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Syncope

Syncope. Teresa Menendez Hood , M.D. Definition.

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Syncope

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  1. Syncope Teresa Menendez Hood , M.D.

  2. Definition • Syncope is a symptom in which there is transient (<30 secs) and self-limited loss of consciousness usually leading a fall. The onset is rapid and recovery is spontaneous, complete and prompt. The underlying mechanism is relatively abrupt cerebral hypoperfusion.The onset may or may not have warning and some older patients may have retrograde amnesia. Fatigue is common post-syncope. • Just this week: “Palestinian leader improving after collapse”

  3. SYNCOPE STATS • 25% people will have syncope at some point • 6% of hospital admits are for syncope • 3% of all ER visits • 30% have recurrences • 40% remain undiagnosed after initial evaluation

  4. Syncope: Etiology Neurally- Mediated Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary Non- Cardio- vascular * 24% 14% 12% 11% 4% Unknown Cause = 34% DG Benditt, UM Cardiac Arrhythmia Center

  5. Causes of Syncope • Neurally-mediated reflex syncope-a reflex that when triggered gives rise to vasodilation and/or bradycardia • Vasovagal-look for precipitating events: fear, pain, prolonged standing • Carotid sinus-turning head to one side, age >40 • Situational-cough, micturition, post-exercise, post-prandial, swallow, defecation….

  6. Causes of Syncope • Orthostatic • Autonomic Failure- the autonomic nervous system does not work well and one does not get the vasoconstrictor mechanisms to upright posture : • primary or multisystem, secondary (DM, amyloid), drug induced (the most common). Look for autonomic problems in other organs..i.e cannot sweat, impotence, disturbed micturition • Volume depletion • Cardiac Arrhythmias • Sinus node dysfunction, AVN disease, SVT/VT, inherited diseases(LQT, Brugada, WPW,ARVD,HCM)

  7. Causes of Syncope • Structural Cardiac or Cardiopulmonary disease-an obstruction of blood flow • Valvular disease • Obstructive CM • Atrial Myxoma • Aortic dissection • Tamponade • PE

  8. Causes of Syncope • Cerebrovascular • Vascular steal syndrome-subclavian steal:rare, syncope associated with arm exercise: the blood vessel supplies both the brain and the arm. Check for BP in both arms! • VetebrobasilarTIA-doubtful that can really cause syncope

  9. Features suggestive of cardiac causes? • Occur in the supine position or during exertion • Preceded by palpitations • Presence of severe heart disease • EKG abnormalities: wide QRS, AV conduction disease, Q waves, LQT, delta wave…

  10. Features suggestive of Neurally-Mediated causes? • Prolonged standing in crowded, warm place • Preceding nausea, feeling cold and sweaty • After exertion or post-prandial • Tonic-clonic movements are short in duration and occur after the loss of consciousness • Long duration of symptoms …>4years

  11. Causes of non-syncopal attacks • Impairment of /loss of consciousness • Metabolic-hypoglycemia , hypoxia, hyperventilation syndrome • Epilepsy-Typical premonitory aura? Post-ictal state? • Loss of muscle control • Cataplexy-usually with narcolepsy • Psychogenic

  12. The Initial Evaluation • Careful History - from patient and witnesses: this is the most important tool in the diagnosis! • Prior to attack, onset, eyewitnesses, end of the attack, PMH, FH, drug history? • Physical exam- include orthostatic BP • Standard EKG

  13. Evaluation • The use of EEG, CT, MRI , carotid dopplers are not usually helpful in the workup of syncope • Hospitalize patients when the features suggest a cardiac cause, when it results in severe injury, or when the syncope is frequent

  14. Evaluation • When the cause of the syncope is not evident after the initial evaluation and there is evidence of heart disease then the possibility of cardiac syncope must be entertained as these patients have a high mortality at one year(18-30% mortality) • Cardiac evaluation: echo, stress test, holter/loop and EP testing. • In a patient with cardiac disease but with negative cardiac workup, then proceed with tilt testing and / or implantable loop recorder.

  15. Evaluation • In those without heart disease, then tilt table testing and carotid massage (more important in the patients > 40) for neurally mediated syncope is recommended for those with recurrent or severe syncope. • SAECG has fallen out of favor. If it is normal it helps.

  16. Reveal® Plus ILR • Offers up to 14 months of continuous, leadless ECG monitoring • High diagnostic yield (65-88%) • High patient compliance • Patient and auto triggered to capture ECG Patient Activator Reveal® Plus ILR 9790 Programmer

  17. Implant zone for optimal auto activation performance • Implant parallel to the midline in the region • From left parasternal area to the mid-clavicular line • First to the fourth rib Implanting in this zone helps minimize inappropriate auto activation – motion artifact due to body/arm movement and changes in posture

  18. mV 0.4 0.2 08:23:21 0.0 -0.2 -0.4 :21 :22 :23 :24 :25 :26 :27 :28 :29 0.4 0.2 8:23:29 0.0 -0.2 -0.4 :29 :30 :31 :32 :33 :34 :35 :36 :37 0.4 0.2 0.0 08:23:37 -0.2 -0.4 :37 :38 :39 :40 :41 :42 :43 :44 :45 Johns Hopkins Hospital, Baltimore, Maryland

  19. Randomized Assessment of Syncope Trial (RAST) Comparison of the Implantable Loop Recorder with Conventional Diagnostic Testing for Unexplained Syncope1 Andrew D. Krahn, George J. Klein, Raymond Yee, Allan C. Skanes University of Western Ontario London Ontario Canada 1. Krahn A, et al. Circ. 2001;104(11):46-51

  20. Methods • Prospective randomized trial (60 patients with unexplained syncope referred for cardiac investigation) • Inclusion: • Recurrent unexplained syncope • Referred to the arrhythmia service for cardiac investigation • No clinical diagnosis after history, physical, ECG and at least 24 hours of cardiac monitoring • Exclusion: • LVEF < 35% • Unable to give informed consent • Major morbidity precluding 1 year of follow-up

  21. Methods • Conventional Investigations: • ELR then HUT then EPS(see below for definitions) • ILR4 • Left sided implant with antibiotics • Patient education • 1 year of follow-up • Crossover • After primary arm was completed, patients were offered crossover to facilitate diagnosis • External loop recorder • Head up tilt test • Electrophysiological study • Reveal Insertable Loop Recorder, Model 9525

  22. Results ILR (n=30) Conventional (n=30) Age (years) 64 +/- 14 68 +/- 14 Gender (# male) 19 (63%) 14 (47%) Syncopal Episodes 4.1 +/- 3.3 5.8 +/- 6.6 Duration of Syncope (yrs) 6.6 +/- 12 8.7 +/- 2.7 LVEF (%) 55 +/- 8 55 +/- 6

  23. RAST Results

  24. RAST Crossover Results

  25. RAST Results • Diagnosis By:ILR* Conventional p value • Primary Strategy 14/27 (52%) 6/30 (20%) p=0.012 • Crossover 8/13 (62%) 1/6 (17%) p=0.069 • Primary and Crossover 22/40 (55%) 7/36 (19%) p=0.0014 • *3 primary ILRs and 8 crossover ILRs have not completed follow up.

  26. Conclusions • This prospective randomized trial suggests that the implanted loop recorder has a superior diagnostic yield as a primary strategy. • The diagnostic yield of conventional testing in these patients is disappointing (19%). • The loop recorder retains high utility when used after conventional testing is negative. • Consideration should be given to use at an earlier stage in the diagnostic cascade in this patient population.

  27. Indications • Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias • Patients who experience transient symptoms that may suggest a cardiac arrhythmia The Reveal Plus Insertable Loop Recorder is indicated for:

  28. Tilt Table Diagnosis • Neurocardiogenic-seen in 50% of patients with heart disease and 75% of patients without heart disease who present with syncope • Type 1 mixed: bp falls before heart rate and the heart rate does not get <40 and no pauses >3 secs and heart rate falls at the time of syncope • Type 2a: cardioinhibitory without asystole-bp falls before the heart rate and heart rate gets below 40 but no asystole > 3 secs • Type 2b: cardioinhibitory with asystole-heart rate falls below 40 for > 10secs and asystole is present >3 secs • Type 3: pure vasodepressor-bp falls but heart rate does not fall >10% from peak heart rate .

  29. Tilt Table Diagnosis • Dysautonomic • Gradual decline in the systolic and diastolic bp with or without a drop in the heart rate. • Orthostatic intolerance is the key problem • POTS-Postural orthostatic tachycardia syndrome • An excessive heart rate response to maintain a low normal blood pressure. Will have an excess of >30 beats increase when placed upright

  30. Tilt Table Diagnosis • Cerebral syncope • Associated with cerebral vasoconstriction in the absence of systemic hypotension and would need a transcranial Doppler for confirmation

  31. Protocols • Westminster • Passive tilt for 45 minutes at 60-80 degrees and has a positive rate of 75% with specificity of 95%

  32. Protocols • Italian • Passive tilt for 20 minutes and the challenge with SUBLINGUAL NITROGLYCERIN while still upright and has specificity of 94%. • Will see a progressive drop in the BP with no bradycardia if the effect is due to the drug alone and this is not a positive test..seen in 20%!

  33. Tilt Holter/ ELR ILR Tilt ILR Syncope History and Physical ECG KnownSHD NoSHD > 30 days; > 2 Events < 30 days Echo EPS - + Tilt/ILR Treat

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