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SYNCOPE

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SYNCOPE Nora Goldschlager, M.D. MACP, FACC, FAHA, FHRS Cardiology San Francisco General Hospital UCSF Disclosures: None ESC GUIDELINES ON SYNCOPE For Dx: Strongly ... – PowerPoint PPT presentation

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Title: SYNCOPE


1
SYNCOPE Nora Goldschlager, M.D. MACP, FACC,
FAHA, FHRSCardiology San Francisco General
HospitalUCSF Disclosures None
2
SCOPE OF THE PROBLEM
  • Cumulative lifetime incidence in general
    population up to 35
  • 1 of all hospital admissions
  • 3 of all ER visits up to 65 are vasovagal
  • 6 incidence in institutionalized elderly
  • Prevalence 7 - 47 in young, healthy subjects
    unknown in elderly
  • Up to 30 of patients may have no diagnosis
    established at hospital discharge
  • 6 annual mortality if no cause established
  • 12 - 25 recurrence

3
50 40 30 20 10 0
Cardiac
Mortality
Noncardiac
Unknown
Yr. of FU 0 1 2 3 4 5 No. at
risk 433 380 349 295 179 44
Kapoor Medicine 691990 N 433 Sudden
death 37
4
SURVIVAL IN SYNCOPAL PATIENTS
No syncope Vasovagal other causes (OH, med
Rx) Unknown cause Neurologic cause Cardiac cause
1.0 .8 .6 .4 .2 0
Probability of survival
0 5 10 15 20 25
Follow-up (yr)
Soteriades et al NEJM 2002347878
(Framingham) N 822/7814
5
PREVALENCE OF SYNCOPE BY AGE
50 40 30 20 10 0
Ganzeboom et al AJC 4.15.03
6
YOUNGER ADULTS
ELDERLY
OH, CSS, situational, seizures, drugs 1
arrhythmia, LV obstruction
OH, situational,seizures, drugs 1
arrhythmia
Vasovagal Undetermined
Cardiogenic Other causes
7
ETIOLOGY OF FIRST SYNCOPE IN PATIENTS gt 65 YEARS
Reflex-mediated (VVS, CSS,
situational) 13-30 Orthostatic 12 Cardi
ac Arrhythmic 8 Nonarrhythmic 3 Dr
ug-induced 8 CNS 6 Unexplained 4
9
Roussanov et al, Am J Geriatric Cardiol
200716249 N304 (VA patients)
8
FEATURES OF UNEXPLAINED SYNCOPE IN OLDER PATIENTS
High incidence of comorbid conditions 24
recurrence rate Concurrent BP and HF Rx
increases susceptibility to HUT Only 9 had
an etiology established during
follow-up Lower diagnostic yield of history
and tests compared in younger patients
Roussanov et al, Am J Geriatric Cardiol
200716249 N304 (VA patients)
9
PROGNOSIS IN UNEXPLAINED SYNCOPE IN PATIENTS gt 65
1.0 .75 .50 .25 0
Control
Syncope
Proportion of pts alive
0 1 2 3 Yrs FU
Roussanov et al Am J Geriatric Cardiol 2007
16249 N 304 VA pts
10
EVALUATION OF SYNCOPE PERTINENT HISTORY
  • Precipitating factors
  • - Posture changes (orthostatic hypotension)
  • - Cough, swallowing, micturition, defecation
    (situational syncope)
  • - Exercise (consider aortic stenosis, HOCM, VT)
  • - Head turning, Valsalva (suggests carotid
    sinus syndrome)
  • Prodromal symptoms
  • Speed of onset and recovery (prolonged
    recovery suggests vasovagal syncope)
  • Aura (suggests seizure)
  • Hx heart disease (predicts cardiac syncope
    95 specificity lt50gt)

11
NATURAL HISTORY OF AORTIC STENOSIS
Onset of Sx
With AVR
100 75 50 25 0
Asx stage
Without AVR
Survival
CHF
Angina
Syncope
10 20 30
Years
12
EVALUATION OF SYNCOPE PERTINENT HISTORY
13
Exercise-induced RVOT VT
14
Tussive bradycardia
15
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16
Deglutition bradycardia
Continuous strips
17
CONGENITAL LQTS
110,000 is a gene carrier 3-4,000 sudden
deaths/yr, mostly young patients 10 sudden
deaths in untreated patients 30 of sudden or
aborted sudden deaths occur as 1st event
Female gender About 10 have normal QTC about
30 have borderline QTC
18
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19
CLUES TO ETIOLOGY OF SYNCOPE FROM PHYSICAL
EXAMINATION
Left ventricular impulse abnormalities
suggesting past myocardial infarction
Ventricular hypertrophy (need for AV
synchrony) Ventricular gallops Murmurs
(aortic stenosis, hypertrophic obstructive
cardiomyopathy) Pulmonary hypertension Mitral
valve prolapse (PSVT, VT, autonomic
dysfunction) Carotid sinus massage indicating
CSH
20
CAROTID SINUS MASSAGE
Generally accepted contraindications -
Carotid bruits - Prior endarterectomy - Prior
TIA or CVA - Known cerebrovascular disease
Responses to CSM - Bradycardia / asystole
usually abrupt - Hypotension often not abrupt,
and outlasts the CSM - Complications (lt 1)
TIA, transient paresis, visual disturbances
21
CLUES TO ETIOLOGY OF SYNCOPE FROM 12-LEAD ECG
Long QT interval Prior MI (substrate for
VT) Epsilon wave, anterior (V1-3) T inversion,
QRS duration V1-3 / V4-6 gt 1.2, suggesting RV
dysplasia Brugada pattern Short QT interval
(with tall symmetric T waves) Ectopy
Bradycardia AV conduction delay / block
Bifascicular block Ventricular hypertrophy
(need for AV synchrony)
22
Epsilon wave of RV dysplasia
V1
V2
V3
Marcus, Fontaine PACE 6.95
23
RV DYSPLASIA
Young pt Can present as syncope or aborted
sudden death ECG - Anterior T inversion
V1-3 - Prominent anterior forces - RIVCD -
Delayed S wave V1-2 MRI is usually (but not
always) diagnostic (fat replacement)
24
RV dysplasia
25
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26
BRUGADA SYNDROME
27
BRUGADA SYNDROME
28
OUTCOME IN PTS WITH BRUGADA ECG
1.0 .8 .6 .4 .2 0
Asymptomatic (57)
Free of events (SD, VF)
Syncope (22)
Sudden death (21)
p 0.00001
0 100 200 300
Mos
Brugada et al Circulation 2002 10573 N
334, all EPS 63 of syncopal pts had VT induced
29
PROGNOSIS OF SYNCOPE IN BRUGADA SYNDROME
1.0 .8 .6 .4 .2 0
Asymptomatic
Syncope
Free of Appropriate ICD Rx
Sudden death
0 12 24 36 48 60
Follow-up (mos)
Antzelevitch et al Circulation 2005 111659
N258 (Registry)
30
ROLE OF ECHOCARDIOGRAPHY IN SYNCOPE
31
NONARRHYTHMIC CARDIAC SYNCOPE OBSTRUCTION TO
FLOW
Aortic stenosis - LV baroceptor stimulation
with reflex peripheral vasodilation -
Ventricular arrhythmias - Transmural ischemic
injury with LV dysfunction Hypertrophic
obstructive cardiomyopathy Tumor Primary
pulmonary hypertension, pulmonic
stenosis Pulmonary embolism
32
Syncope in aortic stenosis
Recorded during syncopal spell. BP unobtainable.
33
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34
SYNCOPE IN HYPERTROPHIC CARDIOMYOPATHY - 1
Causes - SVT (especially AF) - VT - LV
outflow tract gradient - Abnormal baroreceptor
reflexes - Ischemia EP studies unreliable
?-blockers, disopyramide and Ca channel
blockers do not reduce incidence of SD
35
SYNCOPE IN HYPERTROPHIC CARDIOMYOPATHY - 2
ICD indicated for high risk patients - Family
hx syncope/sudden death - LVH gt 3 cm - Aborted
sudden death - Nonsustained VT on Holter
36
SYNCOPE IN PULMONARY HYPERTENSION
Usually exertional or immediately
post-exercise Fixed right sided obstruction
due to high pulmonary vascular resistance
Inability to increase CO in response to SVR
Decreased cerebral perfusion
37
SYNCOPE IN SYSTOLIC HEART FAILURE
In patients with syncope, heart failure is an
independent predictor of mortality Syncopal
patients with ICDs have appropriate therapies
delivered SCD-HeFT - Predictors of syncope
QRSd gt 120 ms, NYHA III, no beta
blocker - Not predictors EF, NSVT, AF, other
HF Rx - 16 with ICD had syncope 41 had
appropriate shock (vs 12 with no
syncope) - Syncope was predictor of total and
CV mortality, but not sudden death and did
not differ among ICD, amio, or placebo
pts - ICDs did not reduce mortality in
syncope patients
38
NEUROCARDIOGENIC (VASOVAGAL) SYNCOPE
Occurs at all ages 17 - 35 suffer
significant injury 5 - 7 have fractures Up
to 4 of pts diagnosed with VVS may have
cardiac syncope
39
FEATURES OF HISTORY IN VVS
Usually occurs in upright position Rare
during exercise 3 phases prodrome, loss of
consciousness, postsyncopal period May have
specific triggers pain, trauma, stress,
situational (swallow, micturition,
defecation) Peri-event amnesia common
Association with chronic fatigue syndrome,
depression, somatic disorders May run in
families ? frequency around menses
40
VASOVAGAL vs ARRHYTHMIC SYNCOPE
P
Male lt .001 Age gt 54 lt .001 Supine NS Upright NS
Precipitant lt .001 No presyncope NS Warning NS Dia
phoresis lt .001
0 20 40 60 80 100
VT AVB Calkins et alAJM 981995
41
VASOVAGAL vs ARRHYTHMIC SYNCOPE
P
Fatigue Post lt .001 Confusion NS Palpitations NS I
ncontinence .02 Injury NS Major
Injury NS Recovery gt 0 lt .001
0 20 40 60 80 100
VT AVB Calkins et alAJM 981995
42
NEUROCARDIOGENIC SYNCOPE
? LV volume
? Venous return
? LV contractility
Peripheral venous pooling
Mechanoreceptor stimulation (myocardial C fibers)
? Vagal tone
Peripheral vasodilation
Vasomotor center
? ???? adrenergic tone
Hypotension
Bradycardia or asytole
43
VVS PHARMACOLOGIC THERAPY
Anticholinergic agents - Disopyramide
(effect vs placebo is controversial) -
Scopolamine Negative inotropic agents -
Disopyramide Fludrocortisone Vasopressin
Alpha-adrenergic agonists - Ephedrine -
Etilephrine - Theophylline - Dexedrine -
Midodrine Serotonin reuptake inhibitors
Watch for urinary retention, torsades de
pointes VT
44
VVS PACEMAKER THERAPY
45
VVS PACING vs ?-BLOCKADE (SYDIT)
1.0 0.9 0.8 0.7 0.6
Pacemaker
syncope free pts
P 0.0031
Atenolol
0 200 400 600 800 1000 Days
Ammirati et al Circulation 2001 10452 N 93
46
ORTHOSTATIC TRAINING FOR REFRACTORY
NEUROCARDIOGENIC SYNCOPE
N 47, mean age 16 5 in hospital training
sessions 40 min BID standing against wall at
home Results (FU 18 5 mos) 96 had
HUT (Control 26) 0 had syncope (Control 57)
Girolamo et al Circulation 19991001798
47
LEG CROSSING AND MUSCLE TENSING TO ABORT /
MITIGATE VASOVAGAL SYNCOPE
  • N 21
  • At onset of sx, leg crossing with tensing of
    abdominal, leg and buttock muscles
  • BP and HR stabilized in all pts in 3 - 6"
  • 5 / 20 aborted syncope
  • 15 / 20 had delayed onset of syncope by 0.5 -
    11'
  • At 10 mo FU, 16 / 19 benefited from maneuver
  • Similar benefit for cardiac pacing

Krediet at al, Circulation 20021061684
48
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49
ISOMETRIC ARM EXERCISE TO ABORT VASOVAGAL SYNCOPE
Control
2 min handgrip
HR 112 90 68 45
BP 178 156 133 111 89 67 44
Asx 11 Syncope 47
Asx 63 Syncope 5
Brignole et al JACC 2002402053 N 19
50
FALLS SCOPE OF THE PROBLEM
  • 30 of pts gt 65 fall / yr
  • 60 of pts in long-term care facilities fall / yr
  • 10 - 20 result in injury
  • 2 - 6 result in fractures
  • Usually unwitnessed
  • 30 have LOC with CSM 80 had amnesia

Kenny et al SAFEPACE JACC 200138 N 175
51
SAFE-PACE TRIALSyncope and Falls in the
Elderly Pacing and Carotid Sinus Evaluation
  • Prospective randomized, controlled trial of
    175 patients gt 50 y.o. with cardioinhibitory
    carotid sinus hypersensitivity and unexplained
    falls
  • Randomized to pacing (with rate-drop response)
    vs. no pacing
  • Follow-up one year
  • Odds-ratio of falls in nonpaced patients 41, 0.
    35 in paced patients

Kenny et al JACC 200138
52
DDD PACING FOR CAROTID SINUS SYNDROME WITH
FALLS, DIZZINESS AND SYNCOPE
100 80 60 40 20 0
Before After
Syncope
Falls
Dizziness
Crilley et al Postgrad Med J 731997 N 42
53
SYNCOPE WORKUP
ECG Holter (overall yield 2-35) Event
Monitor (patient cannot be syncopal) Head-up
tilt table testing Electrophysiologic study
(predictive value variable) Implantable loop
recorder
54
TILT-TABLE TESTING FOR EVALUATION OF SYNCOPE
SUMMARY OF PRINCIPAL INDICATIONS
Tilt-table testing warranted
Recurrent syncope or single syncopal episode
in a high risk patient, whether or not the
medical history is suggestive of neurally
mediated (vasovagal) origin and 1. No evidence
of structural cardiovascular disease, or 2.
Structural cardiovascular disease is present,
but other causes of syncope have been
excluded by appropriate testing
Benditt et al JACC July 1996
55
Tilt-table testing warranted
Further evaluation of patients in whom an
apparent cause has been established (e.g.,
asystole, atrioventricular block), but in whom
demonstration of susceptibility to neurally
mediated syncope would affect treatment plans
Part of the evaluation of exercise-induced or
exercise-associated syncope
56
Reasonable differences of opinion exist
regarding utility of tilt-table testing
Differentiating convulsive syncope from
seizures Evaluating patients (especially the
elderly) with recurrent unexplained falls
Assessing recurrent dizziness or presyncope
Evaluating unexplained syncope in the setting
of peripheral neuropathies or dysautonomias
Follow-up evaluation to assess therapy of
neurally mediated syncope
57
Tilt-table testing not warranted
Single syncopal episode, without injury and
not in a high risk setting, with clear-cut
vasovagal features Syncope in which an
alternative specific cause has been established
and in which additional demonstration of a
neurally mediated susceptibility would not
alter Rx
58
DIAGNOSTIC YIELD OF AMBULATORY ELECTROCARDIOGRAPHI
C MONITORING (AECG) IN SYMPTOMATIC PATIENTS
Sx w/o AECG No Sx with AECG arrhythmia
() arrhythmia ()
No. Zeldis 37 13 34 30 23 Clark 98 3 39
41 17 Jonas 358 4 0 16 80 Kala 108 7 7 16 69 Gibso
n 1,512 2 15 10 79 Boudoulas 119 26 13 27 34Diamo
nd 85 44 20 4 33 TOTAL 2,651 21 48 Overall
yield 2
DiMarco and Philbrick, Ann Intern Med 6/90
59
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62
PATIENT PRESENTING WITH SYNCOPE AND SEIZURE
63
ADVANTAGES AND LIMITATIONS OF IMPLANTABLE LOOP
RECORDERS
Advantages Prolonged ECG recording capability
(to 2 yrs) Memory - allows activation after
syncopal event Automatic recording, allowing
automatic acquisition of ECG events which fall
outside programmable boundaries Elimination
of technical factors which impair good quality
surface ECG recording during sx High sx-ECG
correlation yield Dx made in 25-50 of pts,
and suggested in an additional 15-25
Benditt et al
64
ADVANTAGES AND LIMITATIONS OF IMPLANTABLE LOOP
RECORDERS
Limitations Surgical implantation Does not
record other potentially important parameters
(e.g., BP) Sx - ECG correlation not available
when automatic recordings are obtained Does
not distinguish vasovagal episodes from
conduction system disease
Benditt et al
65
RECOMMENDATIONS FOR IMPLANTABLE CARDIOVERTER
DEFIBRILLATORS IN SYNCOPAL PATIENTS
Class I Syncope of undetermined origin with
clinically relevant, hemodynamically
significant sustained VT or VF induced at
EPS Class IIa Reasonable for patients with
unexplained syncope, significant LV dysfunction,
and nonischemic dilated cardiomyopathy Reasonabl
e for patients with Brugada syndrome who have
had syncope.
ACC/AHA/HRS Guidelines 2008
66
ACC/AHA/ESC 2006
Management of Patients with Ventricular Arrhythmia
s and the Prevention of Sudden Cardiac Death
EP Testing in Patients with Syncope
Class I Patients with syncope of unknown cause
with impaired LV function or structural heart
disease Class IIa Can be useful in patients
with syncope when brady- or tachyarrhythmias are
suspected, and in whom noninvasive diagnostic
studies are not conclusive.
67
RECOMMENDATIONS FOR ICDS IN SYNCOPAL PATIENTS
Class IIb May be consideered in patients with
syncope and advanced structural heart disease
in whom thorough invasive and noninvasive
investigations have failed to define a
cause. Class III Syncope of undetermined cause
in a patient without inducible ventricular
tachyarrhythmias and without structural heart
disease.
ACC/AHA/HRS Guidelines 2008
68
ESC GUIDELINES ON SYNCOPE
Hospital Admission for Syncope Management
  • For Dx Strongly recommended
  • Suspected or known significant heart disease
  • ECG abnormalities suggestive of arrhythmic
    syncope
  • Syncope during exercise
  • Syncope causing severe injury
  • Strong family history of sudden death

Europace 20046 467-537
69
ESC GUIDELINES ON SYNCOPE
  • May need to be admitted
  • Patients with or without heart disease but with
  • Sudden palpitations shortly before syncope
  • Syncope in supine position
  • Worrisome family history
  • Significant physical injury
  • Patients with minimal or mild heart disease
    when there is high suspicion for cardiac
    syncope
  • Suspected pacemaker or ICD problem

Europace 20046 467-537
70
ESC GUIDELINES ON SYNCOPE
Hospital Admission for Syncope Management
  • For Rx
  • Cardiac arrhythmias as cause
  • Syncope due to cardiac ischemia
  • Syncope due to structural cardiac or pulmonary
    disease
  • Stroke or focal neurologic disorders
  • Cardioinhibitory neurally mediated syncope
  • when pacemaker implant is planned

Europace 20046 467 - 537
71
INDICATIONS TO REFER SYNCOPAL PTTO
ELECTROPHYSIOLOGIST
  • Neurocardiogenic syncope, especially if
    refractory to avoidance of triggers and
    drug Rx, or associated with prolonged
    pauses in cardiac rhythm
  • Arrhythmia identified during evaluation
  • - VT due to any cause
  • - Bradyarrhythmia caused by Rx that cannot
    be withheld or changed
  • - Supraventricular tachycardia, esp. with WPW
    conduction

72
INDICATIONS TO REFER SYNCOPAL PT TO
ELECTROPHYSIOLOGIST
Congenital long QT syndrome Brugada
syndrome Structural heart disease Syncope in
athletes Syncope during exercise Short QT
syndrome Origin of syncope remains unknown and
prolonged arrhythmia monitoring by implantable
loop recorder is being considered
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