samuel asirvatham, md & miguel a. gonzalez, md/media/non-clinical/files-pdfs-excel-ms-word...
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Samuel Asirvatham, MD & Miguel A. Gonzalez, MD
Saturday, June 24, 2017
10:25 to 11:10 a.m.
Special
Syncope Guidelines: What’s New?
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Conclusions
• Risk stratification is critical
History, physical examination and simple screening tests
for structural heart disease
• Medical therapy for vasovagal syncope is largely empiric
Beta antagonists, alpha agonists, volume expansion
Role of pacing unclear
• Tilt-testing is useful if it reproduces clinical symptoms
Premature use of tilt test in syncope algorithm is
misleading
• Neurological testing is of little value unless suggested by
history and examination
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Syncope at Mayo Clinic
• 600-1,000 ER patients/year
• 2,000-2,500 outpatient clinic
evaluation/year
• 400 hospital admissions/year
• 30% of electrophysiology practice
500 arrhythmia consults/year
250 EP studies/year
300 tilt table testing/year
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Syncope and Mortality
Kapoor: Medicine, 1990
0
10
20
30
40
50
60
0 1 2 3 4 5 0 1 2 3 4 5
%
Cardiogenic
Undetermined
Noncardiac
Mortality Sudden Death
Years of Follow-up
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Causes of Syncope
• Reflex-mediated
• Orthostatic
hypotension
• Psychiatric
• Neurologic
• Cardiac
• Humorally mediated
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Causes of Syncope
Mayo Clinic: 1996-1998 (n=1,291)
<65 years
n=607
65 years
n=684
Cardiogenic Vasovagal CHS Undetermined
Other
Cardiogenic Vasovagal CHS Undetermined
Other
13%
43%
17%
24%
30%23%
10%18%
19%
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Value of the History and Physical
Examination
Study N Dx by Hx & PE(%)
Dx by ECG(%)
Kapoor 1990 433 32 7Ben-Chetrit 1995 101 33 11Martin 1984 170 53 1Eagle 1983 100 52Silverstein 1982 108 38Day 1982 198 74 2All studies 1100 45 5
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Key Features of History
• Prodromal symptoms
Nausea, diaphoresis, claustrophobia,
palpitations
• Abruptness of onset, offset
Spaghetti vs. celery syncope
• Associated incontinence, seizure activity
Post-ictal confusion, prostration
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Key Features of Examination
• Arterial pressure
Supine, seated, upright, upright after 1-2 mins
Right and left arms
• Precordium
LV aneurysm
RV lift, palpable P2
• Cardiac murmur
Effects of valsalva maneuver, standing,
squatting
Left decubitus position
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Algorithm for Evaluation of Syncope
History, Physical Exam, ECG
Diagnostic
(vasovagal, situational,
orthostatic hypotension)
Trea
t
Suggestive
(AS, PE, seizure
familial SCD)
Specific
tests
Trea
t
Unexplained syncope
-
+
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Algorithm for Evaluation of Syncope
Unexplained Syncope
Organic heart disease
(abnormal ECG, exertional
symptoms, abrupt syncope)
Age> 60 y No suspected heart disease
Evaluate OHD
Arrhythmia
Screen
CSM
+ -
Evaluate OHD
+ -
Arrhythmia
Screen
First
episode
Observe
Infrequent
Tilt test,
psych eval
Frequent
Loop monitor,
tilt test,
psych eval
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Screening for Arrhythmias
• Ambulatory ECG
• Loop recorder
Continuous (King of
Hearts)
Heart Card
Implantable recorder
• Electrophysiologic testing
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24 Hour Ambulatory ECG Yield
Syncope/presyncope
during monitoring
(17%)
Arrhythmia without
symptoms
(15%)
1,512 patients
Documented
arrhythmia (2.1%)
Gibson: AJC 53, 1984
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Transmission (49%)
Arrhythmias (35%) No arrhythmias (14%)
526 patients
Palpitations/syncope/presyncope
Shen: Mayo Clinic Proc, 1987
External Loop Recorder Yield
No transmission (51%)
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Implantable Loop Recorder
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Implantable Loop Recorder
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ILR: Rhythm at time of symptoms
Tachycardia3
Bradycardia18
Sinus rhythm29
Failedactivation
8
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ILR: Etiology of Syncope
Tachycardia3
Bradycardia18
Neurallymediated
7
Nonarrhythmic27
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Yield of EP study
8 studies, 625 patients with syncope
0
25
50
75
100
All patients Pts. With VT Pts. with
bradycardia
Perc
en
t E
PS
+
OHD+ N = 406
OHD- N = 219
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Yield of Neurologic Testing in Syncope
• In patients unselected by history or physical
exam for evidence of neurologic disease, yield of
EEG, cranial imaging, & neurovascular studies is
< 2%
• Carotid disease causes syncope only with high
grade stenosis and contralateral carotid
occlusion
Bruits usually present
• Associated diplopia, paresis, intractable nausea
suggest vertebrobasilar insufficiency
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Transient Loss of Consciousness &
Cerebral Ischemic Events
Ischemic 6.5 Basilar 1.5
Embolic 13.2 Carotid 0
Stroke TIA
Bousser: Ann Med Intern, 1981
Incidence of Syncope (%)
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Tilt Testing
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Tilt Induced Vasovagal Response
Baseline BP 136/67 mmHg
HR = 115 bpm
Baseline Tilt
BP 54/30 mmHg
HR = 39 bpm
Vasovagal response
BP 47/29 mmHg
PCL = 700 msec
A-V pacing CL = 700 ms
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Tilt Testing in Syncope
Technical Issues
Tilt angle 60-80° acceptable70° most common
Tilt duration 30-45 minData support a 45 min protocol
Drug Provocation Isoproterenol, NTG, edrophonium
ACC Expert Consensus Conference JACC 1996
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Tilt Testing in Syncope
Positive yield
(pseudo Specificity Reproducibility
sensitivity) controls
(%) (%) (%)
Passive tilt 20-75 80-90 60-70
Isoproterenol 40-85 55-80 65-90
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• Negative responses are more reproducible than positive
• Interpretation of positive response relies on similarity of
spontaneous and provoked symptoms
• Serial testing for drug efficacy not useful
• Positive response should not halt further evaluation in
patients with structural heart disease
Tilt Testing in Syncope: Caveats
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Treatment of Vasovagal Syncope
• Mechanisms poorly understood
• Few randomized blinded drug trials
Small trials with atenolol and paroxetine
• Spontaneous resolution makes many
treatments
appear effective
• Conflicting data regarding pacing
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Efficacy of Beta-Blockade in VVS
Pt Efficacy Pt Recur Pt Recur Pt Re
cur
Oral drug (no.) (%) (no.) (%) (no.)
(%) (no.) (%)
Atenolol 98 91 71 11 10 40 7 14
Propranolol 33 100 28 7 5 60 2 50
Metoprolol 22 100 16 0 4 25 3 33
Nadalol 4 100 3 67 0 0 1 0
Total 157 94 118 10 19 42 13 23
Repeat tilt
Continued
tilt-proven
drug
Discontinued
tilt-proven
drugReceived
empiric Rx
Cox: JACC, 1995
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Efficacy of Atenolol in VVS
• Randomized, double-blinded, placebo-controlled
study
• Inclusion:
• 50 patients
• At least 2 episodes VVS in past year
• Tilt test followed by IV atenolol
• Placebo (N=24) or atenolol 50 mg / day(N=26)
• End-point: time to recurrence of syncope
Madrid: JACC, 2001
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Efficacy of Atenolol in VVS
• Tilt test positive in 20 patients
• IV atenolol prevented another positive tilt-test
in 5
• One year follow-up:
• Median # of syncopal spells 2 (atenolol), 0
(placebo)
• Median time to recurrence 7 months w/ no
difference between groups
• Conclusion:
• Recurrence rate drops in both groups
• No effect of atenolol provedMadrid: JACC, 2001
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North American Vasosvagal Pacing Study
(VPS)
• Six or more lifetime episodes of syncope
• Tilt test induces syncope/presyncope
Relative bradycardia
• Randomized to rate-drop pacemaker
• 54 patients enrolled
• Endpoint: time to first recurrence of syncope
JACC 1999;33:16-20
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VPS: Results
• 27 patients randomized to pacer/27 to
observation
7% beta-blocker use in both groups
• Time from randomization to syncope
No pacer - 54 days
Pacer - 112 days
• No effect on presyncope
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VPS: Problems
• Non paced group received little medical therapy
• Placebo effect of pacer implant not assessed
• No data regarding frequency of rate-drop pacing and
correlation with abortive symptoms
• Possible type II statistical error due to small sample size
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Conclusions
• Risk stratification is critical
History, physical examination and simple screening tests
for structural heart disease
• Medical therapy for vasovagal syncope is largely empiric
Beta antagonists, alpha agonists, volume expansion
Role of pacing unclear
• Tilt-testing is useful if it reproduces clinical symptoms
Premature use of tilt test in syncope algorithm is
misleading
• Neurological testing is of little value unless suggested by
history and examination
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Those who suffer from frequent and
severe fainting often die suddenly.
Hippocrates 1000
BC
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Syncope: Case Study # 1
• 25 year old female
• Flurry of syncopal spells ages 9 and
14
• Restricted from high school sports
• 4 episodes as a high school senior
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Syncope: Case Study # 1
• June 1996
Witnessed syncope
Impaired consciousness X 5
minutes
No incontinence
Possible retrograde amnesia
• July/ August 1998
Syncope X4 at home
No premonitory symptoms/aura
Retrograde amnesia
No incontinence
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Syncope: Case Study # 1
• Past Medical History
Asthma
Closed head injury age 3
• Family history
Premature CAD
No family history of SCD, syncope,
seizures
• Examination
BP 100/78, pulse 64 seated
BP 100/54, pulse 72 standing
Exam otherwise normal
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Syncope: Case Study # 1
• ECG entirely normal
• Echocardiogram entirely normal
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• 1) Head up tilt test
• 2) EP study
• 3) Neurological evaluation
• 4) Loop recorder
Syncope: Case Study # 1Next Diagnostic Step?
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• With isoproterenol, 70 degrees, presyncope at 3
min
• Provoked symptoms unlike spontaneous
episodes
Syncope: Case Study # 1Head up tilt test
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• 1) EP study
• 2) Neurological evaluation
• 3) Loop recorder
• 4) Treat for vasovagal
syncope and observe
Syncope: Case Study # 1Next Diagnostic/Therapeutic Step?
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• Dual retrograde pathways without
SVT
Syncope: Case Study # 1Electrophysiologic Study
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• Examination normal
• EEG sleep and awake-normal
• MRI normal
• Impression-seizure unlikely
Syncope: Case Study # 1Neurology evaluation
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• Implantable loop recorder placed
• 3 episodes syncope/presyncope
• Device activated by relative after syncopal
spell
Syncope: Case Study # 1Loop recorder
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Syncope: Case Study # 1R-R Intervals at time of syncope
300
350
400
450
500
550
600
650
700
750
-24 -21 -18 -15 -12 -9 -6 -3 0 3 6 9 12 15 18 21 24
R-R interval number
R-R
in
terv
al
(msec)
Activation point
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Syncope: Case Study # 1Inpatient observation on epilepsy
monitoring unit
• Syncope and presyncope observed
• EEG normal
• Hypotension without bradycardia
documented
• Dismissed on fludrocortisone
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Syncope: Case Study #2
• 78 year old male
• 4 episodes syncope in 4 years
1992- Walking in AM, no bkfst, turned head brief
LOC
1993- Standing cooking, rushing in head, brief
LOC
1995- Kneeling in church, no bkfst, rushing in
head, brief LOC
1996-Standing in kitchen, rushing in head, brief
LOC
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Syncope: Case Study #2Medical History
• PMH
Borderline hypertension
Possible Meniere’s disease
• Family history
No SCD/syncope or CAD
• Medication
Nadolol 10 mg/d
Meclizine 37.5 mg/d
• Coronary Risk Factors
Gender, hypertension
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Syncope: Case Study #2
Examination
• Weight 218 lbs
• BP 160/104 R & L, pulse 70 and regular
• Hear, lung vascular, neurological exams
normal
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Syncope: Case Study #2Prior Evaluation
• Chest X ray- LV enlargement
• EKG - Voltage criteria for LVH; one PVC
• Chemistries, CBC, sTSH, UA - normal
• ENT evaluation - no evidence Meniere’s
• Sleep study - suggestive of sleep apnea
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Syncope: Case Study #2Next Diagnostic Step ?
• 1) Head up tilt test
• 2) Loop recorder
• 3)Electrophysiologic
study
• 4) Neurological
evalaution
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Syncope: Case Study #2Head-up tilt test (outside)
• 80 degrees head-up isoproterenol 5 mcg/min
• BP 140 to 90 systolic
• No change in pulse
• Symptoms somewhat similar to spontaneous
episodes
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Syncope: Case Study #2Head-up tilt test (Mayo)
• Normal response to CSM
• 70 degrees head-up, isoproterenol 3 mcg/min
• At 20 min BP fell to 70/40, sinus rate fell to 60
bpm
• Symptoms somewhat similar to spontaneous
episodes
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Syncope: Case Study #2Next Diagnostic/Therapeutic Step ?
• 1) Electrophysiologic study
• 2) Neurological evaluation
• 3) Increase nadolol dose
• 4) Loop recorder
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Syncope: Case Study #2Loop recorder
• Dizzy and lightheaded, but no
syncope/presyncope
• Single PVC detected on strip
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Syncope: Case Study #2Next Diagnostic/Therapeutic Step ?
• 1) Electrophysiologic
study
• 2) Neurological evaluation
• 3) Psychiatric evaluation
• 4) Implantable loop
recorder
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Syncope: Case Study #2Electrophysiologic study
• Transthoracic echo prior to EP study
Inferolateral hypokinesis
Ejection fraction 45 %
• Ventricular tachycardia reproducibly
induced
2 extrastimuli, drive cycle 400, RVA
RBBB NAX CL 230
• VT suppressed with sotalol
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Syncope: Case Study #3
• 68 year old female
• 7 year history of spells
30-60 min lightheadedness
Intermittent syncope
Nausea, vomiting, diarrhea,
palpitations
• Well between episodes
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Syncope: Case Study #3 Medical History
• Cholecystectomy, appendectomy,
tonsillectomy
• Family History
Mother - breast cancer
Brother - myocardial infarction
Sister - valvular heart disease
• Medication - estrogen, Ca suppl, ASA 325/d
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Syncope: Case Study #3 Examination
• BP 110/60 R & L without orthostatic
change
• ENT - nl
• CV - nl
• Skin - no rash
• Abd - nl
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Syncope: Case Study #3 Laboratories
• ECG - ventricular paced rhythm
• CXR - normal pacer lead position
• Echocardiogram - normal chamber
sizes
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Syncope: Case Study #3 Prior Evaluation and Treatment
• 1990 - Coronary angiography normal
• 1993 - EP study and attempted ablation of
atrial tachycardia focus “near sinus node”
• 1995 - AV node ablation and pacer implant
recurrent spell in hospital after
procedure
• Consultations
Neurology - ? Seizures
Gastroenterology - ? Eating epilepsy
Cardiology - ? Postprandial hypotension
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Syncope: Case Study #3
Next Diagnostic/Therapeutic Step
?
• 1) Psychiatry
evaluation
• 2) Urinary
metanephrines
• 3) Urinary 5 HIAA
• 4) Bone marrow
biopsy
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Syncope: Case Study #3
• Bone marrow biopsy - perivascular
infiltrates of tryptase positive cells
• Serum tryptase 28 ng/ml
• Diagnosis: systemic mastocytosis
• Treatment: antihistamines and aspirin
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Syncope: Case Study #3
• Lessons
Wacky symptoms in non-wacky patient warrant
exhaustive search
If all the usual suspects are innocent, round up
the unusual ones
Zebras are mostly in other countries and zoos,
but only mostly
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Samuel Asirvatham, MD & Miguel A. Gonzalez, MD
Saturday, June 24, 2017
10:25 to 11:10 a.m.
Special
Syncope Guidelines: What’s New?