1. Syncope Courtney McIlduff, M. Sc. Catherine Florio Pipas, M. D. Dartmouth Medical School

2. Objectives Present a Clinical Case Present a Clinical Case Define Syncope Define Syncope Provide an Overview of Syncope Statistics Provide an Overview of Syncope Statistics Explore the Differential Diagnosis of Syncope Explore the Differential Diagnosis of Syncope Review a Study to: Review a Study to: Establish a framework for approaching the case Establish a framework for approaching the case Address the question “Why is it so important to distinguish non-cardiac from cardiac causes of syncope?” Address the question “Why is it so important to distinguish non-cardiac from cardiac causes of syncope?” Predict Prognosis using an AFP Point of Care Guide Predict Prognosis using an AFP Point of Care Guide Give a Pop Quiz Give a Pop Quiz Summarize Key Points Summarize Key Points

3. Case Presentation “Jackie” is a 54 year-old woman with Down Syndrome “Jackie” is a 54 year-old woman with Down Syndrome And a history of seizure disorder And a history of seizure disorder Who presents with her caregiver. Who presents with her caregiver. Her chief concern is: “I keep fainting.” Her chief concern is: “I keep fainting.”

4. Case Presentation: HPI 3 episodes of syncope over the previous 8 months - Jackie gets up at 4 am to go to the bathroom - Caregiver hears her fall to the floor - Caregiver finds Jackie on her back and “unconscious” - Jackie remains unarousable for about 5 minutes - Jackie returns to bed

5. Case Presentation: HPI No overt seizure activity No overt seizure activity No injuries No injuries No pain No pain No shortness of breath No shortness of breath No h/o preceding balance trouble No h/o preceding balance trouble No h/o light-headedness No h/o light-headedness No h/o recent illness No h/o recent illness History of low blood pressure (home measurements: 90s/60-70s) History of low blood pressure (home measurements: 90s/60-70s) Taking all medications as prescribed Taking all medications as prescribed

6. Case Presentation: Medications Exelon Exelon Neurontin Neurontin Tegretol Tegretol Seroquel Seroquel Levoxyl Levoxyl Ranitidine Ranitidine Allergies: No known drug allergies

7. Case Presentation: PMH Seizure Disorder Seizure Disorder (“Epilepsy with occasional tendency for tonic-clonic Seizures”) Conduct Disorder (aggressive outbursts) Conduct Disorder (aggressive outbursts) Hypothyroidism Hypothyroidism GERD GERD

8. Case Presentation Family History: Significant for breast cancer (mother) Significant for breast cancer (mother) Social History: Lives with her caregiver Lives with her caregiver Participates in a Day Program Participates in a Day Program Enjoys X-box Enjoys X-box

9. Physical Exam Vitals: AfebrileBP: 90/58HR: 60 Vitals: AfebrileBP: 90/58HR: 60 Gen: well-appearing, slightly sleepy woman who engages well throughout visit with eye contact and conversation Gen: well-appearing, slightly sleepy woman who engages well throughout visit with eye contact and conversation CVS: regular rate and rhythm. Grade II/VI Systolic ejection murmur heard best in aortic region CVS: regular rate and rhythm. Grade II/VI Systolic ejection murmur heard best in aortic region Pulm: Clear to auscultation bilaterally Pulm: Clear to auscultation bilaterally

10. Initial Impression Recurrent syncope Recurrent syncope

11. Definition of Syncope Sudden, transient loss of consciousness due to cerebral hypoperfusion Sudden, transient loss of consciousness due to cerebral hypoperfusion Associated with loss of postural tone Associated with loss of postural tone Usually followed by rapid and complete recovery Usually followed by rapid and complete recovery

12. Syncope Stats Common clinical problem: Common clinical problem: 1/3 of people will experience an episode of syncope in their lifetime 1/3 of people will experience an episode of syncope in their lifetime Incidence increases with age, with sharp rise at 70 years Incidence increases with age, with sharp rise at 70 years Male = female incidence, BUT men more likely to have cardiac cause Male = female incidence, BUT men more likely to have cardiac cause

13. Syncope Stats continued Predictors of Cardiac Causes of Syncope include: Predictors of Cardiac Causes of Syncope include: Cardiovascular Disease – strongest predictor of cardiac cause Cardiovascular Disease – strongest predictor of cardiac cause History of Stroke or TIA History of Stroke or TIA Hypertension Hypertension

14. Differential Diagnosis of Syncope: Non-Cardiac vs Cardiac Non-Cardiac: Neurocardiogenic Neurocardiogenic Orthostatic Hypotension Orthostatic Hypotension Neurologic Neurologic Sz Sz TIA TIA Other: Other: Metabolic: hypoglycemia, hypoxia, anemia Metabolic: hypoglycemia, hypoxia, anemia Psychogenic Psychogenic Drug-Induced Drug-Induced Cardiac: Structural Arrhythmia

15. Category 1: Structural Causes of Cardiac Syncope Endo: Aortic Stenosis, Mitral Stenosis, Pulm. Stenosis Endo: Aortic Stenosis, Mitral Stenosis, Pulm. Stenosis Myo: Myocardial Infarction, Hypertrophic Obstructive Cardiomyopathy Myo: Myocardial Infarction, Hypertrophic Obstructive Cardiomyopathy Peri: Tamponade Peri: Tamponade Vasc: Aortic Dissection, PE Vasc: Aortic Dissection, PE

16. Category 2 : Arrhythmia as a Cause of Cardiac Syncope Tachy: Tachy: 1. Ventricular Tachycardia 2. Supraventricular Tachycardia Diagnosed by ECG

17. Category 2: Arrhythmia as a Cause of Cardiac Syncope Brady Brady 2 nd or 3 rd Degree AV Block 2 nd or 3 rd Degree AV Block Conduction of impulse from atria to ventricles is delayed Conduction of impulse from atria to ventricles is delayed Atrial impulse fails to reach ventricles Atrial impulse fails to reach ventricles Due to Due to Organic heart disease Organic heart disease Medication Medication Diagnosed by ECG or Holter Monitor Diagnosed by ECG or Holter Monitor

18. Category 2: Arrhythmia as a Cause of Cardiac Syncope Bradyarrhythmias continued Bradyarrhythmias continued Sick Sinus Syndrome (SSS) Sick Sinus Syndrome (SSS) Delayed or failed conduction between sinus node and atria Delayed or failed conduction between sinus node and atria Due to Due to Inadequate sinus node pacing Inadequate sinus node pacing Intrinsic / extrinsic (eg meds) conduction disturbances Intrinsic / extrinsic (eg meds) conduction disturbances Diagnosed by ECG or Holter Monitor Diagnosed by ECG or Holter Monitor Sinus pause (>3 s strongly suggestive of SSS) Sinus pause (>3 s strongly suggestive of SSS)

19. Questions How can we put the differential diagnosis into context? How can we put the differential diagnosis into context? Why is it so important to distinguish non-cardiac from cardiac causes of syncope? Why is it so important to distinguish non-cardiac from cardiac causes of syncope?

20. Study: Context for Approaching Jackie’s Case “Incidence and Prognosis of Syncope” Soteriades E et al. N Engl J Med 2002;347:878-885Purpose: To evaluate incidence, etiology, and prognosis of syncope in Framingham Heart Study participants from 1971 to 1998. To evaluate incidence, etiology, and prognosis of syncope in Framingham Heart Study participants from 1971 to 1998.

21. Study Results: Over an average follow-up period of 17 years, 822 of 7814 male and female participants reported an initial episode of syncope Over an average follow-up period of 17 years, 822 of 7814 male and female participants reported an initial episode of syncope Incidence of syncope: 6.2 per 1000 person-years Incidence of syncope: 6.2 per 1000 person-years Etiologies most frequently identified: Etiologies most frequently identified: neurocardiogenic (vasovagal)21.2 % neurocardiogenic (vasovagal)21.2 % cardiac 9.5 % cardiac 9.5 % orthostatic 9.4 % orthostatic 9.4 % unknown36.6 % unknown36.6 % Soteriades E et al. N Engl J Med 2002;347:878-885

22. Study Conclusions Neurocardiogenic (vasovagal) syncope: Benign No increased risk of death Syncope of unknown and neurologic causes: Intermediate increase in risk of death from any cause Cardiac syncope: Increased risk of death by a factor of 2 Increased risk of cardiovascular events Soteriades E et al. N Engl J Med 2002;347:878-885

23. First Distinction: Non-cardiac vs Cardiac Non-cardiac causes most often benign most often benign self-limited self-limited Cardiac  high incidence of subsequent cardiac arrest (~24%)  higher mortality rate

24. Jackie: evidence for non-cardiac causes of syncope Non-Cardiac: → Neurocardiogenic → Neurocardiogenic Micturition Micturition → Orthostatic Hypotension → Orthostatic Hypotension Documented h/o hypotension Documented h/o hypotension Timing of incident: rising from bed to go to bathroom Timing of incident: rising from bed to go to bathroom → Neurologic → Neurologic Documented Seizure disorder Documented Seizure disorder

25. But: evidence for cardiac cause of syncope No Seizure Activity No Seizure Activity No reported prodrome (nausea, diaphoresis) No reported prodrome (nausea, diaphoresis) No triggers (prolonged standing, heat, pain, fear, exercise) No triggers (prolonged standing, heat, pain, fear, exercise) No Recent Medication Changes No Recent Medication Changes Multiple episodes over short period  serious underlying condition Multiple episodes over short period  serious underlying condition Down Syndrome – associated with cardiac abnormalities Down Syndrome – associated with cardiac abnormalities

26. Jackie: Diagnostic Studies Labs: Labs: CBC CBC Complete Metabolic Panel Complete Metabolic Panel TSH TSH Tegretol Level Tegretol Level  all within normal limits  all within normal limits ECG: sinus bradycardia ECG: sinus bradycardia  American College of Emergency Physicians recommends ECG if Hx and PE do not provide dx

27. Jackie: Further Diagnostic Studies 24 hour Holter Monitor – performed due to suspected Sick Sinus Syndrome 24 hour Holter Monitor – performed due to suspected Sick Sinus Syndrome Results: Results: Avg HR: 55 (min = 36, max = 98) Avg HR: 55 (min = 36, max = 98) Sinus Rhythm Sinus Rhythm 395 pauses 395 pauses Longest 2.7 seconds Longest 2.7 seconds

28. Jackie: Update Visit with the Cardiologist Visit with the Cardiologist Choices for Future Follow-up Choices for Future Follow-up Event Monitor Event Monitor Implantable Loop Recorder Implantable Loop Recorder Permanent Pacemaker…. Permanent Pacemaker….

29. Jackie: Predicting Mortality Jackie, her caregiver, and her family decide which follow-up measure to pursue. In the interim, is there a way to predict her one year mortality rate?

30. “First Syncope Rule” Clinical Risk Score for Predicting One-Year Mortality in Patients with Syncope Risk factors Abnormal electrocardiogram* Age older than 45 years History of congestive heart failure History of ventricular arrhythmia Number of risk factorsOne-year mortality rate (%) 01 19 216 3 or 427 *-Abnormal electrocardiogram does not include sinus bradycardia or tachycardia or nonspecific ST- or T- wave changes alone. Ebell, Mark H. Syncope: initial evaluation and prognosis. American Family Physician 2006; 74(8): 1367-70.

31. What is Jackie’s Prognosis? Abnormal ECG* Abnormal ECG* Age older than 45 years Age older than 45 years h/o congestive heart failure h/o congestive heart failure h/o ventricular arrhythmia h/o ventricular arrhythmia No  0 Yes  1 No  0 _____________________ Total1 risk factor = 1% 1-year mortality rate

32. Pop Quiz What are the 3 main categories of Non-Cardiac Causes of Syncope? What are the 3 main categories of Non-Cardiac Causes of Syncope? Hint: N-O-N cardiac…. Hint: N-O-N cardiac….

33. Pop Quiz What are the 2 main categories of Cardiac Causes of Syncope? What are the 2 main categories of Cardiac Causes of Syncope?

34. Summary Non-Cardiac: Neurocardiogenic (vaso- vagal: Reflex Mech.s) Neurocardiogenic (vaso- vagal: Reflex Mech.s) Orthostatic Hypotension Orthostatic Hypotension Neurologic Neurologic Sz Sz TIA TIA Other: Other: Metabolic: hypoglycemia, hypoxia, anemia Metabolic: hypoglycemia, hypoxia, anemia Psychogenic Psychogenic Drug-Induced Drug-Induced Cardiac: Arrhythmia Tachy VT SVT Brady AV Block Sick Sinus Structural Endo: AS, MS, PS Myo: MI, HOCM Peri: tamponade Vasc: aortic dissection, PE

35. Questions?

36. Thank you!

37. References & Resources CIS Records CIS Records CP Online: http://cponline.hitchcock.org/ CP Online: http://cponline.hitchcock.org/ Ebell, Mark H. Syncope: initial evaluation and prognosis. American Family Physician 2006; 74(8): 1367-70. Ebell, Mark H. Syncope: initial evaluation and prognosis. American Family Physician 2006; 74(8): 1367-70. Elpidoforos, Soteriades, S., Evans, Jane C., Larson, Martin G., Chen, Ming Hui, Chen, Leway, Benjamin, Emelia J., and Levy, Daniel. Incidence and prognosis of syncope. New England Journal of Medicine 2002; 347:878-885. Elpidoforos, Soteriades, S., Evans, Jane C., Larson, Martin G., Chen, Ming Hui, Chen, Leway, Benjamin, Emelia J., and Levy, Daniel. Incidence and prognosis of syncope. New England Journal of Medicine 2002; 347:878-885. Olshansky, B (2006).Pathogenesis and etiology of syncope. Retrieved January, 2007 from http://www.uptodateonline.com Olshansky, B (2006).Pathogenesis and etiology of syncope. Retrieved January, 2007 from http://www.uptodateonline.com Sabatine, M. S. (2004). Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine New York: Lippincott Williams & Wilkins. Sabatine, M. S. (2004). Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine New York: Lippincott Williams & Wilkins.