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Syncope the history dr nick gall(2)
1. Dr. Nick Gall
King’s College Hospital
London, UK
London
Syncope 2018
SYNCOPE:
The History
2. Why bother with syncope
You know why you’re here!
There’s a lot of it about
There are lots of causes
It presents to many different
people
We don’t investigate it well
We don’t treat it well
It can be very expensive
…but it doesn’t have to be like
this….
4. The history starts the process….
Are we dealing with T-LOC or something
else?
What sort of T-LOC is it?
Can I decide what sort of syncope it is?
Can I define the risk?
5. Detailed Patient History
Circumstances of recent event
Eyewitness account of event
Symptoms at onset of event
Sequelae
Medications
Circumstances of ALL remote events
Concomitant disease, especially cardiac
Pertinent family history
Cardiac disease
Sudden death
Past medical history
Neurological history
Thijs RD et al. J Neurol 2009;256: 155-167
Wieling W et al. Brain 2009;132:2630-42
6. Historical features (1)
Symptoms from cerebral hypoperfusion
Only remembered if BP fall slow enough to allow memory
Vision blurred, grey, black (retinal ischaemia)
Loss of motor control, freeze, collapse (floppy, stiff if long enough)
LOC generally <20s (up to 5 mins)
Involuntary, non-rhythmic, multifocal jerks very common; start earlier in
younger people; start AFTER the fall; 12-90%
Eyes open, staring, upwards deviated in many
Incontinence: urine possible (also in psychogenic!), faecal rare
Tongue biting rare but possible, side not described
Recovery quick, behaviour appropriate within 30s
Retrograde amnesia particularly in elderly
7. Reflex:
Trigger: pain, fear, emotion,
environment, neck turning etc;
although not in all
Prodrome (30-60s):
uncomfortable, warm, epigastric
discomfort, nausea, abdominal
cramps, desire to sit; need to
open bowels (rare), lightheaded,
cold sweat, fatigue, fading vision,
muffled and distant sounds,
palpitations, hyperventilation,
yawning, restlessness
Autonomic symptoms: sweating,
pallor, nausea, pupillary dilatation
Post event: fatigue, sweating,
nausea, yawning, recurrent events
Cardiac:
Triggers rare except during
exercise, sounds
Often presence of cardiac disease,
onset older than 35
Loss of consciousness may be
slower with VT cf AVB
Orthostatic hypotension:
Absence of autonomic symptoms
Odd visual symptoms first due to
intra-ocular pressure
Coat hanger headache and neck
ache
Post-exercise, post-prandial
Historical features (2)
8. Epilepsy
Triggers: generally not except reflex epilepsy (photosensitivity, startling sounds,
specific music, specific mental activity, hot bath, eating, reading…….)
Aura: any sense, emotion, thought, complex behaviour e.g. rising epigastric
sensation, odd smell / taste, déjà vu; tend to be recurrent
Seizures associated with LOC:
Clonic – coarse, large-scale, powerful, synchronous jerks
Tonic – body and limbs, stiff and extended; often known neurological abnormalities
T-C
Atonic seizures – rare, children with neurological abnormalities
Movements: may be unilateral, start before LOC
Other features: head turning (although not exclusive), frothing, long duration (>5
minutes), long post-ictal confusion
Historical features (3)
9. Pseudo-syncope:
Conversion disorder – unexplained somatic symptoms due to
psychological factors
NOT Factitious disorder – pretend to assume sick role
NOT Malingering – pretend to avoid something
Features:
Eyes closed, active eye closure, averting gaze from examiner, lifted
limbs fall with subtle hesitation
May ignore painful stimuli, can cause injury
Convulsions: asynchronous, waxing and waning, pelvic thrust, tremor,
long duration, frequent events
Historical features (4)
10. Other conditions to be considered:
TIA
Never causes syncope without other neurological features
Subclavian steal
Never causes syncope without other neurological features
Cataplexy
In association with narcolepsy (excessive daytime somnolence)
Patients fall BUT maintain consciousness
PoTS
Frequent dizziness ± blackouts
Multiple systemic symptoms, often associated with hypermobility
Falls
Think syncope in recurrent fallers and in dementia patients
Drop attacks:
Unexpected fall to the knees while walking
Can get up immediately
Memory of hitting the floor
Women over 40 y/o in general
11. Misconceptions
Can have no warning in reflex syncope, esp. elderly (more amnesia,
less autonomic activation)
Automatisms can occur in fainting – lip-smacking, chewing, hair-
ruffling
Can get complex visual and auditory hallucinations in syncope but
on coming round – roaring sounds, screaming, unintelligible voices
12. History is an important diagnostic
tool
FAST – the fainting assessment study
503 patients presenting with TLOC
Structured history, exam, postural BP and ECG
Defined certain, highly likely (>80%) or uncertain diagnosis
Followed at 1 and 2 years to assess diagnostic accuracy
63% correct diagnosis at initial evaluation by including
certain or highly likely diagnoses
If certain, 93% accurate
If highly likely, 85% accurate
13. The Calgary studies (1)
Sheldon R et al. JACC 2002;40:142-8
Syncope symptom study. N=671.
Recruited from hospital clinics and wards; excluded
if more than one possible cause
Diagnostic criteria defined
Secure diagnosis in 538; 270 development sample,
268 test sample
102 seizure, 569 syncope (132 uncertain cause of
syncope)
With certain cause 437 (reflex 267, VT 90, CHB 40, SVT 22,
SSS 4, CSH 4, AS 3, cough syncope 2, PE 2, autonomic
neuropathy 2, hyperventilation 1
Score SN>92%, SP>83%
Limitations:
Only seizure patients with abnormal inter-ictal EEGs
included
Excluded those with more than one diagnosis or
pseudo-events
14. The Calgary Studies (2)
Sheldon R et al. EHJ
2006;27:344-50
N=671; excluded those with more
than one diagnosis, structural heart
disease, epilepsy
Study group n=418
235 reflex syncope, 95 unknown
cause, 88 known cause, non-reflex
118 questions distilled to 7 critical for
the diagnosis
SN 89%, SP 91%
Limitations:
Patients from tertiary clinics,
Tilt positivity as the diagnostic test
15. NICE guidance 2010
Diagnose
uncomplicated
faint if:
No alternative
cause
Posture,
Provoking
factors,
Prodrome
Suspect OH if:
No alternative cause
History typical
Suspect epilepsy if:
Bitten tongue
Head turned during T-LOC
No memory of abnormal behaviour around T-LOC
Unusual posturing
Prolonged limb jerking
Confusion afterwards
Prodromal deja / jamais vu
Consider cardiac if:
Heart failure
T-LOC during exertion
FH of sudden cardiac death
New breathlessness
17. The difficulties with symptoms (1)
Patient factors:
Patient unconscious at the time; asymptomatic at evaluation
Only 25% may seek medical attention
Mixture of features in one event – MSA with syncope and fall
Patients may suffer different forms of syncope at different times or
during one event
Amnesia for the event; may even have amnesia for the amnesia
Witness factors:
Witness accounts may be inaccurate or conflicting; Critical features may
not be recognised
Un-witnessed often
18. The difficulties with symptoms (2)
Doctors factors:
Variable frequencies of different diagnoses depending on assessing
doctor; you’ve got my disease
Causes overlap many different specialties – different knowledge,
different emphasis on diagnostic / therapeutic process
Doctors catastrophize
Experts may disagree over the diagnosis
The history can make the diagnosis in reflex, other diagnoses
require testing
Language difficulties
Does the patient understand what we mean e.g. dizziness?
Do we understand what the patient means e.g. supine T-LOC?
19. Conclusions
Diagnosis from history, examination and ECG may
be possible in up to 2/3 of cases
Remember and focus on the differential diagnosis
Detailed history of all events looking for common
patterns
Try to define the risk as well as the diagnosis
Consider point score use in ED and with
generalists as a guide
20. …AND ON THAT BOMB
SHELL...
THANK YOU FOR YOUR ATTENTION
