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Fainting: Causes and Ways to Minimize Risk
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Fainting: Causes and Ways to Minimize Risk

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Fainting may cause physical injury, lead to hospitalization and be a sign of an underlying cardiac disorder. Our cardiac electrophysiologist will review the causes of fainting, tell who's at risk, and …

Fainting may cause physical injury, lead to hospitalization and be a sign of an underlying cardiac disorder. Our cardiac electrophysiologist will review the causes of fainting, tell who's at risk, and discuss methods to minimize the chances of fainting. Presentation by Summit Medical Group Cardiologist Roy Sauberman, MD FACC

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  • Transient Loss of Consciousness, or TLOC, is just that—as is illustrated here. It can be as simple as a benign ‘faint’ or a symptom of an underlying disease that may lead to sudden death. Or it may not be syncope at all.
  • 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. VVS—Vasovagal Syncope CSS—Carotid Sinus Syndrome ANS—Autonomic Nervous System HCM—Hypertrophic Cardiomyopathy
  • 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. VVS—Vasovagal Syncope CSS—Carotid Sinus Syndrome ANS—Autonomic Nervous System HCM—Hypertrophic Cardiomyopathy
  • WPW—Wolff Parkinson White syndrome HCM—Hypertrophic Cardiomyopathy
  • Carotid sinus massage (CSM) is an often overlooked, yet highly cost effective test, especially in older syncope patients. CSM must be applied with care, and the method described here has proven both safe and effective. Note that an abnormal response to CSM (i.e., Carotid Sinus Hypersensitivity, CSH) is not diagnostic of Carotid Sinus Syndrome (CSS). Reproduction of symptoms is a crucial diagnostic element. To achieve symptom reproduction, it may be useful to conduct CSM with the patient in the upright posture. If the latter is to be done, the patient should be safely secured to a tilt-table in order to prevent injury from a fall. Note: May perform during tilt-table test. *Munro N, McIntosh S, Lawson J, et al. Incidence of complications after carotid sinus massage in older patients with syncope. J Am Geriatr Soc . 1994;42:1248-1251.

Transcript

  • 1. FAINTING Causes and Ways to Minimize Risk Roy Sauberman, MD FACC Summit Medical Group
  • 2.
    • “ Transient loss of consciousness and postural tone with spontaneous recovery”
    Wayne HH: Am J Med 1961;30:418-38
  • 3.
    • loss of consciousness
      • relatively sudden
      • temporary
      • self-terminating
      • usually rapid recovery
    • due to inadequate cerebral perfusion
    • most often triggered by fall in blood pressure
  • 4. People faint for many reasons
    • Standing up too fast
    • Exhaustion
    • Emotional upset and/or stress
    • Overheating
    • Abnormal heart rhythms
    • Illness or some medications
  • 5. 1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997 2 Gendelman HE, et al. NY State J Med 1983 3 Day SC, et al, AM J of Med 1982 4 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175
  • 6. EXPLAINED 60% UNEXPLAINED 60% 40%
  • 7. Cardiac? Non-Cardiac?
  • 8. Prognosis
    • Cardiovascular
      • Overall 1 year mortality rate = 18-33%
    • Non-cardiovascular
      • No overall increased mortality
    Kapoor WN, et al: N Engl J Med 1983;309:197-204
  • 9.
    • Fainting from a cardiac cause is
    • associated with high mortality risk
      • Risk is similar to that of patients without
      • fainting but with similar severity of heart
      • disease.
    Soteriades ES, Evans JC, Larson MG, et al.: N Engl J Med 2002;347(12):878-85
  • 10. A Diagnostic Plan is Essential Modified after ESC Syncope Task Force, 2004
  • 11.
    • GOAL #1
    • Identify probable cause(s) of fainting
    • and assess the risk for future events
  • 12.
    • GOAL #2
    • Rule out possible cardiovascular
    • causes for fainting
      • Use tests with strong negative predictive value
  • 13. Cardiovascular Causes Common Denominator Transient Global Cerebral Hypoperfusion
  • 14. Cardiovascular Causes Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary
    • Vasovagal
    • Carotid sinus
    • Situational
      • Cough
      • Post-micturition
    • Drug-Induced
    • ANS Failure
      • Primary
      • Secondary
    • Bradycardia
      • Sinus pause/arrest
      • AV block
    • Tachycardia
      • VT
      • SVT
    Aortic Stenosis HCM Pulmonary HTN Aortic Dissection Neurally- Mediated Reflex 60% 15% 10% 5%
  • 15. Cardiovascular Causes Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary
    • Vasovagal
    • Carotid sinus
    • Situational
      • Cough
      • Post-micturition
    • Drug-Induced
    • ANS Failure
      • Primary
      • Secondary
    • Bradycardia
      • Sinus pause/arrest
      • AV block
    • Tachycardia
      • VT
      • SVT
    Aortic Stenosis HCM Pulmonary HTN Aortic Dissection Neurally- Mediated Reflex Unexplained Causes = Approximately 10% 60% 15% 10% 5%
  • 16.
    • Seizure (3%)
    • Migraine (rare)
    • Cerebrovascular Disease (rare)
    • Subarachnoid Hemorrhage (rare)
    Neurologic Causes
  • 17.
    • Metabolic
      • Hyperventilation  Hypocapnia
      • Hypoglycemia
      • Hypoxia
    • Hemorrhage
    • Psychogenic (25%)
    Other Causes
  • 18. History and Physical Exam Surface ECG Neurological Testing • Head CT Scan • Carotid Doppler • MRI • Skull Films • Brain Scan • EEG CV Syncope Workup • Holter • ELR • Tilt Table • Echo • EP Testing Other CV Testing • Angiogram • Exercise Test • SAECG Psychological Evaluation ENT Evaluation Endocrine Evaluation
  • 19. Elements of Initial Examination
    • Vital signs
      • Heart rate, regularity
      • Orthostatic blood pressure change
    • CV Exam: Is heart disease present?
      • ECG: Long QT, WPW, conduction system disease
      • Echo: LV function, valve status, HCM
    • Neurological exam
      • Residual deficits?
    • Carotid sinus massage
      • Perform under clinically appropriate conditions preferably during tilt-table test. Monitor BP
  • 20.
    • History
    • Physical Examination
    • Diagnostic Yield = 40%
    Kapoor WN, et al: N Engl J Med 1983;309:197-204
  • 21.
    • History
    • Physical Examination
    • Additional Cardiac Testing
    • Diagnostic Yield = 60%
    Kapoor WN, et al: N Engl J Med 1983;309:197-204
  • 22. Carotid Sinus Massage (CSM)
    • Method
      • Massage, ~10 seconds, firm but do not occlude
      • Supine and upright posture (on tilt-table)
    • Suggests Carotid Sinus Syndrome (CSS) if:
      • >3 sec asystole and/or >50 mmHg fall in systolic BP
      • or
      • Reproduction of symptoms (usually only occurs with CSM during upright posture)
        • Sutton R, Benditt DG: The Evaluation and Treatment of Syncope: A Handbook for Clinical Practice , 2005
  • 23. Cardiovascular Causes
    • Postural Hypotension
      • Hypovolemia
      • Drug-induced
    • Dysautonomia
      • Neurocardiogenic
      • Carotid sinus hypersensitivity
      • Cough, swallow, post-micturition
      • Diabetes, ETOH, Shy-Drager, Amyloidosis
      • Paraneoplastic
  • 24.
    • Mechanical Defects
      • Limitation to forward output
        • AS, HOCM, Myxoma, Pulmonary HTN
      • Restriction of filling
        • Constrictive Pericarditis, Tamponade
      • Significant Right-to-Left Shunt
        • Tetralogy of Fallot, Eisenmenger Syndrome
    Cardiovascular Causes
  • 25.
    • Vascular Defects
      • Cerebrovascular
        • Vertebral-basilar insufficiency
        • Subclavian steal
      • Aortic dissection
      • Pulmonary embolism
    Cardiovascular Causes
  • 26. Echocardiography
    • Left Ventricular Function
      • LV ejection fraction
    • Hypertrophic Cardiomyopathy
      • Asymmetric septal hypertrophy
    • Valvular Disease
      • Aortic stenosis
    • Intracardiac Shunts
  • 27. Echocardiography
  • 28. A AORTIC STENOSIS HYPERTROPHIC CARDIOMYOPATHY
  • 29.  
  • 30. No Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
  • 31. Tilt Table Testing
  • 32. Tilt Table Testing
  • 33. Vasovagal Syncope “ Common Faint”
    • Characterized by a sudden fall in blood pressure in association with increased autonomic activity  hypotension & asystole/bradycardia
    • Associated symptoms:
      • Pallor
      • Nausea
      • Diaphoresis
      • Hyperventilation
  • 34. Tilt Table Testing
    • Sensitivity = 40-60% (drug-free state)
    • Sensitivity = 60-85% (+ NTG or Isuprel)
    • Specificity = 90% (drug-free state)
    • Findings are often not reproducible
    • High incidence of false (+) results in patients with structural heart disease
  • 35.
    • Medical therapy
      • Beta-adrenergic blocking agents
      • Disopyramide
      • Fluorohydrocortisone or salt tablets
      • Anticholinergic agents (scopolamine patch)
      • Midodrine
      • Serotonin reuptake inhibitors
    • Dual chamber pacemakers (rarely required)
    Vasovagal Syncope “ Common Faint”
  • 36. +/- Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1% * 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
  • 37.
      • Bradyarrhythmias
        • Sinus node dysfunction
        • AV conduction disturbance
        • Pacemaker malfunction
      • Tachyarrhythmias
        • Supraventricular tachycardia
        • Ventricular tachycardia
    Arrhythmias
  • 38. Diagnostic Gold Standard for Arrhythmias ECG strip recorded during clinical symptoms ECG Monitoring
  • 39. ECG Monitoring Selected Use Based on Initial Examination and Risk Stratification
      • Hospital Telemetry
      • Holter Monitor
      • External MCOT Loop Recorder
        • Records & transmits ECG data with / without patient activation
      • Insertable Loop Recorder
        • Permits remote ‘downloading’
        • Wireless transmission in certain devices
  • 40. Telemetry Monitoring
    • 24-48 hr continuous ECG monitoring
      • Correlate recurrent symptoms with ECG findings:
        • (+) ECG: Diagnose arrhythmic etiology for syncope
        • (–) ECG: Exclude arrhythmic etiology for syncope
    • Higher yield for bradyarrhythmias
      • Sinus bradycardia, sinus pauses (> 3 sec)
      • High grade AV block
  • 41. Hospital Telemetry
  • 42.
    • Holter monitor
      • Continuous ECG recording
      • 24-48 hours
      • Low diagnostic yield (2-3%)
      • Often nonspecific findings
    • Event recorder (patient-triggered)
      • External device (2-4 weeks)
      • Implantable loop recorder (36 months)
    Ambulatory ECG Monitoring
  • 43. ECG Monitoring Options ILR MCOT External Loop Recorder Event Recorder Holter Monitor 12-Lead 2 Days 7 Days 30+ Days 36 Months 10 Seconds ILR = insertable loop recorder MCOT= mobile cardiac outpatient telemetry
  • 44. Mobile Cardiac Outpatient Telemetry (MCOT) Patient Indicates symptoms on PDA. Abnormal ECG transmitted automatically PDA or cell phone stores ECG data and symptom status. Wireless transmission capability provided. Monitor center receives, reviews and transmits data to physician. Pre-determined ‘urgency’ criteria determine timing of physician alerts Physician receives and acts upon data as medically appropriate
  • 45.  
  • 46.  
  • 47. Implantable Loop Recorder • Battery longevity up to 36 months • Gold standard (symptom – rhythm correlation) • High diagnostic yield for patients with infrequent events • High patient compliance
  • 48.  
  • 49.  
  • 50.  
  • 51. Krahn, Circ. 1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and clinical assessment) Rhythm strip useful in diagnosis of 132 patients (64%) 206 Patients with Syncope Diagnostic Yield
  • 52. 64% Diagnostic Yield Krahn, Circ. 1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and clinical assessment) Rhythm strip useful in diagnosis of 132 patients (64%) 206 Patients with Syncope Diagnostic Yield
  • 53. ILR Advantages • The less frequent the symptoms are . . . – The less likely conventional testing will yield a diagnosis – The more testing will be required – The more costly the attempts to diagnose will be – The longer the diagnostic process – The more frustrated the patient and clinician become – The more likely the patient may be in harm’s way • Breaks the costly & time consuming diagnostic cycle
  • 54.  
  • 55. “ Those who suffer from frequent and severe fainting often die suddenly.” Hippocrates, 1000 BC
  • 56. MicroVolt T Wave Alternans (MTWA) Even Beats Odd Beats Mean V alt V alt
  • 57. Mechanism Linking MTWA to Ventricular Arrhythmias Long APD Short APD Long APD Short APD Action Potential Alternans Leads to T-Wave Alternans Long APD Region Short APD Region Spatially Discordant Alternans Leads to Dispersion of Recovery, Wave Front Fractionation, and Reentry
  • 58. MicroVolt T Wave Alternans Testing
  • 59.  
  • 60. Reduction of noise through adaptive cancellation of artifact LL (Segment) LL Impedance Respiration LL (Center) LL Enhanced Noise Reduction
  • 61.  
  • 62. Ikeda, et al.: Am J Cardiol 2002; 89:79-82 Post-MI CHF Klingenheben, et al.: Lancet 2000;356:651-52 Syncope Bloomfield, et al.: Circulation 1999;100:1-508
  • 63. Gold, et al.: J Am Coll Cardiol 2000;36:2247-53
  • 64. Candidates for MicroVolt T Wave Alternans Testing
    • Prior Myocardial Infarction
    • Left Ventricular Dysfunction (LVEF < 40%)
      • +/- Congestive Heart Failure
      • +/- Palpitations
      • +/- NSVT and/or frequent VPCs
    • Syncope or Presyncope
    • Family History of Unexplained Sudden Cardiac Death
  • 65. Ambulatory ECG Monitoring MTWA Testing
    • Abnormal findings may indicate potential arrhythmic cause(s) and subsequent need for invasive electrophysiological (EP) testing
  • 66. Clues Suggesting Possible Malignant Arrhythmias
      • Older age
      • Left ventricular dysfunction
      • Abrupt onset (no prodrome)
      • Facial and/or head trauma
      • Palpitations prior to syncope
  • 67. Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
  • 68. Electrophysiologic Testing
    • Patients with structural heart disease in whom an anatomical explanation for syncope is not present  EP Study
  • 69.  
  • 70. Intracardiac Recordings PA = Intra-atrial Conduction Interval A = Atrial Electrical Activity AH = Atria-His Bundle Conduction Interval H = His Bundle Electrical Activity HV = His Bundle-Ventricle Conduction Interval V = Ventricular Electrical Activity Surface ECG High Right Atrium IEGM His Bundle IEGM CS IEGM RV Apex IEGM PR Basic Sinus Cycle Length QRS A V V
  • 71. Predictors for Abnormal EP Study
      • STRUCTURAL HEART DISEASE
        • Prior myocardial infarction (Q waves)
        • Congestive heart failure
        • Left ventricular Dysfunction
      • Atrial Fibrillation
      • Bifascicular Block
      • Late Potentials on SAECG
  • 72. EP Study Diagnoses
    • Most common = Ventricular Tachycardia
    • Other arrhythmic causes include:
      • Sinus node dysfunction
      • Carotid sinus hypersensitivity
      • Atrioventricular (AV) block
      • Supraventricular tachycardia
  • 73.  
  • 74. Sudden Death Risk High Coronary Risk Post M I Heart Failure/ EF < 35%) Previous VF / VT Syncope / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)
  • 75. Sudden Death Risk High Coronary Risk Post M I Heart Failure/ EF < 35%) Previous VF / VT Syncope / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)
  • 76.
    • - ~ 450,000 per year 1
      • 1200 per day
      • 50 per hour
      • 1 every 72 seconds
    • - Most cases occur in patients with structural heart disease 2
    Epidemic of SCD in the US 1 Circulation . 2001;104:2158-2163. 2 Myerburg RJ, Castellanos A. Cardiac Arrest and Sudden Cardiac Death, in Braunwald E, Zipes DP, Libby P, Heart Disease, A textbook of Cardiovascular Medicine . 6 th ed. 2001. W.B. Saunders, Co.
  • 77. Leading Causes of Death in the US 1 National Vital Statistics Report , Vol 49 (11), Oct. 12, 2001 2 MMWR . State-specific mortality from sudden cardiac death – US 1999.Feb 15, 2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers
  • 78. Leading Causes of Death in the US 1 National Vital Statistics Report , Vol 49 (11), Oct. 12, 2001 2 MMWR . State-specific mortality from sudden cardiac death – US 1999.Feb 15, 2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers Only ALL cancers combined cause more deaths each year than sudden cardiac arrest!!
  • 79.  
  • 80. Sudden Cardiac Arrest
    • The only effective treatment is usually a prompt electrical shock to convert VT/VF
      • CPR (cardiopulmonary
      • resuscitation) can help
      • maintain the flow of oxygen
      • to the brain and vital organs
      • CPR cannot convert VT/VF to a normal rhythm
  • 81.  
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  • 86. www.fainting.com
  • 87.  
  • 88.