1. Syncope and The Older Patient
Debra L. Bynum, MD
Division of Geriatric Medicine

2. Pretest…
1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope
2. History: 75 year old man reports presyncopal symptoms that occur while he is driving backwards out of his driveway in the morning. This suggests …
3. History: an 80 year old man reports an episode of syncope that occurred after doing arm exercises for a rotator cuff injury. This suggest…
4. The only independent predictor of a cardiac etiology of syncope is a past history of …
5. ____ is a neurodegenerative disease characterized by profound autonomic insufficiency and parkinsonian features on exam
6. An 82 year old man presents with postural hypotension, an idiopathic peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____
7. Name 3 causes of “situational syncope”
8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus massage c. orthostatic hypotension d. all of the above

3. Pretest: bonus question
Sudden cardiac death in young men (originally described in young asian men) associated with this sign on EKG is known as what syndrome?

4. Outline What is syncope What are the causes of syncope
How do you evaluate the patient with syncope?
How do you risk stratify the patient with syncope?
How do you treat?

5. Syncope: Definition
Transient Loss of Consciousness (T-LOC) due to global cerebral hypoperfusion
Rapid onset, short duration, complete recovery
Other causes of T-LOC that are NOT syncope
Seizure (syncope can cause myoclonic movements…)
Hypoglycemia, hypocapnea/hyperventilation
Intoxication
Vertebrobasilar TIA
Other etiologies that do not impair consciousness and are NOT syncope
Drop attacks, falls, TIA from embolic source

6. Causes of Syncope Neurally Mediated (up to 58% in some series)
Orthostatic/postural
Cardiac arrhythmia (20-25%)
Structural cardiac or pulmonary causes
Cerebrovascular or psychiatric (1%)
Unknown (18-30%)

7. Syncope in the Elderly Usually multifactorial
Often confounded by findings (orthostasis and carotid hypersensitivity common and may be found and yet not be the cause…)
Prevalence up to 25% in nursing home population over age 70
Higher pretest probability of cardiac disease or arrhythmia

8. Importance of History and PE
Up to % of patients in prospective studies had probable cause identified based upon history, physical exam and ecg

9. The History… History of Heart Disease
The ONLY independent predictor of cardiac cause (sens 95%, spec 45%)
Absence of heart disease up to 97% specific to rule out cardiac etiology (good NPV)

10. Neurally mediated (reflex)
Terms
Vasovagal
Vasodepressor
Neurovascular
Neurocardiogenic
vasomotor

11. Who gets this? We think of the young/healthy
Older patients can (although often complicated by comorbidities)

12. What is it? (Bezold-Jarisch phenomenon)
The often repeated story
Excessive stimulation of mechanoreceptors due to forceful contraction of underfilled left ventricle leading to paradoxical signals to the CNS – causing change from vasoconstriction to vasodilation – causing drop in blood pressure and bradycardia
The more complicated story
Disordered baroreflex function, paradoxical cerebral autoregulation, endogenous vasodilators… we don’t really know….

13. Think neurally mediated…
Situations
Warm environment, hot bath, post-exercise, prolonged standing, large meals, early morning, valsalva, volume depletion, rising after prolonged bedrest, alcohol, medications
Symptoms
Classic presyncopal symptoms
No underlying neurological or cardiac disease
Prior history

14. Neurally mediated…sort of ….
Situational syncope
Carotid sinus hypersensitivity

15. Situational Syncope Situations… Tussive or laughter syncope
Cough
Micturition
Defecation
Swallow
Diving
pain
Tussive or laughter syncope
More common in obese men over 40, smokers with chronic cough and COPD, children with asthma
More on micturition syncope
Older men, early morning, exacerbated by medications

16. Carotid Sinus Hypersensitivity
History
Stimulation of carotid area near barorecptor (near bifurcation)
Tight collar, neck pressure with head turning or shaving/backing out of driveway

17. CSH… Carotid massage Three responses
3 second pause or > 50 mm drop in SBP
Three responses
1. Cardioinhibitory (bradycardia/asystole)
2. vasodepressor (hypotension)
3. Mixed (features of both, most common)
Cardioinhibitory may benefit from pacing…

18. CSH…
Common in elderly, some concern that massage/testing may over diagnose
Also more likely to have positive response in patients with other degenerative neurological conditions such as Lewy body disease and parkinson’s
Pacing controversial, but may have role in select cases…

19. Summary: Reflex syncope (neural)
Vasovagal (neurally mediated)
Situational
Carotid sinus hypersensitivity

20. Postural Hypotension Orthostatic Autonomic
Volume loss
Blood loss
Drop in blood pressure (SBP 20) with increase in HR
Autonomic
Common in elderly (10-30%) – presence may or may not be the cause of syncope
Often medication related (long list…)

21. Autonomic Insufficiency
Clinical Features
Lack of tachycardic response; no respiratory variability of heart rate
ED, urinary retention, gastric emptying delay
Causes
Diabetes
Paraneoplastic
Amyloid
Multiple Systems Atrophy (Shy-Drager)
Primary Autonomic Failure
Toxins
Parkinson’s, Lewy body processes
Guillain-Barre syndrome
Spinal cord injury
HIV

22. Cardiac: Arrhythmia Bradycardia/asystole Tachycardia
Sick sinus syndrome
2nd or 3rd degree AV blocks
Pacemaker malfunction
Have high suspicion in patients with bundle blocks…
Tachycardia
Ventricular tachycardia
Ventricular fibrillation
SVT
If you see afib, think sick sinus syndrome and bradycardia/pauses…

23. Cardiac: Prolonged QT QTc over 500
Lack of QT shortening with increased heart rate (role of standing or exertional EKG)
Genetic or secondary to medications…
Torsades

24. Brugada Syndrome Triad Structurally normal heart
RBBB pattern in right precordial leads
Transient/persistent ST elevation in v1-v3
Sudden cardiac death
Structurally normal heart
Association with young and healthy men from southeast asia who present with sudden cardiac death
Brugada sign may be asymptomatic
High risk of sudden cardiac death in those who have syncope or family history of sudden death (Indication for AICD based upon observational data)

25. Brugada Sign

26. Structural Cardiac or pulmonary causes
Valvular disease (especially aortic stenosis)
HOCM
Cardiac masses (myxoma)
Pericardial disease (tamponade or restrictive processes)
Prosthetic valve dysfunction
Acute aortic dissection
Pulmonary hypertension (exercise related) PE

27. Subclavian Steal Syndrome
Proximal subclavian artery stenosis
Decreased blood flow to distal subclavian artery worsened with exertion of arm
Blood from vertebral artery on opposite side goes to basilar artery and then down ipsilateral vertebral artery, away from brainstem, to serve as collateral for arm
Usually asymptomatic
Atherosclerosis
Symptoms of vertebrobasilar insufficiency (dizziness, vertigo, diplopia, nystagmus)
Rare to have permanent neurological deficits
Diagnosis with dopplers, MRA
Treatment: surgical revascularization, stents

28. Cerebrovascular Syncope = global hypoperfusion
Vertebrobasilar pathology or bilateral carotid disease…

29. How do you evaluate the patient with syncope?

30. The Older Patient
Positive tests that are more common in the elderly and not necessarily the cause of the syncope:
Orthostasis
Positive carotid massage
Positive tilt table testing
Up to 54% of older patients with syncope may have positive test…
Positive test in 10% of asymptomatic elderly!

31. Evaluation: History Neurally mediated: Absence of heart disease
Long history of recurrent syncope
Associated factor (pain)
Prolonged standing
Associated n/v, diaphoresis, presyncopal symptoms
After a meal
CSH: turning head or pressure on neck

32. History… OH: After standing Prolonged standing
Presence of autonomic insufficiency or parkinson’s
Standing after exertion

33. History… cardiovascular
Presence of structural heart disease (especially systolic dysfunction)
Family history of sudden death
During exertion or supine (BIG FLAG)
Swimming/diving into pool (prolonged QT)
Abnormal EKG
Syncope follows sudden onset of palpitations
EKG: QT
Bundle blocks
Afib, AV blocks
Evidence of prior ischemia
QRS over .12

34. Evaluation EKG Telemetry Rule out ischemia (nursing home patients…)
Carotid sinus massage
Contraindicated in patients with prior TIA/stroke, bruits or known carotid stenosis

35. Evaluation
Orthostatics
Echo

36. Tilt table testing Passive or Isoproterenol
Test: patient held in upright position (60-90 degrees), but weightless to prevent muscles improving venous return; this leads to venous pooling, decreased venous return, and trigger of the neurally mediated reflex
Positive test: bradycardia or hypotension
Passive testing: sensitivity only 70%, specificity %
Isoproterenol: only 55% specificity
Usually does not add much to the history and physical…

37. In-hospital monitoring
Yield low (under 20%)
Recommended in high risk patients

38. Holter Monitoring 24-48 hours (no higher yield with longer)
Low yield (1-2%)
May be useful if symptoms are very frequent

39. External Loop recorders
Loop memory that continuously records and deletes
Patient activates in response to symptoms (some devices also activated in response to rhythm)
Yield: ?25% when used for 4-6 weeks

40. Implantable Loop recorders
Duration up to 3 years
Can be activated by patient or bystander or automatically activated by arrhythmias
May be cost effective to do earlier in the workup than currently doing…
Some series – % patients with prior unexplained syncope were able to have diagnosis

41. Electrophysiology Study (EP)
Underlying structural heart disease (especially depressed LV function)
Suspected bradycardia
Patients with underlying bundle branch block (look for development of His block with incremental atrial pacing)
Suspected tachycardia

42. Exercise Stress Testing
Patients with syncope with/after exertion
Usually of low yield

43. Other evaluations… Imaging, CTA Cardiac catheterization
Directed by history and physical…

44. Least useful tests…
Head CT with negative neuro exam (history should direct whether symptoms suggest stroke/TIA or syncope…)
EEG
Carotid dopplers (see above…)

45. Risk Stratification

46. High Risk Chest pain CHF Valvular disease
History of ventricular arrhythmias
EKG ischemic changes
Prolonged QT c (over 500)
Trifascicular block or pauses over 2 sec
Cardiac devices
Atrial fibrillation

47. High risk: ESC recommended hospitalization
Known heart disease
Syncope during exercise
Trauma (facial)
Family history sudden death
Sudden palpitations prior to syncope
Syncope while supine
Multiple recent episodes

48. Intermediate risk Age over 50 History of ischemic heart disease
Family history of sudden death

49. Low risk Age less than 50 No history of CV disease Normal EKG and exam
Symptoms c/w neurally mediated or vasovagal syncope
Prior history of recurrent syncope with symptoms c/w vasovagal etiology

50. Treatment: reflex syncope and orthostatic intolerance
Lifestyle
Education, reassurance
Avoiding triggers
Maneuvers: supine posture, physical counterpressure, crossing legs)
Avoiding medications, ETOH
Increasing fluids, salt intake

51. Reflex syncope Tilt training Raising head of bed
Progressively prolonged periods of upright posture
Meds:
Beta blockers
SSRI
Ephedrine
Midodrine
No meds work that well…

52. Reflex syncope: Cardiac pacing
5 major RCTs, conflicting results
Significant selection bias
Likely not justified unless spontaneous bradycardia found on prolonged monitoring

53. Orthostatic intolerance
Stop possible medications
Salt/fluid intake
Compression stockings (ideally include abdominal binders, so compliance low)
Leg crossing/squatting with symptoms
Midodrine (alpha-agonist): works better than in patients with reflex syncope…
Fludrocortisone (mineralcorticoid)

54. Indications for Pacing
Class I
Third degree of advanced second degree AV block with symptoms
Bradycardia with symptoms
Asystole over 3 seconds
Escape rate less than 40 bpm
After catheter ablation of AV junction
Postoperative AVB

55. Pacing
Class II a
Asymptomatic 3rd degree AVB or type II second degree AVB with narrow QRS (class I if with a wide QRS)
Syncope with AVB
Drug refractory afib….

56. AICD Unexplained syncope and depressed LVEF (ischemic or nonischemic)
HOCM (II a)
Brugada syndrome (II a unless high risk, such as family history of sudden death)
Long QT
Patients with ischemic cardiomyopathy and preserved LVEF but unexplained syncope (II b)

57. Back to the Pretest…
1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope
2. History: 75 year old man reports presyncopal symptoms that occur while he is driving backwards out of his driveway in the morning. This suggests …
3. History: an 80 year old man reports an episode of syncope that occurred after doing arm exercises for a rotator cuff injury. This suggest…
4. The only independent predictor of a cardiac etiology of syncope is a past history of …
5. ____ is a neurodegenerative disease characterized by profound autonomic insufficiency and parkinsonian features on exam
6. An 82 year old man presents with postural hypotension, an idiopathic peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____
7. Name 3 causes of “situational syncope”
8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus massage c. orthostatic hypotension d. all of the above

58. Answers to Pretest… 1. NPV 2. Carotid Hypersensitivity
3. Subclavian steal syndrome
4. Cardiac history
5. Multiple Systems Atrophy (shy-drager)
6. amyloid
7. micturition, defecation, cough, swallow
8. all of the above
9. bonus: brugada syndrome

59. Selected References
Benditt DG, VanDjjk JG, Sutton R. Syncope: Curr Prob Cardiol 2004; 29(4):
Epstein AE. An update on implantable cardioverter-defibrillator guidelines. Curr Opin Cardiology 2004; 19(1): 23-25
Littman L et al. Brugada syndrome and Brugada sign. Am Heart J 2003; 145(5):
Raj S, Sheldon RS. Role of pacemaker in treating neurocardiogenic syncope. Curr Opinion Cardiol 2003; 18: 47-52
Gregoratos G, Cheitlin MD, Conill A. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrthythmia devices: executive summary: a report of the American College of Cardiology/Am Heart Assoc Task Force on Practice Guidelines. Circulation. 1998; 97:
Connolly SJ et al. The North American Vasovagal Pacemaker Study. J Am Coll Cardiol 1999; 33: 16-20
DiGirolamo et al. Effects of paroxetine on refractory vasovagal syncope. J Am Coll Cardiol 1999; 33:
Sutton R et al. Dual chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope (VASIS). Circulation 2000; 102:

60. Selected References…
Krahn Ad et al. Use of the implantable loop recorder in evaluation of patients with unexplained syncope
Kapoor WN. Current evaluation and management of syncope. Circulation 2002; 106: 1606
Alboni P et al. Diagnostic Value of history in patients with syncope. J Am Coll Cardiol 2001; 37: 1921
Kapoor et al. Evaluation and outcome of patients with syncope. Medicine 1990; 69: 160
Linzer et al. Diagnosing syncope: part I. Ann Int med 1997; 126:989
Linzer et al. Diagnosing syncope: part II. Ann Int Med 1997; 127: 76

61. Primary References:
Chen, LY et al. Management of syncope in adults: an update. Mayo Clin Proc, 2008: 83:
Weimer L, Pezhman Z. Neurological aspects of syncope and orthostatic intolerance. Med Clin N Am 93 (2009)
Strickberger et al. AHA/ACCF statement on the evaluation of syncope, Circulation 2006.
Moya et al. Guidelines for the diagnosis and management of syncope, task force from the ESC. Eur Heart J (2009)30,