1. Syncope - How Do I Figure This One Out?
From the Publishers of
Consult Guys
Syncope - How Do I Figure This One Out?
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3. I’m e-mailing for advice
I’m ing for advice. I am in the ED seeing a patient who is being evaluated for her third episode of syncope in 3 years.
Guys:
She is 35 years old and tells me that she is in excellent health.
Earlier today, while seated at a table in a crowded restaurant, she experienced nausea, became diaphoretic, became pale according to her friends, and then had a 30-second
syncopal episode. No seizure activity was seen. She regained consciousness and felt profound fatigue.
She tells me that this was similar to an episode one year ago. Two years ago she had a syncopal episode while standing for a long period of time waiting to enter a rock concert.
She exercises several times per week. She is a schoolteacher. She does not smoke cigarettes or drink alcohol. No family history of sudden death or cardiovascular disease.
So, Consult Guys, here is the question:
This is her third episode of syncope in three years, and I feel as though we have to get to the bottom of this.
I’d like to admit her for a comprehensive work-up. My colleagues believe that we can do the full and extensive work-up as an outpatient.
It’s a dizzying problem. Can you guys shed some light?
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4. Exam Awake and alert No focal neurologic findings
BP: 120/70 and no orthostatic changes
HR: 70
JVP normal, carotid upstroke normal
No bruit
S1, S2 normal
No murmur, S3, S4
No provocation of murmur with Valsalva maneuver
Bowel sounds normal
Abdomen not tender, no mass
Distal pulses intact
No edema
ECG: NSR (70), normal ECG, QT normal, no LVH
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5. The Case 35-year-old healthy woman Exercises
One episode of syncope each year for 3 years
Prodrome: warmth, nausea
Exam unremarkable
“BP no orthostatic change”
ECG normal, no LVH
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6. Twentieth Anniversary
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7. Twentieth Anniversary
Core work-up: history, exam, ECG
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8. Guideline for the Evaluation and Management of Patients With Syncope
Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, et al ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation [PMID: ] doi: /CIR

9. Syncope: Initial Evaluation
Differentiate benign vs. life-threatening
Is hospitalization really needed?
History, exam, ECG
Syncope is a symptom, not a disease
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10. Syncope: Initial Evaluation Is it cardiac?
Arrhythmia, conduction disorder
Structural (such as aortic stenosis)
Hypertrophic cardiomyopathy NO
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11. Syncope: Initial Evaluation Is it neurologic?
No focal findings
No seizure NO
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12. Syncope: Initial Evaluation Is it orthostatic?
No evidence on exam NO
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13. Syncope: Initial Evaluation Is it noncardiac, neurally mediated?
Yes: vasovagal syncope
Young
No cardiac disease
Prodrome: warmth, nausea
Episode after prolonged standing
Prior history with similar characteristics
Other features to look for
Triggers: pain, dehydration, stressful stimuli
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14. Syncope: Hospitalization?
Arrhythmias or conduction abnormalities
VT: sustained or symptomatic
Mobitz II or third-degree AV block
Symptomatic sustained bradycardia
Symptomatic SVT
Long QT
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15. Syncope: Hospitalization?
Myocardial ischemia, infarction
Severe aortic stenosis
Hypertrophic cardiomyopathy
Aortic dissection
Acute heart failure
Moderate to severe left ventricular dysfunction
Pulmonary embolism
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16. Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: the EGSYS score.
Reproduced from Heart, Del Rosso A, Ungar A, Maggi R, Giada F, Petix NR, De Santo T, et al.,12, ,
2008 with permission from BMJ Publishing Group Ltd.

17. First episode of syncope Admitted to hospital
Trauma related to syncope
High probability cardiac syncope (EGSYS score)
Severe coexisting conditions
Failure to identify a cause
Prandoni P, Lensing AW, Prins MH, Ciammaichella M, Perlati M, Mumoli N, et al; PESIT Investigators.
Prevalence of pulmonary embolism among patients hospitalized for syncope.
N Engl J Med. 2016;375: [PMID: ] [PMID: ] doi: /hrt

18. 16% had pulmonary embolus
First episode syncope
Admitted to hospital
Trauma related to syncope
High probability cardiac syncope (EGSYS score)
Severe coexisting conditions
Failure to identify a cause
16% had pulmonary embolus
Prandoni P, Lensing AW, Prins MH, Ciammaichella M, Perlati M, Mumoli N, et al; PESIT Investigators.
Prevalence of pulmonary embolism among patients hospitalized for syncope.
N Engl J Med. 2016;375: [PMID: ] [PMID: ] doi: /hrt

19. Syncope: Hospitalization?
Severe anemia
GI bleed
Major trauma as a result of syncope
Persistent vital sign abnormality
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20. Syncope: Blood Tests? No “routine” tests, no panels
CBC, electrolytes often done
Low yield
Target tests to the patient
Our case
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21. Syncope: Cardiac Tests?
Echo if structural heart disease suspected
AS, HCM, cardiomyopathy
How about echo as a screening test?
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22. Syncope: Neurologic Tests?
Carotid artery imaging
No, in absence of focal neurologic findings
MRI, CT of head
EEG
No, in absence of findings suggestive of seizure
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23. Syncope: Cardiac Rhythm Monitor?
Not in our patient
When arrhythmia suspected, choose monitoring modality based on frequency and nature of syncopal events
For the patient with elusive syncope of unclear etiology, consider implantable cardiac monitor (ICM)
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24. Vasovagal Syncope: How to prevent the next episode?
Avoid triggers
Physical counter-pressure maneuvers (IIa)
Need long prodrome to get into position
Lie supine
Cross legs
Do isometric contractions of legs
Do isometric contractions of arms and hands
Grip hands and pull apart
Increases systolic BP (10%) and CO
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25. Vasovagal Syncope: How to prevent the next episode?
Midodrine (IIa recommendation)
Frequently symptomatic patients
Peripheral alpha agonist
Decreases venous pooling and vasodepression
Do not use in patients with hypertension or CHF
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26. Vasovagal Syncope: Driving?
Check with your state’s Department of Motor Vehicles
Pennsylvania: 6 months
ACC/AHA/HRS 2017 suggestions
1–6 VVS episodes/year: 1 month
>6 VVS episodes/year: not fit to drive until resolution of symptoms
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27. Our Patient Vasovagal syncope No routine labs No echo No monitoring
No CT, MRI, carotid imaging
No admission
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