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Syncope and The Older Patient

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Common in elderly, ... (dizziness, vertigo, diplopia, nystagmus) Rare to have permanent neurological deficits Diagnosis with dopplers, MRA Treatment: ... – PowerPoint PPT presentation

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Title: Syncope and The Older Patient


1
Syncope and The Older Patient
  • Debra L. Bynum, MD
  • Division of Geriatric Medicine

2
Pretest
  • 1. The ECG has the greatest value in its (NPV or
    PPV) in the diagnosis of a cardiac etiology for
    syncope
  • 2. History 75 year old man reports presyncopal
    symptoms that occur while he is driving backwards
    out of his driveway in the morning. This
    suggests
  • 3. History an 80 year old man reports an episode
    of syncope that occurred after doing arm
    exercises for a rotator cuff injury. This
    suggest
  • 4. The only independent predictor of a cardiac
    etiology of syncope is a past history of
  • 5. ____ is a neurodegenerative disease
    characterized by profound autonomic insufficiency
    and parkinsonian features on exam
  • 6. An 82 year old man presents with postural
    hypotension, an idiopathic peripheral neuropathy,
    significant proteinuria and your attending orders
    a rectal biopsy to look for____
  • 7. Name 3 causes of situational syncope
  • 8. Older patients are more likely to have
    positive a. tilt table tests b. carotid sinus
    massage c. orthostatic hypotension d. all of the
    above

3
Pretest bonus question
  • Sudden cardiac death in young men (originally
    described in young asian men) associated with
    this sign on EKG is known as what syndrome?

4
Outline
  • What is syncope
  • What are the causes of syncope
  • How do you evaluate the patient with syncope?
  • How do you risk stratify the patient with
    syncope?
  • How do you treat?

5
Syncope Definition
  • Transient Loss of Consciousness (T-LOC) due to
    global cerebral hypoperfusion
  • Rapid onset, short duration, complete recovery
  • Other causes of T-LOC that are NOT syncope
  • Seizure (syncope can cause myoclonic movements)
  • Hypoglycemia, hypocapnea/hyperventilation
  • Intoxication
  • Vertebrobasilar TIA
  • Other etiologies that do not impair consciousness
    and are NOT syncope
  • Drop attacks, falls, TIA from embolic source

6
Causes of Syncope
  • Neurally Mediated (up to 58 in some series)
  • Orthostatic/postural
  • Cardiac arrhythmia (20-25)
  • Structural cardiac or pulmonary causes
  • Cerebrovascular or psychiatric (1)
  • Unknown (18-30)

7
Syncope in the Elderly
  • Usually multifactorial
  • Often confounded by findings (orthostasis and
    carotid hypersensitivity common and may be found
    and yet not be the cause)
  • Prevalence up to 25 in nursing home population
    over age 70
  • Higher pretest probability of cardiac disease or
    arrhythmia

8
Importance of History and PE
  • Up to 70- 85 of patients in prospective studies
    had probable cause identified based upon history,
    physical exam and ecg

9
The History
  • History of Heart Disease
  • The ONLY independent predictor of cardiac cause
    (sens 95, spec 45)
  • Absence of heart disease up to 97 specific to
    rule out cardiac etiology (good NPV)

10
Neurally mediated (reflex)
  • Terms
  • Vasovagal
  • Vasodepressor
  • Neurovascular
  • Neurocardiogenic
  • vasomotor

11
Who gets this?
  • We think of the young/healthy
  • Older patients can (although often complicated by
    comorbidities)

12
What is it? (Bezold-Jarisch phenomenon)
  • The often repeated story
  • Excessive stimulation of mechanoreceptors due to
    forceful contraction of underfilled left
    ventricle leading to paradoxical signals to the
    CNS causing change from vasoconstriction to
    vasodilation causing drop in blood pressure and
    bradycardia
  • The more complicated story
  • Disordered baroreflex function, paradoxical
    cerebral autoregulation, endogenous vasodilators
    we dont really know.

13
Think neurally mediated
  • Situations
  • Warm environment, hot bath, post-exercise,
    prolonged standing, large meals, early morning,
    valsalva, volume depletion, rising after
    prolonged bedrest, alcohol, medications
  • Symptoms
  • Classic presyncopal symptoms
  • No underlying neurological or cardiac disease
  • Prior history

14
Neurally mediatedsort of .
  • Situational syncope
  • Carotid sinus hypersensitivity

15
Situational Syncope
  • Situations
  • Cough
  • Micturition
  • Defecation
  • Swallow
  • Diving
  • pain
  • Tussive or laughter syncope
  • More common in obese men over 40, smokers with
    chronic cough and COPD, children with asthma
  • More on micturition syncope
  • Older men, early morning, exacerbated by
    medications

16
Carotid Sinus Hypersensitivity
  • History
  • Stimulation of carotid area near barorecptor
    (near bifurcation)
  • Tight collar, neck pressure with head turning or
    shaving/backing out of driveway

17
CSH
  • Carotid massage
  • 3 second pause or gt 50 mm drop in SBP
  • Three responses
  • 1. Cardioinhibitory (bradycardia/asystole)
  • 2. vasodepressor (hypotension)
  • 3. Mixed (features of both, most common)
  • Cardioinhibitory may benefit from pacing

18
CSH
  • Common in elderly, some concern that
    massage/testing may over diagnose
  • Also more likely to have positive response in
    patients with other degenerative neurological
    conditions such as Lewy body disease and
    parkinsons
  • Pacing controversial, but may have role in select
    cases

19
Summary Reflex syncope (neural)
  • Vasovagal (neurally mediated)
  • Situational
  • Carotid sinus hypersensitivity

20
Postural Hypotension
  • Orthostatic
  • Volume loss
  • Blood loss
  • Drop in blood pressure (SBP 20) with increase in
    HR
  • Autonomic
  • Common in elderly (10-30) presence may or may
    not be the cause of syncope
  • Often medication related (long list)

21
Autonomic Insufficiency
  • Clinical Features
  • Lack of tachycardic response no respiratory
    variability of heart rate
  • ED, urinary retention, gastric emptying delay
  • Causes
  • Diabetes
  • Paraneoplastic
  • Amyloid
  • Multiple Systems Atrophy (Shy-Drager)
  • Primary Autonomic Failure
  • Toxins
  • Parkinsons, Lewy body processes
  • Guillain-Barre syndrome
  • Spinal cord injury
  • HIV

22
Cardiac Arrhythmia
  • Bradycardia/asystole
  • Sick sinus syndrome
  • 2nd or 3rd degree AV blocks
  • Pacemaker malfunction
  • Have high suspicion in patients with bundle
    blocks
  • Tachycardia
  • Ventricular tachycardia
  • Ventricular fibrillation
  • SVT
  • If you see afib, think sick sinus syndrome and
    bradycardia/pauses

23
Cardiac Prolonged QT
  • QTc over 500
  • Lack of QT shortening with increased heart rate
    (role of standing or exertional EKG)
  • Genetic or secondary to medications
  • Torsades

24
Brugada Syndrome
  • Triad
  • RBBB pattern in right precordial leads
  • Transient/persistent ST elevation in v1-v3
  • Sudden cardiac death
  • Structurally normal heart
  • Association with young and healthy men from
    southeast asia who present with sudden cardiac
    death
  • Brugada sign may be asymptomatic
  • High risk of sudden cardiac death in those who
    have syncope or family history of sudden death
    (Indication for AICD based upon observational
    data)

25
Brugada Sign
26
Structural Cardiac or pulmonary causes
  • Valvular disease (especially aortic stenosis)
  • HOCM
  • Cardiac masses (myxoma)
  • Pericardial disease (tamponade or restrictive
    processes)
  • Prosthetic valve dysfunction
  • Acute aortic dissection
  • Pulmonary hypertension (exercise related)
  • PE

27
Subclavian Steal Syndrome
  • Proximal subclavian artery stenosis
  • Decreased blood flow to distal subclavian artery
    worsened with exertion of arm
  • Blood from vertebral artery on opposite side goes
    to basilar artery and then down ipsilateral
    vertebral artery, away from brainstem, to serve
    as collateral for arm
  • Usually asymptomatic
  • Atherosclerosis
  • Symptoms of vertebrobasilar insufficiency
    (dizziness, vertigo, diplopia, nystagmus)
  • Rare to have permanent neurological deficits
  • Diagnosis with dopplers, MRA
  • Treatment surgical revascularization, stents

28
Cerebrovascular
  • Syncope global hypoperfusion
  • Vertebrobasilar pathology or bilateral carotid
    disease

29
How do you evaluate the patient with syncope?
30
The Older Patient
  • Positive tests that are more common in the
    elderly and not necessarily the cause of the
    syncope
  • Orthostasis
  • Positive carotid massage
  • Positive tilt table testing
  • Up to 54 of older patients with syncope may have
    positive test
  • Positive test in 10 of asymptomatic elderly!

31
Evaluation History
  • Neurally mediated
  • Absence of heart disease
  • Long history of recurrent syncope
  • Associated factor (pain)
  • Prolonged standing
  • Associated n/v, diaphoresis, presyncopal symptoms
  • After a meal
  • CSH turning head or pressure on neck

32
History
  • OH
  • After standing
  • Prolonged standing
  • Presence of autonomic insufficiency or
    parkinsons
  • Standing after exertion

33
History cardiovascular
  • Presence of structural heart disease (especially
    systolic dysfunction)
  • Family history of sudden death
  • During exertion or supine (BIG FLAG)
  • Swimming/diving into pool (prolonged QT)
  • Abnormal EKG
  • Syncope follows sudden onset of palpitations
  • EKG
  • QT
  • Bundle blocks
  • Afib, AV blocks
  • Evidence of prior ischemia
  • QRS over .12

34
Evaluation
  • EKG
  • Telemetry
  • Rule out ischemia (nursing home patients)
  • Carotid sinus massage
  • Contraindicated in patients with prior
    TIA/stroke, bruits or known carotid stenosis

35
Evaluation
  • Orthostatics
  • Echo

36
Tilt table testing
  • Passive or Isoproterenol
  • Test patient held in upright position (60-90
    degrees), but weightless to prevent muscles
    improving venous return this leads to venous
    pooling, decreased venous return, and trigger of
    the neurally mediated reflex
  • Positive test bradycardia or hypotension
  • Passive testing sensitivity only 70,
    specificity 90-100
  • Isoproterenol only 55 specificity
  • Usually does not add much to the history and
    physical

37
In-hospital monitoring
  • Yield low (under 20)
  • Recommended in high risk patients

38
Holter Monitoring
  • 24-48 hours (no higher yield with longer)
  • Low yield (1-2)
  • May be useful if symptoms are very frequent

39
External Loop recorders
  • Loop memory that continuously records and deletes
  • Patient activates in response to symptoms (some
    devices also activated in response to rhythm)
  • Yield ?25 when used for 4-6 weeks

40
Implantable Loop recorders
  • Duration up to 3 years
  • Can be activated by patient or bystander or
    automatically activated by arrhythmias
  • May be cost effective to do earlier in the workup
    than currently doing
  • Some series 50-80 patients with prior
    unexplained syncope were able to have diagnosis

41
Electrophysiology Study (EP)
  • Underlying structural heart disease (especially
    depressed LV function)
  • Suspected bradycardia
  • Patients with underlying bundle branch block
    (look for development of His block with
    incremental atrial pacing)
  • Suspected tachycardia

42
Exercise Stress Testing
  • Patients with syncope with/after exertion
  • Usually of low yield

43
Other evaluations
  • Imaging, CTA
  • Cardiac catheterization
  • Directed by history and physical

44
Least useful tests
  • Head CT with negative neuro exam (history should
    direct whether symptoms suggest stroke/TIA or
    syncope)
  • EEG
  • Carotid dopplers (see above)

45
Risk Stratification
46
High Risk
  • Chest pain
  • CHF
  • Valvular disease
  • History of ventricular arrhythmias
  • EKG ischemic changes
  • Prolonged QT c (over 500)
  • Trifascicular block or pauses over 2 sec
  • Cardiac devices
  • Atrial fibrillation

47
High risk ESC recommended hospitalization
  • Known heart disease
  • Syncope during exercise
  • Trauma (facial)
  • Family history sudden death
  • Sudden palpitations prior to syncope
  • Syncope while supine
  • Multiple recent episodes

48
Intermediate risk
  • Age over 50
  • History of ischemic heart disease
  • Family history of sudden death

49
Low risk
  • Age less than 50
  • No history of CV disease
  • Normal EKG and exam
  • Symptoms c/w neurally mediated or vasovagal
    syncope
  • Prior history of recurrent syncope with symptoms
    c/w vasovagal etiology

50
Treatment reflex syncope and orthostatic
intolerance
  • Lifestyle
  • Education, reassurance
  • Avoiding triggers
  • Maneuvers supine posture, physical
    counterpressure, crossing legs)
  • Avoiding medications, ETOH
  • Increasing fluids, salt intake

51
Reflex syncope
  • Tilt training
  • Raising head of bed
  • Progressively prolonged periods of upright
    posture
  • Meds
  • Beta blockers
  • SSRI
  • Ephedrine
  • Midodrine
  • No meds work that well

52
Reflex syncope Cardiac pacing
  • 5 major RCTs, conflicting results
  • Significant selection bias
  • Likely not justified unless spontaneous
    bradycardia found on prolonged monitoring

53
Orthostatic intolerance
  • Stop possible medications
  • Salt/fluid intake
  • Compression stockings (ideally include abdominal
    binders, so compliance low)
  • Leg crossing/squatting with symptoms
  • Midodrine (alpha-agonist) works better than in
    patients with reflex syncope
  • Fludrocortisone (mineralcorticoid)

54
Indications for Pacing
  • Class I
  • Third degree of advanced second degree AV block
    with symptoms
  • Bradycardia with symptoms
  • Asystole over 3 seconds
  • Escape rate less than 40 bpm
  • After catheter ablation of AV junction
  • Postoperative AVB

55
Pacing
  • Class II a
  • Asymptomatic 3rd degree AVB or type II second
    degree AVB with narrow QRS (class I if with a
    wide QRS)
  • Syncope with AVB
  • Drug refractory afib.

56
AICD
  • Unexplained syncope and depressed LVEF (ischemic
    or nonischemic)
  • HOCM (II a)
  • Brugada syndrome (II a unless high risk, such as
    family history of sudden death)
  • Long QT
  • Patients with ischemic cardiomyopathy and
    preserved LVEF but unexplained syncope (II b)

57
Back to the Pretest
  • 1. The ECG has the greatest value in its (NPV or
    PPV) in the diagnosis of a cardiac etiology for
    syncope
  • 2. History 75 year old man reports presyncopal
    symptoms that occur while he is driving backwards
    out of his driveway in the morning. This
    suggests
  • 3. History an 80 year old man reports an episode
    of syncope that occurred after doing arm
    exercises for a rotator cuff injury. This
    suggest
  • 4. The only independent predictor of a cardiac
    etiology of syncope is a past history of
  • 5. ____ is a neurodegenerative disease
    characterized by profound autonomic insufficiency
    and parkinsonian features on exam
  • 6. An 82 year old man presents with postural
    hypotension, an idiopathic peripheral neuropathy,
    significant proteinuria and your attending orders
    a rectal biopsy to look for____
  • 7. Name 3 causes of situational syncope
  • 8. Older patients are more likely to have
    positive a. tilt table tests b. carotid sinus
    massage c. orthostatic hypotension d. all of the
    above

58
Answers to Pretest
  • 1. NPV
  • 2. Carotid Hypersensitivity
  • 3. Subclavian steal syndrome
  • 4. Cardiac history
  • 5. Multiple Systems Atrophy (shy-drager)
  • 6. amyloid
  • 7. micturition, defecation, cough, swallow
  • 8. all of the above
  • 9. bonus brugada syndrome

59
Selected References
  • Benditt DG, VanDjjk JG, Sutton R. Syncope Curr
    Prob Cardiol 2004 29(4) 152-229
  • Epstein AE. An update on implantable
    cardioverter-defibrillator guidelines. Curr Opin
    Cardiology 2004 19(1) 23-25
  • Littman L et al. Brugada syndrome and Brugada
    sign. Am Heart J 2003 145(5) 768-778
  • Raj S, Sheldon RS. Role of pacemaker in treating
    neurocardiogenic syncope. Curr Opinion Cardiol
    2003 18 47-52
  • Gregoratos G, Cheitlin MD, Conill A. ACC/AHA
    guidelines for implantation of cardiac pacemakers
    and antiarrthythmia devices executive summary
    a report of the American College of Cardiology/Am
    Heart Assoc Task Force on Practice Guidelines.
    Circulation. 1998 97 1325-1335
  • Connolly SJ et al. The North American Vasovagal
    Pacemaker Study. J Am Coll Cardiol 1999 33
    16-20
  • DiGirolamo et al. Effects of paroxetine on
    refractory vasovagal syncope. J Am Coll Cardiol
    1999 33 1227-30
  • Sutton R et al. Dual chamber pacing in the
    treatment of neurally mediated tilt-positive
    cardioinhibitory syncope (VASIS). Circulation
    2000 102 294-299

60
Selected References
  • Krahn Ad et al. Use of the implantable loop
    recorder in evaluation of patients with
    unexplained syncope
  • Kapoor WN. Current evaluation and management of
    syncope. Circulation 2002 106 1606
  • Alboni P et al. Diagnostic Value of history in
    patients with syncope. J Am Coll Cardiol 2001
    37 1921
  • Kapoor et al. Evaluation and outcome of patients
    with syncope. Medicine 1990 69 160
  • Linzer et al. Diagnosing syncope part I. Ann Int
    med 1997 126989
  • Linzer et al. Diagnosing syncope part II. Ann
    Int Med 1997 127 76

61
Primary References
  • Chen, LY et al. Management of syncope in adults
    an update. Mayo Clin Proc, 2008 83 1280-93.
  • Weimer L, Pezhman Z. Neurological aspects of
    syncope and orthostatic intolerance. Med Clin N
    Am 93 (2009) 427-449.
  • Strickberger et al. AHA/ACCF statement on the
    evaluation of syncope, Circulation 2006.
  • Moya et al. Guidelines for the diagnosis and
    management of syncope, task force from the ESC.
    Eur Heart J (2009)30, 2631-2671.
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