Syncope Courtney McIlduff, M. Sc. Catherine Florio Pipas, M. D. Dartmouth Medical School
Objectives <ul><li>Present a Clinical Case </li></ul><ul><li>Define Syncope </li></ul><ul><li>Provide an Overview of Synco...
Case Presentation <ul><li>“Jackie” is a 54 year-old woman with  Down Syndrome </li></ul><ul><li>And a history of  seizure ...
Case Presentation: HPI <ul><li>3 episodes of syncope over the previous 8 months </li></ul><ul><li>Jackie gets up at 4 am t...
Case Presentation: HPI <ul><li>No overt seizure activity </li></ul><ul><li>No injuries  </li></ul><ul><li>No pain </li></u...
Case Presentation: Medications <ul><li>Exelon </li></ul><ul><li>Neurontin </li></ul><ul><li>Tegretol </li></ul><ul><li>Ser...
Case Presentation: PMH <ul><li>Seizure Disorder  </li></ul><ul><li>(“Epilepsy with occasional tendency for tonic-clonic Se...
Case Presentation <ul><li>Family History: </li></ul><ul><li>Significant for breast cancer (mother) </li></ul><ul><li>Socia...
Physical Exam <ul><li>Vitals:  Afebrile BP: 90/58 HR: 60 </li></ul><ul><li>Gen:  well-appearing, slightly sleepy woman who...
Initial Impression <ul><li>Recurrent syncope </li></ul>
Definition of Syncope <ul><li>Sudden, transient loss of consciousness due to cerebral hypoperfusion </li></ul><ul><li>Asso...
Syncope Stats <ul><li>Common clinical problem:  </li></ul><ul><ul><li>1/3 of people will experience an episode of syncope ...
Syncope Stats  continued <ul><li>Predictors of Cardiac Causes of Syncope include: </li></ul><ul><ul><ul><li>Cardiovascular...
Differential Diagnosis of Syncope: Non-Cardiac vs Cardiac <ul><li>Non -Cardiac: </li></ul><ul><li>N eurocardiogenic </li><...
Category 1: Structural Causes of Cardiac Syncope <ul><li>Endo: Aortic Stenosis, Mitral Stenosis, Pulm. Stenosis </li></ul>...
Category 2 :  Arrhythmia as a Cause of Cardiac Syncope <ul><li>Tachy: </li></ul><ul><li>1.  Ventricular Tachycardia </li><...
Category 2:   Arrhythmia as a Cause of Cardiac Syncope <ul><li>Brady </li></ul><ul><li>2 nd  or 3 rd  Degree AV Block </li...
Category 2:  Arrhythmia as a Cause of Cardiac Syncope <ul><li>Bradyarrhythmias continued </li></ul><ul><li>Sick Sinus Synd...
Questions <ul><li>How can we put the differential diagnosis into context? </li></ul><ul><li>Why is it so important to dist...
Study: Context for Approaching Jackie’s Case <ul><li>“ Incidence and Prognosis of Syncope” </li></ul><ul><li>Soteriades E ...
Study Results:  <ul><li>Over an average follow-up period of 17 years, 822 of 7814 male and female participants reported an...
Study Conclusions <ul><li>Neurocardiogenic (vasovagal) syncope: </li></ul><ul><ul><li>Benign </li></ul></ul><ul><ul><li>No...
First Distinction:  Non-cardiac vs Cardiac <ul><li>Non-cardiac causes  </li></ul><ul><li>most often benign </li></ul><ul><...
Jackie:  evidence for non-cardiac causes of syncope <ul><li>Non-Cardiac: </li></ul><ul><li>->  N eurocardiogenic  </li></u...
But:  evidence for cardiac cause of syncope <ul><li>No Seizure Activity  </li></ul><ul><li>No reported prodrome  (nausea, ...
Jackie: Diagnostic Studies <ul><li>Labs: </li></ul><ul><ul><li>CBC </li></ul></ul><ul><ul><li>Complete Metabolic Panel </l...
Jackie: Further Diagnostic Studies <ul><li>24 hour Holter Monitor – performed due to suspected Sick Sinus Syndrome </li></...
Jackie: Update <ul><li>Visit with the Cardiologist </li></ul><ul><li>Choices for Future Follow-up </li></ul><ul><ul><li>Ev...
Jackie: Predicting Mortality <ul><li>Jackie, her caregiver, and her family decide which follow-up measure to pursue. </li>...
*-Abnormal electrocardiogram does not include sinus bradycardia or tachycardia or nonspecific ST- or T-wave changes alone....
What is Jackie’s Prognosis? <ul><li>Abnormal ECG* </li></ul><ul><li>Age older than 45 years </li></ul><ul><li>h/o congesti...
Pop Quiz <ul><li>What are the 3 main categories of Non-Cardiac Causes of Syncope? </li></ul><ul><li>Hint: N-O-N cardiac…. ...
Pop Quiz <ul><li>What are the 2 main categories of Cardiac Causes of Syncope? </li></ul>
Summary <ul><li>Non-Cardiac: </li></ul><ul><li>N eurocardiogenic (vaso-vagal: Reflex Mech.s) </li></ul><ul><li>O rthostati...
Questions?
Thank you!
References & Resources <ul><li>CIS Records </li></ul><ul><li>CP Online: http://cponline.hitchcock.org/ </li></ul><ul><li>E...
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Syncope A Case Presentation Edited

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Syncope A Case Presentation Edited

  1. 1. Syncope Courtney McIlduff, M. Sc. Catherine Florio Pipas, M. D. Dartmouth Medical School
  2. 2. Objectives <ul><li>Present a Clinical Case </li></ul><ul><li>Define Syncope </li></ul><ul><li>Provide an Overview of Syncope Statistics </li></ul><ul><li>Explore the Differential Diagnosis of Syncope </li></ul><ul><li>Review a Study to: </li></ul><ul><ul><li>Establish a framework for approaching the case </li></ul></ul><ul><ul><li>Address the question “Why is it so important to distinguish non-cardiac from cardiac causes of syncope?” </li></ul></ul><ul><li>Predict Prognosis using an AFP Point of Care Guide </li></ul><ul><li>Give a Pop Quiz </li></ul><ul><li>Summarize Key Points </li></ul>
  3. 3. Case Presentation <ul><li>“Jackie” is a 54 year-old woman with Down Syndrome </li></ul><ul><li>And a history of seizure disorder </li></ul><ul><li>Who presents with her caregiver. </li></ul><ul><li>Her chief concern is: “I keep fainting.” </li></ul>
  4. 4. Case Presentation: HPI <ul><li>3 episodes of syncope over the previous 8 months </li></ul><ul><li>Jackie gets up at 4 am to go to the bathroom </li></ul><ul><li>Caregiver hears her fall to the floor </li></ul><ul><li>Caregiver finds Jackie on her back and “unconscious” </li></ul><ul><li>Jackie remains unarousable for about 5 minutes </li></ul><ul><li>Jackie returns to bed </li></ul>
  5. 5. Case Presentation: HPI <ul><li>No overt seizure activity </li></ul><ul><li>No injuries </li></ul><ul><li>No pain </li></ul><ul><li>No shortness of breath </li></ul><ul><li>No h/o preceding balance trouble </li></ul><ul><li>No h/o light-headedness </li></ul><ul><li>No h/o recent illness </li></ul><ul><li>History of low blood pressure (home measurements: 90s/60-70s) </li></ul><ul><li>Taking all medications as prescribed </li></ul>
  6. 6. Case Presentation: Medications <ul><li>Exelon </li></ul><ul><li>Neurontin </li></ul><ul><li>Tegretol </li></ul><ul><li>Seroquel </li></ul><ul><li>Levoxyl </li></ul><ul><li>Ranitidine </li></ul><ul><li>Allergies: No known drug allergies </li></ul>
  7. 7. Case Presentation: PMH <ul><li>Seizure Disorder </li></ul><ul><li>(“Epilepsy with occasional tendency for tonic-clonic Seizures”) </li></ul><ul><li>Conduct Disorder (aggressive outbursts) </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>GERD </li></ul>
  8. 8. Case Presentation <ul><li>Family History: </li></ul><ul><li>Significant for breast cancer (mother) </li></ul><ul><li>Social History: </li></ul><ul><li>Lives with her caregiver </li></ul><ul><li>Participates in a Day Program </li></ul><ul><li>Enjoys X-box </li></ul>
  9. 9. Physical Exam <ul><li>Vitals: Afebrile BP: 90/58 HR: 60 </li></ul><ul><li>Gen: well-appearing, slightly sleepy woman who engages well throughout visit with eye contact and conversation </li></ul><ul><li>CVS: regular rate and rhythm. Grade II/VI Systolic ejection murmur heard best in aortic region </li></ul><ul><li>Pulm: Clear to auscultation bilaterally </li></ul>
  10. 10. Initial Impression <ul><li>Recurrent syncope </li></ul>
  11. 11. Definition of Syncope <ul><li>Sudden, transient loss of consciousness due to cerebral hypoperfusion </li></ul><ul><li>Associated with loss of postural tone </li></ul><ul><li>Usually followed by rapid and complete recovery </li></ul>
  12. 12. Syncope Stats <ul><li>Common clinical problem: </li></ul><ul><ul><li>1/3 of people will experience an episode of syncope in their lifetime </li></ul></ul><ul><li>Incidence increases with age, with sharp rise at 70 years </li></ul><ul><li>Male = female incidence, BUT men more likely to have cardiac cause </li></ul>
  13. 13. Syncope Stats continued <ul><li>Predictors of Cardiac Causes of Syncope include: </li></ul><ul><ul><ul><li>Cardiovascular Disease – strongest predictor of cardiac cause </li></ul></ul></ul><ul><ul><ul><li>History of Stroke or TIA </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul>
  14. 14. Differential Diagnosis of Syncope: Non-Cardiac vs Cardiac <ul><li>Non -Cardiac: </li></ul><ul><li>N eurocardiogenic </li></ul><ul><li>O rthostatic Hypotension </li></ul><ul><li>N eurologic </li></ul><ul><ul><li>Sz </li></ul></ul><ul><ul><li>TIA </li></ul></ul><ul><li>Other: </li></ul><ul><ul><li>Metabolic: hypoglycemia, hypoxia, anemia </li></ul></ul><ul><ul><li>Psychogenic </li></ul></ul><ul><ul><li>Drug-Induced </li></ul></ul><ul><li>Cardiac: </li></ul><ul><li>Structural </li></ul><ul><li>Arrhythmia </li></ul>
  15. 15. Category 1: Structural Causes of Cardiac Syncope <ul><li>Endo: Aortic Stenosis, Mitral Stenosis, Pulm. Stenosis </li></ul><ul><li>Myo: Myocardial Infarction, Hypertrophic Obstructive Cardiomyopathy </li></ul><ul><li>Peri: Tamponade </li></ul><ul><li>Vasc: Aortic Dissection, PE </li></ul>
  16. 16. Category 2 : Arrhythmia as a Cause of Cardiac Syncope <ul><li>Tachy: </li></ul><ul><li>1. Ventricular Tachycardia </li></ul><ul><li>2. Supraventricular Tachycardia </li></ul><ul><li>Diagnosed by ECG </li></ul>
  17. 17. Category 2: Arrhythmia as a Cause of Cardiac Syncope <ul><li>Brady </li></ul><ul><li>2 nd or 3 rd Degree AV Block </li></ul><ul><ul><li>Conduction of impulse from atria to ventricles is delayed </li></ul></ul><ul><ul><li>Atrial impulse fails to reach ventricles </li></ul></ul><ul><ul><li>Due to </li></ul></ul><ul><ul><ul><li>Organic heart disease </li></ul></ul></ul><ul><ul><ul><li>Medication </li></ul></ul></ul><ul><ul><li>Diagnosed by ECG or Holter Monitor </li></ul></ul>
  18. 18. Category 2: Arrhythmia as a Cause of Cardiac Syncope <ul><li>Bradyarrhythmias continued </li></ul><ul><li>Sick Sinus Syndrome (SSS) </li></ul><ul><ul><li>Delayed or failed conduction between sinus node and atria </li></ul></ul><ul><ul><li>Due to </li></ul></ul><ul><ul><ul><li>Inadequate sinus node pacing </li></ul></ul></ul><ul><ul><ul><li>Intrinsic / extrinsic (eg meds) conduction disturbances </li></ul></ul></ul><ul><ul><li>Diagnosed by ECG or Holter Monitor </li></ul></ul><ul><ul><ul><li>Sinus pause (>3 s strongly suggestive of SSS ) </li></ul></ul></ul>
  19. 19. Questions <ul><li>How can we put the differential diagnosis into context? </li></ul><ul><li>Why is it so important to distinguish non-cardiac from cardiac causes of syncope? </li></ul>
  20. 20. Study: Context for Approaching Jackie’s Case <ul><li>“ Incidence and Prognosis of Syncope” </li></ul><ul><li>Soteriades E et al. N Engl J Med 2002;347:878-885 </li></ul><ul><li>Purpose: </li></ul><ul><li>To evaluate incidence, etiology, and prognosis of syncope in Framingham Heart Study participants from 1971 to 1998. </li></ul>
  21. 21. Study Results: <ul><li>Over an average follow-up period of 17 years, 822 of 7814 male and female participants reported an initial episode of syncope </li></ul><ul><li>Incidence of syncope: 6.2 per 1000 person-years </li></ul><ul><li>Etiologies most frequently identified: </li></ul><ul><ul><li>neurocardiogenic (vasovagal) 21.2 % </li></ul></ul><ul><ul><li>cardiac 9.5 % </li></ul></ul><ul><ul><li>orthostatic 9.4 % </li></ul></ul><ul><ul><li>unknown 36.6 % </li></ul></ul><ul><li>Soteriades E et al. N Engl J Med 2002;347:878-885 </li></ul>
  22. 22. Study Conclusions <ul><li>Neurocardiogenic (vasovagal) syncope: </li></ul><ul><ul><li>Benign </li></ul></ul><ul><ul><li>No increased risk of death </li></ul></ul><ul><li>Syncope of unknown and neurologic causes: </li></ul><ul><ul><li>Intermediate increase in risk of death from any cause </li></ul></ul><ul><li>Cardiac syncope: </li></ul><ul><ul><li>Increased risk of death by a factor of 2 </li></ul></ul><ul><ul><li>Increased risk of cardiovascular events </li></ul></ul><ul><li>Soteriades E et al. N Engl J Med 2002;347:878-885 </li></ul>
  23. 23. First Distinction: Non-cardiac vs Cardiac <ul><li>Non-cardiac causes </li></ul><ul><li>most often benign </li></ul><ul><li>self-limited </li></ul><ul><li>Cardiac </li></ul><ul><li> high incidence of subsequent cardiac arrest (~24%) </li></ul><ul><li> higher mortality rate </li></ul>
  24. 24. Jackie: evidence for non-cardiac causes of syncope <ul><li>Non-Cardiac: </li></ul><ul><li>-> N eurocardiogenic </li></ul><ul><ul><li>Micturition </li></ul></ul><ul><li>-> O rthostatic Hypotension </li></ul><ul><ul><li>Documented h/o hypotension </li></ul></ul><ul><ul><li>Timing of incident: rising from bed to go to bathroom </li></ul></ul><ul><li>-> N eurologic </li></ul><ul><ul><li>Documented Seizure disorder </li></ul></ul>
  25. 25. But: evidence for cardiac cause of syncope <ul><li>No Seizure Activity </li></ul><ul><li>No reported prodrome (nausea, diaphoresis) </li></ul><ul><li>No triggers (prolonged standing, heat, pain, fear, exercise) </li></ul><ul><li>No Recent Medication Changes </li></ul><ul><li>Multiple episodes over short period  serious underlying condition </li></ul><ul><li>Down Syndrome – associated with cardiac abnormalities </li></ul>
  26. 26. Jackie: Diagnostic Studies <ul><li>Labs: </li></ul><ul><ul><li>CBC </li></ul></ul><ul><ul><li>Complete Metabolic Panel </li></ul></ul><ul><ul><li>TSH </li></ul></ul><ul><ul><li>Tegretol Level </li></ul></ul><ul><ul><li> all within normal limits </li></ul></ul><ul><li>ECG : sinus bradycardia </li></ul><ul><li> American College of Emergency Physicians recommends ECG if Hx and PE do not provide dx </li></ul>
  27. 27. Jackie: Further Diagnostic Studies <ul><li>24 hour Holter Monitor – performed due to suspected Sick Sinus Syndrome </li></ul><ul><li>Results: </li></ul><ul><ul><li>Avg HR: 55 (min = 36, max = 98) </li></ul></ul><ul><ul><li>Sinus Rhythm </li></ul></ul><ul><ul><li>395 pauses </li></ul></ul><ul><ul><ul><li>Longest 2.7 seconds </li></ul></ul></ul>                                                   
  28. 28. Jackie: Update <ul><li>Visit with the Cardiologist </li></ul><ul><li>Choices for Future Follow-up </li></ul><ul><ul><li>Event Monitor </li></ul></ul><ul><ul><li>Implantable Loop Recorder </li></ul></ul><ul><ul><li>Permanent Pacemaker…. </li></ul></ul>
  29. 29. Jackie: Predicting Mortality <ul><li>Jackie, her caregiver, and her family decide which follow-up measure to pursue. </li></ul><ul><li>In the interim, is there a way to predict her one year mortality rate? </li></ul>
  30. 30. *-Abnormal electrocardiogram does not include sinus bradycardia or tachycardia or nonspecific ST- or T-wave changes alone. Ebell, Mark H. Syncope: initial evaluation and prognosis. American Family Physician 2006; 74(8): 1367-70. 27 3 or 4 16 2 9 1 1 0 One-year mortality rate (%) Number of risk factors History of ventricular arrhythmia History of congestive heart failure Age older than 45 years Abnormal electrocardiogram * Risk factors “ First Syncope Rule” Clinical Risk Score for Predicting One-Year Mortality in Patients with Syncope
  31. 31. What is Jackie’s Prognosis? <ul><li>Abnormal ECG* </li></ul><ul><li>Age older than 45 years </li></ul><ul><li>h/o congestive heart failure </li></ul><ul><li>h/o ventricular arrhythmia </li></ul><ul><li>No  0 </li></ul><ul><li>Yes  1 </li></ul><ul><li>No  0 </li></ul><ul><li>No  0 </li></ul><ul><li>_____________________ </li></ul><ul><li>Total 1 risk factor </li></ul><ul><li>= 1% 1-year mortality rate </li></ul>
  32. 32. Pop Quiz <ul><li>What are the 3 main categories of Non-Cardiac Causes of Syncope? </li></ul><ul><li>Hint: N-O-N cardiac…. </li></ul>
  33. 33. Pop Quiz <ul><li>What are the 2 main categories of Cardiac Causes of Syncope? </li></ul>
  34. 34. Summary <ul><li>Non-Cardiac: </li></ul><ul><li>N eurocardiogenic (vaso-vagal: Reflex Mech.s) </li></ul><ul><li>O rthostatic Hypotension </li></ul><ul><li>N eurologic </li></ul><ul><ul><li>Sz </li></ul></ul><ul><ul><li>TIA </li></ul></ul><ul><li>Other: </li></ul><ul><ul><li>Metabolic: hypoglycemia, hypoxia, anemia </li></ul></ul><ul><ul><li>Psychogenic </li></ul></ul><ul><ul><li>Drug-Induced </li></ul></ul><ul><li>Cardiac: </li></ul><ul><li>Arrhythmia </li></ul><ul><ul><li>Tachy </li></ul></ul><ul><ul><ul><li>VT </li></ul></ul></ul><ul><ul><ul><li>SVT </li></ul></ul></ul><ul><ul><li>Brady </li></ul></ul><ul><ul><ul><li>AV Block </li></ul></ul></ul><ul><ul><ul><li>Sick Sinus </li></ul></ul></ul><ul><li>Structural </li></ul><ul><ul><li>Endo: AS, MS, PS </li></ul></ul><ul><ul><li>Myo: MI, HOCM </li></ul></ul><ul><ul><li>Peri: tamponade </li></ul></ul><ul><ul><li>Vasc: aortic dissection, PE </li></ul></ul>
  35. 35. Questions?
  36. 36. Thank you!
  37. 37. References & Resources <ul><li>CIS Records </li></ul><ul><li>CP Online: http://cponline.hitchcock.org/ </li></ul><ul><li>Ebell, Mark H. Syncope: initial evaluation and prognosis. American Family Physician 2006; 74(8): 1367-70. </li></ul><ul><li>Elpidoforos, Soteriades, S., Evans, Jane C., Larson, Martin G., Chen, Ming Hui, Chen, Leway, Benjamin, Emelia J., and Levy, Daniel. Incidence and prognosis of syncope. New England Journal of Medicine 2002; 347:878-885. </li></ul><ul><li>Olshansky, B (2006).Pathogenesis and etiology of syncope. Retrieved January, 2007 from http://www.uptodateonline.com </li></ul><ul><li>Sabatine, M. S. (2004). Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine New York: Lippincott Williams & Wilkins. </li></ul>

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