2Objectives Understand the term syncope Differentiate the serious causes of syncope from those that are benignKnow the appropriate testing needed in the evaluation of syncope based upon the presenting history
3Syncope = syn(short) + kope (to cut) Definitions to KnowPalpitations - sensation of strong, rapid, or irregular heart beatsSyncope – transient loss of consciousness and postural tone due to generalized cerebral ischemia with rapid and spontaneous recoveryPresyncope - no complete loss of consciousness occursSyncope = syn(short) + kope (to cut)
4Syncope in children Affects 15% of children between 8-18 Uncommon under age 7 therefore think about:Seizure disordersBreath holdingPrimary cardiac dysrhythmiasCardiovascular causes unusual but life-threateninganatomic abnormalitiescongenital malformationsvalvular diseaseelectrical abnormalities
5Syncope in children Vasovagal Events 32% to 50% of casesDecreased PVRDecreased venous returnDecreased cardiac outputHypotensionBradycardiaIn teens – think about pregnancy and drugs of abuse
6Syncope: Key questions to address with initial evaluation Is the loss of consciousness attributable to syncope or not?Is heart disease present or absent?Are there important clinical features in the history that suggest the diagnosis?
7Syncope Mimics Disorders without impairment of consciousness FallsDrop attacksCataplexyPsychogenic pseudo-syncopeTransient ischemic attacksDisorders with loss of consciousnessMetabolic disordersEpilepsyIntoxicationsVertebrobasilar transient ischemic attacks
8Differential Diagnosis of Syncope: Seizures vs Hypotension ObservationSeizureInadequate PerfusionOnsetSuddenMore gradualDurationMinutesSecondsJerksFrequentRareHeadacheFrequent (after)Occasional (before)Confusion afterIncontinenceEye deviationHorizontalVertical (or none)Tongue bitingProdromeAuraDizzinessEEGOften abnormalUsually normal
9Unexplained Causes = Approximately 1/3 Causes of True SyncopeNeurally-MediatedOrthostaticCardiacArrhythmiaStructuralCardio-Pulmonary1VasovagalCarotid Sinus• SituationalCoughPost-Micturition2Drug-Induced• Autonomic Nervous System FailurePrimarySecondary3BradySN DysfunctionAV Block• TachyVTSVTLong QT Syndrome4Acute Myocardial IschemiaAortic StenosisHCMPulmonary HypertensionAortic DissectionUnexplained Causes = Approximately 1/3
10Likely Causes In Children VasovagalSituationalPsychiatricLong QT*WPW syndromeRV dysplasiaHypertrophic cardiomyopathyCatecholaminergic VTOther genetic syndromes
11Syncope: Key questions to address with initial evaluation Is the loss of consciousness attributable to syncope or not?Is heart disease present or absent?Are there important clinical features in the history that suggest the diagnosis?
12Syncope: Important Historical Features Questions about circumstances just prior to attackPosition (supine, sitting , standing)Activity (rest, change in posture, during or immediately after exercise, during or immediately after urination, defecation or swallowing)Predisposing factors (crowded or warm place, prolonged standing post-prandial period) and of precipitating events (fear, intense pain, neck movements)Questions about onset of the attackNausea, vomiting, feeling cold, sweating, pain in chest
13Syncope: Important Historical Features Questions about attack (eye witness)Skin color (pallor, cyanotic)Duration of loss of consciousnessMovements ( tonic-clonic, etc.)Tongue bitingQuestions about the end of the attackNausea, vomiting, diaphoresis, feeling cold, muscle aches, confusion, skin color, wounds
14Syncope: Important Historical Feature Questions about backgroundNumber and duration of syncope spellsFamily history of arrhythmic disease or sudden deathPresence of cardiac diseaseNeurological diseaseMedications (Hypotensive, negative chronotropic and antidepressant agents)
15Clinical Features Suggesting Specific Cause of Syncope Neurally-Mediated SyncopeAbsence of cardiac diseaseLong history of syncopeAfter sudden unexpected, unpleasant sensationProlonged standing in crowded, hot placesNausea vomiting associated with syncopeDuring or after a mealWith head rotation or pressure on carotid sinusAfter exertion
16Clinical Features Suggesting Specific Cause of Syncope Syncope due to orthostatic hypotensionAfter standing upTemporal relationship to taking a medication that can cause hypotensionProlonged standingPresence of autonomic neuropathyAfter exertion
17Clinical Features Suggestion Cause of Syncope Cardiac SyncopePresence of structural heart diseaseWith exertion or supinePreceded by palpitationsFamily history of sudden death
18Initial Exam: Thorough Physical Vital signsHeart rateOrthostatic blood pressure changeCardiovascular exam: Is heart disease present?ECG: Long QT, pre-excitation, conduction system diseaseEcho: LV function, valve status, HCMNeurological examHCM—Hypertrophic CardiomyopathyBrignole M, Alboni P, Benditt D, et al. Guidelines on management (diagnosis and treatment) of syncope—Update Europace. 2004;6:
19Orthostatic Measurements Classically, abnormal if systolic BP decreases by more than 20 points and/or pulse increases in pulse rate of more than 20 beats per minute after a change from supine to standingIf there is only a pulse increase but no drop in blood pressure, the test is less significant.
20Diagnostic Objectives Distinguish true syncope from syncope mimicsDetermine presence of heart disease and risk for sudden deathEstablish the cause of syncope with sufficient certainty to:Assess prognosis confidentlyInitiate effective preventive treatment
21“…cardiac syncope can be a harbinger of sudden death.” Survival with and without syncope (adults and children)6-month mortality rate of greater than 10%Cardiac syncope doubled the risk of deathIncludes cardiac arrhythmiasNo SyncopeVasovagal/otherCardiac CauseFollow-Up (yr)Probability of Survival1.00.80.60.40.20.0Soteriades ES, et al. N Engl J Med. 2002;347:878.
22Electrocardiogram yield for specific diagnosis low (5%) risk free and relatively inexpensiveabnormalities (BBB, previous MI, nonsustained VT) guide further evaluationrecommended in almost all patients
23Laboratory Tests Routine use not recommended Maybe glucose?Should be done only if specifically suggested by H&PPregnancy testing should be considered in women of child-bearing age
24Neurologic Testing EEG - not useful unless seizures Brain imaging - not useful unless focalityNeurovascular studiesno studiesmay be useful if bruits, or hx suggests vertebrobasilar insufficiency
25Final Words of Wisdom -Is it Syncope?- History is key!!!!Orthostaticstake the time to do them correctlyCardiac vs Non-cardiacIf you are not confident that it is NOT cardiac REFERECGUse it if you got ‘em!