syncope · 2014-11-20 · syncope a symptom, not a diagnosis self-limited loss of consciousness and...
TRANSCRIPT
Syncope Approach
Diagnosis
and Treatment
Robert Satran MD
Transient Loss of Consciousness (TLOC)
Transient Loss of Consciousness (TLOC ) Classification
✓ Syncope
▪ Neurally-mediated reflex
syndromes
▪ Orthostatic hypotension
▪ Cardiac arrhythmias
▪ Structural card iovascular
d isease
Real or Apparent TLOC
Brignole M, et al. Europace, 2004; 6:467-537.
Underly ing Mechanism Is
Transient Global Cerebral Hypoperfusion.
✓ Disorders Mimicking Syncope
▪ With loss of consciousness, i.e.
seizure d isorders, concussion
▪ Without loss of consciousness,
psychogenic “pseudo-syncope”
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
Brignole M, et al. Europace, 2004; 6:467-537.
Etiology ,
Prevalence ,
Impact …
Causes of True Syncope
Orthostatic Cardiac
Arrhythmia
Structural
Cardio-
Pulmonary
✓ VVS
✓ CSS
✓ Situational
▪ Cough
▪ Post-Micturition
✓ Drug-Induced
✓ ANS Failure
▪ Primary
▪ Secondary
✓ Brady
▪ SN Dysfunction
▪ AV Block
✓ Tachy
▪ VT
▪ SVT
✓ Long QT Syndrome
✓ Acute MI
✓ Aortic Stenosis
✓ HCM
✓ Pulmonary HTN
✓ Aortic Dissection
Neurally-
Mediated
Syncope Mimics
✓ Acute intoxication (e.g., alcohol)
✓ Seizures
✓ Sleep d isorders
✓ Somatization d isorder (psychogenic pseudo-syncope)
✓ Trauma/ concussion
✓ Hypoglycemia
✓ Hyperventilation
Brignole M, et al. Europace, 2004; 6:467-537.
Impact of Syncope
1. Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura; 2003:23-27.
2. Kapoor W. Medicine. 1990; 69:160-175.
3. Brignole M, et al. Europace. 2003; 5:293-298.
4. Blanc J-J, et al. Eur Heart J. 2002; 23:815-820.
5. Campbell A, et al. Age and Ageing. 1981; 10:264-270.
Impact of Syncope: US Trends
30
40
50
60
70
80
'96 '97 '98 '99 '00 '01 '02
500
600
700
800
900
Emergency Department Visits* Hospital Outpatient Visits* (000 s)
+
*Syncope and collapse (ICD-9 Code:780.2) listed as primary
reason for visit. NHAMCS 2002.
(000 s(
Quality of Life : UK Population Norms vs. Syncope Patients
Rose M, et al. J Clin Epidemiol. 2000; 53:1209-1216 .
0
13
25
38
50
Mobility
Self-Care
Anxiety/Depression
3 4
1
36
19
26
37
9
49
43
UK Population Norms
Patients with Syncope
%P
reval
ence
Syncope Mortality
✓ Low mortality vs. high
mortality
✓ Neurally-mediated
syncope vs. syncope
with a card iac cause
Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope .
N Engl J Med. 2002;347(12):878-885. [Framingham Study Population]
Syncope and Driving a Vehicle
✓ Those who drive and have recurrent syncope risk their lives
and the lives of others
✓ Places considerable burden
on the physician
✓ Essential to know local laws and physician responsibilities
✓ Some states – Invasion of privacy to notify motor vehicle
department*
✓ Other states – Reporting
is mandatory* If the patient has sufficient warning
of impending syncope Driving may
be permitted
Diagnosis …
Diagnostic Objectives
✓ Distinguish true syncope from syncope mimics
✓ Determine presence of heart d isease
✓ Establish the cause of syncope with
sufficient certainty to:
• Assess prognosis confidently
• Initiate effective preventive treatment
A Diagnostic Plan is Essential
✓ Initial Examination
▪ Detailed patient history
▪ Physical exam
▪ ECG
▪ Supine and upright
blood pressure
✓ Monitoring
▪ Holter
▪ Event
▪ Insertable Loop Recorder (ILR)
✓ Cardiac Imaging
✓ Special Investigations
▪ Head-up tilt test
▪ Hemodynamics
▪ Electrophysiology study
Diagnostic Flow Diagram for TLOC
Initial Exam: Detailed Patient History
✓ Circumstances of recent event
▪ Eyewitness account of event
▪ Symptoms at onset of event
▪ Sequelae
▪ Medications
✓ Circumstances of more remote events
✓ Concomitant d isease, especially card iac
✓ Pertinent family history
▪ Cardiac d isease
▪ Sudden death
▪ Metabolic d isorders
✓ Past medical history
▪ Neurological history
▪ Syncope
Initial Exam: Thorough Physical
✓ Vital signs
▪ Heart rate
▪ Orthostatic blood pressure change
✓ Cardiovascular exam: Is heart d isease present ?
▪ ECG: Long QT, pre-excitation, conduction system d isease
▪ 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
Brignole M, et al. Europace, 2004; 6:467-537.
Carotid Sinus Massage (CSM(
✓ Method 1
▪ Massage, 5-10 seconds
▪ Don’t occlude
▪ Supine and upright posture
(on tilt table)
✓ Outcome
▪ 3 second asystole and/ or 50
mmHg fall in systolic BP with
reproduction of symptoms =
Carotid Sinus Syndrome
✓ Absolute contraindications2
▪ Carotid bruit, known significant carotid
arterial d isease, previous CVA, MI last 3
months
✓ Complications 3
▪ Primarily neurological
▪ Less than 0.2%
▪ Usually transient
1Kenny RA. Heart. 2000; 83:564.
2Linzer M. Ann Intern Med. 1997; 126:989.
3Munro N, et al. J Am Geriatr Soc. 1994; 42:1248-1251.
Other Diagnostic Tests
✓ Ambulatory ECG
▪ Holter monitoring
▪ Event recorder
▪ Intermittent vs. Loop
▪ Insertable Loop Recorder (ILR)
✓ Head-Up Tilt (HUT)
▪ Includes drug provocation (NTG, isoproterenol(
▪ Carotid Sinus Massage (CSM(
✓ Adenosine Triphosphate Test (ATP(
✓ Electrophysiology Study (EPS(
Brignole M, et al. Europace, 2004; 6:467-537.
Diagnostic Assessment: Yields
Yield )%(
Initial Evaluation
History, Physical Exam, ECG, Cardiac Massage
38-40
Other Tests/Procedures
Head-Up Tilt Test 27
External Cardiac Monitoring 5-13
Insertable Loop Recorder (ILR( 43
EP Study <2-5
Exercise Test 0.5
EEG 0.3-0.5
MRI NA
Neurological Tests : Rarely Diagnostic for Syncope
✓ EEG, Head CT, Head
MRI
✓ May help d iagnose
seizure
Brignole M, et al. Europace, 2004; 6:467-537.
Head-Up Tilt Test (HUT(
✓ Protocols vary
✓ Useful as d iagnostic ad junct
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.
Head-Up Tilt Test: ECG Leads and Intra-Arterial Pressure Tracing
2
1
Insertable Loop Recorder (ILR(
Insertable Loop Recorder (ILR(
✓ The ILR is an implantable patient – and automatically – activated
monitoring system that records subcutaneous ECG .
✓ Indicated for:
▪ Patients with clinical syndromes or situations at increased risk of
cardiac arrhythmias
▪ Patients who experience transient symptoms that may suggest a
card iac arrhythmia
Specific Conditions and Treatment …
Specific Conditions ✓ Cardiac arrhythmia
▪ Brady/ Tachy
▪ Long QT syndrome
▪ Torsade de pointes
▪ Brugada
▪ Drug-induced
✓ Structural card io-pulmonary
✓ Neurally-mediated
▪ Vasovagal Syncope (VVS(
▪ Carotid Sinus Syndrome (CSS(
✓ Orthostatic
Cardiac Syncope
✓ Includes card iac arrhythmias and SHD
✓ Often life-threatening
✓ May be warning of critical CV disease
▪ Tachy and brady arrhythmias
▪ Myocard ial ischemia, aortic stenosis, pulmonary hypertension ,
aortic d issection
✓ Assess culprit arrhythmia or structural abnormality aggressively
✓ Initiate treatment promptly
Brignole M, et al. Europace, 2004; 6:467-537.
“Cardiac Syncope …. A Harbinger of Sudden Death .”
✓ Survival with and without syncope
✓ 6- month mortality rate > 10%
✓ Cardiac syncope doubled risk
of death
✓ Includes card iac arrhythmias and
SHD
Soteriades ES, et al. N Engl J Med. 2002; 347:878.
✓ Acute MI/ Ischemia
▪ 2° neural reflex bradycard ia – Vasodilatation,
arrhythmias ,
low output (rare(
✓ Hypertrophic card iomyopathy
▪ Limited output during exertion (increased obstruction,
greater demand), arrhythmias, neural reflex
✓ Acute aortic d issection
▪ Neural reflex mechanism, pericard ial tamponade
Syncope d/t Structural Cardiovascular Disease
Syncope d/t Structural Cardiovascular Disease
✓ Pulmonary embolism/ pulmonary HTN
▪ Neural reflex, inadequate
flow with exertion
✓ Valvular abnormalities
▪ Aortic stenosis – Limited output, neural reflex
d ilation in periphery
▪ Mitral stenosis, atrial myxoma – Obstruction to
adequate flow
Syncope d/t Cardiac Arrhythmias
✓ Bradyarrhythmias ▪ Sinus arrest, exit block
▪ High grade or acute complete AV block
▪ Can be accompanied by vasodilatation (VVS, CSS(
✓ Tachyarrhythmias ▪ Atrial fibrillation/ flu tter with rapid ventricular rate
)eg, pre-excitation syndrome(
▪ Paroxysmal SVT or VT
▪ Torsade de pointes
Brignole M, et al. Europace, 2004; 6:467-537.
ILR Recordings
CASE: 27 year-old man presents to ER
multiple times after falls resulting in
trauma .
VT: Ablated and medicated .
CASE: 83 year-old woman with syncope
due to bradycard ia :
Pacemaker implanted .
Cardiac Rhythms During Unexplained Syncope
Seidl K. Europace. 2000;2(3): 256-262.
Krahn AD. PACE. 2002; 25:37-41 .
No Recurrence 36%
(31-48%)
Normal Sinus Rhythm 31%
(17-44%)
Other 11%
Arrhythmia 21%
(13-32%)
Tachycardia 6%
(2-11%)
Bradycardia 15%
(11-21%)
Long QT Syndromes ✓ Mechanism
▪ Abnormalities of sodium and/ or potassium channels
▪ Susceptibility to polymorphic VT (Torsade de pointes(
✓ Prevalence ▪ Drug-induced forms – Common
▪ Genetic forms – Relatively rare, but increasingly being recognized
▪ “Concealed” forms :
▪ May be common
▪ Provide basis for d rug-induced torsade
Schwartz P, Priori S. In: Z ipes D and Jalife J, eds .
Cardiac Electrophysiology. Saunders; 2004:651-659.
Syncope: Torsade de Pointes
Drug-Induced QT Prolongation
✓ Antiarrhythmics
▪ Class IA ...Quinid ine,
Procainamide, Disopyramide
▪ Class III…Sotalol, Amiodarone
✓ Psychoactive Agents
▪ Phenothiazines, Amitriptyline,
Imipramine, Ziprasidone
✓ Antibiotics
▪ Erythromycin, Pentamidine,
Fluconazole, Ciprofloxacin and its
relatives
✓ Nonsedating antihistamines
▪ Terfenadine*, Astemizole
✓ Others
▪ Cisapride*, Droperidol,
Haloperidol
…List is continuously being updated
Treatment of Long QT ✓ Suspicion and recognition are critical
✓ Emergency treatment
▪ Intravenous magnesium
▪ Pacing to overcome bradycard ia or pauses
▪ Isoproterenol to increase heart rate and shorten repolarization
▪ ICD if prior SCA or strong family history
▪ If d rug induced :
▪ Reverse bradycard ia
▪ Withdraw drug
▪ Avoid ALL long-QT provoking agents
▪ If genetic:
▪ Avoid ALL long-QT provoking agents
✓ For more information visit www.longqt.org
Schwartz P, Priori S. In: Zipes D and Jalife J, eds. Cardiac Electrophysiology. Saunders; 2004:651-659.
Treatment of Syncope Due to Bradyarrhythmia
✓ Class I indication for pacing using dual chamber system
wherever possible
✓ Ventricular pacing in atrial fibrillation with slow
ventricular response
ACC/AHA/NASPE 2002 Guideline
Update. Circ. 2002; 106:2145-2161.
Treatment of Syncope Due to Tachyarrhythmia
✓ Atrial tachyarrhythmia
▪ AVRT due to accessory pathway – Ablate pathway
▪ AVNRT – Ablate AV nodal slow pathway
▪ Atrial fib – Pacing, linear/ focal ablation for paroxysmal AF
▪ Atrial flutter – Ablate the IVC-TV isthmus of the re-entrant circuit
for ‘typical’ flutter
✓ Ventricular tachyarrhythmia
▪ Ventricular tachycard ia – ICD or ablation where appropriate
▪ Torsade de pointes – Withdraw offending drug or implant ICD
(long QT/ Brugada/ short QT)
✓ Drug therapy may be an alternative in many cases
Neurally-Mediated Reflex Syncope
✓ Vasovagal Syncope (VVS)
✓ Carotid Sinus Syndrome (CSS)
✓ Situational syncope
▪ Post-micturition
▪ Cough
▪ Swallow
▪ Defecation
▪ Blood drawing, etc.
Brignole M, et al. Europace, 2004; 6:467-537.
Pathophysiology
Autonomic
Nervous
System
VVS Clinical Pathophysiology
✓ Neurally-mediated physiologic reflex mechanism with
two components:
1 . Cardioinhibitory (↓ HR (
2 . Vasodepressor (↓ BP) despite heart beats, no significant
BP generated
✓ Both components are usually present
Wieling W, et al. In: Benditt D, et al .
The Evaluation and Treatment of Syncope.
Futura. 2003; 11-22.
1 2
VVS Incidence
✓ Most common form of syncope
▪ 8% to 37% (mean 18%) of syncope cases
✓ Depends on population sampled
▪ Young without SHD, ↑ incidence
▪ Older with SHD, ↓ incidence
Linzer M, et al. Ann Intern Med. 1997;126:989.
VVS vs. CSS
✓ In general:
▪ VVS patients younger than CSS patients
▪ Ages range from adolescence to older adults
)median 43 years(
Linzer M, et al. Ann Intern Med. 1997; 126:989.
VVS Recurrences
1Savage D, et al. STROKE. 1985;16:626-29.
2Sheldon R, et al. Circulation. 1996;93:973-81.
• 35% of patients report syncope recurrence during
follow-up ≤3 years1
• Positive HUT with >6 lifetime syncope episodes:
recurrence risk >50% over 2 years2
1000
800
50
100
25
8
4
2
1
1 2 3 6 24 84 480
Months Since Symptoms Began
Two Year Risk
Tota
l N
um
ber
of S
yncopal
Ep
iso
de
s
>75%
50-75%
25-50%
<25%
VVS Diagnosis
✓ History and physical exam, ECG and BP
✓ Head-Up Tilt (HUT) – Protocol :
▪ Fast > 2 hours
▪ ECG and continuous blood pressure, supine, and
upright
▪ Tilt to 70°, 20 minutes
▪ Isoproterenol/ Nitroglycerin if necessary
▪ End point – Loss of consciousness
Benditt D, et al. JACC. 1996; 28:263-275.
Brignole M, et al. Europace, 2004; 6:467-537.
VVS General Treatment Measures
✓ Optimal treatment
strategies for VVS are
a source of debate
✓ Treatment goals
▪ Acute intervention
▪ Physical maneuvers, eg ,
crossing legs or tugging
arms
▪ Lowering head
▪ Lying down
✓ Long-term prevention
▪ Tilt training
▪ Education
▪ Diet, flu ids, salt
▪ Support hose
▪ Drug therapy
▪ Pacing
VVS Tilt Training Protocol
✓ Objectives
▪ Enhance orthostatic tolerance
▪ Diminish excessive autonomic reflex activity
▪ Reduce syncope susceptibility/ recurrences
✓ Technique
▪ Prescribed periods of upright posture against a wall
▪ Start with 3-5 min BID
▪ Increase by 5 min each
week until a duration of
30 min is achieved
Reybrouck T, et al. PACE. 2000;23(4 Pt. 1): 493-498.
VVS Tilt Training: Clinical Outcomes
✓ Treatment of recurrent VVS
✓ Reybrouck, et al.*: Long-term study
▪ 38 patients performed home tilt training
▪ After a period of regular tilt training, 82% remained free of syncope during the
follow-up period
▪ However, at the 43-month follow-up, 29 patients had abandoned the therapy
▪ Conclusion: The abnormal autonomic reflex activity
of VVS can be remedied . Compliance may be an issue.
*Reybrouck T, et al. PACE. 2000; 23:493-498.
VVS Tilt Training: Clinical Outcomes
✓ Foglia-Manzillo, et al.*: Short-term study
▪ 68 patients
– 35 tilt training
– 33 no treatment (control(
▪ Tilt table test conducted after 3 weeks
▪ 19 (59% ) of tilt trained and 18 (60%) of controls had a positive test
▪ Tilt training was not effective in reducing tilt testing positivity rate
▪ Poor compliance in the majority of patients with recurrent VVS
*Foglio-Manzillo G, et al. Europace. 2004; 6:199-204.
VVS Pharmacologic Treatment
✓ Fludrocortisone
✓ Beta-adrenergic blockers
▪ Clinical evidence suggests minimal benefit1
✓ SSRI (Selective Serotonin Re-Uptake Inhibitor(
▪ 1 small controlled trial2
✓ Vasoconstrictors
▪ 1 negative controlled trial (etilefrine)3
▪ 2 positive controlled trials (midodrine)4,5
1Brignole M, et al. Europace, 2004; 6:467-537.
2Di Girolamo E, et al. JACC. 1999; 33:1227-1230.
3Raviele A , et al. Circ. 1999; 99:1452-1457.
4Ward C, et al. Heart. 1998; 79:45-49.
5Perez-Lugones A, et al. J Cardiovasc Electrophysiol .
2001;12(8:)935-938.
Midodrine for VVS
Perez-Lugones A, Schweikert R, Pavia S, et al.
J Cardiovasc Electrophysiol. 2001;12(8):935-938.
Months
p < 0.001
Sym
pto
m-F
ree I
nte
rval
180 160 140 120 100 80 60 40 20 0
100
80
60
40
20
0
Fluid
Midodrine
The Role of Pacing as Therapy for Syncope
✓ VVS with +HUT and card ioinhibitory response:
Class IIb ind ication for pacing
✓ Three randomized , prospective trials reported benefits
of pacing in select VVS patients: ▪ VPS I1
▪ VASIS2
▪ SYDIT3
✓ Subsequent study results less clear ▪ VPS II4
▪ Synpace5
▪ INVASY6
1Connolly SJ. J Am Coll Cardiol. 1999; 33:16-20.
2Sutton R. Circulation. 2000; 102:294-299.
3Ammirati F. Circ. 2001; 104:52-57.
4Connolly S. JAMA. 2003; 289:2224-2229.
5Giada F. PACE . 2003;26:1016 (abstract.)
6Occhetta E, et al. Europace. 2004; 6:538-547.
VPS I )North American Vasovagal Pacemaker Study(
✓ Objective: To evaluate pacemaker therapy for severe
recurrent vasovagal syncope
✓ Randomized , prospective, single center
✓ N=54 patients
▪ 27 : DDD pacemaker with rate drop response
▪ 27 : No pacemaker
✓ Inclusion: Vasodepressor response
✓ Primary outcome: First recurrence of syncope
Connolly SJ. J Am Coll Cardiol. 1999; 33:16-20 .
100
90
80
70
60
50
40
30
20
10
0
0 3 6 9 12 15
Time in Months
No Pacemaker (PM)
P=0.000022
Pacemaker Cum
ula
tive
Ris
k
)%(
Connolly SJ. J Am Coll Cardiol. 1999; 33:16-20 .
Results:
• 6 (22% ) with PM had recurrence vs. 19 (70%) without PM
• 84% RRR (p= 0.000022)
VPS I )North American Vasovagal Pacemaker
Study(
SYNPACE )Vasovagal SYNcope and PACing (
Raviele A, et al. Eur Heart J. 2004;25:1741-1748.
Results: 50% with pacing ON had recurrence vs. 38% with pacing OFF
)not statistically significant(
0.6
0.7
0.8
0.9
1.0
0 200 400 600 800 1000
Pacemaker OFF
%S
yncope-F
ree
p=0.58
0.5
0.4
0.3
0.2
0.1
0.0
Pacemaker ON
Days Since Randomization
CSS Carotid Sinus Syndrome
✓ Syncope clearly associated with carotid sinus stimulation
is
rare (≤1% of syncope (
✓ CSS may be an important cause of unexplained
syncope/ falls
in older ind ividuals
✓ Prevalence higher than previously believed
✓ Carotid Sinus Hypersensitivity (CSH ( ▪ No symptoms
▪ No treatment
Kenny RA, et al. J Am Coll Cardiol. 2001; 38:1491-1496.
Brignole M, et al. Europace. 2004; 6:467-537.
Sutton R. In: Neurally Mediated Syncope: Pathophysiology, Investigation and Treatment .
Blanc JJ, et al. eds. Armonk, NY: Futura; 1996:138.
CSS Etiology
✓ Sensory nerve endings in the carotid sinus walls respond to
deformation
✓ Increased afferent signals to
brain stem
✓ Reflex increase in efferent vagal activity
✓ Decrease of sympathetic tone
✓ BRADYCARDIA AND VASODILATATION
Falls: Incidence, Recurrence, CSH*
1 J Am Geriatr Soc. 1995.
2 Richardson D, et al. PACE. 1997; 20:820.
0
19
38
56
75
Incidence > Age 65 Recurrence CSH* Fallers > Age 50 in ER
30% 1
50% 1
23% 2
*Carotid Sinus Hypersensitivity
Orthostatic Hypotension Etiology
✓ 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, d iet
▪ 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.
Diagnostic Testing in Hospital Strongly Recommended !
✓ Suspected / known ‘significant’ heart d isease
✓ ECG abnormalities suggesting potential life-threatening
arrhythmia
✓ Family history of premature sudden death
✓ Syncope during exercise
✓ Severe injury or accident
Brignole M, et al. Europace. 2004; 6:467-537.
Thank You !