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Syncope

Ed Da Veiga, M.D. August 20, 2008

Learning Objectives
Recognize the vast etiologies of syncope Understand the importance of uncovering underlying organic heart disease Learn diagnostic and management strategies for neurally mediated syncope

You know, medicine is not an exact science, but we are learning all the time. Why, just fifty years ago, they thought a disease like your daughter's was caused by demonic possession or witchcraft. But nowadays we know that Isabelle is suffering from an imbalance of bodily humors, perhaps caused by a toad or a small dwarf living in her stomach. Theodoric, Barber of York

Case Presentation
38 year old male with hangover on flight for honeymoon to St. Lucia Stewardess asks for medical assistance as patient felt funny and then passed out What do you want to know?

Overview
Syncope is a symptom, not a disease In all forms, consists of a sudden decrease or brief cessation of cerebral blood flow Accounts for 3.5% of ER visits and 1-6% of all hospital admissions per year

Definition
Sudden and brief loss of consciousness associated with a loss of postural tone, from which recovery is spontaneous

Distinguishing Syncope
Dizziness, presyncope, Features to distinguish and vertigo syncope from seizure
No LOC or loss of postural tone

Drop attacks
Lead to falls without loss of consciousness Sometimes sign of vertebrobasilar TIA (15%)

Prodromal/ Premonitory symptoms Precipitating event Events that follow it

Precipitants/Prodromal Symptoms
LOC precipitated by pain, exercise, micturition, defecation, or stressful event usually syncope Sweating, nausea = syncope Aura = Seizure Disorientation/ LOC > 5 minutes usually seizure rather than syncope

Important information
WITNESSES? Initial Assessment (especially HISTORY) will often lead to a clear diagnosis and help efficiently direct further workup and/ or treatment H and P leads to identification of cause in 45% of patients

Differential Diagnoses
Neurally Mediated Syncope (24%)
Vasovagal Situational Carotid Sinus

Neurologic Dz (10%) Cardiac Syncope


Organic Heart Disease (4%) Arrhythmias (14%)

Orthostatic Hypotension (10%) Psychiatric Disorders (2%)

UNKNOWN (34%)
50-66% may be neurally mediated based on tilt-table studies

Soteriades, E., et al. Incidence and Prognosis of Syncope. NEJM 2002: 347:881

Structural Heart Disease


Presence of a structural heart disease (CAD, CHF, Valvular Heart Disease, CHD) is the most important risk factor for predicting the risk of death Have risk of death at one year Most arrhythmias are found in these patients

Soteriades, E. et al. Incidence and Prognosis of Syncope. NEJM 2002; 347:883

Risk Factors
Predictors of arrhythmic syncope or cardiac death at one year
CHF Ventricular tachyarrhythmias Abnormal ECG Age >45 years

Presence of 2 or more of these is associated with >10% incidence of syncope or cardiac death

Cardiac Differential
Cardiac Syncope: LOC often w/o prodrome
Indicates Outflow Obstruction AS, HOCM, PAH, Pulmonic Stenosis, PE

MI, USA, Coronary Artery Spasm, Aortic Dissection Arrhythmias


Prolonged QT (either Congenital or Drug Induced) AV Block, Sinus Node Dysfunction Ventricular tachycardia Arrhythmogenic right ventricular dysplasia Supraventricular tachycardia (Wolff-Parkinson-White)

Neurally Mediated Syncope


Most Common Causes Vasovagal, Situational, and Carotid Sinus Syncope Results from sudden reflex mediated hypotension/ and or bradycardia Triggered by various stretch/ mechanoreceptors (carotid sinus, bladder, esophagus, respiratory tract

Carotid Sinus Syncope and Autonomic Dysfunction

Freeman, M. Neurogenic Orthostatic Hypotension. NEJM 2008; 358: 616

Neurally Mediated Syncope Pathophysiology


Peripheral Venous Pooling h causes sudden i in peripheral venous return Leads to cardiac hypercontractile state which activates stretch receptors Neural traffic h to brain mimics severe hypertension and provokes paradoxical bradycardia and i in PVR

TIMBER!!!

Orthostatic Hypotension
Decline of >20mm Hg in SBP/ 10mm Hg in DBP from supine to standing Supine HTN common in these patients Elderly especially vulnerable
Baroreceptor sensitivity, Cerebral Blood Flow, renal sodium wasting, thirst response with aging

Peripheral sympathetic tone impairment


Diabetic neuropathy, antihypertensive medication

Neurologic Causes
Syncope rare manifestation of cerebrovascular disease Subclavian steal syndrome, Basilar Artery Migraine (syncope and HA) Vertebrobasilar insufficiency Drop Attacks

Diagnostic Evaluation
H and P! 45% of time can identify cause CBC, BMP ECG- Low yield but can be important clues to look for underlying heart disease CT Head, EEG: low yield Echocardiogram/ Stress Test: Helpful when presence of underlying cardiac disease cannot be determined clinically

History
Time of day Activities preceding (recurrent/at rest, exercise
associated, on standing)

Prodromes, associated symptoms Duration of LOC Injuries Medications, ingestions Cardiac History

Kapoor WN. NEJM. 2000. 343(25): 1856-1862

Family History
Sudden unexplained death Deafness Arrhythmias Congenital heart disease Seizures Metabolic disorders Myocardial infarction at young age

Physical Exam
Pulse, blood pressure taken supine and standing after 3 minutes Murmurs, clicks of outflow tract obstruction Neurologic examination Carotid Massage (if no bruit)

Arrhythmia Testing
Telemetry Holter: 12-24 hours
symptoms w/ arrhythmia (5%) v. symptoms without arrhythmia (17%)

External Loop Recorders : can wear for weeks to months Implantable Loop Recorders: Monitor for 12-18 months
Provided diagnosis in 55% of pts with unexplained syncope compared to conventional methods

EP Studies: Helpful with structural heart disease

Tilt Table Test


Used to evaluate autonomic nervous system Evaluates predisposition to neurally mediated syncope Specificity of negative test 90%

Indications for Tilt Table Testing


Unexplained recurrent syncope Single episode associated with injury or in settings that pose a high risk of injury If organic heart disease is present, than after cardiac causes have been excluded Evaluation of recurrent syncope in setting of autonomic failure Assessment of recurrent, unexplained falls

Indications for Hospital Admission


History of CAD, CHF, Ventricular Arrhthmia Accompanying Chest Pain Abnormal ECG Moderate to severe orthostatic hypotension Age > 70 yrs Resulting Trauma

Management

Management of Neurally Mediated Syncope

Grubb BP.

NEJM. 2005. 352(10): 1004-1010

Patient Instructions
Preventing Syncope or Vasovagal Spells
Avoid EtOH, lack of sleep, warm environment Maintain adequate hydration and food intake Avoid drugs that lead to hypotension Avoid activities that precipitate syncope

Preventing LOC or Injury


Assume supine position upon onset of prodrome Avoid driving or other activities that could lead to injury

Bibliography
Kapoor, WN Syncope. NEJM 2000; 343: 1856-62 Freeman, R Neurogenic Orthostatic Hypotension NEJM 2008; 358: 615-624 Soteriades, et al. Incidence and Diagnosis of Syncope. NEJM 2002; 347:878-885 Grubb, B. Neurocardiogenic Syncope. NEJM 2005; 1004-1010

Thanks!

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