1. SYNCOPE Suggestions for Lecturer -1-hour lecture
-Use GNRS slides alone or to supplement your own teaching materials.
-Refer to GNRS for further content, including strength of evidence (SOE) levels.
-Refer to Geriatrics at Your Fingertips for updated information.
-The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

2. OBJECTIVES
Know and understand:
The factors that may lead to syncope in older adults
The elements of evaluation (history, physical examination, testing) of older adults with syncope
The treatment options for syncope

3. TOPICS COVERED
Pathophysiology
Causative Factors
Evaluation and Management

4. SYNCOPE: INTRODUCTION
Sudden, transient loss of postural tone and conscious-ness (not due to trauma) with spontaneous full recovery
Accounts for:
About 3% of emergency department visits
2%–6% of hospital admissions
80% of those hospitalized for syncope are aged 65+
Generally caused by reduced cerebral perfusion
In older adults, may be multifactorial
Possible causes are numerous

5. NORMAL REFLEXES THAT PREVENT SYNCOPE
1/3 of blood volume pools in legs while standing
Reflex pathways facilitate venous return and increase cardiac output
Baroreceptor reflex
Sympathetic renal stimulation
Veno-arteriolar axon reflex
Abdominal-respiratory pump
Baroreceptor reflex: Increased autonomic sympathetic tone leads to peripheral vasoconstriction and increased heart rate
Sympathetic renal stimulation: Increased renin release from juxtaglomerular apparatus leads to production of angiotensin II (causes vasoconstriction) and aldosterone (causes sodium retention)
Veno-arteriolar axon reflex: Increased vasoconstriction of resistance vessels; the myogenic reflex increases smooth muscle contraction of resistance vessels, in turn leading to increased venous return
Abdominal-respiratory pump: facilitates venous return and increased preload

6. PATHOPHYSIOLOGY OF SYNCOPE: EFFECTS OF AGING
Reflex mechanisms are less responsive
Decreased ability to increase heart rate in response to sympathetic stimulation
Increased sensitivity to effects of dehydration and vasodilator drugs
Comorbidities that affect postural responses are common (eg, diabetes mellitus, Parkinson disease )
Drugs may further impair postural reflexes (eg, vasodilators, antidepressants, -blockers, -blockers, tricyclic antidepressants)

7. SYNCOPE: NATURAL HISTORY
Altered systemic blood pressure or
Vertebral basilar insufficiency from atherosclerosis
Reduced cerebral perfusion
Syncope
Causes may be benign or life-threatening
Causes may be multiple

8. COMMON CAUSES OF SYNCOPE: Reduced Cardiac Output
Cardiac causes
Rhythm disturbances
Structural heart diseases: aortic stenosis, hypertrophic cardiomyopathy
Coronary artery disease
Reduced intravascular volume
Dehydration
Bleeding
Pulmonary causes
Massive pulmonary embolus
Drugs causing reduced cardiac output

9. COMMON CAUSES OF SYNCOPE: Altered Peripheral Vascular Resistance
Functional autonomic reflexes
Vasovagal
Carotid sinus syndrome
Situational: swallowing, micturition, defecation
Structural autonomic insufficiency
Primary conditions: pure autonomic failure, multisystem atrophy
Secondary conditions: diabetes mellitus, spinal cord lesions, uremia
Drugs causing altered peripheral resistance

10. PREDICTING CARDIAC SYNCOPE: EGSYS SCORE
Variable
Score
Palpitations preceding syncope 4
Heart disease or abnormal ECG 3
Syncope during effort
Syncope while supine 2
Precipitating or predisposing factors, or both (warm or crowded place, prolonged orthostasis, fear, pain or emotional distress) –1
Autonomic prodromes (nausea/vomiting)
EGSYS = Evaluation of Guidelines in Syncope Study
Scores ≥3 are associated with higher rates of cardiac syncope and higher mortality.
SOURCE: Data from Del Rosso A, Ungar A, Maggi R, et al. Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: the EGSYS score. Heart ;94(12):1620–1626.

11. SYNCOPE EVALUATION: HISTORY (1 of 2)
Precipitants?
Eating
Urinating
Coughing
Medication
Emotional stress
Physical exertion
Turning head
Prodromal symptoms?
Chest pain
Palpitations
Dyspnea
Diaphoresis
Presyncope
Nausea
Vomiting

12. SYNCOPE EVALUATION: HISTORY (2 of 2)
Medications?
How, when taken, what doses
Relationship to meals and activities
Recent changes
Any witnesses?
Duration of event
Appearance of patient during event (flaccid tone and motionless or increased tone and motion?)
Comorbid conditions?
For example, CAD, diabetes mellitus

13. SYNCOPE CAUSED BY ARRHYTHMIA
Prior to event
Occurs in any position, <5 sec warning
No precipitant; palpitations rare
During event
Flaccid tone; pulse faint or absent
Blue, ashen skin
Incontinence (rare)
Recovery
Rapid and complete

14. VASOVAGAL SYNCOPE Prior to event Aborted if person lies flat
Seconds to minutes of warning
Precipitant present; nausea/diaphoresis common
Visual changes
During event
Motionless; relaxed tone; slow, faint pulse
Pale color; dilated, reactive pupils
Recovery
Fatigue, nausea, and diaphoresis common
No retrograde amnesia

15. SYNCOPE CAUSED BY SEIZURE
Prior to event
Occurs in any position
No warning or prodrome
During event
Rigid tone; rapid pulse; elevated BP
Tonic eye deviation common
Frothing at mouth
Recovery
Slow, incomplete
Disorientation; focal neurologic findings

16. SYNCOPE EVALUATION: PHYSICAL EXAMINATION (1 of 2)
Pulse in supine and standing positions
Orthostatic vital signs: Measure BP in both arms, 1 min after standing and again after standing for 3 min
Carotid pulse examination
Delayed upstroke and low volume may identify aortic stenosis
Perform carotid massage only with continuous ECG and resuscitation equipment available
Contraindicated with carotid bruit, CVD, recent MI

17. SYNCOPE EVALUATION: PHYSICAL EXAMINATION (2 of 2)
Cardiac examination for murmurs, extra heart sounds
Stool for occult blood
Neurologic examination for focal deficits

18. SYNCOPE EVALUATION: TESTING (1 of 2)
ECG for all syncopal older adults; assess for:
Acute or remote MI
Conduction abnormalities and pre-excitation
Sinus bradycardia
Prolonged QT interval
Ambulatory ECG
Among patients able and willing to operate loop recorders, diagnostic yield is ~25%
Implantable loop recorders
May increase ability to establish diagnosis in patients with syncope who have no structural heart disease
Unfortunately, the occurrence of symptoms during ambulatory ECG monitoring is relatively rare in most patients with syncope that remains unexplained after a history, physical examination, and ECG. On average, studies examining the diagnostic yield of ambulatory ECG report an arrhythmia correlating with symptoms in approximately 4% of patients. In another 15% of patients studied, an arrhythmia was excluded by the presence of symptoms during the recording, but without evidence of an arrhythmia; in approximately 14% of patients, arrhythmias occurred but without concomitant symptoms. These patients may represent a diagnostic dilemma.
However, certain arrhythmias, even asymptomatic ones such as nonsustained ventricular tachycardia, second- and third-degree AV block, and sinus pauses in excess of 3 seconds, are rare in people without heart disease. Their presence in a patient with a history of syncope, even if they are asymptomatic, indicates the need for further evaluation.
Subcutaneous implantable loop recorders have been developed; these devices are placed in the prepectoral region under local anesthesia. The devices have long-term memories and a battery life of approximately 14 to 18 months. Generally, no patient intervention is required for the device to store recordings, but the patient can also trigger the device to record and retain an ECG if symptoms occur. In a randomized study of patients with recurrent syncope who did not have evidence of structural heart disease, implantable loop recorders significantly increased the ability to establish a diagnosis.

19. SYNCOPE EVALUATION: TESTING (2 of 2)
Echocardiography
Tilt-table testing
Electrophysiologic studies
Neurologic testing (MRI and CT, plus EEG) if focal neurologic signs or symptoms are present, or if the history suggests seizure
Echocardiography: In the absence of features suggestive of heart disease by history, physical examination, or ECG, two-dimensional echocardiography has a low yield. It is most useful in confirming a specific diagnosis suspected by other assessment. Occult coronary artery disease is also relevant among older adults, and stress testing is often used for screening. In some patients, particularly those with the suggestion of structural cardiac abnormalities and ischemia by history, physical examination, or ECG, it is efficient to perform stress echocardiography as a single procedure.
Tilt-Table Testing: Head-up tilt-table testing results in pooling of blood in the legs, and in susceptible individuals it can trigger syncope mediated by neurocardiogenic mechanisms or confirm postural hypotension. Tilt-table testing is useful for patients suspected of having vasovagal syncope and those with unexplained syncope who are not suspected of having a cardiac cause. Responses to tilt testing performed for evaluation of syncope tend to differ by age among adults without significant structural heart disease. Those ≥65 years old tend to have far higher rates of symptoms due to pure vasodilatation without significant change in heart rate than individuals ≤35 years old. In contrast, individuals ≤35 years old tend to have more profound cardioinhibitory responses, characterized by profound bradycardia or asystole induced by tilt testing. The different patterns of responses suggest that different mechanisms for neurocardiogenic syncope predominate at different ages.
Electrophysiologic Study (EPS): The development of effective noninvasive methods, such as prolonged rhythm monitoring, has decreased the importance of EPS as a diagnostic test. Nevertheless, this test is still useful for diagnosis in suspected intermittent bradycardia, tachyarrhythmia, or in patients with bundle-branch block (suggestive of impending high- grade AV block). EPS is not recommended for patients with a normal ECG or those without a history of heart disease or symptoms of palpitations.

20. TREATMENT OF SYNCOPE (1 of 3)
Focus on treating the underlying disorder
In older patients, treatment of multiple possible causes is often necessary
Discontinuation of medications that increase the risk of syncope is always an early step

21. TREATMENT OF SYNCOPE (2 of 3)
Cause
Treatment
Myocardial ischemia
Revascularization or aggressive medical therapy
Valvular heart disease (especially aortic stenosis)
Usually surgery; avoid preload reduction
Symptomatic SVT
Medical therapy or electrophysiology ablation
Significant ventricular tachyarrhythmia
Implanted defibrillator or medical therapy
Bradyarrhythmia
Usually pacemaker
SVT = supraventricular tachycardia

22. TREATMENT OF SYNCOPE (3 of 3)
Cause
Treatment
Orthostatic hypotension
Adjust medications, ensure adequate volume, other conservative measures
Vasovagal syncope
Avoidance of triggers; medical therapy is somewhat controversial (clonidine, paroxetine, midodrine, pyridostigmine, octreotide, erythropoietin, desmopressin)
Carotid sinus hypersensitivity
Avoid stimulating factors (tight collars or rapid neck movements); pacemaker
Postprandial hypotension
Avoid alcohol and high-carbohydrate meals; remain recumbent after meals
Conservative measures that may help reverse orthostatic hypotension include the use of waist-high compression stockings, squatting, and sleeping in a head-up position. Avoidance of excessively warm environment and activities associated with straining (Valsalva) may also be beneficial. If autonomic dysfunction is present and hypertension, heart failure, and hypokalemia are not concerns, then low-dose fludrocortisone may be effective.

23. RECURRENT SYNCOPE WITHOUT IDENTIFIABLE CAUSE
Help patients avoid harm to themselves or others
Consider recommending against driving for several months and resuming if patient remains recurrence-free (American Heart Association guidelines)
Many states have reporting laws or restrictions regarding driving with a history of syncope

24. SUMMARY In older adults the cause of syncope is often multifactorial
Most diagnostic procedures for syncope are expensive and have a low yield unless findings from the H & P suggest a particular cause
The absence of cardiac disease strongly suggests that the cause of syncope is not cardiac
Treatment of syncope focuses on treating the underlying disorder

25. CASE 1 (1 of 3)
A 69-year-old man comes to the office because 1 week ago he lost consciousness for about 20 seconds. His son witnessed the episode and states that his father was walking across the room, appeared pale, said “I don’t feel quite right,” and collapsed. The patient says he felt lightheaded for about 5 seconds before loss of consciousness and felt normal within a few minutes after.
History includes hyperlipidemia and prostatic hyperplasia.
Blood pressure is 128/56 mmHg with no postural changes. All other findings are normal.

26. Two-dimensional echocardiography
CASE 1 (2 of 3)
Which of the following is the most appropriate initial diagnostic test?
Two-dimensional echocardiography
Doppler ultrasonography of the carotid artery
Electrocardiography
MRI of the brain
Tilt table test 26

27. Two-dimensional echocardiography
CASE 1 (3 of 3)
Which of the following is the most appropriate initial diagnostic test?
Two-dimensional echocardiography
Doppler ultrasonography of the carotid artery
Electrocardiography
MRI of the brain
Tilt table test
ANSWER: C
Electrocardiography is indicated for all patients who have syncope; the American College of Emergency Physicians considers this a Class A recommendation. It can be performed in the office, is fairly inexpensive, and can be used to discern whether an underlying arrhythmia or conduction abnormality caused the episode. In this case, the sudden loss of consciousness with only a brief prodrome suggests that an arrhythmia could be the cause. Normal ECG findings are associated with a more favorable prognosis.
Two-dimensional echocardiography would not be the first test to order, particularly in the absence of focal neurologic signs that suggest embolic stroke. Doppler ultrasonography yields information regarding vessel integrity of the carotid arteries, which provide anterior circulation to the brain. A cerebrovascular cause of syncope, however, would more likely reflect lack of perfusion to the posterior circulation (specifically, the reticular activating system in the brain stem), which maintains alertness, which was not the case for this patient. A problem with bi-hemispheric anterior circulation could also lead to syncope but would involve bilateral simultaneous occlusion of the carotid arteries, an unlikely event.
Typically, in the absence of focal neurologic signs or other contributing information, MRI is not ordered for evaluation of syncope, and certainly not as the initial test. A head-up tilt table test would identify whether autonomic dysfunction contributed to the syncope. This patient provided no information (such as rising from sitting to standing position) to suggest orthostatic syncope. The tilt table test is also more likely to be used once cardiovascular causes are excluded, and thus would not be the initial test in this patient’s evaluation. 27

28. CASE 2 (1 of 2)
Each of the following 68-year-old patients has had an episode of syncope. Which one should be assigned the highest priority for admission to the hospital for expedited evaluation?
A woman who reports low energy and feelings of worthlessness
A man whose syncope occurred while he was urinating
A man with hypertension who had syncope after shoveling snow
A woman with diabetes mellitus who had syncope after standing in line for several hours for tickets to a play 28

29. CASE 2 (2 of 2)
Each of the following 68-year-old patients has had an episode of syncope. Which one should be assigned the highest priority for admission to the hospital for expedited evaluation?
A woman who reports low energy and feelings of worthlessness
A man whose syncope occurred while he was urinating
A man with hypertension who had syncope after shoveling snow
A woman with diabetes mellitus who had syncope after standing in line for several hours for tickets to a play
ANSWER: C
Syncope that occurs during or after exertion warrants priority hospitalization for evaluation. In the case of the man who shoveled snow, the syncope may be a harbinger of a more serious cardiac condition. Evidence of a cardiovascular cause for syncope from history, examination, or abnormal ECG typically warrants inpatient admission. Priority inpatient admission is also necessary if the syncope may be related to adverse effects of medications, severe orthostatic hypotension, or a possible neurologic disorder, such as stroke.
The woman with low energy may have depression. Her syncope and psychiatric issues need to be addressed but not necessarily in an inpatient setting.
The man whose episode occurred during urination likely has situational syncope. Situational syncope is benign, and the patient’s status returns quickly to baseline after the event, without delayed sequelae. Patient education is important. For example, if carotid sinus syncope is suspected, the patient should be informed about possible precipitants of syncope, such as wearing a tight collar. There would be acceptable risk in discharging the patient for follow- up with his primary care provider.
For the woman with diabetes mellitus, the syncope after prolonged standing may be the result of autonomic instability related to her diabetes. Evaluation for her would not be as urgent as for the patient with post-exertion syncope. In the former case, arranging for outpatient follow-up with tilt table test would be reasonable. 29

30. CASE 3 (1 of 3)
An 85-year-old man is brought to the emergency department because he lost consciousness while playing with his grandchildren. He regained consciousness quickly but was unable to stand and walk without assistance. He reports constant vertigo since the episode.
History includes DM, hypertension, and CHD.
On examination, blood pressure is 205/110 mmHg. There is vertical nystagmus, dysarthric (slurred) speech, and mild tongue deviation to the right. 30

31. Which of the following should be done first? Tilt table test
CASE 3 (2 of 3)
Which of the following should be done first?
Tilt table test
Two-dimensional echocardiography
Immediate administration of fludrocortisone
Urgent cardiology consultation
Urgent CT of the head 31

32. Which of the following should be done first? Tilt table test
CASE 3 (3 of 3)
Which of the following should be done first?
Tilt table test
Two-dimensional echocardiography
Immediate administration of fludrocortisone
Urgent cardiology consultation
Urgent CT of the head
ANSWER: E
This patient needs urgent CT of the head to exclude brain-stem stroke. He has vertigo, and findings on examination (vertical nystagmus, dysarthria, and tongue deviation) refer to cranial nerves. The increased blood pressure is consistent with stroke, and he has several risk factors, such as diabetes mellitus, hypertension, and coronary heart disease. If brain-stem stroke is under way and intracerebral hemorrhage is excluded by CT of the head, he would need to be started on aspirin and a lipid-lowering agent and be admitted to a close-monitoring unit with regular neurology checks. If he is found to have a basilar occlusion, he may be a candidate for thrombolysis if he is brought to the hospital within 6 hours of onset of symptoms.
Echocardiography is typically part of a stroke evaluation, but it would not be the first test ordered. Once stroke is confirmed, echocardiography is warranted to evaluate its cause. Fludrocortisone is a corticosteroid that can be used in instances of orthostatic hypotension to increase blood pressure by expanding plasma volume. This patient’s systolic blood pressure is >200 mmHg. An immediate cardiology consultation is not optimal because the evidence points to an acute neurologic event, not acute cardiac dysfunction. If it is available, urgent neurologic consultation would be preferable. A tilt table test is used to discern autonomic instability. Because there is no evidence of orthostatic or autonomic dysfunction, the test would not be useful and would increase danger to the patient by delaying efficient evaluation. 32

33. Copyright © 2014 American Geriatrics Society
GNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Win-Kuang Shen, MD and Sushmitha Patibandla, MD and questions by Stephen Krieger, MD and Jagat Shetty, MD Managing Editor: Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society