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Down for the Count The Evaluation of Syncope

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Department of Emergency Medicine. Mayo Clinic and Mayo Medical School. OUTLINE. Case ... Mayo Clinic: 1996-1998 (n=1,291) 65 years. n=607. 65 years. n=684. 13 ... – PowerPoint PPT presentation

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Title: Down for the Count The Evaluation of Syncope


1
Down for the Count! The Evaluation of Syncope
  • Wyatt W. Decker, M.D.
  • Department of Emergency Medicine
  • Mayo Clinic and Mayo Medical School

2
OUTLINE
  • Case
  • Epidemiology
  • Signs and symptoms
  • What data help to risk-stratify patients with
    syncope?
  • Who should be admitted after a syncopal event?

3
Case Presentation
  • 82-year-old male was found by son, unresponsive
  • When ambulance arrived, his pulse was 70 and BP
    was 160/98

4
Case Presentation 82-Year-Old Male
  • History HTN on HCTZ
  • Exam Facial contusion, unable to move (L) wrist
  • ECG SR, LBBB, PVCs
  • X-ray (L) wrist fracture

5
Case Presentation 82-Year-Old Male
  • What to do?
  • 1) Holter as outpatient
  • 2) Echo
  • 3 ) Admit for EP studies
  • 4) Admit for 23 monitoring

6
Case Presentation 82-Year-Old Male
  • Risk Stratification
  • 1) High risk for an adverse event
  • 2) Moderate risk
  • 3) Low risk

7
Case Presentation 82-Year-Old Male
  • Question orthostatic blood pressure
  • 1) Always check - very useful
  • 2) Sometimes check - can be useful
  • 3) Never check - is useless

8
SYNCOPE Definition
  • A transient loss of consciousness
  • Spontaneous and full recovery
  • Loss of postural tone
  • No prolonged confusion

9
  • Syncope and sudden death are the same, except
    that in one you wake up

- Anonymous
10
SYNCOPE Epidemiology
  • 6 hospital admits
  • Up to 3 ED visits
  • 12-40 of young adults
  • 6 incidence in 75 y/o

11
SYNCOPE Natural History
Mortality
Sudden Death
60
50
40

30
20
10
0
1
2
3
4
5
0
1
2
3
4
5
Y
ear of follow-up
Cardiogenic
Undetermined
Kapoor Medicine, 1990
Noncardiac
12
SYNCOPE Etiology - Noncardiac
  • Vasodepressor (1-29)
  • Situational (1-8)
  • Seizure
  • Psychogenic
  • Orthostatic (4-12)
  • Drug-induced (2-9)
  • Carotid sinus
  • Neuralgia
  • Neurologic (TIA, stroke, migraine)

13
SYNCOPE Drug Induced
N 70 Syncope Clinic 13
probable drug related
  • B-blocker
  • Nitrates
  • CCB
  • Ace I
  • Phenothiazines antidepressants
  • Antiarrhythmics
  • Diuretics
  • Digoxin
  • Insulin
  • Drugs of abuse
  • EtoH

14
SYNCOPE Etiology Cardiac
  • Obstruction to flow (3-11)
  • HOCM, AS, MS, myxoma
  • PS, PE, Pulm HTN
  • MI, tamponade, AD
  • Arrhythmias (5-30)
  • Sick sinus, AV block, pacer
  • VT, SVT

15
Age-Dependent Causes of Syncope Mayo Clinic
1996-1998 (n1,291)
?65 years n684
3
18
17
10
19
24
43
23
30
13
16
SYNCOPE Signs/Symptoms
  • Age
  • Those less than 45 tend to do well
  • Those over 65 are higher risk
  • Ages in between are incremental
  • There is no age cutoff

Kapoor, et al NEJM 3091983
17
SYNCOPE Signs/Symptoms
  • SZ vs. syncope
  • N 94
  • SZ 41 No SZ 53
  • Logistic Regression Analysis
  • SZ Diagnosis
  • Frothing
  • Tongue biting
  • Disoriented
  • LOC 50 min
  • Not a SZ
  • Sweating, nausea prior and oriented after event
  • 45 y/o

Hoefnagels, et al J Neurology 238 1991
18
SYNCOPE Signs/Symptoms
  • Tongue-biting
  • 106 SZ patients vs. 45 syncope patients
  • Sensitivity 24 specificity 99
  • Based on 8 patients with tongue-biting

Benbadis, et al Arch Int Med 1551995
19
SYNCOPE Signs/Symptoms
Feature
Diagnosis
- Postexertional
- Structural heart disease
- 2 minutes of standing
- Orthostatic
- Cardiac
- No prodrome
- Vasovagal
- Stress-related
- Micturition syncope
- Situational
20
SYNCOPE Signs/Symptoms
  • CHF poor outcome
  • N 491 12 with syncope
  • Cardiac syncope 49 dead 1 year
  • Noncardiac syncope 39 dead 1 year
  • No syncope 12 dead 1 year
  • Risk factor for poor outcome in multiple studies

Middlekauff, et al JACC 211 1993
21
SYNCOPE Signs/Symptoms
Orthostatic hypotension
  • Generally defined as drop in systolic BP 20
    mmHg on standing
  • Present in 40 patients 70 years
  • Present in up to 23 patients
  • Reproduction of symptoms may be useful

22
SYNCOPE Diagnostic Testing
  • ECG - diagnostic ? 2-12
  • Blood work - low yield, not helpful
  • Only lab abnormalities found are those expected
    based on history/PE
  • Holter monitoring
  • Tilt table
  • Electrophysiology studies

Day, et al Am J Med 731982.
23
SYNCOPE Evaluation - ECG
  • What to look for
  • VT (3 or more beats)
  • Sinus pause ( 2 seconds)
  • Bradycardia with symptoms
  • SVT with symptoms or hypotension
  • AF slow vent response
  • 2 3 AV block
  • Pacemaker malfunction

Martin, et al Ann Emerg Med 294 1997
24
Diagnostic Efficacy of 24 Hour Holter Monitoring
for Syncope
1,512 patients
Syncope/presyncope during monitoring (17)
Arrhythmia without symptoms (15)
Documented arrhythmia (2.1)
Gibson AJC 53, 1984
25
Tilt Table Testing
  • Positive yield (pseudo Specificity
    Repro- sensitivity () controls ()
    duciblity ()
  • Passive tilt 20-75 80-90 60-70
  • Isoproterenol 40-85 55-80 65-90

26
Results of Electrophysiologic Testing in Patients
with Syncope of Unknown Cause
  • Patient Abnormal
  • Reference (no.) EP ()
  • Sra et al 86 34
  • DiMarco et al 25 68
  • Gulamhusein et al 34 18
  • Hess et al 32 56
  • Akhtar et al 30 53
  • Olshansky et al 105 37

27
SYNCOPE The Dilemma
  • Diagnostic challenge
  • Initial HP, ECG non-diagnostic ? 30-60 ED
    patients

Kapoor, et al NEJM 19833094
28
Discord in the Evaluation of Syncope
Neurologist
Cardiologist
29
SYNCOPE The Dilemma
  • Disposition Challenge
  • Patients often asymptomatic in ED
  • Majority of causes benign
  • Concern of sudden death

30
SYNCOPE Risk Stratification
  • Identify low-risk patients who need minimal
    testing and have a low likelihood of an adverse
    event
  • Identify high-risk patients in whom a more
    aggressive approach towards care is indicated

31
SYNCOPE Risk Stratification
  • Syncope patients in ED
  • Derivation N 252
  • Validation N 374
  • Data History, PE, ECG
  • Outcome Arrhythmias and mortality at 1 year

Martin, et al Ann Emerg Med 291997
32
SYNCOPE Risk Stratification Mortality at 1 Year
Died within one year of syncopal episode
Strictly defined arrhythmias or died of a cardiac
cause in the 1st year
33
SYNCOPE Management
  • Risk factors 45 years, ventricular
    arrhythmia, abnormal ECG, CHF
  • Martin, et al
  • 72 cardiac mortality 0 with no risk factors
  • 1 year mortality 57 with 3
  • 1 year mortality 80 with 4

34
ACEP Clinical Policy Syncope
  • 1. What data help risk stratify?
  • Level B
  • Over 60 years high risk
  • CHF high risk
  • Under 45 years low risk
  • Level C
  • PE, c/w cardiac outflow obstruction high risk
  • Hx c/w vasodepressor etiology low risk

35
ACEP Clinical Policy Syncope
  • Diagnostic testing
  • Level B Obtain 12-lead ECG when history, PE
    indeterminate

36
ACEP Clinical Policy Who Should be Admitted
  • Level B Admit patients with syncope and any of
    the following
  • A history of CHF or ventricular arrhythmias
  • Associated chest pain or other symptoms
    compatible with acute coronary syndrome
  • Evidence of significant CHF or valvular heat
    disease on PE
  • ECG findings of ischemia, arrhythmia, prolonged
    QT interval, or bundle branch block

37
ACEP Clinical Policy Admission
Level C Consider admission for patients with
syncope and any of the following Age older than
60 years History of coronary artery disease or
congenital heart disease Family history of
unexpected sudden death Exertional syncope in
younger patinets without an obvious benign
etiology for the syncope
38
Syncope Summary
  • Etiology is often unclear
  • Risk stratification is key
  • Admit high risk patients
  • Intermediate risk?
  • Low risk Send out

39
THANK YOU
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