1. Syncope

2. What we will discuss? Background information Evaluation of syncope
Treatment of certain causes of syncope
Useful, practical items

3. Definition Sudden and brief loss of consciousness
Associated with loss of postural tone
Recovery is spontaneous
A symptom and not a disease

4. Scope of the problem Occurs in 3-37% of general population
6% annual incidence amongst elderly residents of long-term care institutions
3.5% of all ER visits
1-6% of all hospital admissions

5. Is it syncope? Presyncope Dizziness Vertigo Drop attacks Seizures
Cardiac arrest

6. Pathophysiology
Sudden decrease in or brief cessation of cerebral blood flow and nutrient delivery (seen in all forms)
Mechanisms:
- Decrease in cardiac output, including loss of preload, mechanical outflow obstruction, and arrhythmias
- Loss of vascular resistance, often by neurocardiogenic reflex mechanisms
- Focal or generalized decrease in cerebral perfusion caused by cerebrovascular disease
- Causes in which cerebral blood flow is essentially normal, such as hypoglycemia, hypoxia, and seizures

7. Neurocardiogenic reflex mechanisms

8. Causes of Syncope

9. More causes of syncope

10. Causes of Syncope
Kapoor, W. N. N Engl J Med 2000;343:

11. Diagnosing the cause History is key
Presence of structural heart disease
Physical exam
EKG
The findings from this initial assessment will guide your evaluation.

12. Historical aspects Number of episodes Associated symptoms/Prodrome
Preceding events
Witnessed appearance
Recovery or postevent period
PMHx/Family hx/Medications

13. More on history Number of episodes
- Single episode or multiple episodes over many years vs. multiple episodes over a short period time
Associated symptoms/Prodrome
- Dyspnea, angina, focal neurologic abnormalities
- Nausea, warmth, pallor, lightheadedness, diaphoresis
Preceding events
- Coughing, eating, drinking cold liquid, urinating, defecating, exertion
Recovery or postevent period
- Persistence of nausea, pallor, diaphoresis
- Significant neurologic changes or confusion

14. Other historical features
Age
- Young vs. elderly
Position
- Supine vs. standing
Duration of symptoms
- Brief vs. prolonged
Injury
- Tongue biting
- Important to determine if syncope places individuals or others at risk

15. Preexisting medical conditions
Psychiatric illness
Diabetes mellitus
- Orthostatic hypotension secondary to autonomic neuropathy
HTN
- Antihypertensive medications can result in syncope
Presence of heart disease

16. Importance of heart disease
Only independent predictor of cardiac cause of syncope (sensitivity 95%, specificity 45%)
Most important factor for predicting risk of death and likelihood of arrhythmias
Increased risk of death regardless of the cause of syncope

17. Obtaining information from Cardiology
Can page EKG tech ( )
Make copies of old EKG’s, echo reports, cath reports, clinic SF600’s (before CHCS-II)
If you are in the Cardiology clinic, can obtain this information from front desk area, record/storage room (code to door is 7843)

18. Physical examination Vital signs Heart rate, Orthostatics, RR
Cardiac exam
Systolic murmurs and physiologic maneuvers
Neuro exam
Focal signs, mental status
Carotid sinus massage

19. Carotid sinus massage
Each carotid palpated and auscultated for presence of bruits (test not performed in those with evidence of carotid artery disease)
Pressure applied to one carotid sinus for 2-3 secs with vigorous/circular movements
Done with simultaneous EKG monitoring
Positive test if there is pause for > 3 secs
Use cautiously in elderly patients

20. EKG findings Sinus bradycardia
AV nodal disease (2nd or 3rd degree heart block)
Bundle branch and/or fascicular block
Prolonged QT interval
Presence of EKG findings does not prove causality unless findings are captured during actual event/symptoms.

21. Other EKG findings

22. Prolonged QT syndrome

23. Diagnostic Tests Basic laboratory tests
- Leads to specific cause in 2-3% of patients
Echocardiogram
Stress testing
Ambulatory monitoring or continuous-loop event monitor
Electrophysiologic studies
Tilt table testing
Neurologic testing
Psychiatric evaluation

24. Echocardiogram
May diagnose underlying structural heart disease (LV dysfunction, hypertrophic cardiomyopathy, significant aortic stenosis)

25. Stress testing Frequently obtained in patients with cardiac disease
Useful in patients with exertion-related syncope or exercise-induced arrhythmias

26. Testing for arrhythmias
Symptoms occurring with arrhythmias occur in 4% of patients in studies using Holter monitoring.
Event recorders require the patient to activate the unit to have the rhythm stored at the time of symptoms.
Intermittent loop recorders can store several minutes of recording if the unit has the ability.
Event recorders and Holter monitors can be ordered via CHCS

27. Ordering monitoring devices
Ordered in CHCS
Under consult procedure to cardiology
- Holter or event monitor
Specify in consult amount of time for event monitor (# of weeks)
Make sure you have a correct address on patient because event monitor is mailed to them.

28. Implantable loop recorders
Placed in subcutaneous pocket, usually in left pectoral region
Can store about 45 minutes of retrospective electrocardiographic recording
Can record automatically or be activated by the patient after an event
Usually reserved for recurrent syncope in whom diagnosis remains uncertain
Diagnostic yield between 25-40% during a period 8-10 months

29. Monitoring devices

30. Electrophysiologic studies
Yield depends on whether there is structural heart disease or abnormal findings on EKG
Among patients with heart disease, ~ 21% have inducible ventricular tachycardia and 34% have bradycardia (14% with multiple diagnoses)
In patients with abnormal EKG’s, ~ 3% have inducible ventricular tachycardia and 19% have bradycardia
Poor sensitivy/specificity for bradyarrhythmias

31. Tilt table testing
Used for diagnosis of neurocardiogenic or vasovagal syncope
Positive test is one where a hypotensive episode is provoked that reproduces a patient’s symptoms
Specificity of negative test on passive tilt at angles between degrees is close to 90%
Sensitivity of test is uncertain because of no gold standard

32. Tilt table test protocol
Variety of protocols have been described
Angle of tilt (60-90 degrees)
Duration of tilt (10-60 minutes)
Patient monitored in supine position for five minutes, then placed in head-up tilt position
Second tilt can be performed with isoproterenol infusion if patient asymptomatic during first tilt (nitrates are another agent used)
Carotid massage can be performed with test

33. Indications for Tilt-Table Testing Indications for Tilt-Table Testing
Grubb, B. P. N Engl J Med 2005;352:
Grubb, B. P. N Engl J Med 2005;352:

34. Demonstration of the Use of a Tilt Table
Grubb, B. P. N Engl J Med 2005;352:

35. Neurologic testing EEG Head CT scan MRI Carotid doppler ultrasound
- May be helpful to rule out seizures/epilepsy
- Provides diagnostic information in < 2% of cases of syncope
Head CT scan
MRI
Carotid doppler ultrasound
CT angiography

36. Psychiatric evaluation
Generalized anxiety disorder, panic disorder, and major depression may cause syncope by predisposing patients to neurally mediated reactions.
Fainting is a known manifestation of somatization disorder.
Alcohol and drug dependence/abuse may also lead to syncope.

37. Useful hints on the wards
Fall precautions
- Protocol: yellow armband, bed alarm, side rails up, offer toileting q2 while awake/qhs/qAM, frequent reorientation PRN
Seizure precautions
Telemetry monitoring
- Speak to in person or call using hotline phones to telemetry tech for any events
- Also a telemetry chart that you can look at

38. Treatment Neurocardiogenic - Avoidance of predisposing factors
- Patient should be instructed to lie down at onset of prodromal symptoms
- Isometric contractions of arm and leg muscles, intense hand gripping
- Increased fluid and salt intake
- Tilt training (standing for minutes each day against a wall)
- Pharmacologic agents (beta-blockers, fludrocortisone, midodrine, SSRI’s)
- Permanent cardiac pacing

39. Treatment Orthostatic hypotension
- Volume replacement in those with intravascular volume depletion
- Discontinuing or reducing doses of drugs
- In cases of autonomic failure, increasing intake of salt and fluid, use of waist-high support stockings and abdominal binders
- Fludrocortisone or midodrine

40. Treatment Neurologic causes
- Antiseizure medications for seizure disorder
- Surgical intervention for severe carotid artery disease
Psychiatric causes
- Psychiatric referral
- Medications (antidepressive, anxiolytic)

41. Treatment for cardiac causes
Ventricular arrhythmias
- Antiarrhythmic therapy, ICD placement, radiofrequency ablation, electrophysiologic guided surgery
Bradycardia due to conduction abnormalities
- Pacemaker placement (sinus node dysfunction, high grade AV block,)
Severe aortic stenosis
- Aortic valve replacment
Hypertrophic cardiomyopathy
- Beta blockers or CCB’s, RV pacing, myomectomy, mitral valve replacment

42. Pacemakers/ICD
                                                              

43. References
Kapoor W. N. Primary Care: Syncope. N Engl J Med 2000; 343: , Dec 21, 2000.
Grubb B. P. Neurocardiogenic Syncope. N Engl J Med 2005; 352: , Mar 10, 2005.
Olshansky B. Evaluation of the patient with syncope. UpToDate 2005.
Olshansky B. Pathogenesis and etiology of syncope. UpToDate 2005.
Olshansky B. Mangement of the patient with syncope. UpToDate 2005.
MedStudy

44. Questions?