Dizziness and Syncope Karen E. Hauer, MD University of California,  San Francisco
Dizziness and Syncope: Outline <ul><li>Dizziness: common etiologies </li></ul><ul><ul><li>Case examples </li></ul></ul><ul...
Dizziness <ul><li>“ There can be few physicians so dedicated to their art that they do not experience a slight decline in ...
<ul><li>Vertigo 50% </li></ul><ul><li>Disequilibrium 2% </li></ul><ul><li>Psychiatric 2-16% </li></ul><ul><li>Presyncope 4...
Case <ul><li>A 72 year old woman with hypertension and migraine has 2 episodes of sudden onset dizziness. She reports “sid...
Case <ul><li>A 72 year old woman with hypertension and migraine has 2 episodes of  sudden onset  dizziness. She reports “s...
<ul><li>Central (15%) </li></ul><ul><li>Brainstem infarct/ischemia </li></ul><ul><li>Tumor </li></ul><ul><ul><li>Cerebello...
<ul><li>Central  </li></ul><ul><li>Gradual onset (except stroke) </li></ul><ul><li>Persistent </li></ul><ul><li>Neuro find...
Anatomy American Academy of Otolaryngology/HNS
Dix-Hallpike maneuver: to induce positional vertigo and nystagmus <ul><li>Benign positional vertigo: #1 cause of periphera...
Dix-Hallpike maneuver:  diagnostic and therapeutic <ul><li>Positional vertigo: </li></ul><ul><ul><li>Vertigo/nystagmus rep...
<ul><li>Rule out tumor  </li></ul><ul><ul><li>1/9307 - dizziness, normal hearing </li></ul></ul><ul><ul><li>1/638  - dizzi...
Case: unsteadiness <ul><li>A 78 year old woman with coronary artery disease, type 2 diabetes, cataracts, anxiety and depre...
Disequilibrium: often multifactorial <ul><li>Sense of imbalance -w orse with walking </li></ul><ul><li>Contributing factor...
Dizziness: a geriatric syndrome <ul><li>24% of community-living elders had dizziness > 1 month </li></ul>Tinetti, Ann Inte...
Case: “I feel like I’m going to faint”   <ul><li>A 30 year old woman reports episodes of feeling as if she will faint, wit...
Dizziness: psychiatric etiology <ul><li>Young healthy patient </li></ul><ul><li>Symptoms reproduced with hyperventilation ...
Establishing Diagnosis of Syncope Presyncope & syncope: similar etiologies & workup  Syncope:  sudden transient loss of co...
Syncope:  scope of the problem <ul><li>Common </li></ul><ul><ul><li>3% Emergency Department visits  </li></ul></ul><ul><ul...
Diagnostic Challenges <ul><ul><ul><li>History often unclear </li></ul></ul></ul><ul><ul><ul><li>Prognosis varies widely </...
Syncope: management questions <ul><li>Diagnostic challenges </li></ul><ul><ul><li>What is the best diagnostic test? </li><...
Case Presentation <ul><li>50 yo healthy woman, standing at church </li></ul><ul><ul><li>Becomes weak, lightheaded, & nause...
Etiology of Syncope <ul><li>Idiopathic 34% </li></ul><ul><li>Neurally-mediated </li></ul><ul><li>Vasovagal 18% </li></ul><...
The Key to Diagnostic Evaluation <ul><li>History and Exam establish diagnosis in 45%   </li></ul><ul><ul><li>History: sett...
Diagnostic Algorithm Syncope Cardiac Noncardiac Idiopathic Arrhythmia Mechanical Neurocardiogenic Orthostatic Neurologic P...
Cardiac syncope:  inadequate cardiac output, arrhythmia <ul><li>Cardiac enzymes -  only   if history or EKG suggestive of ...
Arrhythmia evaluation - telemetry <ul><li>Indication:  suspected arrhythmia </li></ul><ul><ul><li>palpitations, no prodrom...
Arrhythmia evaluation:  24 hr ambulatory (Holter) monitoring   <ul><li>2612 syncope/dizzy patients </li></ul><ul><ul><li>S...
Arrhythmia evaluation:  improving the yield   <ul><li>Loop recorder  </li></ul><ul><ul><li>Indication:  recurrent syncope ...
Neurocardiogenic Syncope Vasovagal Micturition Vasodepressor Neurally - mediated Reflexive Orthostatic intolerance Carotid...
<ul><li>May be predominantly </li></ul><ul><li>Cardioinhibitory  </li></ul><ul><ul><li>(bradycardia) </li></ul></ul><ul><l...
Neurocardiogenic Syncope:  Pathophysiology
Diagnosing neurocardiogenic syncope by history and exam <ul><li>Precipitant </li></ul><ul><ul><li>Vasovagal:  pain, emotio...
Is Laughter Really the  Best Medicine? <ul><li>“ A 63-year-old man was referred with a 20-year history of syncope preceded...
Tilt table testing 60-80˚ <ul><li>Goal:   provoke neurocardiogenic syncope </li></ul><ul><li>Indication:  recurrent  unexp...
Tilt table testing:  why the controversy? <ul><li>Accuracy difficult to define </li></ul><ul><ul><li>Gold standard?  </li>...
Neurocardiogenic syncope:  treatment <ul><li>Indicated for frequent syncope </li></ul><ul><ul><li>Lifestyle modification <...
Vasovagal syncope:  pacemakers ineffective <ul><li>Randomized double-blind trial </li></ul><ul><li>DDD pacer vs. sensing-o...
“ Idiopathic” syncope:  improving diagnostic yield <ul><li>Up to 40% patients </li></ul><ul><ul><li>Prognosis good  </li><...
Prognosis: Framingham 25 year follow up *p<0.01 NEJM 2002;347:878 1.08  Vasovagal 1.32* Idiopathic 1.54* Neurologic 2.01* ...
Prognosis:  ED risk stratification <ul><li>ED predictors of arrhythmia or mortality </li></ul><ul><ul><li>Abnormal EKG </l...
Prognosis:  Guideline for admission - the San Francisco Syncope Rule   <ul><li>Prediction rule to identify patients at ris...
<ul><li>C HF - history of </li></ul><ul><li>H ematocrit <30% </li></ul><ul><li>E CG abnormal </li></ul><ul><li>S hortness ...
ACP Guidelines for Hospital Admission <ul><li>Definitely admit </li></ul><ul><li>HPI:  chest pain </li></ul><ul><li>PMH:  ...
Guidelines for Hospital Admission:   implications for practice <ul><li>Myth:  Every syncope patient should be admitted </l...
Syncope in the elderly: the geriatric challenge <ul><li>History often obscure </li></ul><ul><ul><li>Syncope vs. dizziness ...
Syncope in the elderly: a poor prognostic sign Kapoor, Am J Med, 1986
Recommendations for Driving:  following the law <ul><li>Laws vary by state - available from DMV </li></ul><ul><ul><li>Cali...
American Heart Association Guidelines for Driving <ul><li>VT/VF (treated with medical or ICD therapy )  </li></ul><ul><ul>...
The Potentially Costly Workup <ul><li>Test Charge* </li></ul><ul><li>H & P $160 </li></ul><ul><li>EKG $90 </li></ul><ul><l...
Trust the Careful History: Excess Cost of Vasodepressor Syncope <ul><li>30 patients referred for “undiagnosed” syncope </l...
Case Presentation:  Is typical practice cost effective? <ul><li>Hypothetical scenario presented to 916 MDs </li></ul><ul><...
Cost-effective workup: Internists vs. cardiologists <ul><li>Diagnosis:  vasovagal syncope </li></ul><ul><li>Intended plan:...
Dizziness: key points <ul><li>Vertigo is most common etiology </li></ul><ul><ul><li>Positional triggers, nystagmus help co...
Syncope:  key points <ul><li>History, exam, EKG guide further testing </li></ul><ul><li>Identify possible cardiac syncope ...
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  • 3 Dizziness And Syncope. Karen Hauer, Md

    1. 1. Dizziness and Syncope Karen E. Hauer, MD University of California, San Francisco
    2. 2. Dizziness and Syncope: Outline <ul><li>Dizziness: common etiologies </li></ul><ul><ul><li>Case examples </li></ul></ul><ul><li>Syncope </li></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Efficient workup </li></ul></ul><ul><ul><li>Management </li></ul></ul>
    3. 3. Dizziness <ul><li>“ 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]” </li></ul><ul><li>WB Matthews, 1975 </li></ul>
    4. 4. <ul><li>Vertigo 50% </li></ul><ul><li>Disequilibrium 2% </li></ul><ul><li>Psychiatric 2-16% </li></ul><ul><li>Presyncope 4-14% </li></ul><ul><li>Single etiology 52% </li></ul><ul><li>Kroenke, Ann Intern Med 1992 </li></ul><ul><li>UpToDate 2005 </li></ul>Etiology of dizziness
    5. 5. Case <ul><li>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. </li></ul>
    6. 6. Case <ul><li>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. </li></ul>
    7. 7. <ul><li>Central (15%) </li></ul><ul><li>Brainstem infarct/ischemia </li></ul><ul><li>Tumor </li></ul><ul><ul><li>Cerebellopontine angle </li></ul></ul><ul><ul><li>Brainstem </li></ul></ul><ul><li>Migraine </li></ul>Vertigo: acute vestibular asymmetry <ul><li>Peripheral (85%) </li></ul><ul><li>Benign positional </li></ul><ul><li>Labyrinthitis </li></ul><ul><li>Meniere’s </li></ul><ul><li>Otitis media </li></ul>
    8. 8. <ul><li>Central </li></ul><ul><li>Gradual onset (except stroke) </li></ul><ul><li>Persistent </li></ul><ul><li>Neuro findings common </li></ul><ul><li>Nystagmus any direction - changes with gaze </li></ul><ul><li>Nystagmus not suppressable </li></ul><ul><li>Unable to stand </li></ul>Vertigo: history and exam <ul><li>Peripheral </li></ul><ul><li>Sudden, severe </li></ul><ul><li>Episodic </li></ul><ul><li>Ear symptoms common </li></ul><ul><li>Nystagmus horizontal/torsional, no change with gaze </li></ul><ul><li>Nystagmus suppressed with fixation </li></ul><ul><li>Able to stand, lean to lesion </li></ul>
    9. 9. Anatomy American Academy of Otolaryngology/HNS
    10. 10. Dix-Hallpike maneuver: to induce positional vertigo and nystagmus <ul><li>Benign positional vertigo: #1 cause of peripheral vertigo </li></ul><ul><ul><li>Episodic symptoms </li></ul></ul><ul><ul><li>Free floating debris in semicircular canals </li></ul></ul>
    11. 11. Dix-Hallpike maneuver: diagnostic and therapeutic <ul><li>Positional vertigo: </li></ul><ul><ul><li>Vertigo/nystagmus reproduced </li></ul></ul><ul><ul><ul><li>Latency 5-15 seconds </li></ul></ul></ul><ul><ul><ul><li>Decreases w/in 30 seconds </li></ul></ul></ul><ul><ul><ul><li>Fatigues on repeat </li></ul></ul></ul>
    12. 12. <ul><li>Rule out tumor </li></ul><ul><ul><li>1/9307 - dizziness, normal hearing </li></ul></ul><ul><ul><li>1/638 - dizziness, asymmetric hearing loss </li></ul></ul><ul><li>Rule out vascular compromise </li></ul><ul><li>Indications </li></ul><ul><li>New neuro symptoms/signs </li></ul><ul><ul><ul><ul><li>Sudden vertigo & stroke risk factors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vertigo & new severe headache </li></ul></ul></ul></ul><ul><li>Test of choice: MRI/ MRA </li></ul><ul><ul><li>Gizzi, Arch Neurol 1996 </li></ul></ul>Vertigo: when to image?
    13. 13. Case: unsteadiness <ul><li>A 78 year old woman with coronary artery disease, type 2 diabetes, cataracts, anxiety and depression has chronic dizziness - “unsteady while walking” </li></ul><ul><li>Meds: insulin, lovastatin, atenolol, fludrocortisone, prozac </li></ul><ul><li>Neuro exam: slightly wide based gait. DTRs absent in ankles. Reduced vibration sense to ankle bilaterally. Short of breath with neuro exam maneuvers. </li></ul>
    14. 14. Disequilibrium: often multifactorial <ul><li>Sense of imbalance -w orse with walking </li></ul><ul><li>Contributing factors </li></ul><ul><ul><li>Vision, hearing impairment </li></ul></ul><ul><ul><li>Peripheral neuropathy </li></ul></ul><ul><ul><li>Musculoskeletal disease/gait disturbance </li></ul></ul><ul><ul><li>Medications </li></ul></ul>
    15. 15. Dizziness: a geriatric syndrome <ul><li>24% of community-living elders had dizziness > 1 month </li></ul>Tinetti, Ann Intern Med 2000 1.31 Prior MI 1.31 Postural hypotension 1.30 > 4 meds 1.34 Impaired balance 1.27 Decreased hearing 1.36 Depression 1.69 Anxiety Relative risk Risk factor
    16. 16. Case: “I feel like I’m going to faint” <ul><li>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. </li></ul>
    17. 17. Dizziness: psychiatric etiology <ul><li>Young healthy patient </li></ul><ul><li>Symptoms reproduced with hyperventilation </li></ul><ul><ul><li>Nystagmus suggests vestibular lesion </li></ul></ul><ul><li>Treat underlying anxiety/depression </li></ul>
    18. 18. 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
    19. 19. Syncope: scope of the problem <ul><li>Common </li></ul><ul><ul><li>3% Emergency Department visits </li></ul></ul><ul><ul><li>1-6% hospital admissions </li></ul></ul><ul><li>Costly </li></ul><ul><ul><li>Multiple diagnostic tests often performed </li></ul></ul><ul><ul><ul><li>Average charge for each diagnostic test ranges from $284 to $4678 </li></ul></ul></ul><ul><li>Linzer, Ann Intern Med, 1997 </li></ul>
    20. 20. Diagnostic Challenges <ul><ul><ul><li>History often unclear </li></ul></ul></ul><ul><ul><ul><li>Prognosis varies widely </li></ul></ul></ul><ul><ul><ul><ul><li>Common etiologies are benign </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Potentially high mortality </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Need to identify high-risk patient early </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Many available tests </li></ul></ul></ul><ul><ul><ul><li>40% of patients may elude diagnosis </li></ul></ul></ul>
    21. 21. Syncope: management questions <ul><li>Diagnostic challenges </li></ul><ul><ul><li>What is the best diagnostic test? </li></ul></ul><ul><ul><li>How and when to rule out arrhythmia? </li></ul></ul><ul><ul><li>How to diagnose neurocardiogenic syncope? </li></ul></ul><ul><ul><li>How to decrease the # “idiopathic”? </li></ul></ul><ul><li>Management dilemmas </li></ul><ul><ul><li>When to admit? </li></ul></ul><ul><ul><li>How are the elderly different? </li></ul></ul><ul><ul><li>When to resume driving? </li></ul></ul>
    22. 22. Case Presentation <ul><li>50 yo healthy woman, standing at church </li></ul><ul><ul><li>Becomes weak, lightheaded, & nauseated </li></ul></ul><ul><ul><li>Collapses, awakens after 1 minute </li></ul></ul><ul><ul><li>Feels well in ED - “I want to go home” </li></ul></ul><ul><ul><li>Normal exam, EKG, labs, CXR </li></ul></ul><ul><li>Diagnosis? </li></ul><ul><li>Plan - Admit? Further testing? </li></ul><ul><ul><li>Glassman, Arch Intern Med, 1997 </li></ul></ul>
    23. 23. Etiology of Syncope <ul><li>Idiopathic 34% </li></ul><ul><li>Neurally-mediated </li></ul><ul><li>Vasovagal 18% </li></ul><ul><ul><li>Other (situational, carotid sinus) 6% </li></ul></ul><ul><li>Cardiac </li></ul><ul><li>Arrhythmia 14% </li></ul><ul><li>Mechanical 4% </li></ul><ul><li>Neurologic 10% </li></ul><ul><li>Orthostatic 8% </li></ul><ul><li>Medications 3% </li></ul><ul><li>Psychiatric 2% </li></ul><ul><li>Linzer, Ann Intern Med, 1997 </li></ul>
    24. 24. The Key to Diagnostic Evaluation <ul><li>History and Exam establish diagnosis in 45% </li></ul><ul><ul><li>History: setting, symptoms, medical hx, meds </li></ul></ul><ul><ul><li>Exam: HR, BP, cardiovascular, neurologic </li></ul></ul><ul><li>EKG adds 5% diagnostic yield </li></ul><ul><ul><li>Cheap, non-invasive, readily available </li></ul></ul><ul><ul><li>Can indicate important cardiac disease </li></ul></ul><ul><ul><ul><li>Prior MI, ventricular hypertrophy, long QT </li></ul></ul></ul><ul><ul><ul><li>Bradycardia, conduction block </li></ul></ul></ul><ul><li>Abnormalities guide further testing </li></ul>
    25. 25. Diagnostic Algorithm Syncope Cardiac Noncardiac Idiopathic Arrhythmia Mechanical Neurocardiogenic Orthostatic Neurologic Psychiatric
    26. 26. Cardiac syncope: inadequate cardiac output, arrhythmia <ul><li>Cardiac enzymes - only if history or EKG suggestive of MI </li></ul><ul><ul><li>1-10% MI’s present with syncope </li></ul></ul><ul><ul><li>EKG up to 100% sensitive for MI </li></ul></ul><ul><li>Echo - rule out structural heart disease </li></ul><ul><ul><li>before stress test if obstruction suspected </li></ul></ul><ul><ul><li>yield: 5-10% </li></ul></ul><ul><li>Exercise stress test - exertional syncope </li></ul><ul><ul><li>identifies exertional arrhythmia </li></ul></ul><ul><ul><li>yield: low (1%) </li></ul></ul><ul><ul><li>Georgeson, J Gen Intern Med, 1992 </li></ul></ul><ul><ul><li>Linzer, Ann Intern Med, 1997 </li></ul></ul>
    27. 27. Arrhythmia evaluation - telemetry <ul><li>Indication: suspected arrhythmia </li></ul><ul><ul><li>palpitations, no prodrome </li></ul></ul><ul><ul><li>Idiopathic syncope or underlying heart disease </li></ul></ul><ul><li>Routine telemetry low yield </li></ul><ul><ul><li>2240 non-ICU telemetry patients </li></ul></ul><ul><ul><li>10% syncope/dizzy </li></ul></ul><ul><ul><ul><li> all syncope </li></ul></ul></ul><ul><ul><ul><li>ICU transfer-arrhythmia 0.8% 0.4% </li></ul></ul></ul><ul><li>Telemetry “Helpful” 12.6% 16% </li></ul><ul><li> Mortality 0.9% 0 </li></ul><ul><li>Linzer, Ann Intern Med, 1997 </li></ul><ul><li>Estrada, Am J Cardiol, 1995 </li></ul><ul><ul><li>Glassman, Arch Intern Med, 1997. </li></ul></ul>Estrada, Am J Cardiol, 1995
    28. 28. Arrhythmia evaluation: 24 hr ambulatory (Holter) monitoring <ul><li>2612 syncope/dizzy patients </li></ul><ul><ul><li>Symptomatic arrhythmia = positive result </li></ul></ul><ul><ul><ul><li>Diagnostic arrhythmia in 4% </li></ul></ul></ul><ul><ul><li>Symptoms without arrhythmia </li></ul></ul><ul><ul><ul><li>Arrhythmia ruled out in 15% </li></ul></ul></ul><ul><li>Bottom line </li></ul><ul><ul><li>Benefit: monitors during usual activity </li></ul></ul><ul><ul><li>Limitation: brief duration limits yield unless daily symptoms </li></ul></ul><ul><ul><li>Linzer, Ann Intern Med, 1997 </li></ul></ul>
    29. 29. Arrhythmia evaluation: improving the yield <ul><li>Loop recorder </li></ul><ul><ul><li>Indication: recurrent syncope with normal heart </li></ul></ul><ul><ul><ul><li>frequent syncope -> continuous loop recorder (weeks) </li></ul></ul></ul><ul><ul><ul><li>infrequent syncope -> implantable loop recorder (years) </li></ul></ul></ul><ul><li>Electrophysiologic study </li></ul><ul><ul><li>Indication: syncope with organic heart disease </li></ul></ul><ul><li>Signal average EKG </li></ul><ul><ul><li>Detects late potential in QRS - substrate for VT/VF </li></ul></ul><ul><ul><li>indication: normal heart, idiopathic syncope? </li></ul></ul><ul><ul><li>Linzer, Ann Intern Med, 1997 </li></ul></ul><ul><ul><li>Zimetbaum , Ann Intern Med, 1999 </li></ul></ul>
    30. 30. Neurocardiogenic Syncope Vasovagal Micturition Vasodepressor Neurally - mediated Reflexive Orthostatic intolerance Carotid sinus syncope Cardioneurogenic
    31. 31. <ul><li>May be predominantly </li></ul><ul><li>Cardioinhibitory </li></ul><ul><ul><li>(bradycardia) </li></ul></ul><ul><li>Vasodepressor </li></ul><ul><ul><li>(hypotension) or </li></ul></ul><ul><li>Both </li></ul>Neurocardiogenic Syncope Clinical Presentation Syncope Trigger
    32. 32. Neurocardiogenic Syncope: Pathophysiology
    33. 33. Diagnosing neurocardiogenic syncope by history and exam <ul><li>Precipitant </li></ul><ul><ul><li>Vasovagal: pain, emotion, standing </li></ul></ul><ul><ul><li>Situational: vagal stimulus </li></ul></ul><ul><li>Autonomic symptoms </li></ul><ul><li>Rapid recovery of mental status </li></ul><ul><ul><li>Bradycardia, pallor may persist </li></ul></ul><ul><li>Carotid sinus massage </li></ul><ul><ul><li>>3 sec asystole or hypotension=hypersensitivity </li></ul></ul>
    34. 34. Is Laughter Really the Best Medicine? <ul><li>“ 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. </li></ul><ul><li>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.” </li></ul><ul><li>Braga. Lancet 2005 </li></ul>
    35. 35. Tilt table testing 60-80˚ <ul><li>Goal: provoke neurocardiogenic syncope </li></ul><ul><li>Indication: recurrent unexplained syncope without cardiac disease </li></ul><ul><li>Protocol: passive tilt 45-60 min </li></ul><ul><ul><li>positive response reproduces symptom </li></ul></ul>
    36. 36. Tilt table testing: why the controversy? <ul><li>Accuracy difficult to define </li></ul><ul><ul><li>Gold standard? </li></ul></ul><ul><ul><li>Protocol? </li></ul></ul><ul><ul><li>Reproducibility 71-87% </li></ul></ul><ul><li>Positive tilt test with idiopathic syncope: </li></ul><ul><ul><li>49% with passive tilt </li></ul></ul><ul><ul><li>66% with tilt plus isoproterenol </li></ul></ul><ul><ul><ul><li>Tradeoff: decreased specificity </li></ul></ul></ul><ul><ul><ul><li>Kapoor, Am J Med, 1994 </li></ul></ul></ul>
    37. 37. Neurocardiogenic syncope: treatment <ul><li>Indicated for frequent syncope </li></ul><ul><ul><li>Lifestyle modification </li></ul></ul><ul><ul><ul><li>Add salt, avoid triggers </li></ul></ul></ul><ul><ul><ul><li>Handgrip, tense arms and legs </li></ul></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><ul><li>B blocker, SSRI, midodrine, fludrocortisone </li></ul></ul></ul><ul><ul><ul><li>Repeat tilt test on therapy? </li></ul></ul></ul><ul><ul><li>Pacemaker </li></ul></ul>
    38. 38. Vasovagal syncope: pacemakers ineffective <ul><li>Randomized double-blind trial </li></ul><ul><li>DDD pacer vs. sensing-only pacer </li></ul>Connolly, JAMA 2003 p = NS %
    39. 39. “ Idiopathic” syncope: improving diagnostic yield <ul><li>Up to 40% patients </li></ul><ul><ul><li>Prognosis good </li></ul></ul><ul><ul><li>Potential morbidity, lifestyle implications </li></ul></ul><ul><li>Consider: </li></ul><ul><ul><li>Diagnosis Testing </li></ul></ul><ul><ul><li>Neurocardiogenic Tilt table </li></ul></ul><ul><ul><li>Anxiety/depression Psychiatric evaluation </li></ul></ul><ul><ul><li>Arrhythmia EPS, implanted event monitor </li></ul></ul><ul><li>Empiric pacemaker? </li></ul>
    40. 40. Prognosis: Framingham 25 year follow up *p<0.01 NEJM 2002;347:878 1.08 Vasovagal 1.32* Idiopathic 1.54* Neurologic 2.01* Cardiac Adjusted risk of death Etiology of syncope
    41. 41. Prognosis: ED risk stratification <ul><li>ED predictors of arrhythmia or mortality </li></ul><ul><ul><li>Abnormal EKG </li></ul></ul><ul><ul><li>Prior VT/VF </li></ul></ul><ul><ul><li>History of CHF </li></ul></ul><ul><ul><li>Age > 45 </li></ul></ul><ul><ul><li>Martin, Ann Emerg Med, 1997 </li></ul></ul>
    42. 42. Prognosis: Guideline for admission - the San Francisco Syncope Rule <ul><li>Prediction rule to identify patients at risk of bad outcomes (need admit) over 30 days </li></ul><ul><ul><li>Death, MI, arrhythmia, PE, stroke, transfusion </li></ul></ul><ul><ul><li>Syncope or related event requiring procedure, ED visit or admit </li></ul></ul><ul><li>First assess the patient for cause of syncope </li></ul><ul><li>If cause unknown, apply the rule </li></ul><ul><ul><li>98% sensitive </li></ul></ul><ul><ul><li>56% specific </li></ul></ul><ul><ul><li>Quinn, Ann Emerg Med, 2006 </li></ul></ul>
    43. 43. <ul><li>C HF - history of </li></ul><ul><li>H ematocrit <30% </li></ul><ul><li>E CG abnormal </li></ul><ul><li>S hortness of breath </li></ul><ul><li>S ystolic blood pressure <90 mm Hg at triage </li></ul><ul><li>Quinn, Ann Emerg Med, 2006 </li></ul>Prognosis: Guideline for admission - the San Francisco Syncope Rule
    44. 44. ACP Guidelines for Hospital Admission <ul><li>Definitely admit </li></ul><ul><li>HPI: chest pain </li></ul><ul><li>PMH: CAD, CHF, ventricular arrhythmia </li></ul><ul><li>Exam: CHF, valve dz, focal neurologic deficit </li></ul><ul><li>EKG: ischemia/MI, arrhythmia, bundle branch block </li></ul><ul><li>Often admit </li></ul><ul><li>HPI: age >70, exertional syncope, frequent syncope </li></ul><ul><li>Exam: tachycardia, orthostatic hypotension, injury </li></ul><ul><li>Cardiac dz suspected </li></ul><ul><li>Linzer, Ann Intern Med, 1997 </li></ul>
    45. 45. Guidelines for Hospital Admission: implications for practice <ul><li>Myth: Every syncope patient should be admitted </li></ul><ul><li>Recommendation: Establish clear goals for admission, usually diagnostic </li></ul><ul><li>Myth: Every syncope patient requires “rule out MI” </li></ul><ul><li>Recommendation: Admission not necessary with careful history ruling out symptoms of ischemia and normal EKG </li></ul><ul><li>Myth: Telemetry improves outcomes </li></ul><ul><li>Recommendation: One-year mortality rarely affected by 24 hours of monitoring </li></ul>
    46. 46. Syncope in the elderly: the geriatric challenge <ul><li>History often obscure </li></ul><ul><ul><li>Syncope vs. dizziness vs. fall? </li></ul></ul><ul><li>Often multifactorial - elderly at high risk for </li></ul><ul><ul><li>Situational syncope </li></ul></ul><ul><ul><li>Polypharmacy, adverse drug events </li></ul></ul><ul><ul><li>Cardiac, neurovascular disease </li></ul></ul><ul><ul><li>Decreased physiologic reserve </li></ul></ul><ul><ul><li>Atypical presentation of disease </li></ul></ul><ul><li>Abnormalities do not prove causation </li></ul>
    47. 47. Syncope in the elderly: a poor prognostic sign Kapoor, Am J Med, 1986
    48. 48. Recommendations for Driving: following the law <ul><li>Laws vary by state - available from DMV </li></ul><ul><ul><li>California law requires reporting of any loss of consciousness </li></ul></ul><ul><ul><ul><li>County health officer receives report </li></ul></ul></ul><ul><ul><ul><li>DMV determines fitness to drive </li></ul></ul></ul><ul><li>Physician can provide influential prognostic information to DMV </li></ul><ul><ul><li>Physicians’ recommendations variable </li></ul></ul><ul><ul><li>Awareness of law often poor </li></ul></ul>
    49. 49. American Heart Association Guidelines for Driving <ul><li>VT/VF (treated with medical or ICD therapy ) </li></ul><ul><ul><li>Risk greatest 1st 6 mo, up to 10% at 1 year </li></ul></ul><ul><ul><li>Resume driving: 6 months arrhythmia free </li></ul></ul><ul><li>Bradycardia with syncope </li></ul><ul><ul><li>Resume driving: 1 week after pacemaker </li></ul></ul><ul><li>Neurocardiogenic syncope -> risk stratify </li></ul><ul><ul><li>Mild: presyncope, clear warning & precipitant </li></ul></ul><ul><ul><ul><li>Resume driving: immediately </li></ul></ul></ul><ul><ul><li>Severe: syncope, no warning or precipitant, frequent </li></ul></ul><ul><ul><ul><li>Resume driving: after therapy, waiting period (duration?) </li></ul></ul></ul>
    50. 50. The Potentially Costly Workup <ul><li>Test Charge* </li></ul><ul><li>H & P $160 </li></ul><ul><li>EKG $90 </li></ul><ul><li>24-hour Holter $468 </li></ul><ul><li>Loop recorder - 30 day $284 </li></ul><ul><li>Electrophysiology study $4678 </li></ul><ul><li>Psychiatric evaluation $150 </li></ul><ul><li>CT brain $888 </li></ul><ul><li>Echo $580 </li></ul><ul><li>Stress test $433 </li></ul><ul><li>Tilt table test $683 </li></ul><ul><li>*Average at 4 academic centers, Linzer, 1997 </li></ul>
    51. 51. Trust the Careful History: Excess Cost of Vasodepressor Syncope <ul><li>30 patients referred for “undiagnosed” syncope </li></ul><ul><ul><li>All characteristic vasodepressor history </li></ul></ul><ul><ul><li>Mean cost of prior testing $3763 - 1991 </li></ul></ul><ul><ul><li>Majority had Holter, echo, CT </li></ul></ul><ul><ul><li>Calkins, Am J Med, 1993 </li></ul></ul><ul><ul><li>Calkins, Am J Med, 1991. </li></ul></ul>
    52. 52. Case Presentation: Is typical practice cost effective? <ul><li>Hypothetical scenario presented to 916 MDs </li></ul><ul><ul><li>Becomes weak, lightheaded, & nauseated </li></ul></ul><ul><ul><li>Collapses, awakens after 1 minute </li></ul></ul><ul><ul><li>Feels well in ED - “I want to go home” </li></ul></ul><ul><ul><li>Normal exam, EKG, labs, CXR </li></ul></ul><ul><li>Diagnosis? </li></ul><ul><li>Plan - Admit? Further testing? </li></ul><ul><ul><li>Glassman, Arch Intern Med, 1997 </li></ul></ul>
    53. 53. Cost-effective workup: Internists vs. cardiologists <ul><li>Diagnosis: vasovagal syncope </li></ul><ul><li>Intended plan: observation +/- overnight tele </li></ul><ul><li>Survey results: aggressive approach </li></ul><ul><li>Cardiologists Internists YOU </li></ul><ul><li>Admit? 79% 72% ? </li></ul><ul><li>Mean # </li></ul><ul><li>additional tests 2.7 2.3 ? </li></ul><ul><ul><li>Glassman, Arch Intern Med, 1997 </li></ul></ul>
    54. 54. Dizziness: key points <ul><li>Vertigo is most common etiology </li></ul><ul><ul><li>Positional triggers, nystagmus help confirm peripheral etiology </li></ul></ul><ul><ul><li>Neuro findings, stroke risk prompt imaging </li></ul></ul><ul><li>Disequilibrium - commonly due to multifactorial deficits in elderly </li></ul><ul><li>Presyncope - manage like syncope </li></ul>
    55. 55. Syncope: key points <ul><li>History, exam, EKG guide further testing </li></ul><ul><li>Identify possible cardiac syncope early </li></ul><ul><ul><li>Admit if high risk of cardiac disease </li></ul></ul><ul><li>Neurocardiogenic syncope - diagnosed clinically or by tilt table </li></ul><ul><li>Idiopathic syncope has multiple etiologies and good prognosis </li></ul>

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