syncope
DESCRIPTION
Syncope. Joseph P. Ornato , MD, FACP, FACC, FACEP Professor & Chairman, Department of Emergency Medicine. Syncope – A symptom, not a diagnosis. Self-limited loss of consciousness and postural tone Relatively rapid onset Variable warning symptoms - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/1.jpg)
Syncope
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor & Chairman, Department of Emergency Medicine
![Page 2: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/2.jpg)
Syncope – A symptom, not a diagnosis
Self-limited loss of consciousness and postural tone
Relatively rapid onsetVariable warning symptomsSpontaneous, complete, and usually prompt
recovery without medical or surgical intervention
Underlying mechanism is transient global cerebral hypoperfusion.
Brignole M, et al. Europace, 2004;6:467-537.
![Page 3: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/3.jpg)
Classification of Transient Loss of Consciousness (TLOC)
SyncopeNeurally-mediated reflex
syndromesOrthostatic hypotensionCardiac arrhythmias Structural cardiovascular
disease
Disorders Mimicking Syncope
With loss of consciousness (i.e., seizure disorders, concussion)
Without loss of consciousness, i.e., psychogenic “pseudo-syncope”
Real or Apparent TLOC
Brignole M, et al. Europace, 2004;6:467-537.
![Page 4: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/4.jpg)
Causes of true syncope
Orthostatic CardiacArrhythmia
StructuralCardio-
Pulmonary
1• Vasovagal
syndrome• Carotid sinus
syndrome• Situational
CoughPost- Micturition
2• Drug-induced• Autonomic
nervous system failure
PrimarySecondary
3• Bradyarrhythmia
Sinus node dysfunction
AV block•Tachyarrhythmia
VTSVT
• Long QT syndrome
4 • Acute
myocardial ischemia
• Aortic stenosis• Hypertrophic
cardiomyopathy• Pulmonary
hypertension• Aortic dissection
Neurally-Mediated
Unexplained Causes = Approximately 1/3
![Page 5: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/5.jpg)
Syncope mimics
Acute intoxication (e.g., alcohol)SeizuresSleep disordersSomatization disorder (psychogenic
pseudo-syncope)Trauma/concussionHypoglycemiaHyperventilation
Brignole M, et al. Europace, 2004;6:467-537.
![Page 6: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/6.jpg)
Impact of syncope
1Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27.2Kapoor W. Medicine. 1990;69:160-175.
3Brignole M, et al. Europace. 2003;5:293-298.4 Blanc J-J, et al. Eur Heart J. 2002;23:815-820.5Campbell A, et al. Age and Ageing. 1981;10:264-270.
40% will experience syncope at least once in a lifetime1
1-6% of hospital admissions2
1% of emergency department visits per year3,4
10% of falls by elderly are due to syncope5
Major morbidity reported in 6%1
(fractures, motor vehicle crashes)
Minor injury in 29%1
(lacerations, bruises)
![Page 7: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/7.jpg)
Impact of syncope: costs
Estimated hospital costs exceeded $10 billion1
Estimated physician office expenses exceeded $470 million2
Over $7 billion is spent annually in the US to treat falls in older adults4
1Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27.2OutPatientView v. 6.0. Solucient LLC, Evanston IL.3Farwell D, et al. J Cardiovasc Electrophysiol. 2002;13(Supp):S9-S13.4Olshansky B. In: Grubb B and Olshansky B. eds. Syncope: Mechanisms and Management. Futura. 1998:15-71.
![Page 8: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/8.jpg)
Impact of syncope: Quality of life
1Linzer M. J Clin Epidemiol. 1991;44:1037.2Linzer M. J Gen Int Med. 1994;9:181.
0
20
40
60
80
100
Anxiety/Depression
Alter DailyActivities
RestrictedDriving
ChangeEmployment
73%171%2
60%2
37%2
Perc
ent o
f Pat
ient
s
![Page 9: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/9.jpg)
Syncope mortality
Low mortality vs. high mortality
Neurally-mediated syncope vs. syncope with a cardiac cause
Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347(12):878-885. [Framingham Study Population]
![Page 10: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/10.jpg)
Diagnostic objectives
Distinguish true syncope from syncope mimics
Determine presence of heart disease Establish the cause of syncope with
sufficient certainty to:Assess prognosis confidentlyInitiate effective preventive treatment
![Page 11: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/11.jpg)
Diagnostic planInitial Examination
Detailed patient historyPhysical examECGSupine and upright
blood pressureMonitoring
HolterEventInsertable loop recorder (ILR)
Cardiac ImagingSpecial Investigations
Head-up tilt testHemodynamics (cardiac cath) Electrophysiology study Brignole M, et al. Europace, 2004;6:467-537.
![Page 12: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/12.jpg)
Detailed patient history
Circumstances of recent eventEyewitness account of
eventSymptoms at onset of
eventSequelaeMedications
Circumstances of prior events
Brignole M, et al. Europace, 2004;6:467-537.
Concomitant disease, especially cardiac
Pertinent family historyCardiac diseaseSudden deathMetabolic disorders
Past medical historyNeurological historySyncope
![Page 13: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/13.jpg)
Initial exam
Vital signs Heart rate Orthostatic blood pressure change
Cardiovascular exam: Is heart disease present? ECG: Long QT, pre-excitation, conduction system disease Echo: LV function, valve status, hypertrophic cardiomyopathy
Neurological exam Carotid sinus massage
Perform under clinically appropriate conditions preferably
during head-up tilt test Monitor both ECG and BP
Brignole M, et al. Europace, 2004;6:467-537.
![Page 14: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/14.jpg)
Specific conditionsNeurally-mediated
Vasovagal Syncope (VVS)Carotid Sinus Syndrome (CSS)
Cardiac arrhythmiaTachy-brady syndromeLong QT syndromeTorsade de pointesBrugada syndromeDrug-induced
Structural cardio-pulmonary diseaseOrthostatic
![Page 15: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/15.jpg)
Neurally-mediated reflex syncope
Vasovagal syncope (VVS)Carotid sinus syndrome (CSS)Situational syncope
Post-micturitionCoughSwallow DefecationBlood drawing, etc.
![Page 16: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/16.jpg)
Vasovagal syncope
Most common form of syncope8% to 37% (mean 18%) of syncope
casesDepends on population sampled
Young without structural heart disase, ↑ incidence
Older with structural heart disease, ↓ incidence
![Page 17: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/17.jpg)
Tilt table test
Useful as diagnostic adjunct to confirm vasovagal syncope
Useful in teaching patients to recognize prodromal symptoms
Brignole M, et al. Europace. 2004;6:467-537.
60° - 80°
![Page 18: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/18.jpg)
Orthostatic hypotension
EtiologyDrug-induced
(very common)DiureticsVasodilators
Primary autonomic failureMultiple system
atrophyParkinson’s
DiseasePostural
Orthostatic Tachycardia Syndrome (POTS)
Secondary autonomic failureDiabetes Alcohol Amyloid
![Page 19: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/19.jpg)
Hypersensitive carotid sinus syndrome
Syncope clearly associated with carotid sinus stimulation is rare (≤1% of syncope)
CSS may be an important cause of unexplained syncope/falls in older individuals
Kenny RA, et al. J Am Coll Cardiol. 2001;38:1491-1496.Brignole M, et al. Europace. 2004;6:467-537.Sutton R. In: Neurally Mediated Syncope: Pathophysiology, Investigation and Treatment. Blanc JJ, et al. eds. Armonk, NY: Futura;1996:138.
![Page 20: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/20.jpg)
Carotid sinus massage (CSM)
Method1
Massage, 5-10 seconds Don’t occlude Supine and upright posture
(on tilt table) Outcome
3 second asystole and/or 50 mmHg fall in systolic BP with reproduction of symptoms = Carotid Sinus Syndrome
Absolute contraindications2
Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months
Complications Primarily neurological Less than 0.2%3
Usually transient
1Kenny RA. Heart. 2000;83:564.2Linzer M. Ann Intern Med. 1997;126:989.3Munro N, et al. J Am Geriatr Soc. 1994;42:1248-1251.
![Page 21: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/21.jpg)
Other diagnostic tests
Ambulatory ECGHolter monitoring Insertable loop recorder (ILR)
Tilt table testIncludes drug provocation (NTG,
isoproterenol)Cardiac catheterization
Electrophysiology study (EPS)Brignole M, et al. Europace, 2004;6:467-537.
![Page 22: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/22.jpg)
Heart monitoring options
ILR
Event Recorders(non-lead and loop)
Holter Monitor
12-Lead
1 day
7-30 days
Up to 14 Months
10 Seconds
OPTION
TIME (Months)
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Brignole M, et al. Europace, 2004;6:467-537.
![Page 23: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/23.jpg)
Diagnostic yield of various tests
Initial Evaluation Yield (%)
History, Physical Exam, ECG, Cardiac Massage 38-40
Other Tests/Procedures Head-Up Tilt 27
External Cardiac Monitoring 5-13
Insertable Loop Recorder (ILR) 43-883-5
EP Study <2-5
Exercise Test 0.5
EEG 0.3-0.5
![Page 24: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/24.jpg)
Neurological tests
EEG
Head CT
Brignole M, et al. Europace. 2004;6:467-537.
![Page 25: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/25.jpg)
Cardiac syncope Includes cardiac arrhythmias and structural heart
diseaseOften life-threateningSuspect if syncope exercise-inducedMay be warning of critical CV disease
Tachy and brady arrhythmiasMyocardial ischemia, aortic stenosis, pulmonary
hypertension, aortic dissectionAssess culprit arrhythmia or structural abnormality
aggressively Initiate treatment promptly
![Page 26: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/26.jpg)
Syncope due to cardiac arrhythmias
BradyarrhythmiasSinus arrest, exit blockHigh grade or acute complete AV blockCan be accompanied by vasodilatation (VVS,
CSS)Tachyarrhythmias
Atrial fibrillation/flutter with rapid ventricular rate (eg, pre-excitation syndrome)
Paroxysmal SVT or VTTorsade de pointes
![Page 27: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/27.jpg)
Factors contributing to sudden death likelihood
Cardiovascular pathologyCoronary artery disease Severe left ventricular dysfunction Cardiomyopathy
Hypertrophic cardiomyopathyArrhythmogenic right ventricular cardiomyopathy
Congenital heart disease, especially coronary artery anomaliesValvular heart diseaseCardiac pacemaker and conducting system disease Hereditary channelopathies (Sudden Arrhythmic Death Syndrome (SADS))Brugada syndromeEarly repolarization syndrome (ERS)Long QT syndrome (LQTS)Short QT syndrome (SQTS)Catecholaminergic polymorphic ventricular tachycardia (CPVT)
![Page 28: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/28.jpg)
Importance to emergency physicians
Often present as recurrent syncope or brief seizures in children or young adults before sudden death occurs
May have young relatives who have had sudden death
ECG findings are often diagnostic Effective preventive treatment is available (ICD) Astute emergency physician may be the ONLY
healthcare provider who can make the diagnosis and prevent tragic loss of a young life
![Page 29: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/29.jpg)
Brugada syndrome
Male predominance Autosomal dominant Common in Asians 40-60% prevalence of
life-threatening ventricular arrhythmias and SCD
Presents as syncope Downsloping ST-segment
elevation in ECG leads V1–3
![Page 30: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/30.jpg)
Early repolarization syndrome (ERS)
Male predominance1-2% of adultsNormalizes with
exercise
Type I – 43% ↑ in SCD
Type II – no ↑ in SCD
![Page 31: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/31.jpg)
Long Q-T syndrome
Bazett FormulaQTc = 0.35-0.44 at HR= 60
HereditaryAutosomal recessive (Jervell Lange-Nielsen syndrome) with hereditary nerve deafness
Autosomal dominant (Romano Ward syndrome w/out deafness)
Syncope, VF, SCDAcquired causes Hypocalcemia Hypokalemia Hypomagnesemia Ischemia Anorexia CNS pathology QT-prolonging drugs (www.azcert.org)
𝑄𝑇𝑐𝑜𝑟𝑟𝑒𝑐𝑡𝑒𝑑=𝑄𝑇𝑚𝑒𝑎𝑠𝑢𝑟𝑒𝑑 √𝑅𝑅𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙
![Page 32: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/32.jpg)
Short Q-T syndromeHereditary
Autosomal dominantAtrial fibrillationSyncope, VF, SCDEarly repolarization inferolateral
leads in 65%
Acquired causesHypercalcemiaHyperkalemiaAcidosisSystemic inflammatory
syndromeMyocardial ischemiaIncreased vagal tone
![Page 33: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/33.jpg)
Exercise-related syncope
Anomalous L coronary artery off the pulmonary artery
Hypertrophic cardiomyopathy Severe aortic stenosis Catecholaminergic polymorphic ventricular
tachycardiaHereditary defect in myocardial calcium handlingStress-related syncope, VF, SCDECG – unexplained sinus bradycardia at rest50% carry a diagnosis of epilepsy before correct
diagnosis established
![Page 34: Syncope](https://reader035.vdocuments.us/reader035/viewer/2022062501/56816190550346895dd12b35/html5/thumbnails/34.jpg)
Conclusion
Syncope is a common symptom with many causes
Deserves thorough investigation and appropriate treatment
Clinical decision (observation) unit at VCU is an appropriate location to initiate the evaluation