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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
