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Syncope To Refer or Not

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					                                                                                Definition: Syncope
Syncope: To Refer or Not?


         Kathryn K. Collins MD
      Pediatric Arrhythmia Center
 University of California, San Francisco
                May 2007
                                                                     Sudden and transient loss of consciousness and postural
        Kathryn.collins@ucsf.edu                                      tone with spontaneous recovery.
                                                                     As many as 15% of children experience at least one
                                                      UC SF           syncopal event prior to the end of adolescence.




                 Causes of syncope
                                                                        If it is the cardiac-related,
Syncope in pediatric patients in an ER (n=226)                              what is the problem?
Neurocardiogenic 80%
Neurologic 9%
Cardiac     2%
Psychogenic     3.5%                                                  Simple Faint                              SUDDEN
Breath holding 2%
Intoxication     2%                                                                                             DEATH
Obstructive respiratory disease 0.4%
Hypoglycemia      0.4%
Aplastic crisis during parvovirus infection 0.4%
                                                                       Reminder: patients I will be referring to are otherwise normal
                                                                       and specifically without a history of congenital heart disease
                                           Massin J Pediatr 2004




                                News Release
                                                                          Neurocardiogenic syncope
                                        A Death in the Family
                                        By Glenn Nelson                       (simple fainting)
                                        HoopGurlz
                                          PublisherPosted: Apr 13,
                                          2007
                                        Just before the start of         Cardioinhibitory - predominant bradycardia
                                          the Deep South                  or asystole
             QuickTime™ and a
                                          Classic in Raleigh-
   TIFF (Uncompressed) decompressor
      are needed to see this picture.     Durham, N.C., a rising
                                          young star loses her
                                          life, and the
                                                                         Vasodepressor - predominantly hypotension
                                          teammates she left
                                          behind honor her by
                                          playing - and winning.         Mixed - components of both




                                                                                                                                        1
           Neurally Mediated Syncope                                                       Associations with
                   SYNCOPE
                                                                                       neurocardiogenic syncope
Standing


                                                                                      Prolonged standing
                      Increased vagal tone        Increased sympathetic tone

Blood Pooling                                                                         Hair grooming
                Decreased HR
                                                                                      Pain/fear (venipuncture)
Decreased       Decreased BP
                                  Brainstem
                                                         Increased HR                 Hot temperatures (outside, in shower)
                                                         Increased DBP
                                                                                      Not eating/drinking
venous return
                                                         Stable or decreased SBP



Decreased                      Mechanoreceptors                                       ***prodrome prior to syncope***
stroke volume                  (PA, Ao, Carotid sinus,
                               atria, ventricles)




                         Treatment                                                    Cardiac causes of syncope
           Increase salt and water in the diet
           Avoid caffeine                                                             Cardiac disease accounts for 30-80% of
           Be aware of symptoms
                                                                                       sudden death in the pediatric
                                                                                       population
           If symptoms persist and interfere with everyday
             life, then:
           Florinef                                                                   In these patients, history of prior
           Midodrine                                                                   syncope is a fairly common finding,
           Beta-blocker                                                                particularly exercise-related syncope.
           Pacemaker for cardioinhibitory syncope




            Cardiac causes of syncope
                                                                                       Cardiac causes of syncope
            Cardiomyopathy
              restrictive
              hypertrophic                                                         Primary arrhythmia
              dilated                                                                Long QT syndrome
                                                                                     Brugada
            Structural                                                               Chatecholaminergic ventricular tachycardia
              Post-operative congenital heart disease                                Idiopathic ventricular tachycardia
              Aortic stenosis                                                        Wolff-Parkinson-White syndrome
              Arrhythmogenic right ventricular dysplasia                             Atrioventricular block
              Anomalous coronary artery                                              Atrioventricular reciprocating tachycardia

            Primary pulmonary Hypertension




                                                                                                                                  2
WPW with Atrial Fibrillation              Torsades de point




Hypertrophic cardiomyopathy
                                   Anomalous takeoff of LCA




                                         How to distinguish
    How to distinguish
                               • Story of event
                                  – Appropriate for age?
                                  – Syncope with exercise or stress
    • Family history              – Syncope in a swimming pool
                                  – Syncope without a prodrome
      – Premature death
                                  – Syncope followed by seizure
      – Drowning death            – CPR instituted
      – Unexplained death         – Syncope preceded by palpitations
                                  – Syncope resulting in significant injury

                                  – Seizure - refer to neurologist and cardiologist




                                                                                      3
                                                   Evaluation of patients with
           How to distinguish
                                                            syncope:
• Physical examination
   – Deafness                                      ***Red flags***
   – New murmur                                      – Syncope with exercise
   – Signs of congestive heart failure               – Syncope without a prodrome
   – Irregular rhythm                                – Family history of syncope, sudden
   – Neurologic signs                                  death
   – Any suggestions of neurocutaneous or            – Injury with syncope
     neuromuscular disorders (kearns-Sayre,          – Other cardiac symptoms
     friedreich ataxia)




    Syncope secondary to
                                                          Case 1: don’t refer
 noncardiac vs cardiac causes
                                                   13 year old girl presents to the emergency room
Positive     Noncardiac   Cardiac      P             with a single episode of syncope. She was
Variable      (n=458)     (n=22)     Value           cheerleading at a football game - outside on a
                                                     hot day. She hadn’t eaten anything all day.
Exercise        143         10       0.19            She was standing around after a dance
                                                     routine. She felt hot, tired, lightheaded.
Family Hx       153         9         0.50           She saw spots and then had tunnel vision. The
Exam            38          2         0.09           next thing she remembers is waking up with her
                                                     fellow cheerleaders looking down at her.
EKG             52          16       <0.001
                                                   History: consistent with vasovagal syncope

                          Ritter Pediatrics 2000




            Case 2-4: Refer                                   Case 5: Refer
 6 year old boy passed out while wrestling         10 year old boy has had multiple episodes
   with his brother on 2 occasions.                  of passing out, generally after he fell
  (died from anomalous coronary)                     and hurt himself (while skateboarding).
                                                     Each time, after passing out, he has a
 13 year old girl passed out in mid-stride           brief stiffening and likely seizure
   while running down a basketball court.            activity.
  (diagnosed with HCM)
                                                   (diagnosed with cardioinhibitory syncope
 12 year old girl passed out in the swimming         and was treated with a pacemaker)
   pool. (diagnosed with long QTc)




                                                                                                      4
               Cardiac Evaluation                                                                EKG
                                                                    •   Wolff-Parkinson-White syndrome
      • EKG                                                         •   Long Qtc
      • Holter                                                      •   Ventricular ectopy
      • Event monitors/Implantable loop recorder                    •   Atrioventricular block
      • Echocardiogram                                              •   Ventricular hypertrophy
      • Cardiac MRI                                                 •   Brugada syndrome
      • Exercise stress test                                        •   Ischemia
      • Tilt table test
      • Invasive electrophysiology study                            • EKG: low diagnostic yield
      • Drug challenge (epinephrine for Long QT,                        – (Steinberg 2005; Gordon 1987; Lerman-Sagie 1994)
        procainamide for Brugada)
      • Genetic testing (Long QT)                                   • EKG: Highly sensitive test for heart disease
                                                                        – Ritter 2000; of 480 patients, abnormal history, PE and EKG
                                                                          identified 21/22 patients with cardiac cause of syncope




                 Echocardiogram                                                     Tilt table testing
•   Hypertrophic cardiomyopathy
•   Dilated cardiomyopathy                                          • In children:
•   Restrictive cardiomyopathy
                                                                         – Sensitivity 45%-57%
•   Anomalous coronary artery
                                                                         – Specificity 83%-100%
                                                                    • In young adults:                              QuickTime™ and a
                                                                                                          TIFF (Uncompressed) decompressor
• Echocardiogram:                                                        – Sensitivity 75%                   are needed to see this picture.
   – Ritter 2000; of 480 patients with syncope
                                                                         – Specificity 35%-55%
   – Echocardiograms performed in 322 (67%)
      • 2 cardiomyopathies detected as possible cause of syncope
      • 35 other non-significant findings on echocardiogram - not
        cause of syncope                                                 Reproducibility 67-87%
      • Sensitivity of echocardiography for detecting a cardiac
        cause of syncope = 18%
      • “This study shows little benefit of screening                                                         Sabri 2006; Cohen 2005
        echocardiography”




      New Technology for Evaluation:                                                Cost of Evaluation
          Medtronic Reveal™ implantable loop
                      recorder                                                                                     Review of 169
                                                                                                                     pediatric patients
                                                                                                                     with new syncope;

                                                                                                                   A total of 663 tests
                                                                                                                      performed at a
                                                                                                                      cost/patient of
                                                                                                                      $1055

                                                                                                                   Only 26 tests (4%)
                                                                                                                     were diagnostic in
                                                                                                                     24 patients (14%)

                                                                                                                       Steinberg J
                                                                                                                       Pediatr 2005




                                                                                                                                               5
    Who requires further cardiac
            evaluation:
•   Anyone who worries you
•   Positive family history
•   All syncope with injury
•   All syncope with exercise
•   Abnormal cardiac exam
•   Abnormal ECG




Syncope Evaluation Flow Chart




     Smars, Curr Opinion in Cardiology 2007




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