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Approach to the
patient withSYNCOPE
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Syncope
“Those who suffer from frequent and
severe fainting often die suddenly.”
Hippocrates, 1000 BC
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1 Grubb, Olshansky (eds). Syncope: Mechanisms and Management. Armonk, NY: Futura Publishing Co., Inc., 1998, p.1
What Is Syncope?Syncope is:
• A sudden temporary loss of consciousness
associated with loss of postural tone• Due to abrupt reduction or loss of
cerebral perfusion1
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Cardiac Diseases and Arrhythmias:
Most serious due to high mortality rates
Arrhythmias Structural Heart Disease
- Bradyarrhythmias - Obstruction to flow
- Tachyarrhythmias - Pump failure
- Cardiac tamponade
- Aortic dissection1 Day SC, et al. Am J of Med 1982;73:15-23.2 Kapoor W. Medicine 1990;69:160-175.3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189.
4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.
Syncope Can Be A Serious Clinical
Problem
• Some causes of syncope are potentially fatal
• Causes with high mortality and majormorbidity rates
– 7.5% overall1
– 18-33% mortality in patients with a cardiac cause1-4
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1 Day SC, et al. Am J of Med 1982;73:15-23.2 Kapoor W. Medicine 1990;69:160-175.3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189.
4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.
• Some causes of syncope are potentially fatal• Cardiac causes of syncope have the highest mortality rates
The Significance of Syncope
0%
5%
10%
15%
20%
25%
S y
n c o p e M o r t a l i t y
Overall Due to Cardiac Causes
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The Significance of Syncope
The only difference between
syncope and sudden death
is that in one you wake up.1
1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: 403-412.
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Section I:
Prevalence and Impact
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The Significance of Syncope
1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997
2 Blanc J-J, L’her C, Touiza A, et al. Eur Heart J, 2002; 23: 815-820.
3 Day SC, et al, AM J of Med 1982
4 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175
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• Individuals <18 yrs
• Military Population 17- 46 yrs
• Individuals 40-59 yrs*
• Individuals >70 yrs*
15%
20-25%
16-19%
23%
Syncope
Reported Frequency
*during a 10-year periodBrignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306.
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Section II:
Etiology
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Syncope:
A Symptom…Not a Diagnosis
• Self-limited loss of consciousness and
postural tone
• Relatively rapid onset
• Variable warning symptoms
• Spontaneous complete recovery
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Syncope: Etiology
OrthostaticCardiac
Arrhythmia
StructuralCardio-
Pulmonary
*
1• Vasovagal• Carotid
Sinus• SituationalCoughPost-
micturition
2• DrugInduced
• ANSFailurePrimarySecondary
3• BradySick sinusAV block
• TachyVTSVT
• Long QTSyndrome
4• Aortic
Stenosis• HOCM• PulmonaryHypertension
5• Psychogenic• Metabolic
e.g. hyper-ventilation
• Neurological
Non-Cardio-vascular
Neurally-Mediated
Unknown Cause = 34%
24% 11% 14% 4% 12%
DG Benditt, UM Cardiac Arrhythmia Center
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Causes of Syncope-like States
• Migraine*
• Acute hypoxemia*
• Hyperventilation*
• Somatization disorder (psychogenic syncope)
• Acute Intoxication (e.g., alcohol)
• Seizures
• Hypoglycemia
• Sleep disorders
* may cause ‘true’ syncope
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Features that suggest
a non-syncopal attack :
• Confusion after attack for more than 5minutes (seizure)
• Prolonged ( 15 sec) tonio-clonicmovements starting at the onset of theattack (seizure)
• Frequent attacks with somatic complaintsno organic heart disease (psychiatric)
• Associated with vertigo, dysarthria,diplopia (transient ischaemic attack)
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Section III:
Diagnosis andEvaluation Options
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Syncope
Diagnostic Objectives• Distinguish ‘True’ Syncope from other ‘Loss
of Consciousness’ :
– Seizures– Psychiatric disturbances
• Establish the cause of syncope with sufficient
certainty to:– Assess prognosis confidently
– Initiate effective preventive treatment
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The “3 key questions”:
• Is loss of consciousness attributable to
syncope or not?
• Are there important clinical features in
the history that suggest the diagnosis?
• Is heart disease present or absent?
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Initial Evaluation
(Clinic/Emergency Dept.)
• Detailed history• Physical examination
• 12-lead ECG
• Echocardiogram (as available)
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Syncope
Basic Diagnostic Steps
• Detailed History & Physical– Document details of events
– Assess frequency, severity– Obtain careful family history
• Heart disease present?
– Physical exam– ECG: long QT, WPW, conduction system disease
– Echo: LV function, valve status, HOCM
S
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SyncopeEvaluation and Differential
Diagnosis
• Complete Description– From patient and observers
• Type of Onset
• Duration of Attacks
• Posture
• Associated Symptoms
History – What to Look for
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12-Lead ECG
• Normal or Abnormal?
– Acute MI
– Severe Sinus Bradycardia/pause
– AV Block
– Tachyarrhythmia (SVT, VT)
– Preexcitation (WPW), Long QT, Brugada
• Short sampling window (approx. 12 sec)
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Method Comments
Holter (24-48 hours) Useful for infrequent events
Event Recorder •Useful for infrequent events
•Limited value in sudden LOC
Loop Recorder •Useful for infrequent events
•Implantable type moreconvenient (ILR)
Wireless (internet) Event
Monitoring
In development
Ambulatory ECG
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Value of
Event
Recorderin
Syncope
Linzer M. Am J Cardiol. 1990;66:214-219.
*Asterisk denotesevent marker
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Patient Activator Reveal ® Plus ILR 9790 Programmer
Reveal®
Plus
Insertable Loop Recorder
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ILR Recordings*
56 yo woman with syncopeaccompanied with seizures.Infra-Hisian AV Block: Dualchamber pacemaker
65 yo man with syncopeaccompanied with briefretrograde amnesia.VT and VF: ICD and meds
*Medtronic data on file
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Diagnosing VVS
• Patient history and physical exam
• Positive tilt table test(ACC Consensus Protocol)
– Overnight fast– ECG
– Blood pressure
– Supine and upright
– Tilt to 60-80 degrees
– Isoproterenol
– Re-tilt
DG Benditt, Tilt Table Testing, 1996.
60°- 80°
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Head-Up Tilt Test (HUT)
DG Benditt, UM Cardiac Arrhythmia Center
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Conventional EP Testing in Syncope
• Limited utility in syncope evaluation
• Most useful in patients with structural heartdisease
– Heart disease……..50-80%
– No Heart disease…18-50%
• Relatively ineffective for assessing
bradyarrhythmias
Brignole M, Alboni P, Benditt DG, et al. Eur Heart Journal 2001; 22: 1256-1306.
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EP Testing in Syncope:
Useful Diagnostic Observations
• Inducible monomorphic VT
• SNRT > 3000 ms or CSRT > 600 ms• Inducible SVT with hypotension
• HV interval ≥ 100 ms (especially in
absence of inducible VT)
• Pacing induced infra-nodal block
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Electroencephalogram
• Not a first line of testing
• Syncope from Seizures• Abnormal in the interval between
two attacks – Epilepsy
• Normal – Syncope
C ti l Di ti M th d /Yi ld
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Conventional Diagnostic Methods/YieldTest/Procedure Yield
(based on mean time to diagnosis of 5.1 months7
History and Physical
(including carotid sinus massage)
49-85% 1, 2
ECG 2-11% 2
Electrophysiology Study without SHD* 11% 3
Electrophysiology Study with SHD 49% 3
Tilt Table Test (without SHD) 11-87% 4, 5
Ambulatory ECG Monitors:
• Holter 2% 7
• External Loop Recorder
(2-3 weeks duration)
20% 7
• Insertable Loop Recorder
(up to 14 months duration)
65-88% 6, 7
Neurological †
(Head CT Scan, Carotid Doppler) 0-4% 4,5,8,9,10
* Structural Heart Disease† MRI not studied
1 Kapoor, et al N Eng J Med, 1983.2
Kapoor, Am J Med , 1991.3 Linzer, et al. Ann Int. Med , 1997.4 Kapoor, Medicine , 1990.
5 Kapoor, JAMA, 19926
Krahn, Circulation , 19957 Krahn, Cardiology Clinics , 1997.8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.
9 Day S, et al. Am J Med. 1982; 73: 15-23.10 Stetson P, et al. PACE. 1999; 22 (part II): 782.
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When to hospitalize a patient with syncope
• suspected or known significant heart disease
• ECG abnormalities suspected of arrhythmic
syncope• syncope occurring during exercise
• syncope causing severe injury
• family history of sudden death• sudden onset of palpitations before syncope
• syncope with chest pain
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Task Force on Syncope, European Society of Cardiology
The Initial Evaluation of Patients with Syncope
For full text refer to Guidelines on Evaluation of Syncope, JACC 2006; 47: 473 - 484.
The “Initial evaluation”:
• Careful history from patient and witnesses about
circumstances, attack onset and termination
• Physical examination including orthostatic blood pressure
measurements
• Standard electrocardiogram (ECG)