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Evaluation of the Patient with Syncope

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Evaluation of the Patient with Syncope George N. Seavy, D.O. Presentation overview Definition of syncope Differentiation from other disorders Etiology/differential ... – PowerPoint PPT presentation

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Title: Evaluation of the Patient with Syncope


1
Evaluation of the Patient with Syncope
  • George N. Seavy, D.O.

2
Presentation overview
  • Definition of syncope
  • Differentiation from other disorders
  • Etiology/differential diagnosis
  • History
  • Physical Exam
  • Diagnostic tests and their uses

3
What is Syncope?
  • Definition
  • Greek origin syncoptein - to cut short
  • synkope - a swoon
  • loss of consciousness and postural tone caused
    by diminished cerebral blood flow
  • Stedmans Medical
    Dictionary

4
  • a sudden and brief loss of consciousness
    associated with a loss of postural tone, from
    which recovery is spontaneous
  • NEJM
    3431856

5
Background
  • Estimated that 30 - 50 of adult population will
    experience at least one episode of syncope
  • recurrence will occur in 30 of patients that
    experience syncope
  • 3 of E.D. visits
  • 1 to 6 of admissions

6
Syncope is a symptom, not a disease
  • symptom any morbid phenomenon or departure
    from the normal in structure, function, or
    sensation experienced by the patient, and
    indicative of disease
  • Stedmans
    Medical Dictionary
  • syncope, then, can have many causes

7
Syncope must be differentiated from other
disorders
  • dizziness
  • presyncope
  • vertigo
  • sleep disorders
  • coma
  • shock
  • delirium
  • drop attacks
  • seizures

8
  • Differentiation of syncope from these other is
    disorders based on
  • history
  • physical exam
  • select diagnostics

9
The big picture for the cause of syncope
  • Transient lack of blood flow and/or nutrient
    delivery to brain centers responsible for
    consciousness
  • brain stem reticular activating system
  • cerebral hemispheres

10
General Mechanisms
  • ? cardiac output
  • ? vascular resistance
  • ? in cerebral perfusion
  • causes with normal cerebral blood flow
  • hypoglycemia
  • hypoxia

11
Causes of syncope (Summary of 5 studies, 1980s)
  • Cause Prevalence () Severity
  • Neurally mediated
  • vasovagal 18 (8-37) benign
  • situational 5 (1-8) benign
  • carotid-sinus 1 (0-4) benign
  • Psychiatric disorders 2 (1-7) benign
  • Orthostatic hypotension 8 (4-10) benign
  • Medications 3 (1-7) benign to severe
  • Neurologic Disease 10 (3-32) mod. to severe
  • Cardiac syncope
  • Organic heart disease 4 (1-8) severe
  • Arrhythmias 14 (4-35)
  • bradyarrhythmias moderate
  • tachyarrhythmias severe
  • Unknown 34 (13-41)

12
Neurally mediated syncope
  • Neurocardiogenic, vasovagal, situational, carotid
    sinus hypersensitivity, neuralgia
  • Mechanism uncertain
  • Proposed mechanism
  • peripheral venous pooling
  • ?venous return
  • ? contractility ventricles
  • activation mechanoreceptors
  • surge in afferent traffic to brain stem
  • mimic conditions normally seen during
    hypertension
  • paradoxical sympathetic withdrawal leading to
    hypotension and bradycardia

13
Neurally mediated syncope
  • Proposed components
  • reflex mediated changes in vascular tone or heart
    rate
  • CNS
  • receptor activation (heart, bladder, carotid
    sinus, etc)
  • ? in vagal efferent activity
  • sympathetic withdrawal
  • neurohumoral agents
  • serotonin, vasopressin, endorphins, epinephrine

14
Neurally Mediated Syncope - Vasovagal
  • 55 y.o.
  • Female
  • Precipating event
  • Diaphoresis
  • Palpitations
  • Fatigue post event

15
Psychiatric
  • Psychiatric component present in up to 25 of
    syncope cases
  • Common disorders
  • general anxiety disorder
  • panic disorder
  • major depression
  • EtOH
  • drug dependence

16
Orthostatic hypotension
  • Volume depletion
  • dehydration
  • blood loss
  • Medicines
  • vascular tone
  • heart rate
  • Secondary autonomic dysfunction
  • diabetes mellitus
  • toxins
  • Primary autonomic failure
  • Shy Drager syndrome

17
Common Causes of Orthostatic Hypotension
  • Systemic Disorders
  • Dehydration
  • Deconditioning
  • Prolonged immobility
  • Adrenocortical insufficiency
  • CNS Disorders
  • Multiple systems atrophy
  • Parkinsons disease
  • Multiple cerebral infarctions
  • Myelopathy
  • Brain-stem lesions
  • Medications
  • Antipsychotics
  • MAOIs, Tricyclics
  • Antihypertensives, Diuretics
  • Vasodilators (nitrates)
  • Levodopa
  • Beta blockers
  • Calcium channel blockers
  • ACE Inhibitors
  • Peripheral autonomic neuropathy
  • Pure autonomic failure
  • Diabetes mellitus
  • Amyloidosis
  • Tabes dorsalis
  • Paraneoplastic
  • EtOH, nutritional

18
Neurologic
  • migraine
  • seizure
  • subclavian steal
  • transient ischemic attack
  • carotid a.
  • vertebrobasilar a.

19
Heart Disease
  • Common theme inadequate cardiac output
  • Structural/Organic
  • AS, HOCM, myxoma, m.i., coronary spasm., P.E.
    tamponade, pulmonary hypertension, aortic
    dissection
  • Arrhythmias
  • bradyarrhythmia
  • sinus node dis., 2nd or 3rd degree heart block,
    pacer malfunction, drug induced
  • tachyarrhythmia
  • ventricular tachycardia, torsade de pointes, SVT

20
Importance of heart disease related to syncope
  • The presence of either an abnormal ECG or
    underlying heart disease in a syncopal patient
    increases the mortality and incidence of sudden
    death
  • 1 year mortality 18 to 33 in patients with
    syncope and cardiac disease vs. 0-12 in patients
    with non-cardiac syncope
  • 1 year incidence of sudden death 24, vs. 3 in
    pts. without cardiac disease

21
Initial Assessment
  • Initial assessment should consist of
  • History and physical (HP)
  • ECG
  • Routine labwork (CBC, lytes, BUN, creatinine,
    glucose) not recommended unless to confirm
    clinical suspicion.
  • HP identifies cause in 45 of cases
  • HP ECG identifies cause in 50 of cases

22
Key Historical Points
  • Situation
  • Prodrome
  • Witnessed appearance
  • Postevent residua
  • Past medical history
  • Family history
  • Medicines

23
Key Historical Points (cont.)
  • Situation
  • sudden standing or sitting
  • severe pain, fear, instrumentation
  • micturition, defecation
  • severe coughing (especially in COPD patients)
  • during or immediately following exertion
  • arm exercise

24
Key Historical Points (cont.)
  • Prodrome
  • Diaphoresis, nausea, warmth, lightheadness
  • diploplia, dysarthria, focal neurologic symptoms,
    headache
  • chest pain, shortness of breath
  • duration of prodrome

25
Key Historical Points (cont.)
  • Witnessed appearance
  • tonic/clonic movements
  • cyanosis
  • urinary incontinence
  • tongue biting

26
Key Historical Points (cont.)
  • Postevent residua
  • confusion
  • fatigue, warmth, nausea
  • neurologic symptoms
  • injury from fall
  • duration of recovery

27
Key Historical Points (cont.)
  • Past medical history
  • previous syncopal episodes
  • psychiatric disease
  • history of arrhythmias
  • CHF, cardiomyopathy
  • coronary disease risk factors
  • cerebrovascular accident, TIA
  • pulmonary hypertension
  • pulmonary embolism risk factors
  • recent dehydration, g.i. bleeding

28
Key Historical Points (cont.)
  • Family history
  • sudden death
  • C.A.D.
  • long QT syndrome

29
Key Historical Points (cont.)
  • Medications
  • antihypertensives - ACEIs, a1 blockers, ß
    blockers, etc.
  • antidepressants - tricyclics, MAOIs
  • antianginals - nitrates, sildenafil citrate
  • diuretics
  • analgesics
  • CNS depressants
  • Q-T prolonging agents
  • many others, including insulin, digoxin, EtOH,
    opiates

30
Physical exam
  • V.S.
  • Orthostatic B.P. / tilt
  • various definitions
  • symptoms
  • ? SBP gt 20 mmHg, ? DBP gt 10 mmHg
  • ? HR gt 20
  • narrowed pulse pressure

31
Physical Exam
  • Neurological findings
  • diplopia
  • dysarthria
  • pupillary asymmetry
  • nystagmus
  • ataxia/gait instability
  • slowly resolving confusion
  • bruits (carotid, cerebral)

32
Physical Exam
  • Cardiac findings
  • JVD
  • rales
  • Systolic ejection murmur AS, HOCM
  • Loud S2
  • precordial lift
  • S3
  • pericardial rub
  • unequal BP upper extremities

33
Diagnostic evaluation of syncope
  • Can be difficult to reproduce syncope under
    diagnostic situations
  • eg. episodic nature of some arrhythmias

34
Diagnostic tests for evaluation of syncope
  • HP 160
  • ECG 90
  • 24 hr. Holter monitor 468
  • Loop recorder 284
  • Signal ave. ECG 152
  • EP studies 4678
  • Echo 580
  • Stress test 433
  • Thallium stress test 685
  • Tilt table test 683
  • Carotid massage 0-100
  • Psychiatric eval. 150
  • CT brain 888
  • EEG 393
  • Carotid doppler 464
  • Transcranial U.S. 400

35
Diagnostic evaluation - Neurally mediated
  • Tilt table testing
  • provoke hypotension /- bradycardia
  • sensitivity 67-83, specificity 75-100
  • Carotid sinus massage

36
Tilt table testing
  • Procedure
  • Outline in handout
  • prior pregnancy test, stress test in appropriate
    pts.
  • supine equilibration
  • three ECG leads, cont. BP monitor
  • upright at 70, 30-45 min.
  • pharmacologic provocation, if necessary
  • isoproteronol, nitroglycerin, edrophonium
  • Positive test reproduction of typical symptoms

37
Tilt table testing
  • Indications
  • Unexplained recurrent or single episode syncope
    in whom cardiac causes have been excluded
  • with or without structural cardiovascular disease
  • Pts. in whom demonstration of neurally mediated
    syncope would alter treatment
  • Evaluation of exercise-induced or
    exercise-associated syncope

38
Carotid sinus massage
  • Used to Dx carotid sinus hypersensitivity
  • Syncope associated with head rotation or pressure
    on carotid sinus
  • turning head while driving
  • shaving
  • tight collars
  • tumor
  • Patients without carotid bruit or evidence of
    carotid artery disease

39
Carotid sinus massage (cont.)
  • Procedure
  • visual inspection
  • auscultate - bruits?
  • pt. supine
  • ECG and BP monitoring
  • head neutral (with respect to flexion and
    extension)
  • tilt head away from examiner
  • reposition head until strongest carotid pulse
    felt
  • longitudinal massage or static pressure
  • do not exceed five seconds
  • avoid carotid occlusion
  • palpate or doppler ipsilateral temporal or
    supraorbital a.
  • 15 seconds between stimulations

40
Carotid sinus massage (cont.)
  • Dx of carotid sinus hypersensitivity
  • asystole gt 3 sec (cardioinhibitory response)
  • 50 mm Hg drop in SBP (vasodepressor response)
  • Complication rate
  • transient neurological effects 0.10 -0.14
  • permanent neurological sequela 0.03 (or 2 out of
    7000 procedures)
  • (right side response generally greater than left
    side response)

41
Carotid Massage
42
Diagnostic evaluation - Orthostatic hypotension
  • Tilt test
  • Proper conduction
  • Interpretation of results

43
Diagnostic evaluation - Psychiatric syncope
  • General anxiety disorder, panic disorder, major
    depression, EtOH, drug dependence
  • Hyperventilation maneuver
  • Open mouthed hyperventilation for 2-3 min.
  • Positive test near syncope or true syncope
  • PPV 59
  • Also may use tilt table test

44
Diagnostic evaluation - Neurologic syncope
  • EEG
  • pts. with history of seizures
  • CT
  • findings indicative of cause or consequence of
    syncope?
  • Neurovascular studies
  • pts. with bruits or Hx supporting vertebrobasilar
    insufficiency
  • transcranial ultrasonography
  • carotid ultrasonography

45
Diagnostic evaluation - Heart disease
  • ECG
  • low yield (5), inexpensive, low risk, can lead
    to further evaluation detecting life threatening
    disorders
  • Echo
  • initial step in cardiac eval., yield 5-10
  • Exercise stress test
  • evaluate exertional syncope
  • exercise induced tachyarrhythmias
  • reproduce exercise-associated or post-exertional
    syncope

46
Diagnostic evaluation - Heart disease
  • 24 Holter Monitor
  • Who?
  • symptoms suggest arrhythmic syncope (brief LOC,
    no prodrome, palpitations)
  • unexplained cause
  • heart disease
  • abnormal ECG
  • Negative test does not rule out arrhythmic syncope

47
Diagnostic evaluation - Heart disease
  • External loop recorder
  • Who?
  • clinically normal heart but with conduction
    system disease, frequent episodes
  • 2 leads worn for 30 days, connected to small
    monitor
  • pt. activates after syncopal episode
  • freezes prev. 2-5 min. and subsequent 60 sec. in
    memory
  • transmit data via phone
  • requires compliance

48
Diagnostic evaluation - Heart disease
  • Signal averaged ECG
  • predicts inducible v-tach in pts. with syncope
  • sensitivity 73-89, specificity 89-100
  • Electrophysiologic studies
  • syncope and serious heart disease
  • not for clinically normal heart normal ECG
  • prev. m.i., CHF, pre-excitation

49
Miscellaneous diagnostics
  • VQ scan
  • suspect pulmonary embolism
  • glucose tolerance
  • low yield
  • hypoglycemia is an uncommon cause of syncope (lt
    1)

50
Emergency Department evaluation
  • triage patients into high, intermediate, and low
    risk groups
  • admit high risk patients
  • observe intermediate risk patients, perform
    appropriate diagnostics
  • discharge low risk patients

51
Emergency Department evaluation
  • High Risk
  • acute neurologic signs
  • chest pain
  • age gt 70
  • Hx/ECG evidence structural heart disease (i.e.
    old m.i., LBBB)
  • serious arrhythmia
  • prolonged QT
  • current anti-arrhythmic therapy
  • major trauma

52
Emergency Department evaluation
  • Intermediate risk
  • recurrent syncope
  • age gt40
  • abnormal ECG w/o prior m.i.
  • unexplained orthostatic hypotension
  • mild trauma
  • pacemaker with known dysfunction
  • carotid sinus hypersensitivity
  • occupational risk

53
Emergency Department evaluation
  • Low risk
  • age lt 40
  • 1st episode
  • no Hx/suspicion of heart disease
  • normal ECG
  • no occupational risk
  • trauma

54
Who to treat as an outpatient?
  • Likely neurally mediated
  • No heart disease
  • No abnormal ECG

55
Guidelines for hospital admission
  • For evaluation
  • Structural heart dis.
  • Symptoms suggesting arrhythmia
  • Symptoms suggesting ischemia
  • Abnormal ECG
  • For treatment
  • Certain specific forms of heart dis.
  • Aortic stenosis
  • Hypertrophic cardiomyopathy
  • Severe Orthostasis
  • Adverse drug reactions

56
Special consideration - Elderly patients
  • Syncope often associated with
  • polypharmacy
  • abnormal physiologic response to daily events
  • Greater incidence of cardiac and neurologic
    pathology

57
Summary
  • diagnostic yield of history, physical, and ECG
    50
  • neurologic testing rarely helpful, unless
    neurologic symptoms present
  • pts. with known/suspected structural heart
    disease or exertional syncope are at increased
    risk of adverse events
  • syncope in elderly often associated with
    polypharmacy and abnormal physiologic responses
    to daily events
  • tilt table testing is most useful in patients
    with recurrent syncope in whom heart disease is
    not suspected
  • psychiatric evaluation can detect mental
    disorders associated with syncope in 25 of cases
  • hospitalize patients at high risk for cardiac
    syncope or with neurologic signs

58
Thank you.
59
References
  • Benditt DG, Ferguson DW, Grubb BP, et al. Tilt
    table testing for assessing syncope. JACC.
    199628 (1)263-275.
  • Cunningham R, Mikhail MG. Management of patients
    with syncope and cardiac arrhythnias in an
    emergency department observation unit. E Med
    Clin N Amer. 200119pp?
  • Fenton AM. Vasovagal syncope. Ann Intern Med.
    2000133(9)714-725.
  • Jeong HA, Hanusa BH, Kapoor WN. Do symptoms
    predict cardiac arrhythmias and mortality in
    patients with syncope. Arch Intern Med.
    1999159375-380.

60
References (cont.)
  • Kapoor WN. Using a tilt table to evaluate
    syncope. Am J Med Sci. 1999317(2)110-116.
  • Kapoor WN. Syncope. NEJM. 20003431856-1862.
  • Kapoor WN, Fortunato M, Hanusa BH, Schulberg HC.
    Psychiatric ilness in patients with syncope. Am
    J Med. 199599505-512.
  • Linzer MA, Yang EH, Estes III ME, et al.
    Diagnosing syncope. Part 1 Value of history,
    physical examination, and electrocardiography.
    Ann Intern Med. 1997126989-996.
  • Linzer MA, Yang EH, Estes III ME, et al.
    Diagnosing syncope. Part 2 Unexplained
    syncope. Ann Intern Med. 199712776-86.

61
References (cont.)
  • Mosqueda-Garcia R. The elusive pathophysiology
    of neurally mediated syncope. Circulation.
    2000102(23)2898-2906.
  • Schnipper JL, Kapoor WN. Diagnostic evaluation
    and management of patients with syncope. Med
    Clin N Amer. 200185pp?
  • Strasburg B, Sagie A, Erdman S, et al. Carotid
    sinus hypersensitivity and the carotid sinus
    syndrome. Prog Cardiovasc Dis.
    198931(5)379-391.

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Just for fun ...
  • Syncope upon standing
  • orthostatic hypotension
  • syncope while laughing or coughing
  • situational
  • syncope with sudden onset, palpitations
  • arrhythmia

66
Just for fun ...
  • Frequent syncope, young patient, no injury, no
    history disease
  • psychiatric
  • confusion post event
  • seizure
  • syncope with head rotation
  • carotid sinus hypersensitivity

67
Just for fun ...
  • Sudden syncope with unexpected pain, fear, or
    unpleasant sight, sound, or smell
  • vasovagal
  • syncope with exertion
  • structural cardiac disease, i.e. aortic stenosis
  • sudden onset, no prodrome, Hx heart disease
  • arrhythmia
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