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  • Impact of Syncope Syncope result in substantial cost to patients and to society. For example, syncope patients live with lifestyle altering restrictions that affect daily activities, mobility, and employment. In addition, syncope and falling in the elderly commonly cause injury, institutionalization and premature death. Falls directly or indirectly cause 12% of deaths in geriatric population. (Baraff 1997 ). ____________________ Linzer M, Pontinen M, Gold DT, et al. Impairment of physical and psychological function in recurrent syncope. J Clin Epidemiol. 1991;44:1037-1043 . Linzer M, Gold DT, Pontinen M, et al. Recurrent syncope as a chronic disease: Preliminary validation of a disease-specific measure of functional impairment. J Gen Int Med. 1994;9:181-186 .
  • This slide provides a simple classification of the principal causes of syncope. This scheme lists the causes of syncope from the most commonly observed (Left) to the least common (Right). This ranking may be helpful in thinking about the strategy for evaluating syncope in individual patients . Within the boxes,the most common causes of syncope are indicated for each of the major diagnostic groups. The numbers at the bottom of each column provide an approximate value for the average frequency (Kapoor 1998) with which that category appears in published reports summarizing diagnostic findings. It should be noted that orthostatic causes are not often referred to specialists and consequently tend to be under represented in the literature .
  • The Reveal ® Plus Insertable Loop Recorder system offers long-term, continuous, subcutaneous ECG monitoring and event-specific recording. This implantable device is designed to improve patient compliance with long-term AECG monitoring . The system includes an implanted loop recorder, a hand-held patient Activator, and a programmer with telemetry head that communicates noninvasively with the implanted device . When a patient experiences an episode, the device stores an ECG using the Activator or through the use of a auto-activating feature . The Reveal ® Plus ILR can monitor continuously for up to 14 months. The probability of capturing an event is high—approximately 65-88%. 1,2 The ECG captured during the episode may “reveal” the ECG during the patient’s episode or may allow the clinician to rule in or rule out arrhythmic causes . The stored ECG data is retrieved, viewed, and printed or saved to a disk, using a Medtronic 9790 programmer with a 9766 A or AL programmer head . The Reveal ILR can then be re-started for continued monitoring . 1 . Krahn A, et al. Final results from a pilot study with an insertable loop recorder to determine the etiology of syncope in patients with negative noninvasive and invasive testing. Am J Cardiol, 1998;82:117-119 . 2 . Krahn A, Klein GJ, Yee R, Skanes AC. Randomized assessment of syncope trial. Conventional diagnostic testing versus a prolonged monitoring strategy. Circulation 2001;104:46-51
  • Examples of ECG recordings obtained by the Reveal® ILR system in 2 symptomatic patients. See associated text for details .
  • Results of the initial phase of RAST are summarized here. Among patients randomized to ILR, there appeared to be greater diagnostic yield than in patients randomized to the conventional diagnostic pathway .
  • In RAST, patients who remained undiagnosed after completion of the first arm of the study (see preceding slide) were offered crossover to the other diagnostic strategy arm. Once again, ILR proved superior to the conventional diagnostic strategy
  • Results show patients implanted with the ILR are more likely to receive a diagnosis in any category . The ILR was almost 5 times better at detecting bradycardia compared to conventional testing . Reference Krahn A, Klein GJ, Yee R, Skanes AC. Randomized assessment of syncope trial. Conventional diagnostic testing versus a prolonged monitoring strategy. Circulation 2001;104:46-51
  • Diagnosing VVS VVS is most effectively diagnosed if the detailed medical history is ‘classic’. However, this is not often the case, and supporting evidence is needed, Such supportive evidence may include : Patient history, physical examination, ECG, and other tests provide no diagnosis for patient complaints of syncope . Patient experiences syncope during head-up tilt table testing. Test completion without syncope is a negative result . The following HUT protocol is based on the ACC Consensus Document on tilt table testing (Benditt 1996). Other accepted HUT protocols do exist . Overnight fast, morning test ECG (at least 3 leads ) Continuous blood pressure monitoring Patient remains supine on the table for 15-30 minutes . Tilt to 60-80 degrees for 20-45 minutes . Lower to horizontal and administer isoproterenol at 1-5  g/min until heart rate increases 25% . Re-tilt for 10 minutes REFERENCE : Benditt DG, Ferguson DW, Grubb BP, et al. Tilt table testing for syncope. ACC Expert Consensus Document. JACC. 1996;28(1):263-275 .
  • A yield is defined as information that will point to more finely focused tests, specialties, or treatments . Patient history and physical exam are the most productive diagnostic tools for recurrent syncope, accounting for 49-85% of all syncope diagnoses. 1,2 An ECG, also considered a first-line test, is diagnostic in 2-11% of cases. 2 Beyond that, other tests have variable diagnostic yields. Holter monitors (worn for 1-3 days) capture ECGs during a syncopal episode in only 1% of patients, based on a mean time to recurrent event of 5.1 months. 7 The effectiveness of tilt table tests, a common tool used to identify vasovagal syncope, depends on several factors, including patient selection and use of provocative drugs. Depending on these factors, the rate of positive tests has been reported in the range of 11-87%. 3,5 However, about 10% or more of the population (who do not experience syncope) will have positive tilt table tests. 4,6 External loop recorders (worn for 2-3 weeks) are most productive in motivated patients who experience relatively frequent syncope. They provide a diagnostic yield of 20%. 7 Electrophysiology (EP) studies are generally more productive in patients with structural heart disease (SHD) and therefore are generally a higher priority for patients in this group. 1 EP studies are used to diagnose syncope by inducing symptoms under controlled conditions, thereby attaining a “presumptive” diagnosis. 1 EP testing usually fails to identify intermittent bradycardia as a cause of syncope (6%) and may sometimes reveal unrelated rhythm disturbances that may be mistakenly identified as the cause of syncope. 2 1 . Kapoor W, et al. A prospective evaluation and follow-up of patients with syncope. N Engl J Med 1983;309:197-204 . 2 . Kapoor W. Diagnostic evaluation of syncope. Amer J Med 1991;90:91-106 . 3 . Linzer M, et al. Clinical guideline: Diagnosing syncope: Part 2: Unexplained syncope. Ann Intern Med 1997;127:76-86 . 4 . Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175 . 5 . Kapoor W. Evaluation and management of the patient with syncope. JAMA 1992;268:2553-2560 . 6 . Krahn A, et al. The etiology of syncope in patients with negative tilt table and electrophysiological testing. Circulation 1995;92:1819-1824 . Krahn A, Klein G, Yee R: Recurrent syncope. Experience with an implantable loop recorder. Cardiology Clinics 1997; 15(2):313-326 . 8 . Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8 . 9 . Day S, et al. Am J Med. 1982; 73: 15-23 . 10 . Stetson P, et al. PACE. 1999; 22 (part II): 782 . Please also see : Brignole M, Alboni P, Benditt DG, et al. “Guidelines on Management (Diagnosis and Treatment) of Syncope. Eur Heart Journal 2001; 22: 1256-1306 .


  • 1. Syncope … The Right Test for the Right Patient(Osama Alhadramy MD, FRCP(C * Engel GL. 7th century
  • 2. Objectives Who should be admitted? Who should admit/see the patient in the ER ?(getting the right consult( What is the right test for your patient? Cases
  • 3.  76y M with high lipids ,HTN (HCT 4 /12( Recurrent exersional syncope q 4 days for 2/12 Seen by GP , D/C HCT for postural hypotension without improvement . Exersional SOB for 2 y class I-III Nausea and Diarrhea for 2 weeks Multiple injuries O/E Obese , no CHF, no murmer
  • 4.  84 y M with no health issues First episode witnessed syncope Minimal CP on exertion for months O/E B9, no murmurs -ve CK / Trop
  • 5. ?Are we doing good job WHO**Statistical Information System**
  • 6. Definition Syncope is a transient loss of consciousness, associated with loss of postural tone, with :1. spontaneous return to baseline neurologic function2. requiring no resuscitative efforts .*AHA/ACCF Scientific Statement on the Evaluation of SyncopeJ Am Coll Cardiol 2006;47:473– 84.*EHA statement 2004
  • 7. Impact of Syncope 100% 73% 1 71% 2 80% Proportion of Patients 60% 2 60% 37% 2 40% 20% 0% Anxiety/ Alter Daily Restricted Change Depression Activities Driving EmploymentLinzer, J Clin Epidemiol, 1991.1Linzer, J Gen Int Med, 1994.2
  • 8. Syncope: Etiology Structural Non- Neurally- Cardiac Orthostatic Cardio- Cardio- Mediated Arrhythmia Pulmonary vascular 1 2 3 4 5 • Vasovagal • Drug • Brady • Aortic • Psychogenic • Carotid Induced Sick sinus Stenosis AV block • Metabolic Sinus • ANS • HOCM • Tachy e.g. hyper- • Situational Failure • Pulmonary Cough Primary VT* ventilation SVT Hypertension Post- Secondary • Long QT • PE micturition Syndrome Unknown CauseDG Benditt, UM Cardiac Arrhythmia Center
  • 9. Neurally Mediated Syncope
  • 10. Definitions EHA executive statement EHJ (2004( 25, 2054–2072
  • 11. Famous MCQ in medicine …….. is the best tool to diagnose syncope and to determine the etiology .EPSHistory /PhysicalILRHMTelemetryKings of HeartCTEEG
  • 12. How good is H/P 15 June 1997 • Annals of Internal Medicine
  • 13. Clues in history
  • 14. Associated symptoms Neurally-mediated syncope:1. Absence of cardiac disease2. Long history of syncope (Chronic presentation(3. After unpleasant sight, sound, smell or pain4. Prolonged standing or crowded, hot places5. Nausea, vomiting associated with syncope6. With head rotation, pressure on carotid sinus (as in tumors, shaving, tight collars(
  • 15.  Syncope due to orthostatic hypotension:1. After standing up2. Temporal relationship with start of medication leading to hypotension or changes of dosage3. Presence of autonomic neuropathy or Parkinsonism
  • 16. Things suggestive of seizure Prodrome (aura) Episode of abrupt onset associated with injury Presence of a tonic phase before the onset of rhythmic clonic activity Head deviation or unusual posturing during the episode Tongue biting (particularly involving the lateral aspect of the tongue) Loss of bladder or bowel control Prolonged postictal phase during which the patient is confused and disoriented. .J Am Coll Cardiol 2002 Jul 3;40(1):142-8
  • 17. Are there predictors for ?cardiac syncope
  • 18. Predictors of cardiac syncope all comers Am J Med 2001 Aug 15;111(3(:177-84
  • 19. Predictors in patients with SHD JACC Vol. 37, No. 7, 2001 June 1,2001:1921– 8
  • 20. Patients without SHDJACC Vol. 37, No. 7, 2001 June 1, 2001:1921–8
  • 21. Absence of Pre-syncope The sudden loss of consciousness without warning (pre-syncope( is most likely to result from an arrhythmia (bradycardia or tachycardia(.
  • 22. American Heart Journal 818 Krahn et al May 2001
  • 23. Duration of symptoms A prolonged loss of consciousness may indicate a seizure or aortic stenosis. By comparison, arrhythmias and neurocardiogenic syncope are often associated with a brief period of syncope, since the supine position reestablishes some blood flow to the brain and can therefore result in the restoration of consciousness
  • 24. Recovery Persistence of nausea, pallor, and diaphoresis in addition to a prolonged recovery from the episode suggest a vagal event. Significant neurologic changes or confusion during the recovery period may be due to a stroke or seizure.
  • 25. PHYSICAL EXAMINATION Postural hypotension Irregular heart beats : AF Tachypnea : Massive PE Murmur CNS Rectal exam
  • 26. work up Carotid sinus massage ECG Holter Monitor Implantable loop recorder Echocardiography Stress testing and angiogram Electrophysiological study*ACC/AHA 2006
  • 27. Carotid sinus massageClass I inpatients abovethe age of 40
  • 28. ECG yield 2-10% * Not classified but class I (my guidelines(* Kapoor, Am J Med, 1991.
  • 29. Telemetry Class I1. For patient with structural heart disease2. High risk of life threatening arrhythmias.
  • 30. Holter monitorYield 2-10% Holter Monitor 15 June 1997 • Annals of Internal Medicine
  • 31. Holter Monitor Class I1. patients who have the clinical or ECG features suggesting an arrhythmic cause of syncope.2. Patients with very frequent syncopes
  • 32. ?Is one HM enough
  • 33.  Series of 95 patients with syncope1. 1st HM 14/95 (15%(2. 2nd HM 9/ 81 (11%(3. 3rd HM 3 /72 (4.2%( Arch Intern Med. 1990 May;150(5):1073-8
  • 34. Predictors of abnormal HM1. age above 65 years2. history of heart disease3. initial none sinus rhythm Arch Intern Med. 1990 May;150(5):1073-8
  • 35. (Event recorders (Kings of heart Yield 20% * often do not provide useful information since the patient must be conscious in order to activate the unit and "store" the rhythm at the time of the symptom . .Krahn, Cardiology Clinics, 1997*
  • 36. Implantable loop recorder Yield 65-90% ** (ILR( is a subcutaneous monitoring device for the detection of cardiac arrhythmias. It stores recorded ECG strips either when the device is activated automatically according to programmed criteria or when the patient manually activates it with magnet application Krahn, Circulation, 1995* Krahn, Cardiology Clinics, 1997*
  • 37. Insertable Loop RecorderPatient Activator Reveal® Plus ILR Programmer
  • 38. 56 y woman with syncope accompanied with seizures. AV Block65 yo man with syncope.VT and VF
  • 39. RAST trial Unexplained Syncope n=60 ILR Conventional n=30 n=30In Follow-up Diagnosed Undiagnosed Diagnosed Undiagnosed n=3 n=14 n=13 n=6 n=24 Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.
  • 40. RAST Crossover Results Unexplained Syncope n=60 13/30 24/30 Undiagnosed after monitoring Undiagnosed after conventional 6 accepted crossover to conventional 21 accepted crossover to ILRDiagnosed Undiagnosed Diagnosed Undiagnosed In follow-up n=1 n=5 n=8 n=5 n=8 Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.
  • 41. RAST - Diagnoses 14 12number of patients 10 ILR Conventional 8 6 4 2 0 Bradycardia Tachycardia Vasovagal Seizures Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.
  • 42.  Class I1. When the mechanism of syncope remains unclear after conventional work up.2. Patients who have the clinical or ECG features suggesting an arrhythmic syncope3. History of recurrent syncope with injury.
  • 43. Are there patients who do not need any cardiac ?monitor
  • 44. No need for any monitoring Class III (ECG monitoring is unlikely to be useful( :1. Do not have the clinical or ECG features suggesting an arrhythmic or structural heart disease2. No recurrent syncope( single episode(
  • 45. Can they exclude cardiac causes of ?syncope
  • 46.  Class I ECG monitoring excludes an arrhythmic cause when there is a correlation between syncope and no rhythm variation
  • 47. Echocardiography Diagnoses of underlying structural heart disease such as left ventricular dysfunction, hypertrophic cardiomyopathy, or significant aortic stenosis . Yield 0-20%
  • 48. Heart. 2002 Oct;88(4(:363-7.
  • 49.  CONCLUSIONS: Echocardiography was most useful for assessing the severity of the underlying cardiac disease and for risk stratification in patients with unexplained syncope but with a positive cardiac history or an abnormal ECG
  • 50.  Class I ECHO is recommended if suspect structural or coronary heart disease.
  • 51. Upright tilt table test  Very useful in young, and healthy patients in whom the diagnosis of neurocardiogenic syncope is suspected .  Yield 11-90% ****PACE, Vol. 20 April 1997, Part I 875*Kapoor, JAMA, 1992
  • 52. Diagnosing VVS(ACC Consensus Protocol(  Overnight fast  ECG  Blood pressure  Supine least 5 -20 min  Tilt minimum of 20 min and a 60° 80° maximum of 45 min
  • 53. PACE, Vol. 20 April 1997, Part I 875
  • 54.  Class I1. Unexplained single syncopal episodes in high risk settings2. Recurrent episodes in the absence of organic heart disease3. In the presence of organic heart disease, after cardiac causes of syncope have been excluded.
  • 55. Coronary angiogram / stress testing Class I1. In patients with syncope suspected to be due to myocardial ischemia.2. Patients with syncope and risk factors for CAD and symptoms of angina or angina equivalent.3. Syncope related to exersice
  • 56. Electrophysiology study Patients who may benefit from an EP study include those with:1. Left ventricular dysfunction2. Significant coronary artery disease3. A prior myocardial infarction4. Other structural heart disease5. Conduction system disease (eg, bundle branch block( Yield 50% Stetson P, et al. PACE. 1999; 22 (part II): 782
  • 57.  Class I1. Abnormal electrocardiography2. Structural heart disease3. syncope associated with palpitations or family history of sudden death
  • 58. Can EPS role out cardiac causes of ??syncope
  • 59. Class INormal electrophysiological findings can not completely exclude an arrhythmic cause of syncope.
  • 60. ?What to do then
  • 61. :Further work up(ILR (preferred HMKings of heart
  • 62. BNP148 patients with syncope THE AMERICAN JOURNAL OF CARDIOLOGY VOL. 93 JANUARY 15, 2004
  • 63. ?Who should be admitted Abnormal ECG History of cardiac disease, chest pain or heart failure Persistently low blood pressure (systolic <90 mmHg( Exersional SOB or angina Hematocrit <30 (if obtained( Older age >60 Family history of sudden cardiac death Ann Emerg Med. 2007 Apr;49(4):431-44 Am J Emerg Med. 2005 Oct;23(6):782-6
  • 64. ?Why should we care
  • 65. PrognosisN Engl J Med, Vol. 347, No. 12 September 19, 2002
  • 66. .AHA/ACC 2006 ©
  • 67. Conventional Diagnostic Methods/Yield Test/Procedure Yield History and Physical 49-85% 1, 2 (including carotid sinus massage( ECG 2-11% 2 Electrophysiology Study without SHD* 11% 3 Electrophysiology Study with SHD 49% 3 Tilt Table Test (without SHD) 11-87% 4, 5 Ambulatory ECG Monitors: • Holter 2% 7 • External Loop Recorder 20% 7 (2-3 weeks duration( • Insertable Loop Recorder 65-88% 6, 7 (up to 14 months duration( Neurological † (Head CT Scan, Carotid Doppler( 0-4% 4,5,8,9,101 Kapoor, et al N Eng J Med, 1983. 5 Kapoor, JAMA, 1992 9 Day S, et al. Am J Med. 1982; 73: 15-23.2 Kapoor, Am J Med, 1991. 6 Krahn, Circulation, 1995 10 Stetson P, et al. PACE. 1999; 22 (part II(: 782. * Structural Heart Disease3 Linzer, et al. Ann Int. Med, 1997. 7 Krahn, Cardiology Clinics, 1997. 8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8. † MRI not studied4 Kapoor, Medicine, 1990.
  • 68. Bottom line In young patients without suspicion of heart or neurological disease and recurrent syncope , tilt testing should be done first. Older patients, carotid sinus massage is recommended as first step. Patients with evidence of structural heart disease from H&P , palpitation, extensional symptoms cardiac work up should be done first .
  • 69. ..Back to the cases
  • 70.  76y M with high lipids ,HTN (HCT 4 /12( Recurrent syncope q 4 days for 2/12 Seen by GP , D/C HCT for postural hypotension without improvement . Exersional SOB for 2 y class II Nausea and Diarrhea for 2 weeks Multiple injuries O/E Obese , no CHF, no murmer
  • 71.  Telemetry : no arrhythmia ECHO:EF 40% with segmental RWMA, mild AV sclerosis MIBI: High risk Circ ischemia , EF 45%
  • 72.  84 y M with no health issues First episode witnessed syncope Minimal CP on exertion for months O/E B9, no murmurs -ve CK / Trop
  • 73.  EP : Pace maker ECHO: EF 45-50% with DD D/C home 10 days later came with syncope / fall New ant T changes with Trop 23 , no CP
  • 74. Thanks