syncope, sudden death and ekg
TRANSCRIPT
SAQIB RANA03/12/15
SYNCOPE, SUDDEN DEATH and ECG
“symptom complex comprising a brief loss of consciousness associated with an inability to maintain postural tone that resolves spontaneously without medical intervention”
SYNCOPE
CARDIAC REFLEX MEDIATED
NEUROLOGIC UNKNOWN
CAUSES OF SYNCOPE
29 Y/O MALE PRESENTS AFTER A SYNCOPAL EPISODE
Many other names : IHSS, ASH, HOCMCharacteristic anatomic abnormalities - Hypertrophied, non-dilated LV (normal CXR) - Thickened usually prominent in septumFamilial incidence in 55% of casesAverage age at diagnosis is 30-40 yMortality 3.5% per year
Hypertrophic Cardiomyopathy
Pathophysiology (theories) - Inherited abnormality in myocardium’s response to adrenergic stimulation - Abnormal diastolic function - Subaortic obstruction to cardiac flow - Anterior mitral leaflet obstructs LV outflow
Hypertrophic Cardiomyopathy
Clinical features - Syncope, chest pain, palpitations, dyspnoea, sudden death Often associated with exertion (not
always!!!) Attributable to dysrhythmias or sudden
reductions in cardiac output Systolic murmur at apex or LLSB - Increases with valsalva, standing - Decreases with trendelenburg and squatting
Hypertrophic Cardiomyopathy
ECG abnormalities present in 85-93%Definitive diagnosis – DOPPLER ECHO - Doppler helps assess severity of obstruction at rest and with provocative maneuversTreatment - Beta blockers, calcium channel blockers - Amiodarone if ventricular dysrhythmias
Hypertrophic Cardiomyopathy
30 yo woman presents after a syncopal episode
First described in 1992 by Pedro and Josep Brugada
Associated with sudden cardiac deathIndividuals are usually healthy with
structurally normal heartsGenerally considered a hereditary disease
The Brugada Syndrome
Mortality ~ 10% per year if not treated with Internal cardioverter- defibrillator (ICD)
-Anti arrythmics have NO effect on prognosisSyndrome characterized by -ECG abnl in leads V1-V3 - Polymorphic or monomorphic VT - Structurally normal heart - Familial occurrence in ~ half of patients
The Brugada Syndrome
ECG findings in V1-V3 - RBBB or IRBBB pattern - ST segment elevation – 2 types -Coved type (most common) - Saddle type - Findings can vary depending on many factorsDefinitive diagnosis - EPS
The Brugada Syndrome
The Brugada Syndrome
30 yo woman with palpitations, near- syncope
Ventricular pre-excitation - 0.1-3% population - Classic triad . Shortened PR interval . Widened QRS interval . Delta wave
Wolf Parkinson White Syndrome
WPW Syndrome
WPW Syndrome - NSR
WPW with Orthodromic SVT
After Adenosine
WPW with Antidromic SVT
After shock
Atrial Fibrillation with WPW
Atrial fibrillation - Very rapid irregularly irregular tachycardia (rates may approach 300 beats/min) - Often misdiagnosed as SVT, VT or atrial fibrillation with BBB - Misdiagnosis and treatment with AVN blockers can be deadly
Atrial Fibrillation with WPW
ECG appearance - Irregularly irregular tachycardia - Wide QRS complexes - QRS morphologies vary - Rates may approach 300 BPM
Atrial Fibrillation with WPW
40 yo woman presents after syncope vs. seizure
QT interval vary based on rateCorrected QT interval (QTc) based on Bazett
formula How long is too long? - Major risk occurs in patients when QTc >= 500msec - Major concern : Development of Torsade de pointes
Prolonged QT
What do you do with a prolonged QT? - Search for and treat underlying cause - Congenital/ idiopathic: beta blockersTreatment of torsade de pointes - cardiovert/defibrillate - magnesium bolus and infusion - Overdrive pacing rarely needed - Avoid amiodarone, procainamide, lidocaine
Prolonged QT
Hypokalemia (due to U wave)HypomagnesemiaHypocalcemiaSodium-channel blockers (e.g. Type Ia anti –
arrhytmics, TCAs, etc.)Miscellaneous : Elevated ICP, ACS,
hypothermia, hereditary, etc)
Causes of prolonged QT
Acute coronary syndromeTachyarrythmiasBradyarrhtymias and AV blocksHOCMBrugada syndromeWPW syndromeLong QT interval
SYNCOPE
History of heart failure
Abnormal ECG
Hematocrit less than 30
Shortness of breath
SBP <90 in emergency department
SAN FRANCISCO SYNCOPE RULE
Diagnosis established
YES
Serious diagnosis(cardiac, neurologic)
Non serious diagnosis (Reflex
mediated)
NO
UNEXPLAINED SYNCOPE (risk
stratify)
ACEP GIDELINES