Syncope

MRS SHAGUFTA ISHTIAQ

RESPIRATORY AND CIRTICAL CARE TECHNOLOGIST.

DIMT-Dow University of Health Sciences

OBJECTIVES

AT THE END OF LECTURE STUDENTS WILL BE ABLE TO

Understand syncope

Know Know

Etiology of syncope the Impact of syncope

Classification of Transient Loss of Consciousness (TLOC)

Real or Apparent Transient Loss of Syncope (TLOC)

Syncope

Neurally-mediated reflex
syndromes

Disorders Mimicking Syncope

With loss of consciousness, i.e.,

seizure disorders

Orthostatic hypotension Cardiac arrhythmias Structural cardiovascular

disease

Without loss of consciousness,

i.e., psychogenic pseudosyncope

Brignole M, et al. Europace, 2004;6:467-537.

Syncope A Symptom, Not a Diagnosis

Self-limited loss of consciousness and postural tone Relatively rapid onset Variable warning symptoms Spontaneous, complete, and usually prompt recovery without medical or surgical intervention

Underlying mechanism is transient global cerebral hypoperfusion.

Brignole M, et al. Europace, 2004;6:467-537.

Section I

Causes of True Syncope

NeurallyMediated

Orthostatic

Cardiac Arrhythmia

Structural CardioPulmonary
4
Acute Myocardial Ischemia Aortic Stenosis

1
Vasovagal syncope (VVS) Carotid sinus syndrome (CSS) Situational
Cough PostMicturition

2
Drug-Induced Autonomic

3
Brady
Sinus Node Dysfunction Atro Ventricular Block

Nervous System (ANS)

Failure

Tachy
Vent Tacycardia VT Sinus VT (SVT)

Hypertrophic Cardiomyopa thy (HCM)

Pulmonary Hypertension Aortic Dissection

Long QT Syndrome

Section II:
Diagnosis

Diagnostic Objectives

Distinguish true syncope from syncope mimics Determine presence of heart disease Establish the cause of syncope with sufficient

Assessment of prognosis

effective preventive treatment

A Diagnostic Plan is Essential

Initial Examination Detailed patient history Physical exam ECG Supine and upright
blood pressure

Monitoring Holter Event Insertable Loop Recorder (ILR) Cardiac Imaging Special Investigations Head-up tilt test Hemodynamics Electrophysiology study

Diagnostic Flow Diagram for Transient Loss of Consiousness TLOC

Initial Evaluation

Syncope
Certain Diagnosis Suspected Diagnosis Unexplained Syncope

Not Syncope

Cardiac Likely

Neurally-Mediated or Orthostatic Likely

Frequent or Severe Episodes

Single/Rare Episodes

Confirm with Specific Test or Specialist Consultation

Cardiac Tests

Tests for NeurallyMediated Syncope

Tests for NeurallyMediated Syncope

No Further Evaluation

Re-Appraisal

Re-Appraisal

Treatment

Treatment

Treatment

Treatment

Initial Exam: Detailed Patient History

Circumstances of recent event Eyewitness Symptoms at onset of event Sequelae Medications Circumstances of more remote events Concomitant disease, especially cardiac Pertinent family history Cardiac disease Sudden death Metabolic disorders Past medical history Neurological history Syncope

Brignole M, et al. Europace, 2004;6:467-537.

Initial Exam: Thorough Physical

Vital signs

Heart rate

Orthostatic blood pressure change

Cardiovascular exam: Is heart disease present?

ECG: Long QT, pre-excitation, conduction system disease

Echo: LV function, valve status, HCMHypertrophic Cardiomyopathy

Neurological exam Carotid sinus massage

Perform under clinically appropriate conditions preferably

during head-up tilt test

Monitor both ECG and BP

Brignole M, et al. Europace, 2004;6:467-537.

Carotid Sinus Massage (CSM)

Method1

Absolute contraindications2

Massage, 5-10 seconds

Carotid bruit, known significant

carotid arterial disease, previous CVA, MI last 3 months

Dont occlude
Supine and upright posture
(on tilt table)

Complications

Outcome

Primarily neurological

3 second as ystole and/or

50 mmHg fall in systolic BP with reproduction of symptoms = Carotid Sinus Syndrome

Less than 0.2%

Usually transient

60 - 80

Other Diagnostic Tests

Ambulatory ECG

Holter monitoring

Event recorder

Intermittent vs. Loop Insertable Loop Recorder (ILR)

Head-Up Tilt (HUT)

Includes drug provocation (NTG, isoproterenol) Carotid Sinus Massage (CSM)

Adenosine Triphosphate Test (ATP) Electrophysiology Study (EPS)

Brignole M, et al. Europace, 2004;6:467-537.

Heart Monitoring Options

OPTION

12-Lead 10 Seconds
2 Days

Holter Monitor Event Recorders

(non-lead and loop)

7-30 Days Up to 14 Months

ILR 0 1 2 3 4 5 6 7 8 9 10 11 12 13

14

TIME (Months)

Brignole M, et al. Europace, 2004;6:467-537.

Head-Up Tilt Test (HUT)

Protocols vary Useful as diagnostic adjunct in atypical syncope cases Useful in teaching patients to recognize prodromal symptoms Not useful in assessing treatment

60 - 80

Brignole M, et al. Europace. 2004;6:467-537.

Insertable Loop Recorder (ILR)

Click once on black screen to play video.

Reveal Plus ILR

Typical Location of the Reveal Plus ILR

Insertable Loop Recorder (ILR)

The ILR is an implantable patient and automatically activated monitoring system that records subcutaneous ECG and is indicated for:
Patients with clinical syndromes or situations at increased risk of

cardiac arrhythmias
Patients who experience transient symptoms that may suggest a

cardiac arrhythmia

Section III:
Specific Conditions and Treatment

Specific Conditions
Cardiac

arrhythmia

Brady/Tachy

Long QT syndrome
Torsade de pointes Brugada

Drug-induced
Structural

cardio-pulmonary

Neurally-mediated

Vasovagal Syncope (VVS)

Carotid Sinus Syndrome (CSS)
Orthostatic

Cardiac Syncope

Includes cardiac arrhythmias Often life-threatening May be warning of critical CV disease

Tachy and brady arrhythmias Myocardial ischemia, aortic stenosis, pulmonary hypertension,
aortic dissection

Assess culprit arrhythmia or structural abnormality aggressively Initiate treatment promptly

Brignole M, et al. Europace. 2004;6:467-537.

Syncope Due to Structural Cardiovascular Disease: Principle Mechanisms

Acute MI/Ischemia

2 neural reflex bradycardia

Vasodilatation, arrhythmias, low output (rare)

Pulmonary embolus/ pulmonary hypertension

Neural reflex, inadequate

flow with exertion

Hypertrophic cardiomyopathy

Valvular abnormalities

Limited output during exertion

(increased obstruction, greater demand), arrhythmias, neural reflex

Aortic stenosis Limited output,

neural reflex dilation in periphery

Mitral stenosis, atrial myxoma

Obstruction to adequate flow

Acute aortic dissection

Neural reflex mechanism,

pericardial tamponade

Brignole M, et al. Europace. 2004;6:467-537.

Syncope Due to Cardiac Arrhythmias

Bradyarrhythmias

Sinus arrest, exit block

High grade or acute complete AV block

Can be accompanied by vasodilatation (VVS, CSS)

Tachyarrhythmias

Atrial fibrillation/flutter with rapid ventricular rate

(eg, pre-excitation syndrome)

Paroxysmal SVT or VT Torsade de pointes

Brignole M, et al. Europace. 2004;6:467-537.

Cardiac Rhythms During Unexplained Syncope-ILR

Composite: N=133 to 7109

Bradycardia 16% (11-21%)

Arrhythmia 22%
(13-32%)

No Recurrence 36% (31-48%)

Tachycardia 6% (2-11%) Other 11% Normal Sinus Rhythm 31% (17-44%)

Seidl K. Europace. 2000;2(3):256-262. Krahn AD. PACE. 2002;25:37-41. Medtronic ILR Replacement Data. FY03, 04. On file.

Long QT Syndromes

Mechanism

Abnormalities of sodium and/or potassium channels

Susceptibility to polymorphic VT (Torsade de pointes)

Prevalence

Drug-induced forms Common

Genetic forms Relatively rare, but increasingly being recognized

Concealed forms:

May be common Provide basis for drug-induced torsade

Schwartz P, Priori S. In: Zipes D and Jalife J, eds. Cardiac Electrophysiology. Saunders;2004:651-659.

Syncope: Torsade de Pointes

From the files of DG Benditt, MD. U of M Cardiac Arrhythmia Center

Long QT Syndromes: 12-Lead ECG

From the files of DG Benditt, MD. U of M Cardiac Arrhythmia Center

Drug-Induced QT Prolongation
(List is continuously being updated)

Antiarrhythmics

Antibiotics

Class IA

Erythromycin, Pentamidine,
Fluconazole, Ciprofloxacin and its relatives

Class III
Antianginal

Agents

Nonsedating antihistamines

Psychoactive Agents

Terfenadine*, Astemizole
Others

Cisapride*, Droperidol,
Haloperidol

*Removed from U.S. Market

Brignole M, et al. Europace, 2004;6:467-537.

Syncope Due to Bradyarrhythmia

0.4 nV 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

08:23:37

0.0 -0.2 -0.4 :37 :38 :39 :40 :41 :42 :43 :44 :45

ACC/AHA/NASPE 2002 Guideline Update. Circ. 2002;106:2145-2161.

Treatment of Syncope Due to Tachyarrhythmia

Atrial tachyarrhythmias

AVRT due to accessory pathway Ablate pathway AVNRT Ablate AV nodal slow pathway Atrial fib Pacing, linear/focal ablation for paroxysmal AF

Atrial flutter Ablate the IVC-TV isthmus of the re-entrant circuit

for typical flutter

Ventricular tachyarrhythmias

Ventricular tachycardia ICD or ablation where appropriate

Torsade de pointes Withdraw offending drug or implant ICD
(long QT/Brugada/short QT)

Drug therapy may be an alternative in many cases

Brignole M, et al. Europace. 2004;6:467-537.

Neurally-Mediated Reflex Syncope

Vasovagal Syncope (VVS) Carotid Sinus Syndrome (CSS) Situational syncope

Post-micturition Cough

Swallow
Defecation Blood drawing, etc.

Brignole M, et al. Europace, 2004;6:467-537.

VVS Diagnosis

History and physical exam, ECG and BP

Head-Up Tilt (HUT) Protocol:

Fast > 2 hours ECG and continuous blood
pressure, supine, and upright
60 - 80

Tilt to 70, 20 minutes Isoproterenol/Nitroglycerin if

necessary

End point Loss of consciousness

Benditt D, et al. JACC. 1996;28:263-275. Brignole M, et al. Europace, 2004;6:467-537.

VVS General Treatment Measures

Optimal treatment strategies for VVS are a source of debate

Treatment goals

Long-term prevention

Acute intervention

Physical maneuvers, eg, crossing legs or tugging arms Lowering head Lying down

Tilt training Education Diet, fluids, salt

Support hose
Drug therapy Pacing

Brignole M, et al. Europace, 2004;6:467-537.

VVS Tilt Training Protocol

Objectives

Enhance orthostatic tolerance

Diminish excessive autonomic

reflex activity

Reduce syncope
susceptibility/recurrences

Technique

Prescribed periods of upright

posture against a wall

Start with 3-5 min BID Increase by 5 min each

week until a duration of 30 min is achieved

Reybrouck T, et al. PACE. 2000;23(4 Pt. 1):493-498.

CSS Etiology

Sensory nerve endings in the carotid sinus walls respond to deformation Deafferentation of neck muscles may contribute

Increased afferent signals to brain stem

Reflex increase in efferent vagal activity and diminution of sympathetic tone results in bradycardia and vasodilatation

Carotid Sinus

Orthostatic Hypotension

Etiology Drug-induced (very common)

Secondary autonomic failure

Diabetes

Diuretics Vasodilators

Alcohol Amyloid

Primary autonomic failure

Multiple system atrophy Parkinsons Disease Postural Orthostatic Tachycardia

Syndrome (POTS)

Brignole M, et al. Europace, 2004;6:467-537.

Syncope: Diagnostic Testing in Hospital Strongly Recommended

Suspected/known significant heart disease ECG abnormalities suggesting potential life-threatening arrhythmic cause Syncope during exercise Severe injury or accident

Family history of premature sudden death

Brignole M, et al. Europace. 2004;6:467-537.

Conclusion

Syncope is a common symptom with many causes Deserves thorough investigation and appropriate treatment A disciplined approach is essential

Brignole M, et al. Europace, 2004;6:467-537.

Brief Statement
Indications 9526 Reveal Plus Insertable Loop Recorder The Reveal Plus ILR is an implantable patient- and automatically activated monitoring system that records subcutaneous ECG and is indicated for Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias Patients who experience transient symptoms that may suggest a cardiac arrhythmia

6191 Activator
The Model 6191 Activator is intended for use in combination with a Medtronic Model 9526 Reveal Plus Insertable Loop Recorder. Contraindications There are no known contraindications for the implantation of the Reveal Plus ILR. However, the patients particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated. Warnings/Precautions 9526 Reveal Plus Insertable Loop Recorder Patients with the Reveal Plus ILR should avoid sources of magnetic resonance imaging, diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing. 6191 Activator Operation of the Model 6191 Activator near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device. Potential Complications Potential complications include, but are not limited to, body tissue rejection phenomena, including local tissue reaction, infection, device migration and erosion of the device through the skin. 2090 Programmer

The Medtronic/Vitatron CareLink programmer system is comprised of prescription devices indicated for use in the interrogation and programming of implantable medical devices. Prior to use, refer to the Programmer Reference Guide as well as the appropriate programmer software and implantable device technical manuals for more information related to specific implantable device models. Programming should be attempted only by appropriately trained personnel after careful study of the technical manual for the implantable device and after careful determination of appropriate parameter values based on the patient's condition and pacing system used. The Medtronic/Vitatron CareLink programmer must be used only for programming implantable devices manufactured by Medtronic or Vitatron.
See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1-800-328-2518 and/or consult Medtronics website at www.medtronic.com. To learn more about syncope, visit www.fainting.com. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.