syncope
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Syncope. Tim Evans July 30, 2014. Syncope Background. Syncope Podcast—Steve Carroll, DO Syncope— Saklani P, Circulation. 2013;127:1330-1339 - PowerPoint PPT PresentationTRANSCRIPT
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SYNCOPE
Tim EvansJuly 30, 2014
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Syncope Background• Syncope Podcast—Steve Carroll, DO• Syncope—Saklani P, Circulation. 2013;127:1330-1339• Clinical Policy: Critical Issues in the Evaluation and Management of
Adult Patients Presenting to the Emergency Department with Syncope—ACEP Clinical Policies Subcommittee, Ann Emerg Med. 2007;49:431-444
• AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, etc, Circulation. 2006;113:316-327
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A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE—Kapoor WN, et al: N Eng J Med 1983; 309: 197-204
• Results• 204 patients evaluated and followed for up to more than one year
—97 patients never found to have an etiology of syncope identified• Tests performed
• Labs in every patient—no cause for syncope found• ECG in every patient—12 causes for syncope found,
• Sinus bradycardia (2) • Complete heart block (3)• Pacemaker malfunction (1)• MI (2)• Sinus pause (1)• V Tach (3)
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A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE• Results (continued)
• Tests performed• Prolonged electrocardiographic monitoring—190 patients, 29 causes for
syncope found• Sinus pauses greater than 2 seconds (8)• Symptomatic sinus bradycardia (1)• V Tach (14)• A fib (2)• Symptomatic SVT (2)• Mobitz II AV block (2)
• Electrophysiologic Studies—23 patients, 3 inducible V Tach patients identified• Cardiac cath—25 patients, 5 with aortic stenosis, 2 with pulmonary
hypertension• Cerebral angiography—11 patients, 2 with subclavian steal• EEG—101 patients, 3 with abnormalities, 1 perhaps causing seizures• CT scan head—65 patients, no cause of syncope found
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A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE• Diagnostic Studies that Determined Cause of Syncope
• H+P—52• ECG—12• ECG monitoring—29• Electrophysiologic studies—3• Cardiac cath—7• Cerebral angiography—2• EEG--1
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A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE
Cardiovascular Cause for Syncope—53 patients
• V Tach—20• Sick Sinus—10• Aortic Stenosis—5• SVT—3• Complete heart block—3• Bradycardia—2• Mobitz II AV block—2• MI—2• Pulm HTN—2• PE—1• Pacer malfunction—1• Carotid Sinus Syncope—1• Aortic Dissection--1
Non-cardiovascular Cause for Syncope—54 patients
• Situational Syncope—15• Orthostatic Syncope—14• Vasodepressor Syncope—10• Drug Induced—6• TIA—3• Seizure—3• Subclavian Steal-2• Conversion--1
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Deaths During the Follow up PeriodCardiovascular cause (N=53)
Non cardiovascular cause (N=54)
Unknown Cause(N=97)
Sudden Death 11 2 3
Non sudden cardiovascular death
2 0 0
Death due to other underlying diseases
3 4 3
Mortality at 12 months
30 12 6.4
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•The only difference between syncope and sudden death is that in one you wake up.
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Detailed Patient history• Circumstance of recent
event• Eyewitness account• What was patient doing at
time of event?• Symptoms at onset of event
—was there a prodrome?• Position during event• Sequelae
• Circumstance of prior events
• Past Medical History• Cardiac• Neurologic
• Family History• Cardiac• Sudden Cardiac Death
• Medications
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Drugs Commonly implicated in Syncope
• Antihypertensives• Beta Blockers• Cardiac glycosides• Diuretics• Antidysrhythmics• Nitrates
• Antipsychotics• Antidepressants• Phenothiazines
Antiparkinsonism
AlcoholCocaine
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Physical Exam• Vital signs• Orthostatic hypotension• Cardiovascular exam—murmurs? Heart failure?• Neurologic exam—focal deficits?• Evidence of trauma?• Carotid Sinus Massage
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Risk Stratification tools for syncope• Bottom Line—no single decision rule is sufficiently
sensitive or specific to use in the ED
• But not useless—provide framework for clinical decision making
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Decision Rules• Martin and Kapoor—history of arrhythmias, abnormal ecg, hx
of chf, age>45• San Francisco Syncope Rule—CHESS-hx chf, hct < 30, ecg
with changes or non-sinus rhythm, sbp<90, sob• Osservatorio Epidemiolgicalao sulla Sincope nel Lazio (OESIL)
—age>65, hx cardiovascular dx, syncope without prodrome, abnormal ecg—if 2 positive increased risk of sudden death
• Risk Stratification of Syncope in ED (ROSE)—bnp>300, brady <50, gi blood, anemia, cp, O2 sat <94—if one positive admit
• Boston Syncope Criteria-signs and symptoms of cad, cardiac hx, persistent abnormal vital signs in ED, volume depletion, conduction abnormalities, valvular heart disease by history or exam
• Evaluation of Guidelines in Syncope Study (EGSYS)—abnormal ecg, heart disease, palpitations before syncope, syncope with effort or supine, no prodrome, no precipitants
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High Risk Criteria• Abnormal ECG—Bundle branch block or ivcd,
bradycardia or 1st degree block in absence of beta blockers or physical training, short PR, short or long QT, ischemia, infarction
• Suspicion of structural heart disease –hx or signs/symptoms of MI, CHF, valvular heart disease
• SOB• Syncope during exertion or with recumbency• SBP < 90• HCT < 30• Family hx of sudden cardiac death—particularly if
under age 50• Advanced age
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Brugada Syndrome
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Wolff Parkinson White
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Syncope--Summary• Do thorough H+P—this is where the diagnosis will be made
• Do an ECG—look for the obvious and the not so obvious—infarcts, abnormal intervals, right heart strain
• Limit labs—HCG in fertile females, not much else• Don’t do CT unless abnormal neuro or looking for traumatic injury
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Is it true syncope? Transient LOC with return to baseline
neurologic function
History, examination, investigation of other
symptoms, ECG
Yes No (e.g.seizure, stroke, head trauma, other)
Appropriate management
Diagnosis established?
Yes No
Syncope with clear cause
Unexplained syncope
Risk stratificationSerious
cause?
Appropriate management; admission
Likely discharge
Cardiac syncope Arrhythmia Myocardial infarction Pericardial effusion Pulmonary embolism Neurologic syncope Subarachnoid hemorrhage Subclavian steal syndrome Transient ischemic attackSignificant hemorrhage GI/GU/Gyn bleed Trauma
Neurocardiogenic/vasovagal Vasomotor syncope Carotid hypersensitivity Situational syncopeMedication relatedOrthostatic hypotension
High-risk Criteria*
Low risk and asymptomatic
Discharge with follow-upAdmission for evaluation and cardiac monitoring*High-risk criteria: Abnormal ECG Suspicion of structural heart
disease, especially a history of CHF
HCT <30 Shortness of breath SBP <90 mmHg Family history of sudden
cardiac death Advanced age****There is no discrete age limit, and other factors such as cardiovascular risk play a greater role; age <45 appears to clearly be low risk if no other factors are present