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Syncope in Elderly

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From 1997-2000 National Health Ambulatory Medical Survey of ED visits in USA. ... ( 0.65% of all visits) with the diagnosis of syncope unrelated to injury ... – PowerPoint PPT presentation

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Title: Syncope in Elderly


1
Syncope in Elderly
2
SYNCOPE
  • Syncope (Greek synkope cut-off) is a brief
    transient loss of consciousness (fainting) and
    postural tone (collapse) with rapid spontaneous
    recovery

3
SYNCOPE
  • From 1997-2000 National Health Ambulatory Medical
    Survey of ED visits in USA.
  • 2.63 million ED pt.( 0.65 of all visits) with
    the diagnosis of syncope unrelated to injury
  • 1.1 million pt.(40.8) were 65 yrs or older
  • 63.8 were female
  • Among pt. older than 65 yrs, admit rate for
    syncope was 61.8 and was the sixth most common
    admission diagnosis

4
Incidence of syncope in the Framingham Heart
Study
5
SYNCOPE
  • Age-dependent morphological and physiological
    changes
  • Old patients often take drugs (sedatives,
    diuretics, vasodilators, anti-hypertensives)
  • Old patients display a higher incidence of
    chronic pathologies such as diabetes mellitus,
    congestive heart failure, coronary disease,
    cerebrovascular pathologies and multiple
    sensorial deficiency.

6
Age-related physiological changes that predispose
to syncope
  • Blood vessel
  • Heart
  • Autonomic nervous system
  • Other non cardiological changes

7
Blood vessel
  • Atherosclerosis is also universally present in
    older humans
  • Impair endothelial-dependent nitric oxide release
  • Increase endothelin release in the ageing vessels
  • This impairs both the cardiac and cerebral
    circulation which may predispose to syncope in
    the elderly.

8
Heart
  • Age-related stiffening of arterial vessels
    produces high afterload.
  • Ventricular walls become more fibrotic and
    noncompliant leading to ventricular diastolic
    dysfunction.
  • LV systolic dysfunction is also common because of
    the high prevalence of HTN and IHD among the
    elderly
  • Increase incidence of age-related mitral and
    aortic valvular diseases.

9
Heart
  • A progressive fall in the ratio of nodal myocytes
    to collagenous stroma with age particularly in
    the SA node increases the incidence of AF, heart
    block and sick sinus syndrome.

10
Autonomic nervous system
  • Beta-adrenergic response to plasma noradrenaline
    is blunted in the elderly
  • Diminished beta-1 responses lead to reduced
    cardioacceleration and cardiac contractility
  • Diminished beta-2 results in increased vascular
    tone because of the unopposed alpha-1
    vasoconstriction.
  • Baroreflex mediated cardioacceleration is also
    reduced

11
Autonomic nervous system
  • HR increase in response to stress is less
    effective.
  • Sympathetic and parasympathetic autonomic
    responses are reduced in health ageing
  • Blunted autonomic responses together with other
    factors including dehydration, vasodilator
    medications, sodium wasting may result in
    orthostatic hypotension, cerebral underperfusion
    and syncope in the elderly.

12
Other non cardiological change
  • Plasma renin and aldosterone fall with age and
    this results in sodium wasting.
  • impaired thirst response of many elderly people
    to hyperosmolality may cause hypovolaemia and
    consequent orthostatic hypotension

13
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14
Causes of syncope of the elderly
  • Cardiac diseases
  • - Primary cardiac arrhythmias
  • - Structural cardiovascular
    diseasesobstruction to left ventricular outflow
  • - Obstruction to right ventricular outflow
  • Neurally mediated syncopal syndromes
  • - Vasovagal syncope
  • - Situational syncope
  • - Carotid sinus hypersensitivity
  • Orthostatic and dysautonomic disturbance of blood
    pressure control
  • Postprandial hypotension
  • Cerebrovascular, neurological, and psychiatric
    causes

15
Primary cardiac arrhythmias
  • Probably the most common cause of syncope in
    patients with structural heart or vascular
    disease.
  • An age-related fall in nodal myocytes
    particularly in the sino-atrial node increases
    the incidence of atrial fibrillation, heart block
    and sick sinus syndrome
  • Polypharmacy

16
Drugs predisposing to syncope
  • Vasodilators nitrates, CCB, hydralazine, ACEIs
  • AntiHT clonidine, BB
  • Prolongation of QT(torsade de pointes)
  • - Antiarrhythmic agent class IA,III
  • - ATB macrolide(erythromycin), bactrim
  • - Others terfenadine,TCA, cisapride,
    phenothiazines, probucol

17
Conditions predisposing to a prolonged QT
interval and torsade des pointes
18
Structural cardiovascular diseases obstruction to
left ventricular outflow
  • Aortic stenosis is the most common structural
    lesion associated with syncope in the elderly
  • - Age lt 70 yr. Congenital bicuspid


    valves
  • - Age gt 70 yr. Degenerative changes
  • Hypertrophic obstructive cardiomyopathy (HOCM)
  • Vasodilator drugs or even vasodilatation after a
    hot bath can induce syncope in these patients

19
Obstruction to right ventricular outflow
  • The limitations to right ventricular outflow may
    lead to diminished capacity to increase cardiac
    output.
  • 18 of elderly pts admitted to an acute geriatric
    ward had pulmonary embolism in one study
    (Impallomehi et al., 1995)
  • Myoxma, pulmonary stenosis and pulmonary
    hypertension

20
Vasovagal syncope
The mechanism of tilt or haemorrhage-induced
vasovagal syncope
21
Situational syncope
  • Peripheral receptors similar to ventricular
    mechanoreceptors are found in lung, bladder, GI
    tract
  • Cough or micturition related syncope

22
Carotid sinus hypersensitivity
  • 20 of older people who presented with
    unexplained syncope (Parry and Eltrafi).
  • Defined as asystole of 3 s or more and/or a
    decrease in systolic pressure of 50 mmHg or more
    during carotid sinus massage.

23
Orthostatic and dysautonomic disturbance of BP
control
  • 30 of community-dwelling adults over 75 years of
    age have orthostatic hypotension (Lipsitz, 1989).
  • Autonomic failure such as multiple system atrophy
    and diabetes mellitus.
  • The combination of the blunted age-related
    autoregulatory changes, medications (diuretic,
    vasodilators), and chronic diseases predispose
    older adults to orthostatic hypotension.

24
Postprandial hypotension
  • 8 of syncope cases in older nursing home
    patients in one study (Jansen et al., 1995).
  • Defined as 20 mmHg or greater decline in systolic
    blood pressure within 90 min after a meal.
  • Common in older adults and can coexist with
    orthostatic hypotension in the same individual (
    Jansen and Lewis, 1995).
  • Pathophysiological mechanism of postprandial
    hypotension is still a matter of debate.

25
Cerebrovascular, neurological, and psychiatric
causes
  • Syncope is rarely due to cerebrovascular disease
    unless there are accompanying focal neurological
    deficits.
  • Transient posterior circulation ischaemia can
    result in loss of consciousness and there are
    usually brain stem signs present including
    diplopia, vertigo, dysarthria, or hemiparesis.
  • Vasovagal syncope may mimic seizures
  • Psychiatric disturbances including hysterical
    reaction, panic attack with hyperventilation can
    either mimick or may lead to true syncope

26
Differentiating syncope from seizure
27
Diagnostic evaluation
  • An emergency physician, when faced with a
    syncope-patient in an ED setting, should first
    seek to exclude life-threatening causes of
    syncope, which require immediate diagnostic
    evaluation/treatment hospital admission

28
Diagnostic evaluation
  • AMI
  • PE
  • aortic dissection
  • cardiac tamponade
  • tension pneumothorax
  • leaking AAA
  • active internal bleeding
  • malignant cardiac arrhythmias
  • SAH
  • carotid artery/vertebral artery dissection

29
Diagnostic evaluation
  • If there are no overt life-threatening causes of
    syncope, then an emergency physician should
    attempt to identify patients with situational
    syncope, vasovagal syncope and benign orthostatic
    (postural) syncope - who are candidates for home
    discharge after any necessary stabilization
    treatment in the ED
  • If the cause of the syncope is not readily
    apparent after initial clinical evaluation in the
    ED, then an emergency physician should attempt to
    decide whether certain categories of
    syncope-patients require admission to hospital

30
History
  • An eye-witness account is very important
  • mode of onset and progression of event
  • Body position at onset of event
  • Depth of altered consciousness
  • Duration of the syncopal episode
  • Rate of recovery of consciousness
  • Identify any precipitants including meals, pain,
    cough, micturition, defaecation, swallowing,
    postural change, neck movement and exercise

31
History
  • Associated symptoms such as palpitation,
    dyspnoea, chest pain
  • History of panic attack and hyperventilation
  • pscyhological triggering events (painful stimuli,
    sudden bad news)
  • Drug history is obviously important.
  • Past medical history and risk factors for
    ischaemic heart disease

32
CLINICAL CLUE TABLE
33
CLINICAL CLUE TABLE
34
CLINICAL CLUE TABLE
35
Physical examination
  • Search for trauma and assessment of severity
  • Cardiovascular examination
  • - BP
  • - Pulse volume
  • - Neck bruits
  • - JVP
  • - Apex beat, Heart sounds
  • Abdomen
  • Neuro exam

36
BP
  • Difference in BP between lt. and rt. upper limbs
    gt 20mmHg is abnormal (suggests dissecting aortic
    aneurysm or subclavian steal syndrome)
  • Difference in BP between upper and lower limbs gt
    20mmHg when recumbent is abnormal (suggests a
    dissecting aortic aneurysm)
  • Orthostatic vital signs positive test is
    defined as a SBP decrease of gt 20 - 30mmHg, a DBP
    decrease of gt10 - 15mmHg and/or HR increase of
    greater than 30 bpm when standing

37
BP
  • A significant drop in BP fixed HR suggests
    dysautonomia
  • A significant drop in BP increased HR suggests
    volume depletion and/or excessive vasodilatation
  • An insignificant drop in BP marked increase in
    HR suggests postural tachycardia syndrome
    (history of frequent fainting, symptoms of
    autonomic overactivity - palpitations,
    diaphoresis, tremulousness, visual blurring,
    non-anginal chest pain, "spaced-out" feelings,
    inability to concentrate, inability to breathe,
    sensations of impending doom)

38
Pulse volume
  • Decreased and delayed upstoke (aortic
    stenosis/hypertrophic obstructive cardiomyopathy)
  • Positive pulsus paradoxus (cardiac tamponade,
    massive pulmonary embolism)
  • Absent pulses (dissection of the aorta, cardiac
    emboli)

39
Heart sounds
  • Decreased (pericardial tamponade)
  • 3rd/4th heart sounds (ventricular failure or LV
    overload)
  • Loud second heart sound (pulmonary embolism or
    pulmonary hypertension)
  • Ejection systolic murmurs (aortic stenosis or
    hypertrophic cardiomyopathy - increased murmur
    when standing, decreased when squatting)
  • Machinary murmur (air embolism)
  • "tumor plop" or diastolic murmur (atrial myxoma)
  • Varying heart sounds/murmurs (thrombotic
    occlusion of a prosthetic valve)

40
Abdomen
  • Pulsatile masses (abdominal aneurysm)
  • Rectal exam for melena or heme-occult positive
    stools (gastro-intestinal bleeding)
  • Absent/decreased femoral pulses (dissection of
    the aorta)

41
Investigation
  • EKG
  • Echocardiography
  • Carotid sinus massage
  • Exercise stress test
  • Ambulatory continuous electrocardiography
  • Event and memory loop ambulatory electrocardigram
    recording
  • Signal-averaged electrocardiography
  • Invasive electrophysiological studies
  • Tilt table testing

42
EKG
  • an abnormal ECG may be etiologically significant,
    although the 'definitive' diagnostic yield is low
    (lt 5)
  • ECG abnormalities include-
  • previous or acute cardiac ischemic changes
  • signs of pericarditis or electrical alternans
    (cardiac tamponade)
  • LVH (hypertension, aortic stenosis, HOCM)
  • RVH (PE or pulmonary hypertension)
  • classical/non-specific ECG signs of PE
  • WPW syndrome
  • LBBB or bifasicular block (conducting system
    disease)
  • bradyarrythmias or tachyarrhythmias
  • long QT interval
  • Brugada syndrome (partial RBBB with elevated ST
    segments in leads V1-3 and peculiar downsloping
    of the elevated ST segments inverted T waves in
    those leads)
  • arrhythmogenic right ventricular dysplasia (RBBB,
    QRS complex gt 110 msec in leads V 1-3, inverted T
    wave or epislon wave

43
Carotid sinus massage
  • first performed on the right side for a minimum
    of 5 seconds (preferably 15 seconds) gt measure
    pulse rate and blood pressure gt wait 120 seconds
    gt repeat test on the left side
  • positive response longer than 3 seconds of
    asystole, and/or systolic blood pressure drop of
    gt 50 mmHg when supine
  • borderline positive response slowing of heart
    rate gt 30 - 40 and/or systolic blood pressure
    drop of gt 30mmHg when supine

44
Carotid sinus massage
  • Carotid sinus syncope can only be definitively
    diagnosed when syncope or near-syncope occurs
    during carotid massage
  • Carotid sinus massage is contra-indicated in
    patients with a history of a CVA, a recent AMI or
    when a neck bruit is present

45
24-hour Holter (continuous ambulatory
electrocardiographic) monitoring
  • traditional approach to syncope of unknown
    etiology with low yield
  • only 17 of patients with syncope undergoing 24-h
    monitoring experience symptoms and 2 have an
    arrhythmia-related symptom in one study (Gibson
    and Heitzman, 1984)
  • extending the continuous ambulatory
    electrocardiograhic monitoring to 72 hours
    results in a slightly higher yield
  • if no symptoms/arrhythmias are detected,
    arrhythmogenic syncope cannot be excluded

46
Tilt table testing
  • Provocative test used to determine a patient's
    susceptibility to neurally mediated syncopal
    syndrome.
  • An important non-invasive investigation for
    syncope particularly for those with no structural
    heart disease
  • The details of tilt table testing technique and
    protocol are beyond the scope of this review.

47
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48
Indication for admission
  • Admit patients with syncope and any of the
    following
  • 1. A history of congestive heart failure or
    ventricular arrhythmias 2. Associated chest pain
    or other symptoms compatible with acute coronary
    syndrome 3. Evidence of significant congestive
    heart failure or valvular heart disease on
    physical     examination 4. ECG findings of
    ischemia, arrhythmia, prolonged QT interval, or
    bundle branch block
  • Consider admission for patients with syncope and
    any of the following
  • 1. Age older than 60 years 2. History of
    coronary artery disease or congenital heart
    disease 3. Family history of unexpected sudden
    death 4. Exertional syncope in younger patients
    without an obvious benign etiology for the    
    syncope

49
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