syncope and the older patient
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Syncope and The Older Patient. Debra L. Bynum, MD Division of Geriatric Medicine. Pretest…. 1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope - PowerPoint PPT PresentationTRANSCRIPT
Syncope and The Older Patient
Debra L. Bynum, MD
Division of Geriatric Medicine
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
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?
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?
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
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%)
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
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
The History…
History of Heart DiseaseThe 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)
Neurally mediated (reflex)
TermsVasovagalVasodepressorNeurovascularNeurocardiogenicvasomotor
Who gets this?
We think of the young/healthy Older patients can (although often
complicated by comorbidities)
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 don’t really know….
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
Neurally mediated…sort of ….
Situational syncope Carotid sinus hypersensitivity
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
Carotid Sinus Hypersensitivity
HistoryStimulation of carotid area near barorecptor
(near bifurcation)Tight collar, neck pressure with head turning
or shaving/backing out of driveway
CSH…
Carotid massage3 second pause or > 50 mm drop in SBP
Three responses1. Cardioinhibitory (bradycardia/asystole)2. vasodepressor (hypotension)3. Mixed (features of both, most common)
Cardioinhibitory may benefit from pacing…
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 parkinson’s
Pacing controversial, but may have role in select cases…
Summary: Reflex syncope (neural)
Vasovagal (neurally mediated) Situational Carotid sinus hypersensitivity
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…)
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 Parkinson’s, Lewy body processes Guillain-Barre syndrome Spinal cord injury HIV
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…
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
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)
Brugada Sign
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
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
Cerebrovascular
Syncope = global hypoperfusion Vertebrobasilar pathology or bilateral
carotid disease…
How do you evaluate the patient with syncope?
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!
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
History…
OH:After standingProlonged standingPresence of autonomic insufficiency or
parkinson’sStanding after exertion
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
Evaluation
EKG Telemetry Rule out ischemia (nursing home
patients…) Carotid sinus massage
Contraindicated in patients with prior TIA/stroke, bruits or known carotid stenosis
Evaluation
Orthostatics Echo
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…
In-hospital monitoring
Yield low (under 20%) Recommended in high risk patients
Holter Monitoring
24-48 hours (no higher yield with longer) Low yield (1-2%) May be useful if symptoms are very
frequent
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
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
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
Exercise Stress Testing
Patients with syncope with/after exertion Usually of low yield
Other evaluations…
Imaging, CTA Cardiac catheterization
Directed by history and physical…
Least useful tests…
Head CT with negative neuro exam (history should direct whether symptoms suggest stroke/TIA or syncope…)
EEG Carotid dopplers (see above…)
Risk Stratification
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
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
Intermediate risk
Age over 50 History of ischemic heart disease Family history of sudden death
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
Treatment: reflex syncope and orthostatic intolerance Lifestyle
Education, reassuranceAvoiding triggersManeuvers: supine posture, physical
counterpressure, crossing legs)Avoiding medications, ETOH Increasing fluids, salt intake
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…
Reflex syncope: Cardiac pacing
5 major RCTs, conflicting resultsSignificant selection biasLikely not justified unless spontaneous
bradycardia found on prolonged monitoring
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)
Indications for Pacing
Class IThird 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
Pacing
Class II aAsymptomatic 3rd degree AVB or type II
second degree AVB with narrow QRS (class I if with a wide QRS)
Syncope with AVBDrug refractory afib….
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)
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
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
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
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; 126:989
Linzer et al. Diagnosing syncope: part II. Ann Int Med 1997; 127: 76
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.