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Evaluation and Management of Syncope

Evaluation and Management of Syncope. Syncope. Definition: Sudden transient loss of consciousness and postural tone with subsequent spontaneous recovery. ( Greek synkope , “cessation, pause”). Transient inadequate cerebral perfusion. Syncope - Epidemiology.

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Evaluation and Management of Syncope

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  1. Evaluation and Management of Syncope

  2. Syncope • Definition: Sudden transient loss of consciousness and postural tone with subsequent spontaneous recovery. ( Greek synkope, “cessation, pause”). Transient inadequate cerebral perfusion.

  3. Syncope - Epidemiology • 1% of hospital admissions • 3% of ER visits • 6% annual incidence in the elderly • Upto 50% of young adults have history of isolated LOC • Annual cost $2 B (2005) Clin Electrophysiol 22:1386,1999 Sun BC, Am J Cardiol 95:668, 2005

  4. Syncope - Prognosis • Highest mortality in patients with cardiac cause • Neurally mediated syncope/ medication induced syncope did not increase mortality Soteriades ES, et al: N Eng J Med 347:878, 2002

  5. Causes of Syncope • Vascular ( 58 – 62 % ) : Reflex mediated, orthostatic, anatomic • Cardiac ( 10 – 23 % ): Arrhythmias, anatomic • Neurologic/cerebrovascular* ( 0.5 – 5 % ) • Metabolic/drugs ( 0 – 2 % ) • Psychogenic* ( 0.2 – 1.5 % ) • Syncope of unknown origin ( 14 – 18 % ) Sarasin FP, Am J Med 111: 177, 2001 Alboni P, JACC 37, 1921, 2001

  6. Differential Diagnosis of Syncope

  7. Syncope - Clinical Features Suggestive of Specific Causes

  8. Syncope – Clinical Features Suggestive of Specific Causes (cont’d )

  9. Syncope – Clinical Features Suggestive of Specific Causes ( cont’d )

  10. Seizure vs Syncope • Seizure: Aura, frothing at the mouth Horizontal eye deviation, tongue biting Elevated BP, sinus tach Sustained tonic clonic movements, incontinence Disorientation, slow recovery

  11. Syncope – Diagnostic Tests • History and physical examination: cardiac disease, family h/o SCD, medications, witness • Orthostatic BP check • ECG: Q waves, QTc, delta wave, epsilon wave • Holter monitor: V pause > 3 sec while awake, Mobitz type 2 or CHB, VT. • Arrhythmia event monitor • Echocardiogram • Tilt table test • Electophysiologic testing

  12. Diagnostic Tests for Syncope

  13. Diagnostic Tests for Syncope (cont’d)

  14. Syncope – Indications For Hospitalization • Presence of heart disease, dyspnea, CHF, VT, acute coronary syndrome • ECG suggestive of arrhythmic syncope in: WPW, long QTc, Sick Sinus Syndrome, AV block, VT, Brugada syndrome, RV dysplasia • Syncope with severe injury • Syncope during exercise • Family h/o sudden cardiac death

  15. Sinus Arrest on Holter Monitor ACCSAP 2005

  16. Syncope – Loop Event Recorder ACCSAP 6, 2005

  17. Implantable Loop Recorder

  18. Implanted Loop Event Recorder

  19. Head Up Tilt Table Testing

  20. Tilt Table Testing: When to do it? For diagnosis: • Suspected reflex, atypical presentation • Unexplained syncope at the end of work-up, orthostatic trigger present • Suspected delayed orthostatic hypotension

  21. Neurally Mediated Syncope • Also known as vasovagal syncope. • Recurrent syncope in the absence of structural heart disease is most likely neurally mediated. • Head-upright tilt test maximizes venous pooling, sympathetic activation and circulating catecholamines. • Most vasovagal episodes involve both cardioinhibition (drop in heart rate) and vasodepressor response (drop in BP).

  22. Case # 1 A 20 year old female presents with recurrent near syncope and syncope preceded by nausea, sweating and gradual “tunnel vision”usually after prolonged standing. The ECG and 2-D echocardiogram are normal. What would be the next step? Answer: Tilt table test. Q: What is the mechanism for the visual symptoms? Answer: Collapse of peripheral vessels of the retina.

  23. Syncope:The Role of Electrophysiologic Testing • Most important diagnostic tool is the history • High risk historical elements • Syncope resulting in injury • Syncope resulting in motor vehicle accident • Syncope in the setting of structural heart disease • Syncope preceded by palpitations • Syncope while supine • Abnormal ECG • Lack of “low risk” elements

  24. Guidelines for EP Testing in Syncope • Class I: General agreement Patients with structural heart disease and unexplained syncope • Class II: Less certain, but accepted Patients with recurrent unexplained syncope without structural heart disease and a negative tilt test • Class III: Not indicated Patients with known cause of syncope in whom treatment will not be guided by EP testing

  25. Electrophysiologic Testing in Syncope • Sinus node function: prolonged sinus node recovery time • Abnormal AV conduction: ↑HV interval, infra His block • Inducibility of sustained VT • Inducibility of rapid SVT with symptoms, hypotension

  26. Neurally Mediated Syncope • Precipitating factors: prolonged standing, dehydration, alcohol, diuretics, vasodilators. • Sit/lie down at onset of symptoms, cross the legs and tense them together if sitting. • Salt supplementation and fluids. • Isometric arm, leg counterpressure. • Moderate aerobic and isometric exercise. • Tilt training.

  27. Therapy of Neurocardiogenic Syncope

  28. Pharmacologic Therapy of Neurally Mediated Syncope • Despite the widespread use of drug therapy, none of these pharmacologic agents have been demonstrated to be effective in large prospective randomized clinical trials. • A small study has reported the efficacy of midodrine. • Metoprolol, propranolol and nadolol are no more effective than placebo.

  29. Orthostatic Intolerance Syndrome Delayed Orthostatic Intolerance Vasovagal Syncope Counterpressure Maneuvers Elastic Stockings JACC 2006 48:1652 JACC 2006: 48:1425

  30. Syncope - Prognosis • Highest mortality in patients with cardiac cause • Neurally mediated syncope/ medication induced syncope did not increase mortality Soteriades ES, et al: N Eng J Med 347:878, 2002

  31. Suggested Strategies for Syncope Management

  32. Syncope:May be a harbinger of sudden cardiac death • Evaluation – purpose is to determine if pt is at increased risk for death • Identify pts with underlying heart disease (ischemic CM, non-ischemic CM, HCM), myocardial ischemia, WPW, genetic diseases (long-QT syndrome, Brugada Syndrome), catecholaminergic polymorphic VT

  33. Case # 2 • 65 year old male with h/o inferior wall myocardial infarction 1 year ago presents with rapid palpitation and syncope. An ECG shows SR and old inferior wall myocardial infarction. A 2D echo shows LVEF 40% with inferoapical dyskinesis. Coronary angiography reveals totally occluded right coronary artery with collaterals. What is the next step? • Answer: Electrophysiologic study (to look for inducible sustained VT)

  34. Case #3 72 year old male with chronic atrial fibrillation of greater than 10 years’ duration is admitted following a syncopal episode. A 2D echo shows markedly dilated left atrium and LVEF 60%. Telemetry reveals atrial fibrillation with slow ventricular response and pauses of 5 to 7 seconds associated with near syncope. How would you proceed? Answer: Implant single chamber rate responsive pacemaker

  35. Diagnostic Evaluation of Syncope Syncope Hx, physical exam, supine and upright BP, EKG Unexplained syncope Is there structural heart disease? NO YES Tilt table test Electrophysiologic Study

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