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Dizziness and Syncope Karen E. Hauer, MD University of California, San Francisco.

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Presentation on theme: "Dizziness and Syncope Karen E. Hauer, MD University of California, San Francisco."— Presentation transcript:

1 Dizziness and Syncope Karen E. Hauer, MD University of California, San Francisco

2 Dizziness and Syncope: Outline Dizziness: common etiologies Case examples Syncope Diagnosis Efficient workup Management

3 Dizziness There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits on learning that their patients complaint is of giddiness [dizziness] WB Matthews, 1975

4 Vertigo50% Disequilibrium2% Psychiatric2-16% Presyncope4-14% Single etiology52% Kroenke, Ann Intern Med 1992 UpToDate 2005 Etiology of dizziness

5 Case A 72 year old woman with hypertension and migraine has 2 episodes of sudden onset dizziness. She reports side to side movement lasting several hours, with left sided hearing loss, tinnitus, ear fullness, unsteadiness. Oscillopsia since.

6 Case

7 Central (15%) Brainstem infarct/ischemia Tumor Cerebellopontine angle Brainstem Migraine Vertigo: acute vestibular asymmetry Peripheral (85%) Benign positional Labyrinthitis Menieres Otitis media

8 Central Gradual onset (except stroke) Persistent Neuro findings common Nystagmus any direction - changes with gaze Nystagmus not suppressable Unable to stand Vertigo: history and exam Peripheral Sudden, severe Episodic Ear symptoms common Nystagmus horizontal/torsional, no change with gaze Nystagmus suppressed with fixation Able to stand, lean to lesion

9 Anatomy American Academy of Otolaryngology/HNS

10 Dix-Hallpike maneuver: to induce positional vertigo and nystagmus Benign positional vertigo: #1 cause of peripheral vertigo Episodic symptoms Free floating debris in semicircular canals

11 Dix-Hallpike maneuver: diagnostic and therapeutic Positional vertigo: Vertigo/nystagmus reproduced Latency 5-15 seconds Decreases w/in 30 seconds Fatigues on repeat

12 Rule out tumor 1/ dizziness, normal hearing 1/638 - dizziness, asymmetric hearing loss Rule out vascular compromise Indications New neuro symptoms/signs Sudden vertigo & stroke risk factors Vertigo & new severe headache Test of choice: MRI/ MRA Gizzi, Arch Neurol 1996 Vertigo: when to image?

13 Case: unsteadiness A 78 year old woman with coronary artery disease, type 2 diabetes, cataracts, anxiety and depression has chronic dizziness - unsteady while walking Meds: insulin, lovastatin, atenolol, fludrocortisone, prozac Neuro exam: slightly wide based gait. DTRs absent in ankles. Reduced vibration sense to ankle bilaterally. Short of breath with neuro exam maneuvers.

14 Disequilibrium: often multifactorial Sense of imbalance -worse with walking Contributing factors Vision, hearing impairment Peripheral neuropathy Musculoskeletal disease/gait disturbance Medications

15 Dizziness: a geriatric syndrome 24% of community-living elders had dizziness > 1 month Risk factorRelative risk Anxiety1.69 Depression1.36 Decreased hearing1.27 Impaired balance1.34 > 4 meds1.30 Postural hypotension1.31 Prior MI1.31 Tinetti, Ann Intern Med 2000

16 Case: I feel like Im going to faint A 30 year old woman reports episodes of feeling as if she will faint, with palpitations and lightheadedness, worse when anxious. Three episodes of syncope over past 10 years; none recently - able to avoid by lying down.

17 Dizziness: psychiatric etiology Young healthy patient Symptoms reproduced with hyperventilation Nystagmus suggests vestibular lesion Treat underlying anxiety/depression

18 Establishing Diagnosis of Syncope Presyncope & syncope: similar etiologies & workup Syncope: sudden transient loss of consciousness with loss of postural tone and spontaneous recovery Mechanism:transient hypoperfusion of brainstem or both cerebral hemispheres Differential diagnosis: coma narcolepsy seizure

19 Syncope: scope of the problem Common 3% Emergency Department visits 1-6% hospital admissions Costly Multiple diagnostic tests often performed Average charge for each diagnostic test ranges from $284 to $4678 Linzer, Ann Intern Med, 1997

20 Diagnostic Challenges History often unclear Prognosis varies widely Common etiologies are benign Potentially high mortality Need to identify high-risk patient early Many available tests 40% of patients may elude diagnosis

21 Syncope: management questions Diagnostic challenges What is the best diagnostic test? How and when to rule out arrhythmia? How to diagnose neurocardiogenic syncope? How to decrease the # idiopathic? Management dilemmas When to admit? How are the elderly different? When to resume driving?

22 Case Presentation 50 yo healthy woman, standing at church Becomes weak, lightheaded, & nauseated Collapses, awakens after 1 minute Feels well in ED - I want to go home Normal exam, EKG, labs, CXR Diagnosis? Plan - Admit? Further testing? Glassman, Arch Intern Med, 1997

23 Etiology of Syncope Idiopathic34% Neurally-mediated Vasovagal18% Other (situational, carotid sinus)6% Cardiac Arrhythmia14% Mechanical4% Neurologic 10% Orthostatic8% Medications3% Psychiatric2% Linzer, Ann Intern Med, 1997

24 The Key to Diagnostic Evaluation History and Exam establish diagnosis in 45% History: setting, symptoms, medical hx, meds Exam: HR, BP, cardiovascular, neurologic EKG adds 5% diagnostic yield Cheap, non-invasive, readily available Can indicate important cardiac disease Prior MI, ventricular hypertrophy, long QT Bradycardia, conduction block Abnormalities guide further testing

25 Diagnostic Algorithm Syncope Cardiac Noncardiac Idiopathic Arrhythmia Mechanical Neurocardiogenic Orthostatic Neurologic Psychiatric

26 Cardiac syncope: inadequate cardiac output, arrhythmia Cardiac enzymes - Cardiac enzymes - only if history or EKG suggestive of MI – 1-10% MIs present with syncope – EKG up to 100% sensitive for MI Echo - Echo - rule out structural heart disease – before stress test if obstruction suspected – yield: 5-10% Exercise stress test - Exercise stress test - exertional syncope – identifies exertional arrhythmia – yield: low (1%) Georgeson, J Gen Intern Med, 1992 Linzer, Ann Intern Med, 1997

27 Arrhythmia evaluation - telemetry Indication: suspected arrhythmia palpitations, no prodrome Idiopathic syncope or underlying heart disease Routine telemetry low yield 2240 non-ICU telemetry patients 10% syncope/dizzy all syncope ICU transfer-arrhythmia 0.8% 0.4% Telemetry Helpful 12.6%16% Mortality 0.9% 0 Linzer, Ann Intern Med, 1997 Estrada, Am J Cardiol, 1995 Glassman, Arch Intern Med, Estrada, Am J Cardiol, 1995

28 Arrhythmia evaluation: 24 hr ambulatory (Holter) monitoring 2612 syncope/dizzy patients Symptomatic arrhythmia = positive result Diagnostic arrhythmia in 4% Symptoms without arrhythmia Arrhythmia ruled out in 15% Bottom line Benefit: monitors during usual activity Limitation: brief duration limits yield unless daily symptoms Linzer, Ann Intern Med, 1997

29 Arrhythmia evaluation: improving the yield – Loop recorder – Indication: recurrent syncope with normal heart – frequent syncope -> continuous loop recorder (weeks) – infrequent syncope -> implantable loop recorder (years) – Electrophysiologic study – Indication: syncope with organic heart disease – Signal average EKG – Detects late potential in QRS - substrate for VT/VF – indication: normal heart, idiopathic syncope? Linzer, Ann Intern Med, 1997 Zimetbaum, Ann Intern Med, 1999

30 Neurocardiogenic Syncope Vasovagal Micturition Vasodepressor Neurally - mediated Reflexive Orthostatic intolerance Carotid sinus syncope Cardioneurogenic

31 May be predominantly Cardioinhibitory (bradycardia) Vasodepressor (hypotension) or Both Neurocardiogenic Syncope Clinical Presentation Syncope Trigger

32 Neurocardiogenic Syncope: Pathophysiology

33 Diagnosing neurocardiogenic syncope by history and exam Precipitant Vasovagal: pain, emotion, standing Situational: vagal stimulus Autonomic symptoms Rapid recovery of mental status Bradycardia, pallor may persist Carotid sinus massage >3 sec asystole or hypotension=hypersensitivity

34 Is Laughter Really the Best Medicine? A 63-year-old man was referred with a 20-year history of syncope preceded by intense laughter. We were able to diagnose a gelastic syncope (from the Greek gelos, laughter). Laughter- related syncope may be induced by the Valsalva manoeuvre. We advised him not to laugh so hard in the future, and when we saw him again, he had been able to follow this advice, and had suffered no further syncope. Braga. Lancet 2005

35 Tilt table testing 60-80˚ Goal: provoke neurocardiogenic syncope Indication: recurrent unexplained syncope without cardiac disease Protocol: passive tilt min positive response reproduces symptom

36 Tilt table testing: why the controversy? Accuracy difficult to define Gold standard? Protocol? Reproducibility 71-87% Positive tilt test with idiopathic syncope: 49% with passive tilt 66% with tilt plus isoproterenol Tradeoff: decreased specificity Kapoor, Am J Med, 1994

37 Neurocardiogenic syncope: treatment Indicated for frequent syncope Lifestyle modification Add salt, avoid triggers Handgrip, tense arms and legs Medications B blocker, SSRI, midodrine, fludrocortisone Repeat tilt test on therapy? Pacemaker

38 Vasovagal syncope: pacemakers ineffective Randomized double-blind trial DDD pacer vs. sensing-only pacer Connolly, JAMA 2003 p = NS %

39 Idiopathic syncope: improving diagnostic yield Up to 40% patients Prognosis good Potential morbidity, lifestyle implications Consider: DiagnosisTesting Neurocardiogenic Tilt table Anxiety/depression Psychiatric evaluation Arrhythmia EPS, implanted event monitor Empiric pacemaker?

40 Prognosis: Framingham 25 year follow up Etiology of syncopeAdjusted risk of death Cardiac2.01* Neurologic1.54* Idiopathic1.32* Vasovagal1.08 *p<0.01 NEJM 2002;347:878

41 Prognosis: ED risk stratification ED predictors of arrhythmia or mortality Abnormal EKG Prior VT/VF History of CHF Age > 45 Martin, Ann Emerg Med, 1997

42 Prognosis: Guideline for admission - the San Francisco Syncope Rule Prediction rule to identify patients at risk of bad outcomes (need admit) over 30 days Death, MI, arrhythmia, PE, stroke, transfusion Syncope or related event requiring procedure, ED visit or admit First assess the patient for cause of syncope If cause unknown, apply the rule 98% sensitive 56% specific Quinn, Ann Emerg Med, 2006

43 CHF - history of Hematocrit <30% ECG abnormal Shortness of breath Systolic blood pressure <90 mm Hg at triage Quinn, Ann Emerg Med, 2006 Prognosis: Guideline for admission - the San Francisco Syncope Rule

44 ACP Guidelines for Hospital Admission Definitely admit HPI: chest pain PMH: CAD, CHF, ventricular arrhythmia Exam: CHF, valve dz, focal neurologic deficit EKG: ischemia/MI, arrhythmia, bundle branch block Often admit HPI: age >70, exertional syncope, frequent syncope Exam: tachycardia, orthostatic hypotension, injury Cardiac dz suspected Linzer, Ann Intern Med, 1997

45 Guidelines for Hospital Admission: implications for practice Myth: Every syncope patient should be admitted Recommendation: Establish clear goals for admission, usually diagnostic Myth: Every syncope patient requires rule out MI Recommendation: Admission not necessary with careful history ruling out symptoms of ischemia and normal EKG Myth: Telemetry improves outcomes Recommendation: One-year mortality rarely affected by 24 hours of monitoring

46 Syncope in the elderly: the geriatric challenge History often obscure Syncope vs. dizziness vs. fall? Often multifactorial - elderly at high risk for Situational syncope Polypharmacy, adverse drug events Cardiac, neurovascular disease Decreased physiologic reserve Atypical presentation of disease Abnormalities do not prove causation

47 Syncope in the elderly: a poor prognostic sign Kapoor, Am J Med, 1986

48 Recommendations for Driving: following the law Laws vary by state - available from DMV California law requires reporting of any loss of consciousness County health officer receives report DMV determines fitness to drive Physician can provide influential prognostic information to DMV Physicians recommendations variable Awareness of law often poor

49 American Heart Association Guidelines for Driving VT/VF (treated with medical or ICD therapy ) Risk greatest 1st 6 mo, up to 10% at 1 year Resume driving: 6 months arrhythmia free Bradycardia with syncope Resume driving: 1 week after pacemaker Neurocardiogenic syncope -> risk stratify Mild: presyncope, clear warning & precipitant Resume driving: immediately Severe: syncope, no warning or precipitant, frequent Resume driving: after therapy, waiting period (duration?)

50 The Potentially Costly Workup TestCharge* H & P$160 EKG$90 24-hour Holter$468 Loop recorder - 30 day$284 Electrophysiology study$4678 Psychiatric evaluation$150 CT brain$888 Echo$580 Stress test $433 Tilt table test$683 *Average at 4 academic centers, Linzer, 1997

51 Trust the Careful History: Excess Cost of Vasodepressor Syncope 30 patients referred for undiagnosed syncope All characteristic vasodepressor history Mean cost of prior testing $ Majority had Holter, echo, CT Calkins, Am J Med, 1993 Calkins, Am J Med, 1991.

52 Case Presentation: Is typical practice cost effective? Hypothetical scenario presented to 916 MDs Becomes weak, lightheaded, & nauseated Collapses, awakens after 1 minute Feels well in ED - I want to go home Normal exam, EKG, labs, CXR Diagnosis? Plan - Admit? Further testing? Glassman, Arch Intern Med, 1997

53 Cost-effective workup: Internists vs. cardiologists Diagnosis: vasovagal syncope Intended plan: observation +/- overnight tele Survey results:aggressive approach Cardiologists Internists YOU Admit? 79% 72%? Mean # additional tests ? Glassman, Arch Intern Med, 1997

54 Dizziness: key points Vertigo is most common etiology Positional triggers, nystagmus help confirm peripheral etiology Neuro findings, stroke risk prompt imaging Disequilibrium - commonly due to multifactorial deficits in elderly Presyncope - manage like syncope

55 Syncope: key points History, exam, EKG guide further testing Identify possible cardiac syncope early Admit if high risk of cardiac disease Neurocardiogenic syncope - diagnosed clinically or by tilt table Idiopathic syncope has multiple etiologies and good prognosis

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