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SYNCOPE Module #3

Learn the step-wise approach for evaluating syncope, including history, physical, lab tests, EKG, and additional diagnostic steps to determine the underlying causes. Discover the importance of differential diagnosis and management strategies.

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SYNCOPE Module #3

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  1. SYNCOPEModule #3 Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512

  2. PROCESS Series of 3 modules and questions on Etiologies, Evaluation, & Management Step #1 Power point module with voice overlay Step #2 Case-based question and answer Step # 3 Proceed to additional modules or take a break

  3. EVALUATION Etiologies: The evaluation requires: • Comprehensive approach • Step-wise progression to first rule out the most lethal causes (i.e. cardiac) and then next progressing to the other etiologies as indicated

  4. First step: H &P*, EKG, Labs Suggested (CBC, electrolytes, glucose, BUN/Cr. Ca+ and SaO2, cardiac enzymes) History What to ask? Precipitant Activities Prodrome Medications Witnesses Comorbid conditions EVALUATION First Step

  5. Characteristics of the Three Classes of Syncope

  6. Physical -orthostatic BP & pulse (lying, sitting & standing 1 & 3 min.) -pulmonary -cardiac -neurologic exams History (from patient and witness) will give diagnosis 50% of the time Physical will give diagnosis 20% of the time EVALUATION First Step1

  7. LAB: BMP CBC Gave diagnosis for what % of patients? 2-3% of patients EKG Gave diagnosis for 5% of patients BUT Often gave clue to dx: e.g. (old MI, BBB, arrhythmias) EVALUATION First Step2,3

  8. EVALUATION additional steps4 Echocardiography yields unsuspected findings in----- < 10% of patients (should be performed pre stress test, if patient has exertional syncope to r/o cardiac obstruction; eg septal hypertrophy)

  9. EVALUATION additional steps5 FOR Patients with Structural cardiac abnormalities* * structural heart. Dz: (CAD, CHF, Valve dz, cong. hrt dz) or EKG abnormalities (old MI, BBB, arrhythmias, conduction syst. dz) who have: Ischemic symptoms Perform: Exercise or Pharmacologic StressTesting

  10. EVALUATION additional steps6 If added: Ambulatory ECG (Holter) gave: • correlation of arrhythmia with symptoms 4% of the time • absence of arrhythmia with symptoms 17% of the time (79% of pts. had no arrhythmia or brief arrhythmia) Note: 72 hr ambulatory monitoring did not increase yield for symptomatic arrhythmias over 24 hr monitoring

  11. EVALUATION additional steps Ambulatory loop recorders or Event monitors (“King of Hearts”): (11) • in patients able to operate recorder gave diagnosis 25% of time • in patients unable to operate recorder consider implantable loop recorder

  12. EPS: Electrophysiologic studies7 Indications High yield patients: • structural heart disease with unexplained syncope • detection of arrhythmias in ischemic heart disease Detect arrhythmias by: via by EKG, cardiac monitoring or Holter or Event monitoring Significant findings: • NSVT, Sinus Brady, 3 degree Heart Block, BiFasicular BBB

  13. EPS meta-analysis Ann Intern Med 1997;127:76-86

  14. EVALUATION additional steps • If added: • CT(head) or EEG • yielded diagnosis in only---- 4% of pts (12) (these tests are rarely helpful unless neurologic signs or symptoms are present) • all patients with positive scans had focal neurologicsigns or witnessed seizure)

  15. If added: Head-up tilt table test (HUTT): Indications: -suspect vasovagal or -unexplained syncope in those not suspect or ruled out for cardiac cause when added to above evaluation, these tests gave diagnostic yield to total of .60-76% of patients Specificity 90% Sensitivity 66% Caveat What is false positive rate? Can have false positives: positive tilt table in 10% of the elderly population EVALUATION additional steps8

  16. 1st Passive testing: Technique fasting serial BP’s in various tilt positions up to 60 degrees with patient standing still 2nd Isoproteronol infusion: Technique: as above plus infusion of isoproteronol Positive: demonstrates drop in BP> 20 mm Hg and symptom reproduction * Tilt table testingThe Technique

  17. Definition List the consequences Describe the aging physiology that predisposes to syncope List the causes Describe the evaluation Sudden LOC Mortality high in cardiac Baroreceptor,  B receptors, Volume  MM tone P-A-S-S O-U-T R/o cardiac first H &P, EKG, Labs Review

  18. How to remember the causes?“Mnemonics” • P-A-S-S O-U-T The following mnemonic reviews the etiologies of syncope, and pertinent data on each: P ressure(hypotensive causes) Output (cardiac)/O2 (hypoxia) A rrhythmiasU nusual causes S eizuresT ransient Ischemic Attacks S ugar (hypo/hyperglycemia) & Strokes, CNS dz’s

  19. The End of Module three on Evaluation of Syncope9 Request “Syncope Pearls” summary card from 402.559.3964 orkfturner@unmc.edu

  20. Post Test (10) • A 75-year-old woman has chronic congestive heart failure with normal systolic function. Current medications are furosemide and an angiotensin-converting enzyme (ACE) inhibitor. While sitting in a chair approximately 1 hour after eating breakfast and taking her medications, she suddenly loses consciousness and falls to the floor. On examination at the hospital, her pulse rate is 68 per minute and blood pressure is 160/72 mm Hg. A grade 3/6 midsystolic murmur is heard at the left sternal border and radiates to the carotid arteries. There are good carotid upstrokes and no carotid bruits. Complete blood cell count, serum electrolytes, cardiac enzymes, electrocardiogram, and chest radiograph are normal. One day later, blood pressure is 104/70 mm Hg 1 hour after breakfast. Which of the following is the most appropriate next step?

  21. Which of the following is the most appropriate next step? A. Order Doppler echocardiography. B. Encourage the patient to drink two cups of coffee (250 mg of caffeine) each morning. C. Discontinue furosemide. D. Discontinue the ACE inhibitor. E. Prescribe fludrocortisone, 0.1 mg orally every morning.

  22. Answer: C Discontinue furosemide. This patient has postprandial hypotension, which could be exacerbated by hypotensive medications taken with breakfast. Diuretics have been shown to exacerbate postprandial and orthostatic hypotension, probably because of their preload-reducing effects. In one study, furosemide withdrawal improved postprandial hypotension in elderly patients with heart failure and preserved systolic function.

  23. Doppler echocardiography probably would confirm reduced early diastolic ventricular filling and normal left ventricular function, which are characteristic of diastolic heart failure. This will not change the treatment approach, however. It is possible but unlikely that the systolic murmur represents aortic stenosis or hypertrophic cardiomyopathy. Even if present, these probably are not hemodynamically significant, given the normal physical findings and electrocardiogram. Caffeine has been effective in ameliorating postprandial hypotension in some patients, but tolerance develops rapidly. ACE inhibitors may improve postprandial regulation of blood pressure. Fludrocortisone is useful for chronic orthostatic or postprandial hypotension, but it is relatively contraindicated in patients with heart failure because it causes sodium retention.

  24. Post Test #2 (10) • You are called to see an 80-year-old nursing-home resident with Alzheimer’s disease, reflux esophagitis, and glaucoma who suddenly lost consciousness and fell to the floor at 9:00 am while sitting in the dining room beginning his breakfast. He was noted by his nurse during morning rounds to be more lethargic than usual, not engaging in his usual pacing behavior before breakfast. At 8:00 am he received docusate, omeprazole, and timolol eye drops. After his collapse the patient spontaneously regained consciousness while lying on the floor and was diaphoretic. There were no other symptoms. On examination by the nurse, his supine blood pressure was found to be 168/92 mm Hg, heart rate was regular at 96 per minute, respiration rate was 28 per minute, and axillary temperature was 37.7°C (99.8°F). • What is the most likely diagnosis?

  25. What is the most likely diagnosis? A. Postprandial hypotension B. Arrhythmia C. Pneumonia D. Neurally mediated syncope E. Acute myocardial infarction

  26. Answer; C. Pneumonia • Syncope in the elderly patient is often the atypical manifestation of diseases or situations that may not be expected to result in loss of consciousness. Pneumonia is a common cause of syncope in the elderly patient, possibly as a result of hypoxemia, dehydration, or altered cardiovascular reflexes. In this case there are several signs consistent with this diagnosis. First, the patient was lethargic during morning rounds, suggesting that there was an occult illness. Also, during the nurse’s examination he had a relatively high heart rate and respiration rate, suggesting the presence of an acute respiratory illness. His axillary temperature of 37.7°C (99.8°F) corresponds to an oral temperature of 38.2°C (100.8°F).

  27. Although the patient was eating a breakfast meal, postprandial hypotension usually does not occur until 30 to 45 minutes after the meal. The fact that he was receiving ophthalmic timolol drops might predispose him to a bradyarrhythmia; however, his heart rate was 96 per minute following the event. Certainly an arrhythmia is possible, but this would present acutely and would not be associated with lethargy earlier in the morning. The diagnosis of neurally mediated syncope is less common in the elderly patient but does occur; usually this is preceded by a prodrome of nausea, abdominal discomfort, diaphoresis, or a stressful situation. Finally, it is possible that an acute myocardial infarction precipitated syncope; however, in the setting of lethargy, fever, and tachypnea in a nursing-home patient without prior cardiovascular disease, this diagnosis is less likely than pneumonia. End

  28. Bush D. Syncope. In: Geriatric Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition (Pompei P, Murphy JB, eds.), New York: American Geriatrics Society, Chapter 23, pp168-173, 2006. • 2. Kapoor WN.Current evaluation and management of syncope. Circulation 2002 Sep 24;106(13):1606-9. • 3. Linzer M, Yang EG, Estes NA, et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Ann Int Med 1997; 126:989-996 • 4. Recchia D, Barzilai B. Echocardiography in the evaluation of patients with syncope. J Gen Intern Med 1995 Dec;10(12):649-55. • 5. Kapoor WN. Syncope. N Engl J Med 2000 Dec 21; 343(25):1856-62. • 6. Bass EB, Curtiss EL, ArenVC, et al. The duration of holter monitoring in patients with syncope. Is twenty-four hours enough? Arch Int Med 1990;150(5):1073-1078. • 7. Menozzi C, Brignole M, Garcia-Civera R, et.al. Mechanism of syncope in patients with heart disease and negative electrophysiologic test. Circulation 2002 Jun 11; 105(23):2741-5. • 8. Natale A. Akhtar M, Jazayeri M, et.al. Provocation of hypotension during head-up tilt testing in subjects with no history of syncope or presyncope. Circulation 1995 Jul 11;92(1):54-8. • Bush D. Syncope. In: Geriatric Review Syllabus: A Core Curriculum in Geriatric Medicine, 5th Edition (Cobbs EL, Duthie EH, Murphy JB, eds.), Malden, MA: Blackwell Publishing for the American Geriatrics Society, Chapter 24, pp 165-169, 2002 • Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY. • Bush D. Syncope. Geriatric Review Syllabus, sixth edition,, chapter 23, page 171 • Linzer M., Yang EH. Et. al. Diagnosing syncope; part one: value of history, physical exam, a nation and electrocardiography. Annals Int Med, June 15, 1997; 126:99-996 References

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