Diagnosis and Management of Syncope

1. Diagnosis and Management of Syncope Robert Helm, M.D. Assistant Professor of Medicine Boston University School of Medicine August 2013

2. Case 1 53 year-old obese gentleman with diabetes, hypertension and hyperlipidemia who presented with syncope. This occurred after working at the boat yard on a very hot day. He was taking a break and drinking a cold slurpee, when he suddenly felt pins and needles in his neck, peri-oral numbness, and tingling of his forehead. As he was calling for wife, he lost consciousness and fell to the ground. According to his wife, he was unconscious for about a minute and his entire body was quivering. Upon regaining consciousness, he was confused and disoriented. His wife reports that he was cold, clammy, and very diaphoretic. He sustained some minor bruising of left shoulder but no head injuries.

3. Case 1 No prior syncope but two weeks ago he did a “pirouette” due to sudden brief episode of lightheadedness and loss of balance. He did not lose consciousness. He consulted with his internist, who found relative low blood pressure (100/54 mmHg) and reduced his Lisinopril by half (40 to 20 mg daily). His blood sugars have been well controlled.

4. Case 1 • Past Medical History • Diabetes (HgBA1C 5.8) • Hypertension • Hyperlipidemia • ? myocardial infarction • Obstructive sleep apnea • Social History • Non-smoker • No alcohol or drugs • Family History • Mother had MI at 60 • Brother died suddenly at 48 • Review of system • Negative. Good functional • capacity. Allergies None Medications Cardizem cd 120 mg daily Lisinopril 20 mg daily Lantus 40 units at night Novalog 12 units with meals Aspirin 81 mg daily Lasix 80 mg daily Simvastatin 80 mg at night Fenofibrate 134 mg daily Percocet 5/325 mg as needed for pain Viagra 100 mg – last used 2 days prior Nitroglycerin 0.4 mg SL – never used

5. Case 1 Physical examination BP 124/62 mmHg. Not orthostatic. Normal carotid palpation and auscultation. Normal cardiovascular exam. Bruised right hip. Laboratory BUN 27 ng/dl Creatinine 1.47 ng/dl. Electrolytes and blood count normal. Echocardiogram – normal 1 month ago.

6. Case 1

7. Case 1 Admitted for 24 hour observation and hydration. Diagnosis:“Vaso-vagal syncope”

8. Poll The correct statement is: • The patient has been correctly diagnosed. • The patient should be referred for urgent pacemaker. • The patient should be referred for electrophysiologic study. • The patient should be referred for 30 day event recorder. • The patient should be referred for tilt-table study.

9. Case 2 61 year old gentleman with history of cocaine use who presented with syncope. “He was in kitchen making Thanksgiving dinner and developed lightheadedness. He sat on a step stool and the next thing he remember is being on the floor and his son calling his name. He felt like he couldn’t move. The kitchen was really hot and and he had missed lunch. He reports using cocaine “months ago”.

10. Case 2 • Past Medical History • none • Social History • history of cocaine • Family History • no premature CAD or SCD • Review of system • Negative. Allergies None Medications None

11. Case 2 Physical examination BP 145/91 mmHg. Not orthostatic. Normal carotid palpation and auscultation. Normal cardiovascular exam. Minor bruise on elbow. Laboratory BUN 26 ng/dl Creatinine 1.1 ng/dl. Electrolytes and blood count normal.

12. Case 2

13. Poll The correct next step is: a. Check toxicology screen. If positive then attribute syncope to cocaine use. b. Continuous-loop event monitoring. c. Increase fluid intake and reassure patient. d. Electrophysiology study to assess for inducible VT e. Tilt-table study. f. Implant loop recorder (ILR). g. Echocardiogram. h. B and then D if event monitoring is negative. i. B and then F if event monitoring is negative. j. G and if ejection fraction is < 35% then D

14. Why is syncope a difficult problem? • Physiologic response to a wide variety of medical conditions • By definition it is a transient condition • Occurs with unpredictable and random pattern • Difficult to establish definitive “diagnosis” • “Another patient with syncope….” • History from patient may not be reliable.

15. Amnesia for Loss of Consciousness in Carotid Sinus Syndrome Perry S, et al: J Am Coll Cardiol 2005;45:1840

16. Neurallymediated reflex syncopal syndromes Vasovagal (common) faint Carotid sinus syndrome Situational faint Acute hemorrhage Cough, sneeze Gastrointestinal stimulation (swallow, defecation, visceral pain) Micturition (postmicturition) PostexerciseOther (e.g. brass instrument playing, weightlifting, postprandial) Glossopharyngeal and trigeminal neuralgia Orthostatic Primary autonomic failure syndromes (e.g. pure autonomic failure, multiple system atrophy, Parkinson’s disease with autonomic failure) Secondary autonomic failure syndromes (e.g. diabetic neuropathy, amyloid neuropathy) Volume depletion Hemorrhage, diarrhea, Addison’s disease Cardiac arrhythmias as primary cause Sinus node dysfunction (including bradycardia/tachycardia syndrome) AV conduction system disease Paroxysmal supraventricular and ventricular tachycardiasInherited syndromes (e.g. long QT syndrome, Brugada syndrome, short QT, arrhythmogenicdysplasia) Implanted device (pacemaker, ICD) malfunction Drug-induced proarrhythmiasStructural cardiac or cardiopulmonary disease Cardiac valvular disease Acute myocardial infarction/ischemia Obstructive cardiomyopathyAtrial myxomaAcute aortic dissection Pericardial disease/tamponadePulmonary embolus/pulmonary hypertension CerebrovascularVascular steal syndromes Causes of Syncope

17. Classification of Syncope Common and benign Orthostatic Neurocardiogenic Common and not so benign Sinus node dysfunction, carotid sinus hypersensitivity Paroxysmal AV block Less common, lethal Ventricular tachycardia, ventricular fibrillation Torsade de pointes Everything else

18. Emergency Visits with SyncopeEuropean Society of Cardiology Guidelines 465 patients Brignole M, et al. European Heart Journal 2006;27:76-82

19. Neurally - mediated Reflex syncope Vasovagal Carotid sinus hypersensitivity Situational Post-exercise Glossopharyngeal and trigeminal neuralgia Orthostatic syncope Primary autonomic failure Secondary autonomic failure Volume depletion Drugs and alcohol

20. Reflex Mechanism - Bezold Jarisch Trigger Venous return Vagal efferent HR BP Small ventricle Reflex C-fibers Syncope Sympathetic tone Vagal afferent Wall stretch Vasodilation BP Sympathetic withdrawal Arterial tone Inotropy Contractility BP Chang-Sing P. Cardiol Clinics. 1991;9(4):641-651

21. When is History and Physical Sufficient • Young patient with single presentation or clear situational dependency • Normal physical examination • Normal ECG • No significant injury • Low risk occupation

22. What about the rest of the patients? History & physical exam including CSM ECG Tilt table test Echocardiogram Electrophysiology study Holter monitor / Event recorder / Implantable Loop Recorder (ILR) Neurological evaluation Psychiatric evaluation

23. Role of history in differentiating NMS from cardiac syncope 341 patients Alboni P, et al: J Am Coll Cardiol 2001;37:1921-28

24. Role of history in differentiating NMS from cardiac syncope 341 patients Alboni P, et al: J Am Coll Cardiol 2001;37:1921-28

25. Role of history in differentiating NMS from cardiac syncope 191 patients with cardiac disease Alboni P, et al: J Am Coll Cardiol 2001;37:1921-28

26. Role of history in differentiating NMS from cardiac syncope 191 patients with cardiac disease Alboni P, et al: J Am Coll Cardiol 2001;37:1921-28

27. Case 2 53 year-old obese gentleman with diabetes, hypertension and hyperlipidemia who presented with syncope. This occurred after working at the boat yard on a very hot day. He was taking a break and drinking a cold slurpee, when he suddenly felt pins and needles inhis neck, peri-oral numbness, and tingling of his forehead. As he was calling for wife, he lost consciousness and fell to the ground. According to his wife, he was unconscious for about a minute and his entire body was quivering. Upon regaining consciousness, he was confused and disoriented. His wife reports that he was cold, clammy, and very diaphoretic. He sustained some minor bruising of left shoulder but no head injuries.

28. Case 2

29. ECG – Abnormal conduction • Short PR • Bundle branch blocks • Long QT • Short QT Prolonged PR / heart blocks • Functional • Vagal tone • Medications • Structural • AV nodal or His Purkinje fibrosis • Mitral annular calcification • Infiltrative • Genetic AV node His HV AH Intra-cardiac recording PR interval

30. What about the rest of the patients? History & physical exam including CSM ECG Tilt table test Echocardiogram Electrophysiology study Holter monitor / Event recorder / Implantable Loop Recorder (ILR) Neurological evaluation Psychiatric evaluation

31. Tilt table test

32. Tilt Table Response consistent with NMS Pretest 1 min 12.5 min Recovery ECG Syncope Blood Pressure (mmHg) Tilt 0 70 70 0 HR (BPM) 77 94 40 46 BP (mmHg) 115/70 125/80 55/30 98/55 Sra JS. Ann Intern Med. 1991;114:1013-1019.

33. Echocardiogram • Strongly consider for all patients • Screen for hypertrophic cardiomyopathy • Stratification for EP study Ejection fraction < 30% - meet criteria for ICD 35-50% - test for inducibility of VT

34. Electrophysiology Study • Risk stratification of ventricular arrhythmias – assess for inducibility • It is poor at diagnosing bradycardic arrhythmias • It is highly sensitive for tachycardias.

35. Holter Monitor Yield: Arrhythmia with symptoms = 2% Symtomswithout arrhythmia = 15% Gibson TC et al Am J Cardiol 1984;53:1013-17

36. Comparison of Loop Recorders versus Holter Monitor (COLAPS) Sivakumaran S, et al. Am J Med 2003;115:1-5

37. Event recorder in patient with syncope

38. Implantable Loop Recorders (ILR) Automatically detects bradycardia tachycardia asystole Records rhythm at time of trigger ILR Patient Assist Device

39. ILRs

40. Example tracing from ILR

41. ILR in unexplained syncope with normal conventional work-up Tachycardia Asystole / bradycardia 11% No arrhythmia 33% 56% Diagnostic yield: 35% (175/506 patients) Brignole et al. Europace 2009;11,671-687

42. Suspect Pacemaker malfuction • EKG 2. Interrogate pacemaker – check lead integrity with provocative maneuvers 3. Chest X-ray

43. Importance of Interrogating PPM or ICD Atrial lead Ventricular lead

44. Right ventricular lead Atrial lead 2

45. Syncope – red flags • Syncope resulting in injury • Syncope during exercise • Syncope in the supine position • Suspected or known structural heart disease • ECG abnormality Pre-excitation (WPW) Long QT Bundle-branch block HR<50 bpm or pauses > 3 seconds Mobitz I or more advanced heart block Documented tachyarrhythmia Myocardial infarction • Family history of sudden death • Frequent episodes (>2 per year) • Implanted pacemaker or defibrillator • High risk occupation (bus driver, pilot etc.) Advanced Age

46. Case 1 - review • Witnessed collapse while seated. • Episode of syncope with complete heart block noted on telemetry. • Dual chamber pacemaker implanted. • Discharged home the next day. Discharged after 24 observation with diagnosis of “Vaso-vagal syncope” 2 days later…

47. Case 1 Suspected or known structural heart disease - prior MI Abnormal EKG – trifasicular block Family history of sudden death – brother died at 45 Frequent episodes – “pirouette” 2 weeks prior

48. Case 2 - review • Cardiac arrest at home and successfully defibrillated but prolonged down time. • Had slow neurologic recovery. • ICD implanted for secondary prevention. Discharged after 24 observation with diagnosis of “Vaso-vagal syncope” 3 month later..

49. Case 2

50. Test questions Which of the following historical findings are useful for predicting neurally-mediated syncope in patients with heart disease and recurrent syncope? a. Feeling warm. b. Awareness of being about to faint. c. Recovery duration lasting longer than 60 minutes. d. Confusion during recovery. e. Time (years) between first and last syncopal episodes.