1. Syncope Darius Sholevar, MD FACC

2. Disclosures – Research Collaboration Medtronic St. Jude Boston Scientific Angel medical systems Biosense Webster

3. Definition - Syncope is derived from the Greek words: syn (with) + Koptein (to cut) = to interrupt - It is defined as a transient self limited loss of consciousness due to transient global cerebral hypoperfusion.

4. Impact of Syncope: US Trends – A Common Problem *All patients discharged with syncope and collapse (ICD-9 Code:780.2) listed among diagnoses. NHDS 2003. **Syncope and collapse (ICD-9 Code: 780.2) listed as primary reason for visit. NAMCS 2002. Inpatient Trend*Physician Office Visits**

5. Loss of Consciousness SyncopeUNKOWN - 40%Vasovagal Syncope – 37%Cardiac Arrhythmias – 15%OrthostasisDrug / Medication InducedStructural Heart DiseaseCerebrovascular DiseasePseudo-SyncopeSeizurePsychogenic Syncope

6. Soteriades ES, et al. NEJM. 2002;347:878-885. Syncope Risk by Cause Survival with and without syncope 6-month mortality rate of greater than 10% Cardiac syncope doubled the risk of death N Engl J Med. Sept. 19, 2002

7. What to Do Next?

8. How To Evaluate Syncope History and Physical Transient Cause No testing, Treat Cause and Avoid Neurocardiogenic Syncope Suspected Rare Episodes Lifestyle Modification Frequent EpisodesEKG and Referral Suspect Cardiac Etiology or Structural Heart Disease Admission, Cardiology Evaluation

9. History – Telltale Findings Seizure – Aura, Tongue bites, prolonged confusion after episode, incontinence, automatisms, hemi-lateral seizure activity, aching muscles Watch out for Tonic Clinic Activity from Syncope Neurocardiogenic syncope – noxious stimuli, after exertion, sweating, nausea, very brief tonic clinic movements (less than 30 seconds) Cardiac Etiology – history of congestive heart failure or myocardial infarction, QT prolonging medications, episodes occurs during exertion, family history of sudden death / SIDS Palpitations starting as first symptom Carotid sinus hypersensitivity – tight color or on head or neck turning Orthostasis – prolonged sitting or standing Psychogenic – frequent attacks with somatic complaints and negative symptom rhythm correlation

10. When to Hospitalize Often a clinical decision Arrhythmic, cardiovascular cause New neurological abnormality Multiple, frequent episodes Severe orthostatic hypotension Elderly patient Treatment requiring admission

11. Further evaluation Carotid sinus massage ECG monitoring Echocardiogram Ambulatory ECG Monitoring Holter Event Monitor Implantable loop recorders Tilt testing Electrophysiological testing Stress Testing – syncope during exercise

12. Diagnostic Methods and Yields Procedure History and Physical Exam Yield* 25-35% 1 ECG2-11% 2 Monitoring Holter Monitoring 2% 3 External Loop Recorder20% 3 Insertable Loop Recorder43-88% 4,5,6 Test/Procedure Tilt Table11-87% 1,7 EP Study without SHD**11% 8 EP Study with SHD49% 1

13. Low Yield Testing for Syncope Cardiac enzymes CT scan Carotid Doppler's Neurology consult – 0-4% diagnostic yield EEG Psychiatric consultation

14. Carotid Sinus Massage Outcome Positive if BP drops > 50 mmHg and/or > 3 sec. asystole 1 Absolute contraindications 2 MI, TIA, or stroke in past 3 months; carotid bruits Relative contraindications Previous VF, VT 1 Kenny RA. Heart. 2000;83:564. 2 Linzer M. Ann Intern Med. 1997;126:989.

15. ECG Abnormalities Predicting Cardiac Syncope Bradycardia less than 50 bpm LBBB & Bifasicular Block Second degree AV Block Third Degree AV block Long QT interval Brugada syndrome Pre-excitation Myocardial infarction Ventricular Arrhythmias

16. When to Perform a Heart Monitor Holter monitor is rarely indicated unless there is very frequent syncope or dizziness Exception may be high suspicion of frequent arrhythmias External loop recorders should be considered in patients with a symptom interval of less than 4 weeks Implantable loop recorders should be considered for most people with syncope who have symptoms less than once a month and more than once every three years

17. Up to 1/3 of Patients with Strokes of Unknown Cause may Have Atrial Fibrillation

18. Pause noted at 0630 – Diagnosis?

19. Crystal AF Sanna et al N Engl J Med 2014; 370:2478-2486June 26, 2014

21. Echocardiogram -Screening tool to rule out cardiac disease -Low yield -Mitral valve prolapse is the most frequent coincidental finding

22. Tilt table testing Pathophysiology The autonomic reflex: -arterial and cardiopulmonary mechanoreceptors –brain stem –vagus & the sympathetic efferent neurons Protocols Isoproterenol vs. NTG (94% specificity)

23. When to Perform an EP Study Patients with ischemic heart disease Patients with myocardial scar Bifasicular block Palpitations preceding syncope Other situations where value is unclear – Brugada syndrome, hypertrophic cardiomyopathy, undiagnosed syncope

24. Patient with Syncope and Bifasicular block on EKG

25. A1H1 AH Jump Patient with Syncope Associated with Palpitations

26. Treatment Options BradycardiaPacemaker Ventricular Arrhythmia ICD Neurocardiogenic Syncope Lifestyle modification Support StockingsMedicationsMidodrineFludrocortisoneBeta BlockersPyridostigminePacemaker

27. www.bostonscientific.com/cardiac-rhythm-resources/cameron-health/sicd-system.html The End

28. Questions 1 – What is the highest yield diagnostic maneuver for syncope? 2 – What are two the most important test for ruling out a life threatening cause of cardiogenic syncope? 3 – What is the most important factor when choosing a heart monitor?

29. Questions - Answers 1 – What is the highest yield diagnostic maneuver for syncope? History and Physical Exam 2 – What are two the most important test for ruling out a life threatening cause of cardiogenic syncope? EKG and Echocardiogram 3 – What is the most important factor when choosing a heart monitor? Frequency of Symptoms

31. European Heart Journal (2009) 30, 2631–2671; doi:10.1093/eurheartj/ehp298

32. Treatment Neurocardiogenic/ vasovagal syncope Carotid sinus syndrome Situational syncope Orthostatic hypotension

33. Tilt Training Treatment of malignant and recurrent vasovagal syncope 42 tilt-positive patients performed home tilt training: two, 30-minute sessions daily After follow-up of 15.1±7.8 mos: 36 syncope free; 4 “presyncope”; 1 recurrence Conclusion: The abnormal autonomic reflex activity of vasovagal syncope can be remedied Reybrouck T, et al. PACE. 2000;23:493-498.

34. Prevention Of Syncope Trial (POST) Hypothesis: metoprolol will increase the time to the first syncope recurrence Double-blind, randomized, placebo-control trial, powered to detect 50% relative risk reduction of recurrent syncope Inclusion: >3 vasovagal spells, +TTT, age >18 208 patients; 38% completed follow-up without syncope Metoprolol ineffective overall. Age 42 improved* Conclusion - metoprolol first line drug therapy for age >42 *p=0.026 interaction with age Sheldon R. HRS, San Fran. 2004.

35. Midodrine - Vasovagal Syncope Months p < 0.001 Symptom – Free Interval 180160140120100806040200 100 80 60 40 20 0 Fluid Midodrine Perez-Lugones A, et al. JCE. 2001;12:935-938.

36. Pacemakers for Syncope

37. VPS I (North American Vasovagal Pacemaker Study) Objective: to evaluate pacemaker (PM) therapy for severe recurrent vasovagal syncope Randomized, prospective, single center N=54 Patients 27—DDD pacemaker with rate drop response 27—no pacemaker Inclusion: vasodepressor response Primary outcome: first recurrence of syncope Connolly SJ. J Am Coll Cardiol. 1999;33:16-20.

38. 100 90 80 70 60 50 40 30 20 10 0 03691215 Time in Months No Pacemaker (PM) 2P=0.000022 Pacemaker Cumulative Risk (%) VPS I (North American Vasovagal Pacemaker Study) Inclusion: vasodepressor response Results: 6 (22%) with PM had recurrence vs. 19 (70%) without PM 84% RRR (2p=0.000022) Connolly SJ. J Am Coll Cardiol. 1999;33:16-20.

39. VAsovagal Syncope International Study (VASIS) Results: 1 (5%) with PM had recurrence vs. 14 (61%) without PM. Pacemaker No Pacemaker p=0.0004 Years % syncope-free 100 80 60 40 20 0 23456 Inclusion: cardioinhibitory response Sutton R. Circulation. 2000;102:294-299.

40. VPS II (Vasovagal Pacemaker Study II) Objective: to determine if pacing therapy reduces the risk of syncope in patients with vasovagal syncope Randomized, double-blind, prospective, multi-center N=100 patients: 52—only sensing without pacing 48—DDD pacemaker with rate drop response Inclusion: positive TTT with (HRXBP) < 6000/min X mm Hg Primary outcome: first recurrence of syncope Connolly S. JAMA. 2003;289:2224-2229.

41. VPS II (Vasovagal Pacemaker Study II) Role of Pacing Connolly S. JAMA. 2003;289:2224–2229. Dual Chamber Pacing (DDD) Only Sensing Without Pacing (ODO) 1.0 0.8 0.6 0.4 0.2 0 Months Since Randomization Cumulative Risk 6 5 4 3 2 1 0 Results: 33% with pacing had recurrence vs. 42% with only sensing (p=NS)