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Dizziness and Syncope (PowerPoint download)

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					Dizziness and Syncope

    Karen E. Hauer, MD
    University of California,
        San Francisco
Dizziness and Syncope:
Outline

   Dizziness: common etiologies
       Case examples
   Syncope
       Diagnosis
       Efficient workup
       Management
Dizziness

   “There can be few physicians so
    dedicated to their art that they do not
    experience a slight decline in spirits
    on learning that their patient’s
    complaint is of giddiness [dizziness]”
                                 WB Matthews, 1975
Etiology of dizziness
   Vertigo                 50%
   Disequilibrium          2%
   Psychiatric             2-16%
   Presyncope              4-14%
   Single etiology         52%
                  Kroenke, Ann Intern Med 1992
                                UpToDate 2005
Case

   A 72 year old woman with hypertension and
    migraine has 2 episodes of sudden onset
    dizziness. She reports “side to side
    movement” lasting several hours, with left
    sided hearing loss, tinnitus, ear fullness,
    unsteadiness. Oscillopsia since.
Case

   A 72 year old woman with hypertension and
    migraine has 2 episodes of sudden onset
    dizziness. She reports “side to side
    movement” lasting several hours, with left
    sided hearing loss, tinnitus, ear fullness,
    unsteadiness. Oscillopsia since.
   Vertigo:
   acute vestibular asymmetry
Central (15%)                  Peripheral (85%)
 Brainstem infarct/ischemia    Benign positional

 Tumor                         Labyrinthitis

    Cerebellopontine angle     Meniere‟s
    Brainstem
                                Otitis media
 Migraine
    Vertigo: history and exam
Central                        Peripheral
 Gradual onset (except         Sudden, severe
  stroke)                       Episodic
 Persistent                    Ear symptoms common
 Neuro findings common         Nystagmus
 Nystagmus any direction -      horizontal/torsional, no
  changes with gaze              change with gaze
 Nystagmus not suppressable    Nystagmus suppressed

 Unable to stand                with fixation
                                Able to stand, lean to
                                 lesion
Anatomy




          American Academy of Otolaryngology/HNS
Dix-Hallpike maneuver: to induce
positional vertigo and nystagmus


                      Benign positional
                       vertigo: #1 cause of
                       peripheral vertigo
                          Episodic symptoms
                          Free floating debris
                           in semicircular
                           canals
Dix-Hallpike maneuver:
diagnostic and therapeutic

            • Positional vertigo:
               •Vertigo/nystagmus reproduced
                 •Latency 5-15 seconds
                 •Decreases w/in 30 seconds
                 •Fatigues on repeat
    Vertigo: when to image?
 Rule out tumor
    1/9307 - dizziness, normal hearing

    1/638 - dizziness, asymmetric hearing loss

 Rule out vascular compromise

           Indications
      New neuro symptoms/signs
            Sudden vertigo & stroke risk factors
            Vertigo & new severe headache
      Test of choice: MRI/ MRA
                                                    Gizzi, Arch Neurol 1996
    Case: unsteadiness
   A 78 year old woman with coronary artery disease,
    type 2 diabetes, cataracts, anxiety and depression
    has chronic dizziness - “unsteady while walking”
   Meds: insulin, lovastatin, atenolol, fludrocortisone,
    prozac
   Neuro exam: slightly wide based gait. DTRs absent in
    ankles. Reduced vibration sense to ankle bilaterally.
    Short of breath with neuro exam maneuvers.
Disequilibrium: often multifactorial
   Sense of imbalance -worse with walking
   Contributing factors
       Vision, hearing impairment
       Peripheral neuropathy
       Musculoskeletal disease/gait disturbance
       Medications
       Dizziness: a geriatric syndrome
24% of community-living elders had dizziness > 1 month

              Risk factor       Relative risk
         Anxiety                    1.69
         Depression                 1.36
         Decreased hearing          1.27
         Impaired balance           1.34
         > 4 meds                   1.30
         Postural hypotension       1.31
         Prior MI                   1.31
                                     Tinetti, Ann Intern Med 2000
Case: “I feel like I’m going to faint”

   A 30 year old woman reports episodes
    of feeling as if she will faint, with
    palpitations and lightheadedness, worse
    when anxious. Three episodes of
    syncope over past 10 years; none
    recently - able to avoid by lying down.
Dizziness: psychiatric etiology

   Young healthy patient
   Symptoms reproduced with
    hyperventilation
       Nystagmus suggests vestibular lesion
   Treat underlying anxiety/depression
Establishing Diagnosis of Syncope
Presyncope & syncope: similar etiologies & workup

Syncope:     sudden transient loss of consciousness
             with loss of postural tone and
             spontaneous recovery

Mechanism: transient hypoperfusion of brainstem or
           both cerebral hemispheres

Differential diagnosis:
              coma
              narcolepsy
              seizure
Syncope: scope of the problem
   Common
       3% Emergency Department visits
       1-6% hospital admissions
   Costly
       Multiple diagnostic tests often performed
            Average charge for each diagnostic test ranges
             from $284 to $4678
                                    Linzer, Ann Intern Med, 1997
    Diagnostic Challenges
   History often unclear
   Prognosis varies widely
      Common etiologies are benign

      Potentially high mortality

          Need to identify high-risk patient early

   Many available tests
   40% of patients may elude diagnosis
   Syncope: management questions
Diagnostic challenges
     What is the best diagnostic test?

     How and when to rule out arrhythmia?

     How to diagnose neurocardiogenic syncope?

     How to decrease the # “idiopathic”?

Management dilemmas
     When to admit?

     How are the elderly different?

     When to resume driving?
Case Presentation
   50 yo healthy woman, standing at church
      Becomes weak, lightheaded, & nauseated

      Collapses, awakens after 1 minute

      Feels well in ED - “I want to go home”

      Normal exam, EKG, labs, CXR

   Diagnosis?
   Plan - Admit? Further testing?
                        Glassman, Arch Intern Med, 1997
    Etiology of Syncope
Idiopathic                                         34%
Neurally-mediated
        Vasovagal                                  18%
         Other (situational, carotid sinus)        6%
Cardiac
        Arrhythmia                                 14%
        Mechanical                                 4%
Neurologic                                         10%
Orthostatic                                        8%
Medications                                        3%
Psychiatric                                        2%
                                         Linzer, Ann Intern Med, 1997
The Key to Diagnostic Evaluation

History and Exam establish diagnosis in 45%
        History: setting, symptoms, medical hx, meds
        Exam: HR, BP, cardiovascular, neurologic
EKG adds 5% diagnostic yield

        Cheap, non-invasive, readily available
        Can indicate important cardiac disease
                Prior MI, ventricular hypertrophy, long QT

                Bradycardia, conduction block

Abnormalities guide further testing
Diagnostic Algorithm

              Syncope


              Noncardiac         Idiopathic
  Cardiac

 Arrhythmia   Neurocardiogenic
 Mechanical   Orthostatic
              Neurologic
              Psychiatric
    Cardiac syncope:
    inadequate cardiac output, arrhythmia
Cardiac enzymes - only if history or EKG suggestive of MI
 – 1-10% MI’s present with syncope
 – EKG up to 100% sensitive for MI
Echo - rule out structural heart disease
 – before stress test if obstruction suspected
 – yield: 5-10%
Exercise stress test - exertional syncope
 – identifies exertional arrhythmia
 – yield: low (1%)
                                Georgeson, J Gen Intern Med, 1992
                                      Linzer, Ann Intern Med, 1997
     Arrhythmia evaluation - telemetry
   Indication: suspected arrhythmia
      palpitations, no prodrome

      Idiopathic syncope or underlying heart disease

   Routine telemetry low yield
      2240 non-ICU telemetry patients

      10% syncope/dizzy

                                         all          syncope
        ICU transfer-arrhythmia          0.8%            0.4%
        Telemetry “Helpful”             12.6%           16%
        Mortality                        0.9%            0
                                  Estrada, Am J Cardiol, 1995
                                      Linzer, Ann Intern Med, 1997
                                       Estrada, Am J Cardiol, 1995
   Arrhythmia evaluation:
   24 hr ambulatory (Holter) monitoring

2612 syncope/dizzy patients
   • Symptomatic arrhythmia = positive result

         • Diagnostic arrhythmia in 4%

   • Symptoms without arrhythmia

         • Arrhythmia ruled out in 15%

Bottom line
   • Benefit: monitors during usual activity

   • Limitation: brief duration limits yield unless daily
     symptoms
                                     Linzer, Ann Intern Med, 1997
Arrhythmia evaluation: improving the yield

–   Loop recorder
     – Indication: recurrent syncope with normal heart

        –   frequent syncope -> continuous loop recorder (weeks)
        –   infrequent syncope -> implantable loop recorder (years)
–   Electrophysiologic study
     – Indication: syncope with organic heart disease

–   Signal average EKG
     – Detects late potential in QRS - substrate for VT/VF

     – indication: normal heart, idiopathic syncope?

                                       Linzer, Ann Intern Med, 1997
                                  Zimetbaum , Ann Intern Med, 1999
                                    Reflexive
      Vasodepressor
                           Micturition
Orthostatic
intolerance

   Neurocardiogenic
       Syncope
     Vasovagal
                         Carotid sinus syncope
   Neurally - mediated
                 Cardioneurogenic
   Neurocardiogenic Syncope
   Clinical Presentation
                        Trigger
May be predominantly
 Cardioinhibitory

    (bradycardia)

 Vasodepressor

    (hypotension) or

 Both                            Syncope
Neurocardiogenic Syncope:
Pathophysiology
        Diagnosing neurocardiogenic
        syncope by history and exam

   Precipitant
       Vasovagal: pain, emotion, standing
       Situational: vagal stimulus
   Autonomic symptoms
   Rapid recovery of mental status
       Bradycardia, pallor may persist
   Carotid sinus massage
       >3 sec asystole or hypotension=hypersensitivity
     Is Laughter Really the
     Best Medicine?
   “A 63-year-old man was referred with a 20-year
    history of syncope preceded by intense laughter.
    We were able to diagnose a gelastic syncope
    (from the Greek „gelos‟, laughter). Laughter-
    related syncope may be induced by the Valsalva
    manoeuvre.
   We advised him not to laugh so hard in the future,
    and when we saw him again, he had been able to
    follow this advice, and had suffered no further
    syncope.”
                                        Braga. Lancet 2005
  Tilt table testing
              • Goal: provoke
                neurocardiogenic syncope

              • Indication: recurrent
                     unexplained syncope
                without cardiac disease

60-80˚        • Protocol: passive tilt 45-60 min
                  • positive response reproduces
                    symptom
Tilt table testing:
why the controversy?
   Accuracy difficult to define
       Gold standard?
       Protocol?
       Reproducibility 71-87%


   Positive tilt test with idiopathic syncope:
       49% with passive tilt
       66% with tilt plus isoproterenol
          Tradeoff: decreased specificity

                                 Kapoor, Am J Med, 1994
Neurocardiogenic syncope: treatment


Indicated for frequent syncope
     Lifestyle modification
        Add salt, avoid triggers

        Handgrip, tense arms and legs


     Medications
        B blocker, SSRI, midodrine, fludrocortisone

        Repeat tilt test on therapy?

     Pacemaker
Vasovagal syncope: pacemakers ineffective

      Randomized double-blind trial
     DDD pacer vs. sensing-only pacer


%
      p = NS




                          Connolly, JAMA 2003
    “Idiopathic” syncope:
    improving diagnostic yield
   Up to 40% patients
       Prognosis good
       Potential morbidity, lifestyle implications
   Consider:
        Diagnosis                  Testing
        Neurocardiogenic           Tilt table
        Anxiety/depression         Psychiatric evaluation
        Arrhythmia                 EPS, implanted event monitor
   Empiric pacemaker?
  Prognosis:
  Framingham 25 year follow up

Etiology of syncope   Adjusted risk of
                          death
Cardiac                    2.01*
Neurologic                 1.54*
Idiopathic                 1.32*
Vasovagal                  1.08

                      *p<0.01
 NEJM 2002;347:878
     Prognosis:
     ED risk stratification

   ED predictors of
    arrhythmia or
    mortality
      Abnormal EKG

      Prior VT/VF

      History of CHF

      Age > 45


     Martin, Ann Emerg Med, 1997
     Prognosis:
     Guideline for admission - the San
     Francisco Syncope Rule
   Prediction rule to identify patients at risk of bad
    outcomes (need admit) over 30 days
      Death, MI, arrhythmia, PE, stroke, transfusion

      Syncope or related event requiring procedure, ED
        visit or admit
   First assess the patient for cause of syncope
   If cause unknown, apply the rule
      98% sensitive

      56% specific

                                       Quinn, Ann Emerg Med, 2006
Prognosis:
Guideline for admission - the San
Francisco Syncope Rule

   CHF - history of
   Hematocrit <30%
   ECG abnormal
   Shortness of breath
   Systolic blood pressure <90 mm
    Hg at triage
                       Quinn, Ann Emerg Med, 2006
ACP Guidelines for Hospital
Admission

Definitely admit             Often admit
 HPI: chest pain             HPI: age >70,
                               exertional syncope,
 PMH: CAD, CHF,
                               frequent syncope
  ventricular arrhythmia
                              Exam: tachycardia,
 Exam: CHF, valve dz,         orthostatic hypotension,
  focal neurologic deficit     injury
 EKG: ischemia/MI,           Cardiac dz suspected

  arrhythmia, bundle
  branch block                 Linzer, Ann Intern Med, 1997
       Guidelines for Hospital Admission:
        implications for practice
   Myth: Every syncope patient should be admitted
   Recommendation: Establish clear goals for admission,
    usually diagnostic

   Myth: Every syncope patient requires “rule out MI”
   Recommendation: Admission not necessary with careful
    history ruling out symptoms of ischemia and normal EKG

   Myth: Telemetry improves outcomes
   Recommendation: One-year mortality rarely affected by 24
    hours of monitoring
Syncope in the elderly:
the geriatric challenge
   History often obscure
      Syncope vs. dizziness vs. fall?

   Often multifactorial - elderly at high risk for

      Situational syncope

      Polypharmacy, adverse drug events

      Cardiac, neurovascular disease

      Decreased physiologic reserve

      Atypical presentation of disease



     Abnormalities do not prove causation
Syncope in the elderly:
a poor prognostic sign




                     Kapoor, Am J Med, 1986
Recommendations for Driving:
following the law
   Laws vary by state - available from DMV
       California law requires reporting of any loss of
        consciousness
          County health officer receives report

          DMV determines fitness to drive


   Physician can provide influential prognostic
    information to DMV
       Physicians’ recommendations variable
       Awareness of law often poor
    American Heart Association
    Guidelines for Driving
   VT/VF (treated with medical or ICD therapy)
       Risk greatest 1st 6 mo, up to 10% at 1 year
       Resume driving: 6 months arrhythmia free
   Bradycardia with syncope
       Resume driving: 1 week after pacemaker
   Neurocardiogenic syncope -> risk stratify
       Mild: presyncope, clear warning & precipitant
          Resume driving: immediately


       Severe: syncope, no warning or precipitant, frequent
          Resume driving: after therapy, waiting period (duration?)
 The Potentially Costly Workup
Test                                Charge*
H&P                                 $160
EKG                                 $90
24-hour Holter                      $468
Loop recorder - 30 day              $284
Electrophysiology study             $4678
Psychiatric evaluation              $150
CT brain                            $888
Echo                                $580
Stress test                         $433
Tilt table test                     $683
        *Average at 4 academic centers, Linzer, 1997
          Trust the Careful History:
          Excess Cost of Vasodepressor Syncope

   30 patients referred for
    “undiagnosed” syncope
      All characteristic
       vasodepressor history

       Mean cost of prior
        testing $3763 - 1991

       Majority had Holter,
        echo, CT
        Calkins, Am J Med, 1993
Case Presentation:
Is typical practice cost effective?
   Hypothetical scenario presented to 916 MDs
      Becomes weak, lightheaded, & nauseated

      Collapses, awakens after 1 minute

      Feels well in ED - “I want to go home”

      Normal exam, EKG, labs, CXR

   Diagnosis?
   Plan - Admit? Further testing?
                           Glassman, Arch Intern Med, 1997
 Cost-effective workup:
 Internists vs. cardiologists

Diagnosis:          vasovagal syncope
Intended plan:      observation +/- overnight tele
Survey results:     aggressive approach

              Cardiologists Internists   YOU
Admit?               79%      72%        ?

Mean #
additional tests    2.7       2.3        ?
                            Glassman, Arch Intern Med, 1997
        Dizziness: key points
   Vertigo is most common etiology
       Positional triggers, nystagmus help confirm
        peripheral etiology
       Neuro findings, stroke risk prompt imaging
   Disequilibrium - commonly due to
    multifactorial deficits in elderly
   Presyncope - manage like syncope
    Syncope: key points
   History, exam, EKG guide further testing
   Identify possible cardiac syncope early
       Admit if high risk of cardiac disease
   Neurocardiogenic syncope - diagnosed
    clinically or by tilt table
   Idiopathic syncope has multiple etiologies
    and good prognosis