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Evaluation and Management of Syncope


Evaluation and Management of Syncope Case # 2 65 year old male with h/o inferior wall myocardial infarction 1 year ago presents with rapid palpitation and syncope. – PowerPoint PPT presentation

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Title: Evaluation and Management of Syncope

Evaluation and Management of Syncope
  • Definition
  • Sudden transient loss of consciousness and
    postural tone with subsequent spontaneous
    recovery. ( Greek synkope, cessation, pause).
  • Transient inadequate cerebral perfusion.

Syncope - Epidemiology
  • 1 of hospital admissions
  • 3 of ER visits
  • 6 annual incidence in the elderly
  • Upto 50 of young adults have history of isolated
  • Annual cost 2 B (2005)
  • Clin
    Electrophysiol 221386,1999

Sun BC, Am J Cardiol 95668, 2005
Syncope - Prognosis
  • Highest mortality in patients with cardiac cause
  • Neurally mediated syncope/ medication induced
    syncope did not increase mortality
  • Soteriades ES, et al N
    Eng J Med 347878, 2002

Causes of Syncope
  • Vascular ( 58 62 ) Reflex mediated,
    orthostatic, anatomic
  • Cardiac ( 10 23 ) Arrhythmias, anatomic
  • Neurologic/cerebrovascular ( 0.5 5 )
  • Metabolic/drugs ( 0 2 )
  • Psychogenic ( 0.2 1.5 )
  • Syncope of unknown origin ( 14 18 )

Sarasin FP, Am J Med 111 177, 2001 Alboni P,
JACC 37, 1921, 2001
Differential Diagnosis of Syncope
Obstruction to Flow Aortic Stenosis Hypertrophic Cardiomyopathy Atrial Myxoma Mitral Stenosis Pulmonic Stenosis Pulmonary Hypertension Pulmonary Embolism Cardiac Tamponade Aortic Dissection Bradyarrhythmias Sinus Node Dysfunction AV Block Pacemaker Malfunction Tachyarhythmias Ventricular Tachycardia Torsade de Pointes Supraventricular Tachycardia Other Causes of Syncope Vasovagal Syncope Carotid Sinus Hypersensitivity Drug-Induced Orthostatic Hypotension Cerbrovascular Disease Situational (e.g. cough/micturition syncope) Hypoglycemia Seizure Psychogenic
Syncope - Clinical Features Suggestive of
Specific Causes
Symptom or Finding Diagnostic Consideration
After sudden unexpected pain, unpleasant sight, sound or smell Vasovagal syncope
During/immediately after micturition, cough, swallow or defecation Situational syncope
On standing Orthostatic hypotension
Prolonged standing Vasovagal syncope
Syncope Clinical Features Suggestive of
Specific Causes (contd )
Symptom or Finding Diagnostic Consideration
Well-trained athlete after exertion Neurally mediated
Change in position ( from sitting to lying, bending, turning over in bed ) Atrial myxoma, thrombus
Syncope during exertion Aortic stenosis, pulmonary hypertension, pulmonary embolus, mitral stenosis, IHSS, CAD, neurally mediated syncope
Syncope Clinical Features Suggestive of
Specific Causes ( contd )
Symptom or Finding Diagnostic Consideration
With head rotation, pressure on cartoid sinus (as in tumors, shaving, tight collars) Cartoid sinus syncope
Associated with vertigo, dysarthria, diplopia, and other motor and sensory symptoms of brain stem ischemia Transient ischemic attack, subclavian steal, basilar artery migraine
With arm exercise Subclavian steal
Confusion after episode Seizure
Seizure vs Syncope
  • Seizure
  • Aura, frothing at the mouth
  • Horizontal eye deviation, tongue biting
  • Elevated BP, sinus tach
  • Sustained tonic clonic movements,
  • Disorientation, slow recovery

Syncope Diagnostic Tests
  • History and physical examination cardiac
    disease, family h/o SCD, medications, witness
  • Orthostatic BP check
  • ECG Q waves, QTc, delta wave, epsilon wave
  • Holter monitor V pause gt 3 sec while awake,
    Mobitz type 2 or CHB, VT.
  • Arrhythmia event monitor
  • Echocardiogram
  • Tilt table test
  • Electophysiologic testing

Diagnostic Tests for Syncope
Test Indication Disadvantage
Holter Monitor Frequent symptoms of palpitations or dizziness Low yield if symptoms are intermittent
Continuous-Loop Recorder Intermittent or very transient symptoms patient has little warning before symptoms occur Inconvenient to use for long periods of time
Implantable Loop Recorder Infrequent episodes of syncope diagnosis cannot be made noninvasively Requires invasive procedure
Signal-Averaged ECG Syncope and structural heart disease Low positive predictive value
Diagnostic Tests for Syncope (contd)
Test Indication Disadvantage
Upright Tilt Testing Suspected vasovagal syncope syncope without structural heart disease Inadequate reproducibility
Electrophysiologic Study Syncope when diagnosis cannot be made non-invasively syncope with structural heart disease Invasive low yield when no structural heart disease
Syncope Indications For Hospitalization
  • Presence of heart disease, dyspnea, CHF, VT,
    acute coronary syndrome
  • ECG suggestive of arrhythmic syncope in WPW,
    long QTc, Sick Sinus Syndrome, AV block, VT,
    Brugada syndrome, RV dysplasia
  • Syncope with severe injury
  • Syncope during exercise
  • Family h/o sudden cardiac death

Sinus Arrest on Holter Monitor
Syncope Loop Event Recorder
ACCSAP 6, 2005
Implantable Loop Recorder
Implanted Loop Event Recorder
Head Up Tilt Table Testing
(No Transcript)
Tilt Table Testing When to do it?
  • For diagnosis
  • Suspected reflex, atypical presentation
  • Unexplained syncope at the end of work-up,
    orthostatic trigger present
  • Suspected delayed orthostatic hypotension

Neurally Mediated Syncope
  • Also known as vasovagal syncope.
  • Recurrent syncope in the absence of structural
    heart disease is most likely neurally mediated.
  • Head-upright tilt test maximizes venous pooling,
    sympathetic activation and circulating
  • Most vasovagal episodes involve both
    cardioinhibition (drop in heart rate) and
    vasodepressor response (drop in BP).

Case 1
  • A 20 year old female presents with recurrent
    near syncope and syncope preceded by nausea,
    sweating and gradual tunnel visionusually after
    prolonged standing. The ECG and 2-D
    echocardiogram are normal. What would be the next
  • Answer Tilt table test.
  • Q What is the mechanism for the visual
  • Answer Collapse of peripheral vessels of the

Syncope The Role of Electrophysiologic Testing
  • Most important diagnostic tool is the history
  • High risk historical elements
  • Syncope resulting in injury
  • Syncope resulting in motor vehicle accident
  • Syncope in the setting of structural heart
  • Syncope preceded by palpitations
  • Syncope while supine
  • Abnormal ECG
  • Lack of low risk elements

Guidelines for EP Testing in Syncope
  • Class I General agreement
  • Patients with structural heart disease
    and unexplained syncope
  • Class II Less certain, but accepted
  • Patients with recurrent unexplained
    syncope without structural heart disease and a
    negative tilt test
  • Class III Not indicated
  • Patients with known cause of syncope
    in whom treatment will not be guided by EP testing

Electrophysiologic Testing in Syncope
  • Sinus node function prolonged sinus node
    recovery time
  • Abnormal AV conduction ?HV interval, infra His
  • Inducibility of sustained VT
  • Inducibility of rapid SVT with symptoms,

Neurally Mediated Syncope
  • Precipitating factors prolonged standing,
    dehydration, alcohol, diuretics, vasodilators.
  • Sit/lie down at onset of symptoms, cross the legs
    and tense them together if sitting.
  • Salt supplementation and fluids.
  • Isometric arm, leg counterpressure.
  • Moderate aerobic and isometric exercise.
  • Tilt training.

Therapy of Neurocardiogenic Syncope
Treatment Mechanism
Volume expansion (increase salt and fluid intake, fludrocortisone) Maintain ventricular volume
Beta-Blockers Block response to adrenergic stimulation reduce ventricular contractility prevent activation of ventricular mechanoreceptors
Anticholinergic agents (scopolamine, disopyramide) Block vagal response reduce ventricular contractility (disopyramide)
Serotonin reuptake inhibitors Prevent vasodilation and bradycardia possibly by downregulation of response to serotonin
Methylxanthines Adenosine receptor antagonist Phophodiesterase and Ca transport inhibitor (maintain vascular tone)
Midodrine Adrenergic agonist
Cardiac pacing Maintain heart rate, AV synchrony
Pharmacologic Therapy of Neurally Mediated Syncope
  • Despite the widespread use of drug therapy, none
    of these pharmacologic agents have been
    demonstrated to be effective in large prospective
    randomized clinical trials.
  • A small study has reported the efficacy of
  • Metoprolol, propranolol and nadolol are no more
    effective than placebo.

Orthostatic Intolerance Syndrome
Delayed Orthostatic Intolerance
Vasovagal Syncope

Counterpressure Maneuvers
Elastic Stockings
JACC 2006 481652
JACC 2006 481425
Syncope - Prognosis
  • Highest mortality in patients with cardiac cause
  • Neurally mediated syncope/ medication induced
    syncope did not increase mortality
  • Soteriades ES, et al N
    Eng J Med 347878, 2002

Suggested Strategies for Syncope Management
Syncope May be a harbinger of sudden cardiac
  • Evaluation purpose is to determine if pt is at
    increased risk for death
  • Identify pts with underlying heart disease
    (ischemic CM, non-ischemic CM, HCM), myocardial
    ischemia, WPW, genetic diseases (long-QT
    syndrome, Brugada Syndrome), catecholaminergic
    polymorphic VT

Case 2
  • 65 year old male with h/o inferior wall
    myocardial infarction 1 year ago presents with
    rapid palpitation and syncope. An ECG shows SR
    and old inferior wall myocardial infarction. A 2D
    echo shows LVEF 40 with inferoapical
    dyskinesis. Coronary angiography reveals totally
    occluded right coronary artery with collaterals.
    What is the next step?
  • Answer Electrophysiologic study (to look for
    inducible sustained VT)

Case 3
  • 72 year old male with chronic atrial
    fibrillation of greater than 10 years duration
    is admitted following a syncopal episode. A 2D
    echo shows markedly dilated left atrium and LVEF
    60. Telemetry reveals atrial fibrillation with
    slow ventricular response and pauses of 5 to 7
    seconds associated with near syncope.
  • How would you proceed?
  • Answer Implant single chamber rate
    responsive pacemaker

Diagnostic Evaluation of Syncope
Hx, physical exam, supine and upright BP, EKG
Unexplained syncope
Is there structural heart disease?
Electrophysiologic Study
Tilt table test
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