Sean Mindra, MS3 Thursday July 30th, 2015 Syncope Sean Mindra, MS3 Thursday July 30th, 2015

Objectives Define syncope and review the pathophysiology and clinical manifestations Review the differential diagnosis for syncope Review the initial work-up and management of syncope, recognizing factors which would point to a life-threatening cause of syncope

Case: ID: Tim, 14 y.o. M Reason for visit: loss of consciousness at school a few days ago HR: 72 bpm BP: 122/68 RR: 16 What is syncope and why does it occur?

Syncope **Complete spontaneous recovery! What? - Sudden, abrupt loss of consciousness and tone Why? – transient decrease in global cerebral perfusion **Complete spontaneous recovery!

Why learn about syncope? Quite common – approx. 1 out of 5 pediatric patients will experience a syncopal episode before 15 years of age It is scary (for both patients and the parents)! – thus, very high likelihood for patients to seek medical attention following an episode Most are benign….but our job is to learn about the more sinister causes and recognize them

Back to the case… ID: Tim, 14 y.o. M Reason for visit: loss of consciousness at school a few days ago What sorts of causes are we thinking about as we enter the examination room?

DDx for Syncope: Neurally-mediated syncope/NMS/ “vaso-vagal” = BENIGN! Cardiovascularly mediated syncope Arrythmia vs. structural Non-cardiac pseudosyncope Epilepsy/seizures vs. psychogenic Drug/toxin induced Anaphylaxis Metabolic Mechanical fall Narcolepsy

"Listen to your patient, he is telling you the diagnosis," In cases of suspected syncope, the medical history is of paramount importance Physical examination and initial investigations will generally add very little to the picture With that in mind, what sorts of questions to you want to ask Tim?

History of Presenting Illness: What were you doing at the time? Leading up to event? Were you alone? Was it witnessed? Prodromal symptoms? Injuries? Jerky movements? Post-ictal state? Persisting neurologic deficits? Incontinence? Previous episodes/frequency of episodes

RED FLAG FEATURES History of heart murmur or congenital heart disease Syncope during exercise/exertion Family history of sudden cardiac death, long QT syndrome, heart disease Long-lasting syncope Unusual syncope triggers

Tim: I was at band practice, standing up for about 20 minutes I began to feel warm, dizzy, and mildly nauseated I then lost consciousness – my bandmates tell me I fell to the floor and was out for about 30 seconds They told me I was “very pale and clammy”, so I had a glass of water I felt pretty good after that but my teacher called my parents and I went home

Tim: What would we like to know about Tim’s past medical history? I did not feel my heart pounding or racing I did not feel short of breath No chest pain or discomfort before or after the episode…I just wanted to continue with band practice What would we like to know about Tim’s past medical history?

Past Medical History: Previous episodes Other medical conditions? Seizures Cardiac abnormalities Insulin dependent diabetes Anaphylaxis **Ask for pregnancy if female

Tim’s Parents Say: Is Tim currently on any medications? Tim had one other episode where he lost consciousness This occurred about 1 year ago He was getting bloodwork at the time and looked quite pale Tim said that he felt quite hot and dizzy before passing out for a few seconds in the blood lab He returned to a normal state within a few minutes of regaining consciousness Is Tim currently on any medications?

Meds: Beta/calcium channel blockers Diuretics Vasodilators Medications that prolong QT Anti-depressants Neuroleptics Antibiotics Anti-arrythmics Zofran

Family History What’s next? History of syncope? Pacemaker? Sudden cardiac death? Prolonged QT HOCM MI at a young age? What’s next?

Physical Examination HR: 72 bpm, BP: 122/68, RR: 16 Height: 165cm (50%ile), Weight: 44.7kg (25%ile) Cardiac: Mild pectus excavatum. No heaves or thrills. Normal S1 and normally split S2. 1-2/6 systolic murmur at LLSB that disappeared with upright positioning. JVP normal. Femoral pulses easily palpable with no brachiofemoral delay. Abdo: WNL. Neuro: Non-contributory

Lets Review our DDx:

NMS Most common (60-80%) Often has many triggers (blood, needles, etc.) Prodrome No post-ictal period but can feel tired, warm, and clammy afterwards Positive family history of fainting

Cardiac-mediated Syncope Abrupt onset Absence of usual prodromal symptoms or precipitating factors Unusual syncope triggers (i.e. loud noises) Is there a history of congenital heart disease Family history of sudden cardiac death ***Typically, EXERTIONAL in nature

Pseudo-syncope Epilepsy vs. psychogenic Epilepsy Psychogenic Tonic clonic movements Tongue biting Incontinence Post-ictal period Psychogenic Conscious or unconscious avoidance of unpleasant emotional situation Frequent episodes Prolonged events (can be hours) Almost never leads to injury Can experience syncope in supine position

Which Investigations to Order?

Things to Consider: Investigations ECG Bloodwork Glucose Holter monitor Stress testing EEG CT Head Tilt table testing

Tilt Table Procedure

Management Reassurance! (Mainstay of therapy for NMS b/c not caused by epilepsy or a life-threatening cardiac cause) Education Recurrent episodes are common but most cases resolve within 5 years Avoid triggers Volume expansion for NMS (increasing salt and water intake)

For frequent, recurrent episodes refractory to conservative therapy… Medications/pharmacotherapy Depends on etiology/cause Options include: Beta blockers (Atenolol or metoprolol – mimics increased parasympathetic tone to prevent vagal output) Alpha agonists (stimulate HR and increase peripheral resistance) Mineralocorticoids (e.g. Florinef) for volume expansion (used along with salt/water intake) SSRI’s (has been described for refractory syncope)