syncope – presentation and presentation and investigation in the
TRANSCRIPT
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SyncopeSyncope –– Presentation andPresentation andInvestigation in the AcuteInvestigation in the Acute
SettingSettingSettingSetting
Professor Rose Anne Kenny, StJames Hospital &Trinity College,
Dublin
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DefinitionDefinition-- PresentationPresentation
Syncope is a syndrome consisting of aSyncope is a syndrome consisting of arelativelyrelatively short periodshort period ofof temporarytemporaryandand self limitedself limited loss of consciousnessloss of consciousness
caused by transient reduction in blood flow to thecaused by transient reduction in blood flow to thebrain (most often the result of systemichypotension).
• Transient
• Spontaneous recovery
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SynonymsSynonyms - PresentationPresentation
Syncope
• Faint
• Blackout
• Passing out• Passing out
Pre Syncope
• Near faint/ near pass out
• Gray out
• Funny do
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Syncope in relation to real and apparent loss of consciousnessSyncope in relation to real and apparent loss of consciousness.
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Syncope vs EpilepsySyncope vs Epilepsy
12% ‘tonic clonic like movements’
80% myoclonic
• Brief
• After LOC• After LOC
• Less coarse
• Not tonic clonic (gross flailing, random, contractionof axial muscles different to regular contractions of
epilepsy)
• Video- Mobile phone
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Syncope vs TIASyncope vs TIA
• TIA does not cause syncope
• Vertebral Ischemia - rare- neurology
• Transient cerebral disturbances should not beincluded in the differential for Syncope
• Unnecessary Investigations
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CausesCauses-- InvestigationInvestigation
• Neurally mediated
• Orthostatic
• Cardiac Arrhythmia• Cardiac Arrhythmia
• Structural Heart Disease
• Cerebrovascular
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CausesCauses-- InvestigationInvestigation
Neurally MediatedNeurally Mediated• Vasovagal Syncope
• Carotid Sinus Syncope
• Situational FaintAcute haemorrhageAcute haemorrhage
Cough, sneeze,
Gastrointestinal stimulation
Micturition
Post exercise
Other (brass instrument play, weight lifting, postprandial)
• Glossopharyngeal and trigeminal neuralgia
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CausesCauses-- InvestigationInvestigation
OrthostaticOrthostatic
• Primary Autonomic failure syndromes(PAF, MSA, PD, ? POTS)
• Secondary Autonomic failure• Secondary Autonomic failure
(DM, drugs, Alcohol Amyloid)
• Volume depletion
(Haemorrhage, Diarrhoea, Addison's, ?Age)
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CausesCauses-- InvestigationInvestigation
Cardiac Arrhythmias as primary causeCardiac Arrhythmias as primary cause
• SND
• AV Conduction
• PSVT, VT• PSVT, VT
• Inherited Syndromes (Long QT, Brugada)
• Implanted device malfunction
• Drug Induced Arrhythmia
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CausesCauses-- InvestigationInvestigation
Structural Cardiac/CardiopulmonaryStructural Cardiac/Cardiopulmonary• Cardiac Valvular• Acute MI• Obstructive cardiomyopathy• Atrial Myxoma• Atrial Myxoma• Acute Aortic dissection• Pericardial• Pulmonary Embolus/ HypertensionCerebrovascularCerebrovascular• Vascular Steal Syndromes
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CausesCauses-- OPD; ED studiesOPD; ED studies
Vasovagal/Carotid Sinus Syndrome 35%
Arrhythmia or Cardiac 10%
Orthostatic Hypotension 25%Orthostatic Hypotension 25%
(Canada, USA, UK, Italy)
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EpidemiologyEpidemiology
IncidenceIncidence
• Adults: 6.2 per 1000 person years
• 70-79 : 11 per 1000 person years
• > 80 19 per 1000 person years
Soteriades NEJM 2002
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2525 30
2030203020022002
70%70%
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Comparison of ages of first syncope in 443 patients with vasovagal syncope and88 patients with syncope of other known cause.
ER 1ER 1--3%,3%, Admissions 6%Admissions 6%
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SyncopeSyncope –– Presentation andPresentation andInvestigation in the Acute settingInvestigation in the Acute setting
Admission based on Risk Stratification
• Short Term (7-10)• Short Term (7-10)
• Long term (1 year)
Admission based on Mechanism of Syncopeand its Treatment
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Management of ShortTerm Risk:Management of ShortTerm Risk:10 days10 days
1. STePS1. STePS
(ShortTerm Prognosis of Syncope JACC 2008)
• Abnormal ECG,
• trauma,• trauma,
• absence prodrome,
• male,
10 day higher risk death, serious adverse event(CPR, PM, Defib implant, admit ICU)
• positive predictive value 11-14% low no. events
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Management of ShortTerm Risk:Management of ShortTerm Risk:10 days10 days
2. San Francisco Syncope Rule2. San Francisco Syncope Rule Ann Emer Med 2006,
• Abnormal ECG,• SOB,• Hct <30%,• SBP<90mmHg,• CCF• CCF 98% sens, 56% spec serious adverse event 7 daysdeath, MI, Arrhythmia, PE, Stroke, SAH, Haem, ED return,
Hospital admission
89% sens, 42% spec external validationAnn Emer Med 2007
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Management of ShortTermRisk:Management of ShortTermRisk:10 days10 days
• High Risk important – few days followingindex event
• Deaths, serious outcomes mostly related• Deaths, serious outcomes mostly relatedseverity underlying diseaseunderlying disease > syncope
• Approx 1% death rate1% death rate high risk within 1week presentation
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Clinical policy of the American College ofClinical policy of the American College ofEmergency PhysiciansEmergency Physicians
Factors that lead to stratification as HighHighRisk (Hospital Admission)Risk (Hospital Admission)
• Older Age*• Older Age*
• Abnormal ECG (acute ischemia,dysrhythmias, conduction abnormality)
• Hct<30%
• Hx or presence CCF, CAD, structural HD
Ann Emerg Med 2007
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Management of Long Term Risk:Management of Long Term Risk:1 Year1 Year
RF Syncope n=252;
• >45 yrs• Abnormal ECG• Hx Ventricular Arrhythmia• Hx CCF• Hx CCF
Valid n=374
1 Year Death or Sign Arrhythmias:0% none, 27% 3 > RFs
Ann Emerg Med 1997
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Management of Long Term Risk:Management of Long Term Risk:1 Year1 Year
OESILOESIL Europ Heart J2003
Risk Factor %
0 0
1 0.8•>65•Hx CVD 1 0.8
2 19.6
3 34.7
4 57.1
•Hx CVD•No prodrome•Abn ECG
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Management of Long Term Risk:Management of Long Term Risk:1 Year1 Year
• High Risk important 1 year
• Deaths, serious outcomes mostly related severityunderlying disease > syncope
• death rate depend number risk factors
•• Conclusion:Conclusion: High Risk Patients need close careful F/U,Optimal Treatment and Management
• No evidence immediate hospital admission improveslong term outcome
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SyncopeSyncope –– Presentation andPresentation andInvestigation in the Acute settingInvestigation in the Acute setting
SEEDSSEEDS ( Syncope Evaluation in the ED)
Syncope Observation Unit in ED
Appropriate resources
Multidisciplinary ApproachMultidisciplinary Approach
Complete Hx, physical exam, ECG, 6htelemetry, 1h vital signs, Orthostatic BP,ECHO (abn CV exam or ECG).
…….HUT, CSM, EPS consult
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SEEDSSEEDS
Syncope51
Standard52
p
PresumptiveDiagnosis
67% 10% 0.001
HospitalAdmission
43% 98% 0.001Admission
43% 98% 0.001
Beds Days 140 64 -
Actuarialsurvival
97% 90% ns
Survival freesyncope
88% 89% ns
Shen et al Circulation 2004
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Hospital AdmissionHospital AdmissionESCESC Syncope Guidelines
Recommendations
For DiagnosisDiagnosis
Strong RecommendStrong Recommend
• Suspected or known Heart Disease
• ECG suggest Arrhythmia• ECG suggest Arrhythmia
• Syncope during Exercise
• Syncope causing Injury
• Strong Family History Sudden Death
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Hospital AdmissionHospital AdmissionESCESC Syncope Guidelines
RecommendationsPatients without Heart DiseasePatients without Heart Disease
• Occasionally may need admission
• Sudden onset palpitations before S
• Syncope Supine• Syncope Supine
• Worrisome Family History
• Significant Physical Injury
Patient mild HD but suspicion cardiac syncopePatient mild HD but suspicion cardiac syncope
Suspected PM, defib problemSuspected PM, defib problem
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Hospital AdmissionHospital AdmissionESCESC Syncope Guidelines
Recommendations
For TreatmentTreatment
• Cardiac Arrhythmias
• Syncope due to Cardiac Ischemia
• Syncope secondary to structural• Syncope secondary to structuralCardiac/Cardiopulmonary Disease
• Stroke focal neurological Disorders
• CI NMS PM planned
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MorbidityMorbidity-- VVSVVS
‘Benign’
Driving, Occupation, interpersonal relationships,anxiety, depression, orthopaedic injuries (Linzer 91)anxiety, depression, orthopaedic injuries (Linzer 91)
12% RTA
40% driving restrictions
10% fracture
37% missed 15 days (year) (Connolly RCT 2003)
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Morbidity Older PatientsMorbidity Older Patients
• Loss functional Ability- FracturesFractures
• Loss Independence
• Institutionalisation• Institutionalisation
• Cognitive impairment
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SyncopeSyncope –– Presentation andPresentation andInvestigation in the Acute settingInvestigation in the Acute setting
TLOC presenting ED
Suspected or Unexplained Dx
Risk Stratification
TLOC presenting ED
Suspected or Unexplained Dx
Risk StratificationRisk Stratification
ED Syncope UnitLow Risk D/C
Out Patient syncope Mx
Risk Stratification
High Risk/ESC adm guidelines
ED Syncope Unit
In Hospital Syncope Mx
Low Risk D/C
Out Patient syncope Mx
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Syncope – Presentation andInvestigation in the Acute setting
TLOC presenting ED
Suspected or Unexplained Dx
Risk Stratification
Init Eval: Hx, Exam, OBP, Blds
Risk Stratification
High Risk/ESC adm guidelines
ED Syncope ObsUnit
In Hospital Sync Mx
Low Risk D/C
Out Patient syncope Mx
ED Syncope Obs Unit:Trained personnel,Cardiac MonitorOBP checksEchoSyncope consult- HUT, CSM,Other specialist
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SyncopeSyncope –– Presentation andPresentation andInvestigation in the Acute settingInvestigation in the Acute setting
• Dx yield increased
• Reduced Hospital admissions
• Reduced Resource Consumption• Reduced Resource Consumption
EGSYS Europ Heart J 2006,EGSYS Europ Heart J 2006,Europace 2006,Europace 2006,
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SyncopeSyncope –– Presentation andPresentation andInvestigation in the Acute settingInvestigation in the Acute setting
• Risk stratification
• Cause Syncope
• Multidisciplinary• Multidisciplinary
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Syncope – Presentation andInvestigation in the Acute setting
TLOC presenting ED
Suspected or Unexplained Dx
Risk Stratification
Init Eval: Hx, Exam, OBP, Blds
Risk Stratification
High Risk/ESC adm guidelines
ED Syncope ObsUnit
In Hospital Sync Mx
Low Risk D/C
Out Patient syncope Mx
ED Syncope Obs Unit:Trained personnel,Cardiac MonitorOBP checksEchoSyncope consult- HUT, CSM,Other specialist
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An approach to the evaluation of syncope for all age groups. ATP test, adenosine
provocation test; CSM, carotid sinus massage; ECHO, echocardiogram; EEG,
electroencephalogram; EP study, electrophysiologic study; ECG, electrocardiogram.
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Syncope – Presentation andInvestigation in the Acute setting
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Management of Long Term Risk:1 Year
STePs
• >65yrs
• Neoplasm Hx• Neoplasm Hx
• Cerebrovascular Disease
• Structural Heart Disease
• Ventricular ArrhythmiaAnn Emerg Med 2007
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SyncopeSyncope –– Presentation andPresentation andInvestigation in the Acute settingInvestigation in the Acute setting
Evaluation of Syncope
Diagnosis
• Not life threatening, QOL, Injury
• Mechanism= Treatment= elimination cause,• Mechanism= Treatment= elimination cause,treat underlying predisposition
• Treatment- relative prognostic significance
Prognosis
• stratify risk of future events- related syncope orunderlying disease