Curbside Consult:Syncope

Warren Holshouser, M.D. FACC Cardiac Electrophysiologist

Sanger Heart and Vascular Institutejohn.holshouser@carolinashealthcare.org

• Consulting agreement St Jude Medical

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Disclosures

Objectives—for this talk

• Initial approach for syncope• What are the right (and no so right) tests?• Review treatment for vasovagal syncope• Review some ECGs not to miss

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Two Points• DO NOT assume syncope in the elderly or

patients with structural heart disease is benign.

• Young patients most frequently have benign etiologies for syncope but this population also harbors very dangerous and often undiagnosed etiologies such as long QT syndrome and HCM. They often present to non-cardiologists first.

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Fast Facts

• -Similar incidence in women/men• -Lifetime cumulative incidence>35%• -Bimodal peaks 10-35 then > 70 yo• -Common in office and ED—in ED 30-40% pts admitted• -In most studies —no specific diagnosis made in up to a

third at initial evaluation

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Syncope• IS:• -Loss of consciousness

with accompanying loss of postural tone

• -For cardiac reasons due to cerebral hypo-perfusion– Severe

Bradycardia/asystole– Severe Tachycardia– Hypotension/vasodilata

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• IS NOT:• -Unresponsiveness with

good pulse and BP• -A person still

standing/sitting upright and aware of folks talking—just can’t respond

– -Dizziness– -Not all falls although some

falls are due to syncope

Initial Evaluation• Detailed History

– -What specifically was the patient doing at the time?• -standing, exercise, awakening, fevers/ill

– -Was there a prodrome? Symptoms before AND after?– -Timing of symptoms to syncope?– -Did anyone witness the episode or check a pulse during?– -If EMS called—initial BP and HR?– -History of prior syncopal and NEAR syncopal episodes?– -History of CAD, CHF, LV dysfxn?– -FH of sudden death, drownings, single car accidents?7

Physical Examination

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• Focus on CV system, others important– -Sitting, standing (1min and 3-5mins) HR and BP– -Assess for valvular heart disease—ESP Aortic stenosis—murmur,

carotid upstrokes?– -Signs or sx of CHF– -PAD—increases likelihood of CAD– -Is the patient bradycardic or in atrial fib?– -Sinus tachycardia or neuropathy?

• ECG

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High Risk

• High risk:(ESC/CCS)• -severe structural or CAD, CHF, prior MI, reduced EF• -ECG—Conduction disease, Bifascicular block-(LBBB or RBBB

with hemiblock), IVCD with QRS >/= 120ms, SB<50, pre excitation (WPW), Brugada, neg T waves in right precordial leads

• -Arrhythmia on ECG• -Syncope with exertion, palpitations with syncope, FH SCD<50• -Hypotension

Other tests

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• Echocardiogram• -suspected cardiac disease—HCM, valvular heart

disease or CHF• -should be suggested by history, exam, and ECG

Monitors

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• Holter monitor /Event monitor /ECAT/ Loop recorder• -Holter with limited sampling window of 24-48h but good for

pts with “daily symptoms” • -Event monitor up to 4 weeks so good for pts with

symptoms of some frequency but bad form to document VF

• -ECAT gives continuous information but picks up everything—often non clinical information obtained

• -ECAT very expensive and not paid for my many insurers• -Implantable loop recorders can assist in elusive syncope

with 3 year longevity, remote monitoring but can also record non clinical events, $$$$$$

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Implantable loop recorders

Other tests

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• Exercise testing• -Long QT (fails to shorten), Catecholinergic

Polymorphic VT -(CPVT), ischemia• Tilt table testing

• -when uncertainty regarding vasovagal etiology and a positive test will assist in diagnosis

• -poor sensitivity and specificity• EP testing

• -specific circumstances and not routinely utilized

Less helpful tests

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• Routine carotid ultrasounds in absence of clinical suspicion of CVD

• Routine EEG testing, routine head CT scans in absence of other neurologic symptoms (low yield 2-4%)

• Tilt table testing in the wrong clinical setting due to poor sensitivity and specificity

Case #1

• 34 y.o female with no significant PMH presents to the office after “passing out” at the store. She describes a busy morning then while at the checkout became a bit queasy and weak. She was assisted to the floor and was told that she was “white as a ghost.” Total LOC was a minute or so. No one checked a pulse. She was assisted to a bench at the front of the store, felt better after about 10 minutes and a friend picked her up and took her home. Here to see you.

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• -Normal ECG• -Normal exam• -Additional history reveals history of similar but “milder”

episodes patient has learned to manage with rest, cold water or “breather”

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Case #1

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Case #1• You appropriately make the diagnosis of

Vasovagal syncope

• -Monitoring and tilt table not of additional value here• -Lifestyle modifications and awareness are of most

importance• -MEDS?• -Limited role for pacing in refractory syncope and

prolonged sinus arrest has been documented

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Case #2• 18 yo male college student was home at Christmas break

and presents for evaluation of a “blackout” two weeks ago. There was no alcohol or history of drug/alcohol use around the episode or history of heavy use preceding. He was noted by his roommate to “hit the floor” after waking up that morning and may have had a seizure. He recovered after about 1 minute and felt a little weird for 10-15 mins and then went on his day. He reported that he had “fainted” once when having given plasma for money during his freshman year and one other “blackout” during summer camp in high school.

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• -Syncope due to torsade• -May be exertional (LQTS 1—swimming)• -sudden noise/startle (LQTS 2)• -Normal ECG does NOT exclude—QT can vary but

typically still upper normal. • -Often incorrectly measured• -Upper normal QTc 460

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Long QT syndrome

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Case #3• 75 yo with a history of HTN and type 2 DM presents after “spell” at

home yesterday. Her husband described an episode of fall with unresponsiveness while she was working in the kitchen. The patient has no memory at all and stated there was no warning—only remembered “coming to with my husband standing over me.” She was observed to have just collapsed and went to the floor. He thought she “was dead” and did not check a pulse but after about 3-4 minutes, she came around and then felt fine other than a bruise on the right shoulder. She would not go to hospital but came in today to see you. She reported that she had passed out 30 years ago giving blood but otherwise had “never done this.”

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• -History is still CRUCIAL—these patients can still have non-arrhythmic causes/vasovagal/orthostasis

• -Evaluate for structural heart disease• -Pacing for syncope in bifascular block when other

causes have been excluded is a 2a indication

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Syncope and Bifascicular block

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HCM

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brugada

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brugada

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WPW

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ARVD