SYNCOPE: PRACTICAL CONSIDERATIONS Nora Goldschlager, M.D. MACP, - - PDF document

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SYNCOPE: PRACTICAL CONSIDERATIONS Nora Goldschlager, M.D. MACP, - - PDF document

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SYNCOPE: PRACTICAL CONSIDERATIONS Nora Goldschlager, M.D. MACP, FACC, FAHA, FHRS Cardiology San Francisco General Hospital UCSF Disclosures: None SCOPE OF THE PROBLEM Cumulative lifetime incidence in general population up to 35 -

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SYNCOPE: PRACTICAL CONSIDERATIONS

Nora Goldschlager, M.D. MACP, FACC, FAHA, FHRS

Cardiology – San Francisco General Hospital UCSF

Disclosures: None SCOPE OF THE PROBLEM

  • Cumulative lifetime incidence in general

population up to 35 - 40%

  • 1% of all hospital admissions
  • 3% of all ER visits; up to 65% are vasovagal
  • 6% incidence in institutionalized elderly
  • Up to 15% incidence in ≥ Class III HF
  • Prevalence: 7 - 47% in young, healthy

subjects; unknown in elderly

  • Up to 40% of patients may have no diagnosis

established at hospital discharge

  • 6% annual mortality if no cause established
  • 12 - 25% recurrence
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Kapoor Medicine 69:1990 N = 433 Sudden death: 37%

Mortality % 50 40 30 20 10 Cardiac Noncardiac Unknown

  • Yr. of FU:

1 2 3 4 5

  • No. at risk: 433

380 349 295 179 44

SURVIVAL IN SYNCOPAL PATIENTS

Follow-up (yr)

Soteriades et al NEJM 2002;347:878 (Framingham) N = 822/7814

5 10 15 20 25 Probability of survival 1.0 .8 .6 .4 .2

No syncope Vasovagal & other causes (OH, med Rx) Unknown cause Neurologic cause Cardiac cause

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YOUNGER ADULTS ELDERLY 15% 15% 40% 30% 30% 25% 15% 30% Vasovagal Undetermined Cardiogenic Other causes OH, situational, seizures, drugs 1°arrhythmia OH, CSS, situational, seizures, drugs 1°arrhythmia, LV obstruction

ETIOLOGY OF FIRST SYNCOPE IN PATIENTS > 65 YEARS

%

  • Reflex-mediated

(VVS, CSS, situational) 13-30%

  • Orthostatic

12

  • Cardiac

Arrhythmic 8 Nonarrhythmic 3

  • Drug-induced

8

  • CNS

6

  • Unexplained

49

Roussanov et al, Am J Geriatric Cardiol 2007;16:249 N=304 (VA patients)

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FEATURES OF UNEXPLAINED SYNCOPE IN OLDER PATIENTS

  • High incidence of comorbid conditions
  • 24% recurrence rate
  • Concurrent BP and HF Rx increases

susceptibility to + HUT

  • Lower diagnostic yield of history and

tests compared in younger patients

Roussanov et al, Am J Geriatric Cardiol 2007;16:249 N=304 (VA patients)

PROGNOSIS IN UNEXPLAINED SYNCOPE IN PATIENTS > 65

Proportion of pts alive 1.0 .75 .50 .25 1 2 3 Yrs FU

Roussanov et al Am J Geriatric Cardiol 2007; 16:249 N = 304 VA pts

Control Syncope

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EVALUATION OF SYNCOPE: PERTINENT HISTORY

  • Precipitating factors
  • Posture changes (orthostatic hypotension)
  • Cough, swallowing, micturition, defecation

(“situational” syncope)

  • Exercise (consider AS, HOCM, VT)
  • Head turning, Valsalva (suggests carotid

sinus syndrome)

  • Prodromal symptoms
  • Speed of onset and recovery (prolonged

recovery suggests vasovagal syncope)

  • Aura (suggests seizure)
  • Hx heart disease (predicts cardiac syncope:

95% specificity; sensitivity <50%)

EVALUATION OF SYNCOPE: PERTINENT HISTORY

  • Drugs
  • Diuretics (

hypokalemia, hypomagnesemia)

  • Digitalis (AVB, VT-classically bidirectional)
  • Antihypertensives
  • Antiarrhythmic agents (proarrhythmia)
  • Antianginal medications (preload and afterload reduction)
  • QT prolonging drugs (www.torsades.org)
  • OTC drugs
  • Herbs
  • Illicit drugs, alcohol
  • β-blockers (including ophthalmic)
  • Family history of sudden death (congenital long

QT syndrome, hypertrophic obstructive cardiomyopathy, Brugada)

  • Known rhythm abnormality (e.g., WPW)
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Exercise-induced RVOT VT

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Deglutition bradycardia

Continuous strips

CLUES TO ETIOLOGY OF SYNCOPE FROM PHYSICAL EXAMINATION

  • LV impulse abnormalities

suggesting ICM, NICM

  • Ventricular hypertrophy (need for

AV synchrony)

  • Ventricular gallops
  • Murmurs (AS, HOCM)
  • Pulmonary hypertension
  • Carotid sinus massage indicating CSH
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  • Generally accepted contraindications
  • Carotid bruits
  • Prior endarterectomy
  • Prior TIA or CVA
  • Known cerebrovascular disease
  • Responses to CSM
  • Bradycardia / asystole usually abrupt
  • Hypotension often not abrupt, and
  • utlasts the CSM
  • Complications (< 1%): TIA, transient

paresis, visual disturbances

CAROTID SINUS MASSAGE CLUES TO ETIOLOGY OF SYNCOPE FROM 12-LEAD ECG

  • Long QT interval
  • Prior MI (substrate for VT)
  • Epsilon wave, anterior (V1-3) T inversion, QRS

duration V1-3 / V4-6 > 1.2, suggesting RV cardiomyopathy

  • Brugada pattern
  • Short QT interval
  • AV conduction delay / block
  • Bifascicular block
  • Ventricular hypertrophy (need for AV synchrony)
  • Early repolarization
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Epsilon wave of RV cardiomyopathy Marcus, Fontaine PACE 6.95

V1 V2 V3

BRUGADA ECG

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BRUGADA SYNDROME ROLE OF ECHOCARDIOGRAPHY IN SYNCOPE

  • Aortic stenosis
  • Hypertrophic cardiomyopathy

(especially obstructive)

  • Regional wall-motion disorders

(substrate for VT)

  • Arrhythmic ventricular cardiomyopathy
  • Intracardiac tumor
  • Repaired congenital heart disease
  • Normal echo
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Syncope in aortic stenosis

Recorded during syncopal spell. BP unobtainable.

Syncope in aortic stenosis

Lead III: During syncopal spell

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SYNCOPE IN HYPERTROPHIC CARDIOMYOPATHY - 1

  • Causes
  • SVT (especially AF)
  • VT
  • LV outflow tract gradient
  • Abnormal baroreceptor reflexes
  • Ischemia
  • EP studies unreliable

SYNCOPE IN HYPERTROPHIC CARDIOMYOPATHY - 2

  • ICD indicated for high risk patients
  • Aborted sudden death
  • Family hx syncope/sudden death
  • LVH > 3 cm
  • Nonsustained VT on Holter
  • Hypotension on exercise testing
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NEUROCARDIOGENIC (VASOVAGAL) SYNCOPE

  • Occurs at all ages
  • 17 - 35% suffer significant injury
  • 5 - 7% have fractures
  • Up to 4% of pts diagnosed with

VVS may have cardiac syncope

FEATURES OF HISTORY IN VVS

  • Usually occurs in upright position
  • Rare during exercise
  • 3 phases: prodrome, loss of

consciousness, postsyncopal period

  • May have specific triggers (situational)
  • Peri-event amnesia common
  • Association with chronic fatigue syndrome,

depression, somatic disorders

  • May run in families
  •  frequency around menses
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NEUROCARDIOGENIC SYNCOPE

 LV volume  Venous return Peripheral venous pooling HEAD UP TILT Peripheral vasodilation Hypotension   adrenergic tone  LV contractility Mechanoreceptor stimulation (myocardial C fibers) Vasomotor center  Vagal tone Bradycardia

  • r asytole
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ISOMETRIC ARM EXERCISE TO ABORT VASOVAGAL SYNCOPE

Control 2 min handgrip

Brignole et al JACC 2002;40:2053 N = 19

Asx 11% Syncope 47% Asx 63% Syncope 5%

HR

112 90 68 45

BP

178 156 133 111 89 67 44

SUSPECTED ARRHYTHMIC SYNCOPE WORKUP

  • ECG
  • Holter (overall yield 2-35%)
  • Event Monitor

(patient cannot be syncopal)

  • Patch monitor
  • Implantable loop recorder
  • Head-up tilt table testing
  • Electrophysiologic study
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PATIENT PRESENTING WITH SYNCOPE AND SEIZURE

INDICATIONS TO REFER SYNCOPAL PT TO ELECTROPHYSIOLOGIST

  • Congenital long QT syndrome
  • Brugada syndrome
  • Structural heart disease
  • Syncope in athletes
  • Syncope during exercise
  • Short QT syndrome