mini-meds 2009 syncope christopher hillis class of 2009 michael g. degroote school of medicine
TRANSCRIPT
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Syncope – A Symptom, Not a Diagnosis Self-limited loss of consciousness and postural tone Relatively rapid onset Variable warning symptoms Spontaneous, complete, and usually prompt recovery without
medical or surgical intervention
Underlying mechanism is transient global cerebral hypoperfusion.
Underlying mechanism is transient global cerebral hypoperfusion.
Brignole M, et al. Europace, 2004;6:467-537.
Classification of Transient Loss of Consciousness (TLOC)
Syncope Neurally-mediated reflex
syndromes Orthostatic hypotension Cardiac arrhythmias Structural cardiovascular disease
Disorders Mimicking Syncope
With loss of consciousness, i.e., seizure disorders, concussion, stroke
Without loss of consciousness, i.e., psychogenic “pseudo-syncope”;
Brignole M, et al. Europace, 2004;6:467-537.
Mechanisms of Syncope global cerebral hypoperfusion interruption of sympathetic outflow increased vagal tone other mechanisms -edema, cerebral
autoregulation, central serotonin pathways
The Common Faint
the nucleus tractus solitarius of the brainstem is activated directly or indirectly by the triggering stimulus, resulting in simultaneous enhancement of parasympathetic nervous system (vagal) tone and withdrawal of sympathetic nervous system tone.This results in a spectrum of hemodynamic responses
REST & DIGEST beats up FIGHT or FLIGHT
Parasympathetic cardioinhibitory response:
drop in heart rate drop in blood pressure that is significant enough
to result in a loss of consciousness
A Diagnostic Puzzle History
Syncope? Cardiac? Which pattern?
Physical Diagnostic Tests Reassess Repeat
Pepsi Challenge - NEJM 1999 A 72-year-old man with recurrent dizziness, confusion, and syncope
reported that cold, carbonated beverages caused him to feel strange, dizzy, and confused and might have triggered several episodes over a one-year study period. A carotid Doppler study, 24- hour Holter monitor, cranial MRI scan, CT scan, and echocardiogram were unremarkable. An EEG showed diffuse slowing. Phenytoin was given but provided no improvement. Another internist evaluated the patient's condition and ordered a ETT and another MRI scan, which were negative. A cardiologist was consulted, and the results of a tilt-table test and coronary angiography were normal. After this evaluation, the patient drank a carbonated beverage while driving and wrecked his car. The patient was referred to me for further evaluation, and he gave the same history. Because the episodes were initiated reproducibly with cold, carbonated beverages, a can of Pepsi was given to the patient to drink while he was being monitored with an electrocardiograph. Abrupt bradycardia and hypotension developed, along with the patient's usual symptoms. Carotid-sinus massage was negative.
History Circumstances of recent event
Eyewitness account of event Symptoms at onset of event Sequelae - what happened after? Medications
Circumstances of more remote events Concomitant disease, especially cardiac Pertinent family history
Cardiac disease Sudden death Metabolic disorders
Past medical history Neurological history Syncope
History Prodrome Associated symptoms Activity prior to event Position of patient Witnesses Duration; rate of recovery Trauma?
“He went right funny” 70% experience a prodrome
Pallor, diaphoresis Nausea or vomiting Faintness, dizziness Blurring/dimming vision, constriction of visual
fields, paralysis of voluntary lateral gaze, EOM fixed
Yawning, ringing in ears Parasthesias
Stable? Proceed with exam:
Vital signs Heart rate Orthostatic blood pressure change
Cardiovascular exam: Is heart disease present? ECG: Long QT, pre-excitation, conduction system disease Echo: LV function, valve status, HCM
Neurological exam Carotid sinus massage
Perform under clinically appropriate conditions preferably during head-up tilt test
Monitor both ECG and BP
Orthostatic Vitals Recumbent for 5 minutes prior Stand at least 2 minutes Significant changes include
Systolic ↓ 20 mm Hg Diastolic ↓ 10 mm Hg Heart rate ↑ 30 bpm
High false positive rate in elderly (drop but asymptomatic)
Other Diagnostic TestsBlood WorkAmbulatory ECG
Holter monitoring Event recorder
Intermittent vs. Loop
Head-Up Tilt (HUT)Electrophysiology Study (EPS)
Brignole M, et al. Europace, 2004;6:467-537.
Neurological Tests: Rarely Diagnostic for Syncope EEG, Head CT, Head
MRI May help diagnose
seizure
Brignole M, et al. Europace. 2004;6:467-537.
Head-Up Tilt Test (HUT) Protocols vary Useful as diagnostic
adjunct in atypical syncope cases
Useful in teaching patients to recognize prodromal symptoms
Not useful in assessing treatment
Brignole M, et al. Europace. 2004;6:467-537.
60° - 80°
Treatment Scary? REFER!! Urgently or emergently Educate to avoid triggers / postures Removing offending agent Treat cardiac arrhythmia / valve lesion
Case 1* Case 1 (#22): A 23 yo man with GERD and
“blacking out” while swallowing
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA. 2006.
Giada F, Raviele A. Swallow syncope associated with asystole. In: Syncope Cases. Garcia-Civera R, Baron- Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 62.
Case 1
Case 2* Case 2 (#42): A 20 yo man with
lightheadedness and LOC shortly
(5-10 sec) after standing.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA. 2006.
van Dijk N, Harms MPM, Wieling W. Initial orthostatic hypotension as a cause of syncope in an adolescent. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 118
Case 4
Orthostatic Hypotension Etiology Drug-induced (very
common) Diuretics Vasodilators
Primary autonomic failure Multiple system atrophy Parkinson’s Disease Postural Orthostatic
Tachycardia Syndrome (POTS)
Secondary autonomic failure Diabetes Alcohol Amyloid
Brignole M, et al. Europace, 2004;6:467-537.
Treatment Strategies for Orthostatic Intolerance Patient education, injury avoidance Hydration
Fluids, salt, diet Minimize caffeine/alcohol
Sleeping with head of bed elevated Tilt training, leg crossing, arm pull Support hose Drug therapies
Fludrocortisone, midodrine, erythropoietin Tachy-Pacing (probably not useful)
Brignole M, et al. Europace, 2004;6:467-537.
Case 3*
Case 3 (#86): a 48 yo smoker with discomfort and dizziness while driving, and falls to ground after exiting the car (who then drove to the hospital).
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
Sanchez Gonzalez A, Fournier Andray JA, Ballesteros Pradas SM, Diaz de la Llera LS, Villa Gil-Ortega M. Syncope as an isolated manifestation of left main coronary artery occlusion. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 247.
Case 8