1. Syncope and The Older Patient
Debra L. Bynum, MD
Division of Geriatric Medicine

2. Pretest…
1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope
2. History: 75 year old man reports presyncopal symptoms that occur while he is driving backwards out of his driveway in the morning. This suggests …
3. History: an 80 year old man reports an episode of syncope that occurred after doing arm exercises for a rotator cuff injury. This suggest…
4. The only independent predictor of a cardiac etiology of syncope is a past history of …
5. ____ is a neurodegenerative disease characterized by profound autonomic insufficiency and parkinsonian features on exam
6. An 82 year old man presents with postural hypotension, an idiopathic peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____
7. Name 3 causes of “situational syncope”
8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus massage c. orthostatic hypotension d. all of the above

3. Pretest: bonus question
Sudden cardiac death in young men (originally described in young asian men) associated with this sign on EKG is known as what syndrome?

4. Syncope: Definition
Sudden and temporary loss of consciousness with inability to maintain postural tone, followed by spontaneous recovery

5. Causes of Syncope Neurally Mediated (up to 58% in some series)
Orthostatic/postural
Cardiac arrhythmia (20-25%)
Structural cardiac or pulmonary causes
Cerebrovascular or psychiatric (1%)
Unknown (18-30%)

6. Syncope in the Elderly Usually multifactorial
Often confounded by findings (orthostasis and carotid hypersensitivity common and may be found and yet not be the cause…)
Prevalence up to 25% in nursing home population over age 70
Higher pretest probability of cardiac disease or arrhythmia

7. Importance of History and PE
Up to 70% of patients in prospective studies had probable cause identified based upon history, physical exam and ecg

8. The History… History of Heart Disease
The ONLY independent predictor of cardiac cause (sens 95%, spec 45%)
Absence of heart disease up to 97% specific to rule out cardiac etiology (good NPV)

9. The History Position Presyncopal symptoms Dyspnea (Pulmonary embolus)
Supine: cardiac until proven otherwise
Upon sitting/standing: orthostasis
Prolonged standing: venous pooling/orthostasis/vasovagal
Presyncopal symptoms
Presence suggests vasovagal, but does not rule out arrhythmia
Lack of suggests arrythmia (up to 65% with sudden syncope)
Dyspnea (Pulmonary embolus)
Focal neurologic symptoms (TIA, seizure)
Seizure like activity (including loss of bowel and bladder control, tongue bite, postictal state)

10. The history… Recovery period Situational syncope (vasovagal)
Instant: arrythmia
Feeling hot and nauseated: vasovagal
Confusion/lethargy: postictal
Situational syncope (vasovagal)
Cough
Swallow (cold liquid)
Micturition (urination)
Defecation
Exertional
Ventricular tachyarrhythmia
Aortic stenosis or HOCM
Pulmonary Hypertension

11. The history… Prior “faint” 1-4 years prior suggest vasovagal Age
Medications
Tricyclic antidepressants
Nitrates
Alpha adrenergic antagonists
Diuretics
Injury (facial suggests arrhythmia)
Postprandial (vagally mediated)

12. Specific Causes and Treatment Options for Syncope
Postural Hypotension
Drop in systolic blood pressure of over 20
Medications
Autonomic Insufficiency
No reflex tachycardia
Shy-Drager (multiple systems atrophy)
Primary autonomic failure
Parkinson’s Disease
Diabetes
Aging
Amyloid
Volume Loss
Dehydration
Blood loss

13. Autonomic Insufficiency and Orthostatic Hypotension
Treatment Options
Review of medications
Avoid volume depletion
Arising slowly
Tensing crossed legs while standing
Dorsiflex feet or handgrip prior to standing
Thigh high Jobst stockings (decreases venous pooling)
Avoid prolonged standing (venous pooling)
Increased salt diet
Smaller meals to avoid postprandial drop in BP
Fludrocortisone
Midodrine (alpha 1 adrenergic agonist)
Phenylephrine (not usually used in older patients)
Fluoxetine

14. Mechanical Cardiac Causes
Obstruction to LV outflow
Aortic Stenosis
HOCM
Left atrial myxoma
Mitral Stenosis
Obstruction to pulmonic flow
Pulmonic stenosis
Pulmonary HTN
PE (can also have vasovagal type syncope associated with smaller PEs)
Right atrial myxoma

15. Other Mechanical Cardiac Causes
Large MI with LV dysfunction
CHF
Tamponade
Aortic dissection

16. Cardiac Arrhythmias Bradycardia Tachycardia Sick sinus syndrome
2nd or 3rd degree AV block
Pacemaker malfunction
Tachycardia
Ventricular tachycardia
Ventricular fibrillation
SVT
If you see atrial fibrillation, think sick sinus syndrome as potential cause of syncope…

17. Brugada Syndrome Triad Structurally normal heart
RBBB pattern in right precordial leads
Transient/persistent ST elevation in v1-v3
Sudden cardiac death
Structurally normal heart
Association with young and healthy men from southeast asia who present with sudden cardiac death
Brugada sign may be asymptomatic
High risk of sudden cardiac death in those who have syncope or family history of sudden death (Indication for AICD based upon observational data)

18. Brugada Sign

19. Implantable Cardioverter-Defribrillator Guidelines
AICD indicated for patients with spontaneous Vtach with underlying heart disease or in patients with normal heart when vtach not amenable to other treatments

20. AICD guidelines Ischemic Cardiomyopathy LVEF <30%
At least 1 month after MI and 3 months after revascularization
MADIT-II trial
Multicenter Automatic Defibrillator Implantation Trial
5.6% ARR in mortality over 4 years
Results support prophylactic AICD, but not considered cost wise
Based upon subset analysis, Current recommendation in those with QRS >120 ms
Unclear result: those with ICDs had 5% absolute increased risk of hospitalization for CHF (19% vs 14%): ?artifact, ?due to living longer?, ?detrimental

21. AICD guidelines…
Syncope in patients with advanced structural heart disease
High risk of sudden cardiac death
Inducible Vtach with structural heart disease
Inducible Vtach with normal heart that is not amenable to ablation therapy

22. Subclavian Steal Syndrome
Proximal subclavian artery stenosis
Decreased blood flow to distal subclavian artery worsened with exertion of arm
Blood from vertebral artery on opposite side goes to basilar artery and then down ipsilateral vertebral artery, away from brainstem, to serve as collateral for arm
Usually asymptomatic
Atherosclerosis
Symptoms of vertebrobasilar insufficiency (dizziness, vertigo, diplopia, nystagmus)
Rare to have permanent neurological deficits
Diagnosis with dopplers, MRA
Treatment: surgical revascularization, stents

23. Cerebrovascular Disease
Less common cause of true syncope
Vertebrobasilar disease (presyncope)
Drop Attacks

24. Vasovagal/Neurocardiogenic syncope
Situational Syncope
Micturition
Defecation
Cough
Swallow
Recurrent Neurocardiogenic Syncope
Posprandial
The FAINT

25. Vasovagal Syncope Presyncopal symptoms
Setting (procedure, pain, anxiety)
Prior history

26. Neurally Mediated Syncope
Cardiac sensory receptors in LV stimulated by stretch
Increased neural discharge to vasomotor center in medulla
Increased parasympathetic tone and decreased sympathetic activity
Sudden bradycardia and hypotension

27. Recurrent Neurocardiogenic Syncope
Upright posture lead to pooling of blood in lower extremities
Decreased venous return
Normal response: reflex tachycardia and forceful LV contraction and vasoconstriction
Susceptible individuals: activation of mechanoreceptors triggers reflex bradycardia and hypotension
Response triggered by forceful LV contraction with prolonged standing or with increased catecholamines (anxiety, fear, panic, pain)

28. Treatment of Recurrent Neurocardiogenic Syncope
Medications
Paroxetine
Only agent shown effective in RCT
Midodrine
Alpha adrenergic agonist
Small studies
Fludrocortisone
No good study
Beta blockers
Often used, mixed evidence in studies

29. Pacemakers in the treatment of Recurrent Neurocardiogenic Syncope
3 large RCTs of permanent pacing
North American Vasovagal Pacemaker Study (VPS-1)
Patients with over 6 episodes, positive tilt table test with significant bradycardia
Significant decrease in recurrence with pacer (HR .087)
Vasovagal Syncope International Study
5% recurrence with pacemaker vs 61% without (19 patients)
Syncope Diagnosis and Treatment Study
Pacemaker vs atenolol
93 patients: 4.3% recurrence vs 26%

30. Pacemakers and neurocardiogenic syncope:
Problems with trials…
Small numbers of patients
Not blinded
Highly selected patients
Patients had profound bradycardia on tilt table testing and multiple episodes

31. Pacers and neurocardiogenic syncope…
Bottom line:
May benefit patients with recurrent episodes of clear neurally mediated syncope, associated with significant bradycardic response, who have a decreased QOL otherwise (injuries, driving, etc)

32. Carotid Sinus Hypersensitivity
?Role of Carotid Sinus Massage
Some recommend if no bruits, recent MI, cva or history of vtach
?monitor
Positive response: 3 sec pause
In literature, but most cardiologists would not recommend
High yield of carotid massage in elderly (up to 40% over the age of 75 may have a positive response), but not specific in identifying this as the cause of syncope (PPV not known)
History: syncope/presyncope with turning neck, backing up in car, wearing tight collar

33. Evaluation of Syncope
When a cause of syncope is identified, history and physical lead to etiology in up to 85% cases
The only independent predictor of a cardiac cause of syncope is the presence of underlying heart disease (95% sens, only 45% spec)

34. Orthostasis May be confounder in older patients
Up to 25% of older patients may have orthostasis when tested, the presence of orthostasis may be true, true and unrelated…

35. The ECG Prolonged QT Bradycardia, AVN disease, MI, HOCM, Brugada
Only 2-10% will have diagnostic abnormality
Up to 50% of patients with syncope have abnormal EKG
Greatest use in NPV (negative predictive value) of NORMAL ECG

36. The Holter Monitor 24-48 hours continuous ECG
No added yield with 72 hours
Low yield unless frequent symptoms
Up to 70% of Holter studies negative for diagnosis
One series: only 5% of studies had arrhythmia that correlated with symptoms
Probably good NPV if symptoms documented with benign rhythm

37. Event or Loop Monitors
Higher yield than holter (up to 55% positive yield of symptom-arrhythmia correlation in some series)
Problem with patient education and ability to activate monitor correctly (25% of patients have difficulty)
May be especially problematic in the very elderly or those with dementia

38. Implantable Loop Recorder
Prolonged monitoring for those with syncope of unclear etiology despite workup, especially for those in whom cardiac etiology is suspected
Several small studies suggest that in very selected patients, may increase yield of diagnosis to almost 85%

39. Other Cardiac Tests Echo Exercise or Functional Tests EP studies
Most useful when history or physical suggests specific further testing to be done…

40. Tilt Table Testing… Passive or Isoproterenol
Test: patient held in upright position at degrees and observed for symptoms and hypotension or bradycardia
Passive testing: sensitivity of 70%, specificity of %
Isoproterenol: only 55% specificity
Overall little to add to history and PE; lack of sensitivity with passive testing and lack of specificity with induced testing limits usefulness of test…

41. Lab tests… The basics (anemia)
?BNP: some studies report usefulness as a marker for cardiac cause of syncope: sensitivity of 82% and specificity of 92%, Likelihood ratios of pos and neg tests probably not more useful than pretest probability of underlying heart disease based upon history and physical exam
CK, MB and Troponins
More useful if positive (greater PPV) than neg
One series: up to 10% nursing home patients presenting with syncope had positive enzymes…

42. The Least Useful Tests…
CT head with negative neurological exam
EEG with no neurological symptoms
Carotid Artery Dopplers (useful for evaluation of CVA or TIA, not useful for evaluation of syncope without vertebrobasilar symptoms…)

43. The Older Patient
Positive tests that are more common in the elderly and not necessarily the cause of the syncope:
Orthostasis
Positive carotid massage
Positive tilt table testing
Up to 54% of older patients with syncope may have positive test…
Positive test in 10% of asymptomatic elderly!

44. Algorithm for diagnosing syncope
Linzer, M. et. al. Ann Intern Med 1997;127:76-86

45. Summary of Charges for Diagnostic Tests in Syncope*
Linzer, M. et. al. Ann Intern Med 1997;127:76-86

46. Summary Syncope in the older patient usually multifactorial
Tailor tests based upon history and physical exam
Elderly more likely to have positive tests that may be confounders…
Elderly more likely to have underlying heart disease and higher pretest probability of a cardiac etiology
Use algorithms in older, complicated patients with great caution!!!

47. Back to the Pretest…
1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope
2. History: 75 year old man reports presyncopal symptoms that occur while he is driving backwards out of his driveway in the morning. This suggests …
3. History: an 80 year old man reports an episode of syncope that occurred after doing arm exercises for a rotator cuff injury. This suggest…
4. The only independent predictor of a cardiac etiology of syncope is a past history of …
5. ____ is a neurodegenerative disease characterized by profound autonomic insufficiency and parkinsonian features on exam
6. An 82 year old man presents with postural hypotension, an idiopathic peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____
7. Name 3 causes of “situational syncope”
8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus massage c. orthostatic hypotension d. all of the above

48. Answers to Pretest… 1. NPV 2. Carotid Hypersensitivity
3. Subclavian steal syndrome
4. Cardiac history
5. Multiple Systems Atrophy (shy-drager)
6. amyloid
7. micturition, defecation, cough, swallow
8. all of the above
9. bonus: brugada syndrome

49. Selected References
Benditt DG, VanDjjk JG, Sutton R. Syncope: Curr Prob Cardiol 2004; 29(4):
Epstein AE. An update on implantable cardioverter-defibrillator guidelines. Curr Opin Cardiology 2004; 19(1): 23-25
Littman L et al. Brugada syndrome and Brugada sign. Am Heart J 2003; 145(5):
Raj S, Sheldon RS. Role of pacemaker in treating neurocardiogenic syncope. Curr Opinion Cardiol 2003; 18: 47-52
Gregoratos G, Cheitlin MD, Conill A. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrthythmia devices: executive summary: a report of the American College of Cardiology/Am Heart Assoc Task Force on Practice Guidelines. Circulation. 1998; 97:
Connolly SJ et al. The North American Vasovagal Pacemaker Study. J Am Coll Cardiol 1999; 33: 16-20
DiGirolamo et al. Effects of paroxetine on refractory vasovagal syncope. J Am Coll Cardiol 1999; 33:
Sutton R et al. Dual chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope (VASIS). Circulation 2000; 102:

50. Selected References…
Krahn Ad et al. Use of the implantable loop recorder in evaluation of patients with unexplained syncope
Kapoor WN. Current evaluation and management of syncope. Circulation 2002; 106: 1606
Alboni P et al. Diagnostic Value of history in patients with syncope. J Am Coll Cardiol 2001; 37: 1921
Kapoor et al. Evaluation and outcome of patients with syncope. Medicine 1990; 69: 160
Linzer et al. Diagnosing syncope: part I. Ann Int med 1997; 126:989
Linzer et al. Diagnosing syncope: part II. Ann Int Med 1997; 127: 76