCLOSURE Relevant Financial Relationship(s) None Off Label Usage None

  3. Low Back Pain???

  4. Low Back Pain So Many Causes, So Many Treatments!!

  5. Syncope EvaluationChallenges • Almost always asymptomatic • Potential causes range from benign etiologies to life-threatening conditions • Episodic nature renders establishing a cause and effective relationship difficult • Concerns that “well-appearing" patients may be at risk of significant arrhythmia and sudden death often result in extensive broad-based evaluations and frequent hospital admissions • Challenges in the elderly patients CP1167250-18

  6. Syncope Treatments • Bradycardia: PM therapy • SVT: ablation, drug, device • VT: ICD, drug, ablation • Reflex syncope • Vasovagal syncope • Orthostatic intolerance: POTS, IAST • Carotid sinus hypersensitivity • Unexplained syncope • Recurrent syncope in the elderly • Syncope mimics conditions

  7. Syncope: ObjectivesLow Back Pain of Cardiology • Vasovagal syncope, POTS & IAST • Do we understand mechanisms? • Therapeutic conundrum • Practical approaches • Recurrent syncope and falls in the elderly • Diagnostic challenges • Potential causes of syncope • Therapeutic delima • Clinical pearls • The low back pain is not too bad!!

  8. 24 year-old female with recurrent syncopeA 10-Second Pause During Tilt Table Testing

  9. Case Study: 24 Year-Old Female What would you recommend? Continue observation, apply physical counter maneuvers, avoidance of trigger Start midodrine 10 mg TID EP consult to consider pacemaker Florinef 0.1 mg BID Tilt table training Metoprolol 25 mg BID

  10. Vasovagal Syncope and Drug Targets Fludrocortisone Midodrine Salt/fluids Stockings Midodrine Theophylline Sympatheticefferent Selective serotoninre-uptake inhibitors Vagal efferent Anti-cholinergics -blockers Disopyramide Chen, Expert Opin Pharmacother 7:1154, 2006 CP1237800-5

  11. Vasovagal Physiology: Mixed Response BP 47/29 mmHg PCL = 700 msec BP 54/30 mmHg HR = 39 bpm Baseline BP 136/67 mmHg HR = 115 bpm Vasovagal response Baseline Tilt A-V pacing CL = 700 ms

  12. Vasovagal Physiology: Cardio-Inhibitory Response CP1214460-1

  13. Vasovagal Physiology: Vasodepressor Response Recovery, supine HR 145 bpm BP 138/78 mm Hg 8 minutes after tilt HR 140 bpm BP 70/50 mm Hg Baseline supine HR 85 bpm BP 150/83 mm Hg I V6 BP

  14. Screening Phase ISSUES 3 511 met inclusion criteria and received an ILR Study Phase 89 had ECG documentation of: Syncopal recurrence with asystole ≥3 s (n=72), or Non-syncopal asystole ≥6 s (n=17) 77 randomized 12 refused randomized 38 assigned andreceived Pm ON 39 assigned and received Pm OFF 3 lost to follow-up 8 had Pm reprogrammed DDD/VVI in absence of primary end-point 9 followed-up (registry): 6 implanted Pm 3 no therapy 38 analyzed 39 analyzed 9 analyzed Brignole et al, Circ 2013

  15. Time to first recurrence of syncope according to the intention-to-treat analysis Probability value was calculated at the threshold of statistical significance of 0.4 Pacemaker for Asystolic Reflex Syncope 100 Pacemaker ON 80 Freedomfromsyncopalrecurrence 60 40 Pacemaker OFF 20 Log rank: p=0.039 0 0 3 6 9 12 15 18 21 24 Months No. at risk OFF 39 31 25 21 21 18 15 12 8 ON 38 32 27 22 16 14 13 13 11

  16. Vasovagal syncope • Explanation and reassurance (I, C) • PCM with prodrome (I, B) • Pacing, frequent syncope, age ≥ 40, documented spontaneous pause (IIa, B; ISSUE-3) • Midodrine in refractory patients (IIb, B) • Tilt training (IIb, B)

  17. 27-year-old female nursePalpitations, chest pain, exercise intolerance, lightheadedness, syncope, fatigue for 3 yearsPreviously tried beta-blockers, Ca-channel blockers,florinef, midodrine, serotonin-reuptake blockers V4 aVR V1 I aVL V5 V2 II aVF V3 III V6 CP1056624--11

  18. 9 11 13 15 17 19 21 23 1 3 5 7 9 11 Heart rate Case: 27-year-old female nurse EdiTrendTM–Heart Rate Plot

  19. What is her clinical diagnosis? • Inappropriate sinus tachycardia (IAST) • Postural orthostatic tachycardia sydrome (POTS) • Chronic fatigue syndrome • Anxiety • Dehydration • Don’t know

  20. POTS and IAST: Overlapping Characteristics

  21. Proposed Relationship of IAST, POTS and Overlapping Syndromes Inappropriate Sinus Tachycardia Chronic OrthostaticIntolerance POTS Idiopathic hypovolemia Hyperadrenergic syndrome Sympathotonic orthostatic hypotension Mitral valve prolapse syndrome Chronic Fatigue Syndrome Brady, Low, & Shen, PACE 2005 CP1184849-1

  22. POTS/IASTEpidemiology and Clinical Profile Majority of patients are young women (20-45 yr) Disproportionate occurrence in health care professionals Clinical symptoms complex (intermittent or persistent) Fatigue/exercise intolerance Palpitations Orthostatic intolerance Dyspnea Presyncope/syncope Headache Chest pain/myalgias Anxiety Irritable bowel syndrome Depression Discordance between symptoms and documented tachycardia

  23. BP and HR Response During Head-up Tilt Normal POTS Autonomic Failure 75 150 50 100 25 50

  24. Thermoregulatory Sweat Test Normal POTS Autonomic Failure

  25. Treatment of Orthostatic Intolerance Pharmacological Volume Expansion Fluorohydrocortisone Vasoconstriction Midodrine Pseudoephedrine Ephedrine Others Desmopressin Erythropoietin Non-Pharmacological Gradual postural change Avoid straining Avoid prolonged recumbency Isotonic exercise Counter maneuvers Raise head of bed Adjust drugs Compression stocking Abdominal binder Increase fluid and salt Smaller meals

  26. POTS: Bisoprolol and Fludrocortisone POTS – beforetreatment Heart rate (bpm) Control POTS – aftertreatment Basal Tilt Freitas: Clin Auto Res, 2000 CP1025751-5

  27. Study population: IAST Study design: Double blind, placebo (10 pts) vs. Ivabradine (11 pts), cross over (6 wks) Results: Ivabradine 5 mgs bid Resting HR: 88 +/- 11 vs. 76 +/- 11 (0.011) Standing: 108 +/- 12 vs. 92 +/- 11 (< 0.0001) Exercise: 176 +/- 17 vs. 158 +/- 16 (0.001) Holter: (88 +/- 5 vs. 77 +/- 9 (0.001) Symptoms eliminated 47% pts; all patients reported > 70% symptom improvement; improvement in exercise performance No side effects reported

  28. POTS/IAST: Sinus Node Modification After RFA #14, HR 65 bpm Baseline, HR 120 bpm CP1056623-8

  29. Sinus Node Modification and Ablation

  30. Recurrent Syncope in the Elderly Please don’t faint again!!

  31. After PM is implanted, what will be the risk of recurrent syncope in the next 2-5 years? No recurrence < 10 % ~ 10 - 20% ~ 20 – 30% > 30%

  32. Recurrence of Syncope in Untreated and Paced Patients Affected by CSS Brignole 92 No therapy Pacemaker Blanc 84 Claesson 07 Claesson 07 Menozzi 93 % Brignole 92 Crilley 97 Sugrue 86 Morley 82 Brignole 92 Lopes 11 Claesson 07 Sugrue 86 Walter 78 Brignole 92 Claesson 07 Blanc 84 Stryjer 86 Years Brignole et al: EHJ 34:2281, 2013

  33. After PM is implanted, what will be the risk of recurrent syncope in the next 2-5 years? No recurrence < 10 % ~ 10 - 20% ~ 20 – 30% > 30%

  34. 0 1 2 3 4 Diagnosis (no.) Patients Patients Patients Patients Patients Multiple Causes of Syncope in the Elderly Age (yr) No. % No. % No. % No. % No. % <40 49 19.9 169 68.7 27 11.0 1 0.4 0 40-64 62 22.6 166 60.4 41 14.9 6 2.2 0 65-75 44 16.3 167 61.9 49 18.2 10 3.7 0 76-79 19 16.5 66 57.4 26 22.6 4 3.5 0 80 21 20.0 56 53.3 26 24.8 1 1.0 1 Total 195 19.3 624 61.7 169 16.7 22 2.2 1 Chen, Mayo Clinic Proceedings 2003 CP1041310-3

  35. Diagnostic and therapeutic challenges in the elderly with recurrent syncope and falls History is frequently vague and incomplete Presentation is can be atypical Differentiating falls from syncope can be difficult Multiple co-morbidities, increasing frailty, drug side effects are confounders Potential causes are multiple Response to a single therapy is often incomplete Complications and risks to invasive procedures are increased

  36. Implantable/Injectable Loop Recorder 9 cc 1 cc 0.5 cc

  37. Syncope: Low Back Pain of Cardiology Not Too Bad!! Diagnosis History, induced vs. spontaneous event Pit falls of diagnostic tests, don’t implement therapy too quickly Therapeutic challenges Vasovagal syncope, POTS, IAST Multiple causes especially in elderly patients Drugs, OH, autonomic and cardiac Syncope of unknown causes Continuous and longer monitoring

  38. Syncope Low Back Pain of Cardiology Orlando, ACC 2014

  39. Sympatheticnervous system Parasympatheticnervous system Eye III Mesen-cephalon Ponsmedullaobl Lacrimal & salivaryglands IX, VII X Superiorcervicalganglion Vagusnerve Lung Cervical Stellateganglion Heart Superiormesentericganglion Celiacganglion Thoracic Liver Pancreas Stomach Small intestine Adrena medulla Lumbar Large intestine Inferiormesentericganglion Rectum Sacral Bladder Sympathetictrunk Reproductiveorgans Hypothesis: Increased sympathetic tone InterventionStellate ganglion blockade Sympathectomy Selection criteria Acute response Suitability for permanent sympathectomy CP1262405-49

  40. POTS/IAST Clinic • “Patient Journey” • Standard diagnostic testing protocol • Pre-visit questionnaire • Pre-visit Becks depression index • Standard diagnostic tests • General – CBC, electrolytes, BUN, Cr, glucose, TSH, free T4, liver function tests, lipid profile • CV – ECG, trans-thoracic echo, 24-hour Holter, 24-hour ambulatory blood pressure, tilt table testing, TMET with O2 uptake • Autonomic Neurology – autonomic reflex screen, 24-hour urine sodium, orthostatic catecholamines, thermo-regulatory sweat test*, para-neoplastic panel (only if patient has acute onset of symptoms)

  41. POTS/IAST Clinic …cont • “Patient Journey” • Initial intake with a “generalist” or nurse practitioner to review questionnaire, Beck’s depression index, history, and diagnostic tests. • Pediatric CV, Adult CV, Autonomic Neurology, and Psychiatry consultation; “Just in Time” and/or as needed based on diagnostic test results and patient request • Standard treatment protocol • Standard medication trial • Follow-up with “generalist” or “nurse practitioner” • Cardiovascular rehabilitation with CVHC • Psychiatric evaluation as needed

  42. EEG: Vasodepressor Syncope Pre-syncope (BP 75/45 mm Hg) Tilt (BP 115/70 mm Hg) Nausea (BP 102/56 mm Hg) Eyes open rolled back, Tilt Back Supine (BP 90/65 mm Hg) Syncope (BP 60/40 mm Hg)

  43. Pinches Right Finger Fp1-F3 F3-C3 C3-P3 P3-01 Fp2-F4 F4-C4 C4-P4 P4-02 Fp1-F7 F7-T7 T7-P7 P7-01 Fp2-F8 F8-T8 T8-P8 P8-02 PHO-STM Tilt Table Testing with Ambulatory EEG Psychogenic Syncope Attempt to Open Eye BP 136/68 mm Hg, HR 76 BP 128/64 mm Hg, HR 72

  44. What would you recommend? • One-12 oz of water every hour • Salt tablets supplement • Exercise training • Beta blocker • Midodrine • Ivabradine • Sinus node ablation • Psych consult

  45. Hyperthyroidism Fever Hypovolemia Stress Pheochromocytoma Sepsis Anemia Hypotension and shock Pulmonary embolism Acute myocardial ischemia Chronic pulmonary disease Hypoxia Autonomic stimulants Anxiety, panic attack Other Causes of Sinus Tachycardia

  46. Vasovagal SyncopeTREATMENTS • Salt & fluid: not proven • Counter pressure: preliminary data • Tilt training: observational • Florinef: not proven • Midodrine: helpful in a minority • Pacemaker: ineffective in most • Beta blockers: no benefit; widely used

  47. Sinus Node Tachycardia

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