syncope in older adults - mcfp• rule out seizure, stroke, tia, hypoglycemia, acute illness 2. is...
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SYNCOPE IN OLDER ADULTS
61st Annual Scientific Assembly
April 12, 2019
Lorraine Peitsch MD FRCPC
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Faculty/Presenter Disclosure
■ Faculty: Lorraine Peitsch
■ NO CONFLICT OF INTEREST TO DECLARE
CFPC CoI Templates: Slide 1
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Objectives
1. Identify risk factors for syncope in older
adults
2. Be able to perform a complete initial
evaluation of syncope
3. Know when to refer for cardiology
evaluation
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SYNCOPE Greek: “to interrupt”
■ Sudden, transient loss of consciousness causing
postural collapse
■ Due to transient global cerebral hypoperfusion
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PREVALENCE
■ 19 - 30% of healthy adults have at least one
episode of syncope in their lifetime1,2
■ 3% of emergency visits3; 1% of hospital
admissions4; 8-10% of GIM unit5 are syncope-
related
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Soteriades ES et al. N Engl J Med 2002;347:878-885.
Incidence Rates of Syncope According to Age and Sex.
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Why is syncope more common in older adults?
RISK FACTORS:
■ Changes in physiology
■ Multi-morbidity
■ Polypharmacy
■ Dehydration
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RF: Age-related Changes 1. Blood volume
2. Homeostasis
3. Anticholinergic sensitivity
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RF: Comorbid Conditions
Past Medical
History
Effect on Postural
Hemodynamics
HFrEF Low Cardiac Output
HFpEF Low Cardiac Output if ECV is down
Hypertension Impaired Cerebral Autoregulation
COPD
Pulmonary HTN
Anemia
Low Oxygen Availability
Diabetes
Parkinsonism
Autonomic Dysfunction
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RF: Medications/Polypharmacy Hemodynamic Effects: Cardiac Output 1.Blood Volume – diuretics, anti-hypertensives 2.Vasodilation – nitrates, CCB, opiates, anti-Parkinsonism, alpha-blockers
(tamsulosin), anti-cholinergics (TCA’s, gravol, benadryl, hydroxyzine, oxybutynin)
3.Bradycardia – beta-blockers, cholinesterase inhibitors, digoxin
4.Tachycardia – anti-arrhythmics, digoxin 5.LV Contraction – alcohol, sedative/hypnotics
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Initial Evaluation 3 Key Questions
1. Is it syncope?
• Rule out seizure, stroke, TIA, hypoglycemia, acute
illness
2. Is heart disease present or absent?
• Independent risk factor for cardiac cause of
syncope
• Sensitivity 95%; Specificity 45%
3. Are there important features in the history
and physical exam which suggest the
cause?
Brocklehurst, 2017
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History, Postural Vitals, EKG
Leads to diagnosis in 1/3 of cases
Further evaluation leads to diagnosis
in another 1/3
Remaining 1/3 are unexplained
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History, Postural Vitals, EKG
Collateral is
Essential but
Difficult
Only done in
1/3 of cases
High Sensitivity
Low Specificity
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Initial Evaluation
■ History and Physical and EKG
■ Establish working diagnosis
■ Reduce Risk Factors
■ Re-assess
■ Treat persistent Symptoms
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Initial Evaluation
History History History: ■Circumstance, environment, position, time of
day, trigger, time of last meal, prodrome, chest
pain, shortness of breath, tongue-biting,
incontinence, post episode fatigue
■Collateral: was there actually LOC?
– pallor, cyanosis, prolonged jerking of limbs,
head-turning, post-ictal confusion
■Previous episodes of syncope or falls
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Etiology of Syncope
Decreasing Order of Frequency:
1.Neurally-mediated “Neurogenic” “Reflex”
2.Orthostatic Hypotension
3.Cardiac
– Arrhythmia
– Structural heart disease
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1. NEURALLY-MEDIATED SYNCOPE
■ VASOVAGAL
– Stress
– Prolonged Orthostasis
– Warm Environment
– Situational – cough, micturition, defecation
■ POST-PRANDIAL HYPOTENSION
■ CAROTID SINUS HYPERSENSITIVITY
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VASOVAGAL
■ Predisposition to vasovagal syncope starts early in life
and lasts for decades (Brocklehurst, 2017)
“Have you fainted before, in your younger years?”
In people with syncope6,
■ Age of first faint is <25 in 60%
■ Age of first faint is >65 in 10-15%
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2. ORTHOSTATIC SYNCOPE
■ Postural Drop of 20mmHg SBP or 10mmHg
DBP or SBP nadir <90mmHg
■ Pooling of 300-800ml of volume
■ Most common in morning
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Mechanisms of compensation for
gravitational effects of standing
Autonomic Endocrine
Carotid/aortic baroreceptors renin release
sympathetic tone
peripheral vasoconstriction
& heart rate
angiotensin II
vasoconstriction
aldosterone
sodium retention
Atrial
Natriuretic
Factor
vasodilator
renin-angiotensin
Bedrest
Meds:
ACE-I
ARB
Nitrates
CCB
Diuretics
Opiates
Anti-cholinergics
Diabetes, thyroid,
B12, HIV, ETOH,
Amyloid
PD, LBD, MSA
Parkinson’s Plus
Meds:
Anti-parkinsonism
Anti-psychotics
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3. CARDIAC SYNCOPE highest mortality cause
■ Arrhythmias
– aFib with RVR, VT,
SVT, WPW
– AV block, sick
sinus syndrome
– Long QT
■ Structural Heart
Disease
– Aortic stenosis
– Mitral stenosis
– HCOM
– Ischemia
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Mixed – any combo
■ Vasovagal + Orthostatic Hypotension
■ Postprandial Hypotension + Carotid Sinus
Hypersensitivity
■ Underlying Cardiac Disease + Orthostatic
Hypotension
■ Underlying Cardiac Disease + Postprandial
Hypotension
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Initial Evaluation
Physical Exam
■Evidence of acute illness or exacerbation of
chronic disease
■Postural vital signs
■Cardiac/Respiratory exam
■Peripheral Neuropathy (surrogate markder)
■Parkinsonism
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Initial Evaluation
Investigations:
■Electrolytes, urea, Creatinine, CBC,
glucose, A1C, TSH, B12, HIV
■EKG
– If normal very unlikely cardiac syncope
– If AVB, afib RVR, long QTc, refer to
Cardiology or Emergency
– If old ischemia, BBB, or LVH, and all RFs
for OH removed, refer to Cardiology
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Fig 1 Causes of syncope by age.
Steve W Parry, and Maw Pin Tan BMJ
2010;340:bmj.c880
©2010 by British Medical Journal Publishing Group
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Syncope Evaluations in the Elderly
■ Retrospective Review
from 2002-2006 at Yale
■ 2106 syncope admits,
aged ≥65
■ Admission or discharge
diagnosis of syncope
■ Syncope Etiology:
– Unknown 47%
– Vasovagal 22%
– Orthostasis 13%
– Arrhythmia 12%
– Dehydration 8%
– Other cardiac causes 4%
– Situational 3%
– >1 Etiology 9%
Mendu ML, Arch Intern Med 2009
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CHALLENGES in OLDER ADULTS
■ Less often prodome
■ More often amnesia for loss of consciousness
■ More often unwitnessed
■ More often post-ictal fatigue and sleepiness
■ More often due to mixed etiology
■ More often results in injury
■ More often cardiac cause
BUT, neurally-mediated is still most common cause.
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Further Evaluation
■ Ambulatory BP monitoring if history
consistent with Orthostatic or PP
Hypotension but cannot capture in the
office
■ Post-Prandial BP monitoring
■ ECHO if physical exam concerning for AS,
MS or HF
■ Cardiology referral if concerning arrhythmia
or structural disease
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Further Evaluation
Cardiology referral if:
1.Symptoms consistent with Orthostatic
Hypotension but no drop on exam and all risk
factors removed (Tilt Table)
2.Strongly suspect Carotid Sinus Hypersensitivity
(Carotid Sinus Massage on Tilt Table)
2.AS or MS
3.AV block, afib RVR, long QTc
4.CHF, LBBB, RBBB or bifascicular block if
symptoms ongoing despite removal of RF
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Management
■ Vasovagal – avoid triggers
■ Postprandial Hypotension – small, frequent
meals; avoid large CHO loads
■ Orthostatic Hypotension:
– Deprescribe
– Maintain hydration
– Abdominal binder
– HOB 30o
– Fludrocortisone, midodrine
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Conclusion
■ Consider Neurogenic Syncope
■ Once a fainter, always a fainter
■ Normal cardiac physical exam and normal
EKG excludes cardiac cause of syncope
■ In those with a history of cardiac disease,
neurogenic syncope is still more common
than cardiac syncope
■ Refer to Day Hospital if non-cardiac syncope
and multiple falls risks
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Thank you!
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Appendices
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Cardiology Work-up
■ ECHO
■ Holter monitor
■ Implantable Loop monitor
■ Ambulatory blood pressure monitoring
■ Tilt table testing
■ Stress testing
■ Electrophysiologic study
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Calgary Syncope Symptom Score Is there a history of bifascicular block,
asystole, SVT, or diabetes?
-5
Blue during faint? -4
First episode when age 35 or older? -3
Do you remember anything while
unconscious?
-2
Lightheaded spells or fainting with
prolonged sitting or standing?
+1
Diaphoresis or warm feeling prior to
faint?
+2
Lightheaded spells or fainting with pain
or in medical settings?
+3
Vasovagal syncope if the total point score is ≥ -2
Excludes patients with known cardiomyopathy or myocardial
infarction Sheldon R, Eur Heart J 2006
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Major Risk Factors, any 1 Urgent Cardiology Assessment
Abnormal EKG Any bradyarrhythmia, tachyarrhythmia, or
conduction disease
New ischemia or old infarct
History of CVD Ischemic, arrhythmic, obstructive, valvular
Hypotension Systolic BP<90 mm Hg
Heart Failure Either past history or current state
Minor Risk Factors, 1 or more Consider Cardiology Referral
Age > 60
Dyspnea
Anemia
Hypertension
Cerebrovascular Disease
Famhx of early sudden death
Syncope while supine, during
exercise, with no prodrome
CCS, 2011
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Guidelines
■ CCS, 2011. Standardized Approaches to the Investigation of Syncope: Canadian Cardiovascular Society Position Paper.
■ ACC/AHA/HRS (American College of Cardiology/American Heart Association/Heart Rhythm Society), 2017. Guideline for the Evaluation and Management of Patients with Syncope.
■ ACC/AHA/HRS (American College of Cardiology/American Heart Association/Heart Rhythm Society), 2017. Pacing as a Treatment for Reflex-Mediated (Vasovagal, Situational, or Carotid Sinus Hypersensitivity) Syncope.
■ ESC (European Society of Cardiology), 2018. Guidelines for the diagnosis and management of syncope.
■ NICE (National Institute for Health and Care Excellence, UK), 2014. Transient loss of consciousness (“blackouts”) in over 16s.
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References 1. Chen et al. Prevalence of syncope in a population aged more than 45 years. Am J
Med. 2006 Dec;119(12):1088.e1-7.
2. Ganzeboom et al. Lifetime cumulative incidence of syncope in the general population: a study of 549 Dutch subjects aged 35-60 years. J Cardiovasc Electrophysiol. 2006;17:1172-1176.
3. McCarthy et al. Management of syncope in the emergency department: a single hospital observational case series based on the application of ESC Guidelines. Eurospace. 2009;11:216-224.
4. Shibao et al. Orthostatic hypotension-related hospitalizations in the United States. Am J Med. 2007;120:975-980.
5. Parry et al. Evidence-based algorithms and the management of falls and syncope presenting to acute medical services. Clin Med. 2008;8:157-162.
6. Kenny and King-Kallimanis. Epidemiology of syncope/collapse in younger and older Western patient populations. Prog Cardiovas Dis. 2013;55:357-363.
7. Fillet et al. Brocklehurst’s Textbook Of Geriatric Medicine and Gerontology. 7th Ed. 2010.