syncope – presentation and presentation and investigation in the

SyncopeSyncope –– Presentation andPresentation andInvestigation in the AcuteInvestigation in the Acute

SettingSettingSettingSetting

Professor Rose Anne Kenny, StJames Hospital &Trinity College,

Dublin

DefinitionDefinition-- PresentationPresentation

Syncope is a syndrome consisting of aSyncope is a syndrome consisting of arelativelyrelatively short periodshort period ofof temporarytemporaryandand self limitedself limited loss of consciousnessloss of consciousness

caused by transient reduction in blood flow to thecaused by transient reduction in blood flow to thebrain (most often the result of systemichypotension).

• Transient

• Spontaneous recovery

SynonymsSynonyms - PresentationPresentation

Syncope

• Faint

• Blackout

• Passing out• Passing out

Pre Syncope

• Near faint/ near pass out

• Gray out

• Funny do

Syncope in relation to real and apparent loss of consciousnessSyncope in relation to real and apparent loss of consciousness.

Syncope vs EpilepsySyncope vs Epilepsy

12% ‘tonic clonic like movements’

80% myoclonic

• Brief

• After LOC• After LOC

• Less coarse

• Not tonic clonic (gross flailing, random, contractionof axial muscles different to regular contractions of

epilepsy)

• Video- Mobile phone

Syncope vs TIASyncope vs TIA

• TIA does not cause syncope

• Vertebral Ischemia - rare- neurology

• Transient cerebral disturbances should not beincluded in the differential for Syncope

• Unnecessary Investigations

CausesCauses-- InvestigationInvestigation

• Neurally mediated

• Orthostatic

• Cardiac Arrhythmia• Cardiac Arrhythmia

• Structural Heart Disease

• Cerebrovascular


Neurally MediatedNeurally Mediated• Vasovagal Syncope

• Carotid Sinus Syncope

• Situational FaintAcute haemorrhageAcute haemorrhage

Cough, sneeze,

Gastrointestinal stimulation

Micturition

Post exercise

Other (brass instrument play, weight lifting, postprandial)

• Glossopharyngeal and trigeminal neuralgia


OrthostaticOrthostatic

• Primary Autonomic failure syndromes(PAF, MSA, PD, ? POTS)

• Secondary Autonomic failure• Secondary Autonomic failure

(DM, drugs, Alcohol Amyloid)

• Volume depletion

(Haemorrhage, Diarrhoea, Addison's, ?Age)


Cardiac Arrhythmias as primary causeCardiac Arrhythmias as primary cause

• SND

• AV Conduction

• PSVT, VT• PSVT, VT

• Inherited Syndromes (Long QT, Brugada)

• Implanted device malfunction

• Drug Induced Arrhythmia


Structural Cardiac/CardiopulmonaryStructural Cardiac/Cardiopulmonary• Cardiac Valvular• Acute MI• Obstructive cardiomyopathy• Atrial Myxoma• Atrial Myxoma• Acute Aortic dissection• Pericardial• Pulmonary Embolus/ HypertensionCerebrovascularCerebrovascular• Vascular Steal Syndromes

CausesCauses-- OPD; ED studiesOPD; ED studies

Vasovagal/Carotid Sinus Syndrome 35%

Arrhythmia or Cardiac 10%

Orthostatic Hypotension 25%Orthostatic Hypotension 25%

(Canada, USA, UK, Italy)

EpidemiologyEpidemiology

IncidenceIncidence

• Adults: 6.2 per 1000 person years

• 70-79 : 11 per 1000 person years

• > 80 19 per 1000 person years

Soteriades NEJM 2002

2525 30

2030203020022002

70%70%

Comparison of ages of first syncope in 443 patients with vasovagal syncope and88 patients with syncope of other known cause.

ER 1ER 1--3%,3%, Admissions 6%Admissions 6%

SyncopeSyncope –– Presentation andPresentation andInvestigation in the Acute settingInvestigation in the Acute setting

Admission based on Risk Stratification

• Short Term (7-10)• Short Term (7-10)

• Long term (1 year)

Admission based on Mechanism of Syncopeand its Treatment

Management of ShortTerm Risk:Management of ShortTerm Risk:10 days10 days

1. STePS1. STePS

(ShortTerm Prognosis of Syncope JACC 2008)

• Abnormal ECG,

• trauma,• trauma,

• absence prodrome,

• male,

10 day higher risk death, serious adverse event(CPR, PM, Defib implant, admit ICU)

• positive predictive value 11-14% low no. events

Management of ShortTerm Risk:Management of ShortTerm Risk:10 days10 days

2. San Francisco Syncope Rule2. San Francisco Syncope Rule Ann Emer Med 2006,

• Abnormal ECG,• SOB,• Hct <30%,• SBP<90mmHg,• CCF• CCF 98% sens, 56% spec serious adverse event 7 daysdeath, MI, Arrhythmia, PE, Stroke, SAH, Haem, ED return,

Hospital admission

89% sens, 42% spec external validationAnn Emer Med 2007

Management of ShortTermRisk:Management of ShortTermRisk:10 days10 days

• High Risk important – few days followingindex event

• Deaths, serious outcomes mostly related• Deaths, serious outcomes mostly relatedseverity underlying diseaseunderlying disease > syncope

• Approx 1% death rate1% death rate high risk within 1week presentation

Clinical policy of the American College ofClinical policy of the American College ofEmergency PhysiciansEmergency Physicians

Factors that lead to stratification as HighHighRisk (Hospital Admission)Risk (Hospital Admission)

• Older Age*• Older Age*

• Abnormal ECG (acute ischemia,dysrhythmias, conduction abnormality)

• Hct<30%

• Hx or presence CCF, CAD, structural HD

Ann Emerg Med 2007

Management of Long Term Risk:Management of Long Term Risk:1 Year1 Year

RF Syncope n=252;

• >45 yrs• Abnormal ECG• Hx Ventricular Arrhythmia• Hx CCF• Hx CCF

Valid n=374

1 Year Death or Sign Arrhythmias:0% none, 27% 3 > RFs

Ann Emerg Med 1997


OESILOESIL Europ Heart J2003

Risk Factor %

0 0

1 0.8•>65•Hx CVD 1 0.8

2 19.6

3 34.7

4 57.1

•Hx CVD•No prodrome•Abn ECG


• High Risk important 1 year

• Deaths, serious outcomes mostly related severityunderlying disease > syncope

• death rate depend number risk factors

•• Conclusion:Conclusion: High Risk Patients need close careful F/U,Optimal Treatment and Management

• No evidence immediate hospital admission improveslong term outcome


SEEDSSEEDS ( Syncope Evaluation in the ED)

Syncope Observation Unit in ED

Appropriate resources

Multidisciplinary ApproachMultidisciplinary Approach

Complete Hx, physical exam, ECG, 6htelemetry, 1h vital signs, Orthostatic BP,ECHO (abn CV exam or ECG).

…….HUT, CSM, EPS consult

SEEDSSEEDS

Syncope51

Standard52

p

PresumptiveDiagnosis

67% 10% 0.001

HospitalAdmission

43% 98% 0.001Admission

43% 98% 0.001

Beds Days 140 64 -

Actuarialsurvival

97% 90% ns

Survival freesyncope

88% 89% ns

Shen et al Circulation 2004

Hospital AdmissionHospital AdmissionESCESC Syncope Guidelines

Recommendations

For DiagnosisDiagnosis

Strong RecommendStrong Recommend

• Suspected or known Heart Disease

• ECG suggest Arrhythmia• ECG suggest Arrhythmia

• Syncope during Exercise

• Syncope causing Injury

• Strong Family History Sudden Death


RecommendationsPatients without Heart DiseasePatients without Heart Disease

• Occasionally may need admission

• Sudden onset palpitations before S

• Syncope Supine• Syncope Supine

• Worrisome Family History

• Significant Physical Injury

Patient mild HD but suspicion cardiac syncopePatient mild HD but suspicion cardiac syncope

Suspected PM, defib problemSuspected PM, defib problem


Recommendations

For TreatmentTreatment

• Cardiac Arrhythmias

• Syncope due to Cardiac Ischemia

• Syncope secondary to structural• Syncope secondary to structuralCardiac/Cardiopulmonary Disease

• Stroke focal neurological Disorders

• CI NMS PM planned

MorbidityMorbidity-- VVSVVS

‘Benign’

Driving, Occupation, interpersonal relationships,anxiety, depression, orthopaedic injuries (Linzer 91)anxiety, depression, orthopaedic injuries (Linzer 91)

12% RTA

40% driving restrictions

10% fracture

37% missed 15 days (year) (Connolly RCT 2003)

Morbidity Older PatientsMorbidity Older Patients

• Loss functional Ability- FracturesFractures

• Loss Independence

• Institutionalisation• Institutionalisation

• Cognitive impairment


TLOC presenting ED

Suspected or Unexplained Dx

Risk Stratification

TLOC presenting ED


Risk StratificationRisk Stratification

ED Syncope UnitLow Risk D/C

Out Patient syncope Mx

Risk Stratification

High Risk/ESC adm guidelines

ED Syncope Unit

In Hospital Syncope Mx

Low Risk D/C


Syncope – Presentation andInvestigation in the Acute setting

TLOC presenting ED


Risk Stratification

Init Eval: Hx, Exam, OBP, Blds

Risk Stratification


ED Syncope ObsUnit

In Hospital Sync Mx

Low Risk D/C


ED Syncope Obs Unit:Trained personnel,Cardiac MonitorOBP checksEchoSyncope consult- HUT, CSM,Other specialist


• Dx yield increased

• Reduced Hospital admissions

• Reduced Resource Consumption• Reduced Resource Consumption

EGSYS Europ Heart J 2006,EGSYS Europ Heart J 2006,Europace 2006,Europace 2006,


• Risk stratification

• Cause Syncope

• Multidisciplinary• Multidisciplinary


TLOC presenting ED


Risk Stratification

Init Eval: Hx, Exam, OBP, Blds

Risk Stratification


ED Syncope ObsUnit

In Hospital Sync Mx

Low Risk D/C


ED Syncope Obs Unit:Trained personnel,Cardiac MonitorOBP checksEchoSyncope consult- HUT, CSM,Other specialist

An approach to the evaluation of syncope for all age groups. ATP test, adenosine

provocation test; CSM, carotid sinus massage; ECHO, echocardiogram; EEG,

electroencephalogram; EP study, electrophysiologic study; ECG, electrocardiogram.

Management of Long Term Risk:1 Year

STePs

• >65yrs

• Neoplasm Hx• Neoplasm Hx

• Cerebrovascular Disease

• Structural Heart Disease

• Ventricular ArrhythmiaAnn Emerg Med 2007


Evaluation of Syncope

Diagnosis

• Not life threatening, QOL, Injury

• Mechanism= Treatment= elimination cause,• Mechanism= Treatment= elimination cause,treat underlying predisposition

• Treatment- relative prognostic significance

Prognosis

• stratify risk of future events- related syncope orunderlying disease

syncope – presentation and presentation and investigation in the

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