Syncope

1. Syncope A work up for Internists and Hospitalists Philip Dittmar January 31, 2014

2. I have no conflicts of interest to disclose.

3. Syncope • The current state in healthcare • Classification of syncope • Costs of a “typical” work up • Ways to provide “High Value Cost Conscious Care”

4. Syncope • Transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery. Moya A, Eur Heart J 2009

5. What we want to know? • What caused it to happen? • Will it happen again? • Is this a sign of other things? • Is it deadly?

6. What we do know… • 40% of the adult population has experienced a syncopal episode1 • 1% of ER visits2 • Up to 5% of admissions • Annual healthcare costs estimated at $2.4bn2 • Cost per inpatient work up $5,400 1Soteriades ES, N Engl J Med 2002 2 Sun BC, Am J Cardiol 2005

7. What we do know… • Incidence and rate of hospitalization increases with age 1Soteriades ES, N Engl J Med 2002

8. What does this do to our patients? Functional impairment on par with RA, chronic low back pain, and depressive disorders. Linzer M, J ClinEpidemiol 1991

9. Syncope • The current state in healthcare • Classification of syncope • Costs of a “typical” work up • Ways to provide “High Value Care”

10. Symptom not a Diagnosis • Cardiac syncope • Arrhythmia • Structural heart disease • Non-cardiac syncope • Neurally-mediated syncope • Orthostatic hypotension • Non-syncope • Epilepsy, concussion, psychogenic pseudosyncope

11. Cardiac Syncope • Arrhythmia • Bradycardia • Sick sinus, atrioventicularblock • Tachycardia • Ventricular tachycardia, supraventricular tachycardia, Wolff-Parkinson-White • Long QT syndrome, Brugada syndrome • Structural • Aortic stenosis, mitral stenosis • Hypertrophic obstructive cardiomyopathy • Ischemia

12. Non-Cardiac Syncope • Neurally-mediated syncope • Vasovagal • Carotid sinus • Situational – cough, sneeze, micturition • Orthostatic hypotension • Drug induced • Autonomic nervous system failure

13. Non-Syncope • Epilepsy • Concussion • Psychogenic pseudosyncope • Acute intoxication • Hypoglycemia • Sleep disorders

14. Overall Survival with Syncope Soteriades ES, N Engl J Med 2002

15. Causes of syncope by age Parry SW, BMJ 2010

16. Syncope • The current state in healthcare • Classification of syncope • Costs of a “typical” work up • Ways to provide “High Value Cost Conscious Care”

17. Our patient • 65-year-old man with history of CAD s/p stent with syncope. He does not recall any prodrome, but stated that symptoms started after walking across his living room. His wife was in another room and heard him crash into the coffee table. She noted some jerking movements prior to his return to full alertness. Wife called 911.

18. What we do (on day 0) • Thorough history with witness statement • Physical examination • ECG with telemetry • CBC, CMP, Troponin, CXR, Transthoracic Echo • CT Head • Urinalysis with Toxicology • Cost: >$1,500 https://www.healthcarebluebook.com/

19. What we do (on day 1) • Stress test • Carotid doppler • MRI/MRA • EEG • CTA chest • TSH, lipids, Hgb A1C • Additional cost for testing: >$4,250 https://www.healthcarebluebook.com/

20. …and on day 2 • Left heart catheterization • Send home with a Holter monitor • Could add an addition cost of: $7,0001 • Testing could reach: >$12,500 • Average cost in US per syncope-related hospitalization: $54002 • Average length of stay: 2.7 days 1https://www.healthcarebluebook.com 2 Sun BC, Am J Cardiol2005

21. Syncope • The current state in healthcare • Classification of syncope • Costs of a “typical” work up • Ways to provide “High Value, Cost Conscious Care”

22. How can we do this better? • Syncope. Cost-effective patient workup. • RadackKL, Postgrad Med 1986. • A cost effective approach to the investigation of syncope: relative merit of different diagnostic strategies • Simpson CS, Can J Cardiol1999.

23. AHA/ACCF Statement on the Evaluation of Syncope – 2006Expert Concensus Strickberger, SA, Circ & J Am CollCardiol 2006

24. New Concepts in the Assessment of Syncope. JACC 2012 Brignole M, J Am CollCardiol 2012

25. How do we assess risk? Parry SW, BMJ 2010

26. Calgary Syncope Symptom Score Vasovagal syncope if the total point score is ≥ -2 Excludes patients with known cardiomyopathy or myocardial infarction Sheldon R, Eur Heart J 2006

27. Red Flags – San Fran Syncope Rule • Congestive heart failure history • Hematocrit < 30% • EKG changes • Shortness of breath • Systolic Blood Pressure < 90 mm Hg at triage • No to all = Low risk for serious outcome at 7 days Quinn J, Ann Emerg Med 2004

28. OESIL Risk Score • Abnormal ECG • History of cardiovascular disease • Lack of prodrome • Age > 65 12 month all cause mortality: • 0% - score 0 • 0.6% - score 1 • 14% - score 2 • 29% - score 3 • 53% - score 4 Colvicchi F, Eur Heart J 2003

29. Recap of Risk Factors • Age • Known cardiac disease • Abnormal ECG • Lack of prodrome • Associated chest pain or shortness of breath

30. Syncope Evaluations in the Elderly • Retrospective Review from 2002-2006 at Yale • 2106 syncope admits, aged ≥65 • Admission or discharge diagnosis of syncope • Syncope Etiology: • Unknown 47% • Vasovagal 22% • Orthostasis 13% • Arrhythmia 12% • Dehydration 8% • Other cardiac causes 4% • Situational 3% • >1 Etiology 9% MenduML, Arch Intern Med 2009

31. Diagnostic Yield in Older Patients MenduML, Arch Intern Med 2009

32. Diagnostic Yield in Older Patients MenduML, Arch Intern Med 2009

33. MenduML, Arch Intern Med 2009

34. What is NOT helpful? • EEG • Head CT • Cardiac Enzymes • Carotid US

35. EEG and Syncope • Myoclonic jerks associated with true syncope • Can be mistaken for seizure activity • Ictalasystole is a rare but severe complication of epileptic seizures • 828 patients admitted for presurgery video EEG monitoring between 2003-2013. • 9 (1.08%) had ictalasystole • Lasting 13 +/- 7 seconds • Mostly asymptomatic Nguyen-Michel VH, Epilepsia 2014

36. Head CT and Syncope • Of 293 ED syncope patients, 113 underwent CT head • 5% had abnormal head findings • 2 with subarachnoid hemorrhage • 2 with cerebral hemorrhage • 1 with stroke • Abnormal CTs associated with: • Focal neurological findings, headache, or trauma • Only half of patients undergoing CT had any neurological findings, headache, trauma above the clavicles, or coumadin use. Grossman SA, Intern Emerg Med 2007

37. Cardiac Enzymes and Syncope • Troponin unlikely to be beneficial unless other signs or symptoms point to MI. • Copeptin – surrogate marker for Vasopressin • Studied in Acute Myocardial Infarction • Small studies have found increased levels in patients with positive head up tilt test.1 1Lagi A, Int J ClinPract 2013

38. Carotid US and Syncope • Choosing Wisely Recommendation #2: • Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. Langer-Gould AM, Neuro 2013

39. What does work? • Thorough history with collateral information from witness • Physical examination • Postural blood pressure • ECG • Cost = $435 https://www.healthcarebluebook.com/

40. Take a good history! • “5 Ps” • Precipitants • Prodrome • Palpitations • Position • Post-event phenomena • Appearance • Abnormal Movements • Eyes open or closed • Mental State • Incontinence/Tongue Biting • Chronic medical issues • Family history of SCD Parry SW, BMJ 2010

41. ECG and Telemetry • ECGs are relatively cheap and informative • Structural Heart Disease • Q-waves (infarct) • ST segment changes (ischemia) • Conduction System Disease • Bundle branch block • Atrioventricular (AV) block • Electrical Disease • Wolff-Parkinson-White (WPW) syndrome • Brugada syndrome • Long QT syndrome Marine JE, J Electrocardiol, 2013

42. Outpatient ECG Monitoring • Holter Monitor – daily syncopal episodes • Event Recorder – weekly syncopal episodes • Implantable Loop Recorder – monthly syncopal episodes

43. Postural Blood Pressure • Have the patient lie supine for 10 minutes • Measure blood pressure and pulse • Have the patient stand • Inquire about symptoms • Repeat blood pressure after 1 and 3 minutes • Classical Orthostatic Hypotension is defined by: • Drop in SBP >20 mm Hg or DBP >10 mm Hg within 3 minutes of standing

44. Carotid Sinus Syncope • Carotid Sinus Massage • 10 second sequential (right then left) with patient supine and erect • Hypersensitivity defined by: • Ventricular pause lasting >3 seconds • Fall in systolic BP >50 mm Hg • Carotid Sinus Syncope define by hypersensitivity in the presence of syncope

45. Post - H&P, ECG, and Postural BP • You should be able to answer: • Syncope or not? • Etiology determined based on the above? • High risk of cardiovascular events or death?

46. Echocardiogram and Syncope • Echo is helpful to confirm or refute suspicion of cardiac disease after the basics • Not indicated for syncope without suspicion of cardiac disease • Must have 2nd diagnosis

47. Advanced Cardiac Testing • Stress testing and Left Heart Catheterization • If concern for ischemia • EP study • If concern for tachyarrhythmia • Tilt test • For diagnostic dilemma or if it will affect treatment

48. Tilt Table Testing • An effective technique for providing direct diagnostic evidence indicating susceptibility to vasovagal syncope • Utilizes a drug-free tilt lasting 45 minutes and pharmacologic provocation (Isoproterenol) • Monitor heart rate and blood pressure • Positive test with provocation of neurally-mediated hypotension or bradycardia (or both) Benditt DG, JACC, 1996

49. General Concepts • Perform a comprehensive history and physical examination using evidence based tools • Routinely obtain an ECG • Utilize EEG, Head CT, or MRI only with clinical suspicion of focal neurological deficit or seizure • Consider Holter, event recorder, or implantable loop recorders if an arrythmia is suspected, depending on frequency of events • Utilize cardiac imaging only with clinical suspicion of structural or valvular heart disease • Perform invasive EP study only with clinical suspicion of a tachyarrhythmia • Obtain a Tilt test only for diagnostic dilemma and if it will affect treatment and/or outcome

50. Do’s and Don’ts • Do every time: • H&P, ECG, Postural Blood Pressure • Try to avoid: • EEG, Cardiac Enzymes, Head CT, Carotid US • Other testing as indicated based on findings • Try to avoid the shot gun approach