Syncope and The Older Patient

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

2. 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

3. 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?

4. Outline • What is syncope • What are the causes of syncope • How do you evaluate the patient with syncope? • How do you risk stratify the patient with syncope? • How do you treat?

5. Syncope: Definition • Transient Loss of Consciousness (T-LOC) due to global cerebral hypoperfusion • Rapid onset, short duration, complete recovery • Other causes of T-LOC that are NOT syncope • Seizure (syncope can cause myoclonic movements…) • Hypoglycemia, hypocapnea/hyperventilation • Intoxication • Vertebrobasilar TIA • Other etiologies that do not impair consciousness and are NOT syncope • Drop attacks, falls, TIA from embolic source

6. 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%)

7. 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

8. Importance of History and PE • Up to 70- 85% of patients in prospective studies had probable cause identified based upon history, physical exam and ecg

9. 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)

10. Neurally mediated (reflex) • Terms • Vasovagal • Vasodepressor • Neurovascular • Neurocardiogenic • vasomotor

11. Who gets this? • We think of the young/healthy • Older patients can (although often complicated by comorbidities)

12. What is it? (Bezold-Jarisch phenomenon) • The often repeated story • Excessive stimulation of mechanoreceptors due to forceful contraction of underfilled left ventricle leading to paradoxical signals to the CNS – causing change from vasoconstriction to vasodilation – causing drop in blood pressure and bradycardia • The more complicated story • Disordered baroreflex function, paradoxical cerebral autoregulation, endogenous vasodilators… we don’t really know….

13. Think neurally mediated… • Situations • Warm environment, hot bath, post-exercise, prolonged standing, large meals, early morning, valsalva, volume depletion, rising after prolonged bedrest, alcohol, medications • Symptoms • Classic presyncopal symptoms • No underlying neurological or cardiac disease • Prior history

14. Neurally mediated…sort of …. • Situational syncope • Carotid sinus hypersensitivity

15. Situational Syncope • Situations… • Cough • Micturition • Defecation • Swallow • Diving • pain • Tussive or laughter syncope • More common in obese men over 40, smokers with chronic cough and COPD, children with asthma • More on micturition syncope • Older men, early morning, exacerbated by medications

16. Carotid Sinus Hypersensitivity • History • Stimulation of carotid area near barorecptor (near bifurcation) • Tight collar, neck pressure with head turning or shaving/backing out of driveway

17. CSH… • Carotid massage • 3 second pause or > 50 mm drop in SBP • Three responses • 1. Cardioinhibitory (bradycardia/asystole) • 2. vasodepressor (hypotension) • 3. Mixed (features of both, most common) • Cardioinhibitory may benefit from pacing…

18. CSH… • Common in elderly, some concern that massage/testing may over diagnose • Also more likely to have positive response in patients with other degenerative neurological conditions such as Lewy body disease and parkinson’s • Pacing controversial, but may have role in select cases…

19. Summary: Reflex syncope (neural) • Vasovagal (neurally mediated) • Situational • Carotid sinus hypersensitivity

20. Postural Hypotension • Orthostatic • Volume loss • Blood loss • Drop in blood pressure (SBP 20) with increase in HR • Autonomic • Common in elderly (10-30%) – presence may or may not be the cause of syncope • Often medication related (long list…)

21. Autonomic Insufficiency • Clinical Features • Lack of tachycardic response; no respiratory variability of heart rate • ED, urinary retention, gastric emptying delay • Causes • Diabetes • Paraneoplastic • Amyloid • Multiple Systems Atrophy (Shy-Drager) • Primary Autonomic Failure • Toxins • Parkinson’s, Lewy body processes • Guillain-Barre syndrome • Spinal cord injury • HIV

22. Cardiac: Arrhythmia • Bradycardia/asystole • Sick sinus syndrome • 2nd or 3rd degree AV blocks • Pacemaker malfunction • Have high suspicion in patients with bundle blocks… • Tachycardia • Ventricular tachycardia • Ventricular fibrillation • SVT • If you see afib, think sick sinus syndrome and bradycardia/pauses…

23. Cardiac: Prolonged QT • QTc over 500 • Lack of QT shortening with increased heart rate (role of standing or exertional EKG) • Genetic or secondary to medications… • Torsades

24. 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)

25. Brugada Sign

26. Structural Cardiac or pulmonary causes • Valvular disease (especially aortic stenosis) • HOCM • Cardiac masses (myxoma) • Pericardial disease (tamponade or restrictive processes) • Prosthetic valve dysfunction • Acute aortic dissection • Pulmonary hypertension (exercise related) • PE

27. 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

28. Cerebrovascular • Syncope = global hypoperfusion • Vertebrobasilar pathology or bilateral carotid disease…

29. How do you evaluate the patient with syncope?

30. 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!

31. Evaluation: History • Neurally mediated: • Absence of heart disease • Long history of recurrent syncope • Associated factor (pain) • Prolonged standing • Associated n/v, diaphoresis, presyncopal symptoms • After a meal • CSH: turning head or pressure on neck

32. History… • OH: • After standing • Prolonged standing • Presence of autonomic insufficiency or parkinson’s • Standing after exertion

33. History… cardiovascular • Presence of structural heart disease (especially systolic dysfunction) • Family history of sudden death • During exertion or supine (BIG FLAG) • Swimming/diving into pool (prolonged QT) • Abnormal EKG • Syncope follows sudden onset of palpitations • EKG: • QT • Bundle blocks • Afib, AV blocks • Evidence of prior ischemia • QRS over .12

34. Evaluation • EKG • Telemetry • Rule out ischemia (nursing home patients…) • Carotid sinus massage • Contraindicated in patients with prior TIA/stroke, bruits or known carotid stenosis

35. Evaluation • Orthostatics • Echo

36. Tilt table testing • Passive or Isoproterenol • Test: patient held in upright position (60-90 degrees), but weightless to prevent muscles improving venous return; this leads to venous pooling, decreased venous return, and trigger of the neurally mediated reflex • Positive test: bradycardia or hypotension • Passive testing: sensitivity only 70%, specificity 90-100% • Isoproterenol: only 55% specificity • Usually does not add much to the history and physical…

37. In-hospital monitoring • Yield low (under 20%) • Recommended in high risk patients

38. Holter Monitoring • 24-48 hours (no higher yield with longer) • Low yield (1-2%) • May be useful if symptoms are very frequent

39. External Loop recorders • Loop memory that continuously records and deletes • Patient activates in response to symptoms (some devices also activated in response to rhythm) • Yield: ?25% when used for 4-6 weeks

40. Implantable Loop recorders • Duration up to 3 years • Can be activated by patient or bystander or automatically activated by arrhythmias • May be cost effective to do earlier in the workup than currently doing… • Some series – 50-80 % patients with prior unexplained syncope were able to have diagnosis

41. Electrophysiology Study (EP) • Underlying structural heart disease (especially depressed LV function) • Suspected bradycardia • Patients with underlying bundle branch block (look for development of His block with incremental atrial pacing) • Suspected tachycardia

42. Exercise Stress Testing • Patients with syncope with/after exertion • Usually of low yield

43. Other evaluations… • Imaging, CTA • Cardiac catheterization • Directed by history and physical…

44. Least useful tests… • Head CT with negative neuro exam (history should direct whether symptoms suggest stroke/TIA or syncope…) • EEG • Carotid dopplers (see above…)

45. Risk Stratification

46. High Risk • Chest pain • CHF • Valvular disease • History of ventricular arrhythmias • EKG ischemic changes • Prolonged QT c (over 500) • Trifascicular block or pauses over 2 sec • Cardiac devices • Atrial fibrillation

47. High risk: ESC recommended hospitalization • Known heart disease • Syncope during exercise • Trauma (facial) • Family history sudden death • Sudden palpitations prior to syncope • Syncope while supine • Multiple recent episodes

48. Intermediate risk • Age over 50 • History of ischemic heart disease • Family history of sudden death

49. Low risk • Age less than 50 • No history of CV disease • Normal EKG and exam • Symptoms c/w neurally mediated or vasovagal syncope • Prior history of recurrent syncope with symptoms c/w vasovagal etiology

50. Treatment: reflex syncope and orthostatic intolerance • Lifestyle • Education, reassurance • Avoiding triggers • Maneuvers: supine posture, physical counterpressure, crossing legs) • Avoiding medications, ETOH • Increasing fluids, salt intake