Down for the Count! The Evaluation of Syncope by 74Xghe2

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									   Down for the Count!
The Evaluation of Syncope
                   OUTLINE
• Case
• Epidemiology
• Signs and symptoms
• What data help to risk-stratify patients with
  syncope?
• Who should be admitted after a syncopal
  event?
       Case Presentation

• 82-year-old male was found by
  son, unresponsive

• When ambulance arrived, his
  pulse was 70 and BP was
  160/98
           Case Presentation
           82-Year-Old Male
• History: HTN on HCTZ

• Exam: Facial
  contusion, unable to
  move (L) wrist

• ECG: SR, LBBB, VEs

• X-ray: (L) wrist
  fracture
           Case Presentation
           82-Year-Old Male
• What to do?

 1) Holter as outpatient

 2) Echo

 3 ) Admit for EP studies

 4) Admit for 24° monitoring
       Case Presentation
       82-Year-Old Male
• Risk Stratification

  1) High risk for an adverse event

  2) Moderate risk

  3) Low risk
       Case Presentation
       82-Year-Old Male

• Question orthostatic blood pressure

 1) Always check - very useful

 2) Sometimes check - can be useful

 3) Never check - is useless
     SYNCOPE: Definition

• A transient loss of consciousness

• Spontaneous and full recovery

• Loss of postural tone

• No prolonged confusion
“Syncope and sudden death are the
 same, except that in one you wake up”


                      - Anonymous
SYNCOPE: Epidemiology

 • 6% hospital admits
 • Up to 3% ED visits
 • 12-40% of young adults

 • 6% incidence in > 75 y/o
           SYNCOPE: Natural History
               Mortality               Sudden Death
      60
      50
      40
%     30
      20
      10

           0   1   2   3   4   5   0    1     2    3    4       5

                       Year of follow-up
    Cardiogenic
    Undetermined
    Noncardiac                         Kapoor: Medicine, 1990
SYNCOPE: Etiology - Noncardiac

   •   Vasodepressor (1-29%)
   •   Situational (1-8%)
   •   Seizure
   •   Psychogenic
   •   Orthostatic (4-12%)
   •   Drug-induced (2-9%)
   •   Carotid sinus
   •   Neuralgia
   •   Neurologic (TIA, stroke, migraine)
    SYNCOPE: Drug Induced
• N = 70; Syncope Clinic
• 13% probable drug related
• B-blocker         •   Diuretics
• Nitrates          •   Digoxin
• CCB               •   Insulin
• Ace I             •   Drugs of abuse
• Phenothiazines;   •   EtoH
  antidepressants
• Antiarrhythmics
  SYNCOPE: Etiology Cardiac
• Obstruction to flow (3-11%)
  – HOCM, AS, MS, myxoma
  – PS, PE, Pulm HTN
  – MI, tamponade, AD
• Arrhythmias (5-30%)
  – Sick sinus, AV block, pacer
  – VT, SVT
        Age-Dependent Causes of
               Syncope
       Mayo Clinic: 1996-1998 (n=1,291)
<65 years
                                                              65 years
 n=607 3%                                                       n=684
                 17%                              18%
                                        10%
                                                         19%

       43%             24%
                                         23%
                                                        30%
                 13%




 Cardiogenic   Vasovagal     CHS   Undetermined     Other
 SYNCOPE: Signs/Symptoms

• Age
 –Those less than 45 tend to do well
 –Those over 65 are higher risk
 –Ages in between are incremental
 –There is no age cutoff
                      Kapoor, et al: NEJM 309;1983
SYNCOPE: Signs/Symptoms

• Siezure vs. syncope
  – N = 94
  – SZ = 41; No SZ = 53
• Logistic Regression Analysis
  – Siezure Diagnosis – Not a Siezure
     • Frothing          • Sweating,
     • Tongue biting       nausea prior and
     • Disoriented         oriented after event
     • < 45 y/o          • > 45 y/o
    • LOC > 50 min
                          Hoefnagels, et al: J Neurology 238; 1991
  SYNCOPE: Signs/Symptoms
• Tongue-biting
 –106 SZ patients vs. 45 syncope
  patients
 –Sensitivity 24%; specificity 99%
   • Based on 8 patients with
     tongue-biting
                   Benbadis, et al: Arch Int Med 155;1995
    SYNCOPE: Signs/Symptoms
     Feature             Diagnosis
- Postexertional   - Structural heart disease
- 2 minutes of     - Orthostatic
  standing
                   - Cardiac
- No prodrome

- Stress-related   - Vasovagal

- Situational      - Micturition syncope
  SYNCOPE: Signs/Symptoms
• CHF = poor outcome
 – N = 491; 12% with syncope
 – Cardiac syncope; 49% dead 1 year
 – Noncardiac syncope: 39% dead 1 year
 – No syncope; 12% dead 1 year

 – Risk factor for poor outcome in multiple
   studies
                          Middlekauff, et al: JACC 21:1; 1993
     SYNCOPE: Signs/Symptoms
                     Orthostatic hypotension



                              Proceed
                                with
                              Caution!




• Generally defined as drop in systolic BP
  > 20 mmHg on standing
• Present in 40% patients > 70 years
• Present in up to 23% patients < 60
• Reproduction of symptoms may be useful
SYNCOPE: Diagnostic Testing
• ECG - diagnostic  2-12%
• Blood work - low yield, not helpful
• Only lab abnormalities found are those
  expected based on history/PE
• Holter monitoring
• Tilt table
• Electrophysiology studies    Day, et al: Am J Med 73;1982.
  SYNCOPE: Evaluation - ECG
• What to look for:
  –   VT (3 or more beats)
  –   Sinus pause (> 2 seconds)
  –   Bradycardia with symptoms
  –   SVT with symptoms or hypotension
  –   AF slow vent response
  –   2° + 3° AV block
  –   Pacemaker malfunction
                        Martin, et al: Ann Emerg Med 29:4; 1997
Diagnostic Efficacy of 24 Hour
Holter Monitoring for Syncope



               1,512 patients

Syncope/presyncope      Arrhythmia without
 during monitoring          symptoms
       (17%)                  (15%)

    Documented
 arrhythmia (2.1%)              Gibson: AJC 53, 1984
          Tilt Table Testing
             Positive yield
                (pseudo         Specificity     Repro-
             sensitivity (%)   controls (%)   duciblity (%)
Passive tilt      20-75           80-90         60-70

Isoproterenol    40-85            55-80         65-90
  Results of Electrophysiologic
 Testing in Patients with Syncope
        of Unknown Cause
                    Patient Abnormal
Reference            (no.)   EP (%)
Sra et al             86      34
DiMarco et al         25      68
Gulamhusein et al     34      18
Hess et al            32      56
Akhtar et al          30      53
Olshansky et al      105      37
       SYNCOPE: The Dilemma
•   Diagnostic challenge
     – Initial History and Examination, ECG non-diagnostic
        30-60% ED patients

 Diagnostic Studies That Demonstrated the Cause of Syncope
                           n=204
         Study                           % of Patients
History and physical                        25.4
Electrocardiography                          5.8
Electrocardiographic monitoring             14.2
Electrophysiologic studies                   1.4
Cardiac catheterization                      3.4
Cerebral angiography                         0.9
Electroencephalopgraphy                      0.1
Unknown                                     48.1    Kapoor, et al:   NEJM 1983;309:4
         Discord in the
     Evaluation of Syncope




Neurologist       Cardiologist
   SYNCOPE: The Dilemma
• Disposition Challenge
 – Patients often asymptomatic after
   acute event
 – Majority of causes benign
 – Concern of sudden death
SYNCOPE: Risk Stratification
• Identify low-risk patients who
  need minimal testing and have a
  low likelihood of an adverse event

• Identify high-risk patients in
  whom a more aggressive
  approach towards care is
  indicated
SYNCOPE: Risk Stratification

• Syncope patients in ED
  – Derivation N = 252
  – Validation N = 374
  – Data: History, PE, ECG
  – Outcome: Arrhythmias and
    mortality at 1 year
                         Martin, et al: Ann Emerg Med 29;1997
              SYNCOPE
Risk Stratification Mortality at 1 Year
     1.0                                             1.0

     0.9                                             0.9

     0.8                                             0.8

     0.7                                             0.7

     0.6                                             0.6
                                        Derivation
                                        cohort       0.5
     0.5
                                        Validation
     0.4                                cohort       0.4

     0.3                                             0.3

     0.2                                             0.2

     0.1                                             0.1

     0.0                                             0.0
             0     1      2   3 to 4                         0        1         2      3 to 4

  Died within one year of syncopal episode             Strictly defined arrhythmias or died
                                                        of a cardiac cause in the 1st year
      SYNCOPE: Management
• Risk factors: > 45 years, ventricular
  arrhythmia, abnormal ECG, CHF
• Martin, et al
  – 72° cardiac mortality;
    0% with no risk factors
  – 1 year mortality 57% with 3
  – 1 year mortality 80% with 4
ACEP Clinical Policy: Syncope
1. What data help risk stratify?
  Level B:
    • Over 60 years = high risk
    • CHF = high risk
    • Under 45 years = low risk
  Level C:
    • PE, c/w cardiac outflow obstruction =
      high risk
    • Hx c/w vasodepressor etiology = low
      risk
ACEP Clinical Policy: Syncope

Diagnostic testing
 Level B: Obtain 12-lead ECG when
        history, PE indeterminate
             ACEP Clinical Policy:
               Who Should be Admitted

Level B: Admit patients with syncope
and any of the following:
 A history of CHF or ventricular arrhythmias
 Associated chest pain or other symptoms compatible with acute coronary
    syndrome
 Evidence of significant CHF or valvular heat disease on PE
 ECG findings of ischemia, arrhythmia, prolonged QT interval, or bundle
   branch block
           ACEP Clinical Policy:
               Admission
Level C: Consider admission for
patients with syncope and any of the
following:
 Age older than 60 years
 History of coronary artery disease or congenital heart disease
 Family history of unexpected sudden death
 Exertional syncope in younger patinets without an obvious benign
    etiology for the syncope
    Syncope: Summary

• Etiology is often unclear
• Risk stratification is key
• Admit high risk patients
  –Intermediate risk?
• Low risk: Send out

								
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