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AN APPROACH TO A PATIENT
WITH SYNCOPE
BY:
Dr. Tikal Kansara
R2 Medicine D Unit
What is Syncope?
• Transient, self-limited loss of consciousness
with an inability to maintain postural
tone that is follo...
• Pre-Syncope/ Almost fainting:
– A state consisting of lightheadedness, muscular
weakness, blurred vision, and feeling fa...
• Vertigo
– A sensation of rotation of one’s self (subjective
vertigo) or one’s surroundings (objective vertigo)
in any pl...
Why is it important?
• Syncope can be an isolated benign, stand
alone incident or it can be a trigger of some
serious life...
MECHANISM OF SYNCOPE
• Syncope is the result of global cerebral
hypoperfusion.
• Brain parenchyma cannot store high energy...
Reproduced From: European Heart Journal (2009) 30, 2631–2671
BIO DATA
• Age:
– Two peaks:
• With median of 15 years – VVS (Vasovagal Syncope) is
more common
• With old age patients – ...
HISTORY
• Hx and PE are perhaps the two most
important aspects in diagnosis of Syncope.
• These (Hx & PE) with 12 lead ECG...
KEY ASPECTS IN HISTORY
• The three main points on which the etiology
of syncope can be determined are:
– Precipitant Facto...
Precipitant Factors
• Fatigue
• Food and water deprivation
• Warm and ambient enviornment
• Alcohol
• Pain
• Specific Phob...
Activity prior to the episode
• If occurred at rest
• Change in posture
• On exertion / after exertion
• Specific Situatio...
Position of the patient
• Whether the patient was standing, sitting,
lying down when the syncope occurred.
• Syncope while...
Important Hx questions about the
attack
• Was the loss of consciousness complete?
• Was loss of consciousness with rapid o...
Other associated complaints
• Prior faintness, dizziness, or light-headedness
– denotes p/o syncope in 70 % of patients
• ...
Some Red Flag Signs
• These when present should prompt for further
evaluation of the patient
• These includes:
– Exertiona...
After episode
• Ask about the duration of loss of consciousness
– If in seconds to minutes – p/o Syncope
– If more than th...
MEDICATION HISTORY
• Reduce BP - Anti-hypertensives, diuretics,
nitrates
• Affect Cardiac Output – Beta-blockers,
digitali...
PAST MEDICAL HISTORY
• Cardiac Etiology
– MI, Arrythmias, Structural cardiac diseases,
Cardiomyopathies, CHF, abdominal ao...
PHYSICAL EXAMINATION
• VITALS:
– Temperature : Fever – UTI or Pneumonia
– Pulse:
• Tachycardia – PE, Hypovolemia, tachyarr...
• Higher Functions:
– Patients with genuine syncope should have a
normal baseline mental status
– If confusion, abnormal b...
Causes of Syncope
Reproduced From: European Heart Journal (2009) 30, 2631–2671
CAUSES OF SYNCOPE
• Reflex (Neurally-mediated) syncope NMS
– Vasovagal
• Emotional stress, fear, pain, blood phobia, instr...
Orthostatic Hypotension
• Fall in systolic BP by 20 mmHg or more and/or fall
in diastolic BP by 10 mmHg or more or systoli...
• Orthostatic hypotension
– Primary autonomic failure
• Pure autonomic failure, Parkinson’s disease with
autonomic failure...
Reproduced From: European Heart Journal (2009) 30, 2631–2671
• Cardiac Syncope
– Arrythmias as primary cause:
• Bradycardia:
– Sinus node dysfunction
– AV conduction disease
– Implant...
• Cardiac Syncope
– Structural disease (Cardiac)
• Valvular heart disease, Acute MI/ischemia, HOCM,
Cardiomyopathy, Cardia...
Reproduced From: European Heart Journal (2009) 30, 2631–2671
CONDITIONS MISDIAGNOSED AS
SYNCOPE
• With partial or T-LOC w/o global cerebral hypoperfusion
– Epilepsy
– Metabolic disord...
RISK STRATIFICATION
• SAN FRANCISCO SYNCOPE RULE (SFSR)
– Abnormal ECG
– Congestive Cardiac Failure
– Shortness of breath
...
DIAGNOSTIC TESTS
• ECG is most important investigation which
helps suffice the diagnosis in most of the
situations
• If that does not help ...
Carotid Sinus Massage
• Indicated in patients > 40 years of age with
syncope of unknown etiology after initial
evaluation
...
CAROTID SINUS MASSAGE (CSM)
ACTIVE STANDING
TILT TABLE TESTING
Interpretation Of Tilt Table Test (TTT)
VASIS CLASSIFICATION
• Type 1 – Mixed. Both HR and BP are reduced. BP
reduction pr...
Reproduced from: Journal of American College Of Cardiology
ELECTROCARDIOGRAPHIC MONITORING
• Conventional Ambulatory Holter Monitoring
• In-Hospital Monitoring
• Event Recorders
• E...
In-Hospital Monitoring
• Indicated only when the patient is at high risk
of a life-threathening arrythmia
• To be applied ...
Holter Monitoring
• Conventional 24 – 48
hour, or even 7 days,
Holter recorders.
• Yield may be as low
as 1 – 2 %
External Loop Recorders
• These devices have a loop memory which
records and deletes ECG
• When activated by the patient t...
Implantable Loop Recorders (ILRs)
• Life span of 36 months
• Solid state loop memory that stores
retrospective ECGs when a...
Reproduced From: http://openi.nlm.nih.gov/
Reproduced From: Hall-Garcia Cardiology, Texas
Remote (at home) Telemetry
• External and implantable device systems are
available that are able to provide continuous
ECG...
ELECTROPHYSIOLOGICAL STUDY (EPS)
Echocardiography
• For patients suspected of having a structural
heart disease
Psychiatric Evaluation
• Various psychiatric drugs can precipitate
syncope through OH and prolonging QT
interval
• However...
• Functional Attacks
– Pseudoseizures
– Pseudosyncopes
NEUROLOGICAL INVESTIGATIONS
• Electroencephalogram
• CT/MRI
• Neurovascular Studies
– Doppler USG
TREATMENT
• Principal goals:
– Prolong survival
– Limit physical injuries
– Prevent recurrences
TREATMENT OF REFLEX SYNCOPE
• Lifestyle modifications
– Aviodance of possible triggers
– Early recognition of prodromal sy...
Pharmacological considerations
• α – agonists
– Midodrine
• Fludrocortisone
– Some benefits in adults with reflex syncope
...
Individual considerations
• For VVS
– Tilt table testing
• To make patients familiarize with prodromal symptoms
– PCMs (Ph...
ORTHOSTATIC HYPOTENSION &
OTHROSTATIC INTOLERANCE
• Principal Goals
– Expansion of ECF volume
• In absence of hypertension...
• Sleeping with head end of bed elevated (10◦)
• For gravitational venous pooling
– Abdominal binders or compressive stock...
Other treatment Modalities
• Octreotide
– Post prandial hypotension
• Erythropoetin
– Anaemia
• Pyridostigmine
• Frequent ...
CARDIAC CAUSE - TREATMENT
• Treat the underlying cause
Syncope in the elderly
• Most common cause of syncope are OH, reflex
syncope (especially CSS) and cardiac
arrythmias
• Syn...
• OH is not always repeatable in the elderly
(particularly medication and age related).
Therefore, orthostatic BP appraisa...
Driving and Syncope
• In a large study, 9.8 % had syncope while
driving, which was commonly reflex (37 %) or
cardiac (12%)...
Refereneces
• eMedcape Website
• European Society Of Cardiology (ECS); European
Heart Journal
• www.dizziness-and-balance....
Dr. Tikal Kansara
IInd Year Resident
SSG Hospital & Medical College,
Vadodara
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An approach to a patient with Syncope

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Syncope

  1. 1. AN APPROACH TO A PATIENT WITH SYNCOPE BY: Dr. Tikal Kansara R2 Medicine D Unit
  2. 2. What is Syncope? • Transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. with global cerebral hypoperfusion Aka swoon, blackout, collapse, faint
  3. 3. • Pre-Syncope/ Almost fainting: – A state consisting of lightheadedness, muscular weakness, blurred vision, and feeling faint (as opposed to a syncope, which is actually fainting). •Faintness Sensation of impending loss of consciousness •Giddiness Having a reeling, light headed sensation A feeling of unease and unsteadiness
  4. 4. • Vertigo – A sensation of rotation of one’s self (subjective vertigo) or one’s surroundings (objective vertigo) in any plane. • Dizziness – Vertigo – Syncope – Nonsyncope Nonvertigo • Patients feel that they cannot keep their balance • May become worse on movement
  5. 5. Why is it important? • Syncope can be an isolated benign, stand alone incident or it can be a trigger of some serious life threatening condition; most likely CARDIAC. • Hence, it is important to be vigilante to scrutinize this symptom
  6. 6. MECHANISM OF SYNCOPE • Syncope is the result of global cerebral hypoperfusion. • Brain parenchyma cannot store high energy phosphate bonds like other cells of the body hence depends on the constant supply of glucose for its survival. • Typically cessation of blood supply for 3 to 5 seconds results in syncope.
  7. 7. Reproduced From: European Heart Journal (2009) 30, 2631–2671
  8. 8. BIO DATA • Age: – Two peaks: • With median of 15 years – VVS (Vasovagal Syncope) is more common • With old age patients – Cardiac & OH is more common • Sex: More common in females • Occupation: – Common in painters, formal clothing (tight collar and tie)
  9. 9. HISTORY • Hx and PE are perhaps the two most important aspects in diagnosis of Syncope. • These (Hx & PE) with 12 lead ECG is the only Level A recommendation for diagnosis of Syncope; according to 2007 American College of Emergency Physicians (ACEP) Clinical Policy on Syncope.
  10. 10. KEY ASPECTS IN HISTORY • The three main points on which the etiology of syncope can be determined are: – Precipitant Factors – Activity the patient was involved in before the incident – Patient’s position
  11. 11. Precipitant Factors • Fatigue • Food and water deprivation • Warm and ambient enviornment • Alcohol • Pain • Specific Phobias • Strong emotional stimuli such as fear and appprehension
  12. 12. Activity prior to the episode • If occurred at rest • Change in posture • On exertion / after exertion • Specific Situations: – Shaving, coughing, voiding or prolonged standing. • If occurs within 2 minutes of standing denoted OH (Orthostatic Hypotension – Classical).
  13. 13. Position of the patient • Whether the patient was standing, sitting, lying down when the syncope occurred. • Syncope while sitting or lying down most likely is cardiac
  14. 14. Important Hx questions about the attack • Was the loss of consciousness complete? • Was loss of consciousness with rapid onset and short duration? • Was recovery spontaneous, complete, and without sequelae? • Was postural tone lost?
  15. 15. Other associated complaints • Prior faintness, dizziness, or light-headedness – denotes p/o syncope in 70 % of patients • During pre syncopal period – – Vertigo, blurred or faded vision, pallor, or paresthesias , diaphoresis – p/o syncope – Aura – p/o seizures
  16. 16. Some Red Flag Signs • These when present should prompt for further evaluation of the patient • These includes: – Exertional onset – Chest Pain – Dyspnea – Low back Pain – Palpitations – Severe headache – FND (Focal Neurological Deficits) – Diplopia, ataxia or dysarthria
  17. 17. After episode • Ask about the duration of loss of consciousness – If in seconds to minutes – p/o Syncope – If more than that – p/o Seizures • After regaining consciousness, whether the patient was confused, had oral trauma, incontinence or myalgias. • Post event confusion rare in syncope, and when it occurs, its always less than 30 seconds.
  18. 18. MEDICATION HISTORY • Reduce BP - Anti-hypertensives, diuretics, nitrates • Affect Cardiac Output – Beta-blockers, digitalis, antiarrythmics • Prolong QT-interval – TCAs, phenothiazidines, quinine, amiodarone • Alter sensorium – Alcohol, cocaine, analgesics, sedatives • Alter serum electrolytes - Diuretics
  19. 19. PAST MEDICAL HISTORY • Cardiac Etiology – MI, Arrythmias, Structural cardiac diseases, Cardiomyopathies, CHF, abdominal aortic aneurysm • Neurological Etiologies: – H/o Seizure disorder, CVA, DVT • Diabetes
  20. 20. PHYSICAL EXAMINATION • VITALS: – Temperature : Fever – UTI or Pneumonia – Pulse: • Tachycardia – PE, Hypovolemia, tachyarrythmias or ACS • Bradycardia – Cardiac Conduction defects, ACS – BP – for Orthostatic Hypotension – Glucose – Hypoglycemia
  21. 21. • Higher Functions: – Patients with genuine syncope should have a normal baseline mental status – If confusion, abnormal behavior, headache, fatigue or somnolence is present – p/o toxic, metabolic or CNS cause should be considered. • Signs of Trauma- – Head injury, lacerations, extremity fractures – Tongue bite – p/o seizures • Sos Carotid Sinus massage
  22. 22. Causes of Syncope
  23. 23. Reproduced From: European Heart Journal (2009) 30, 2631–2671
  24. 24. CAUSES OF SYNCOPE • Reflex (Neurally-mediated) syncope NMS – Vasovagal • Emotional stress, fear, pain, blood phobia, instrumentation • Mediated by orthostatic stress – Situational • Cough, sneeze, • Gastrointestinal (swallow, defaecation, visceral pain) • Post-exercise • Post-prandial • Others (laugh, brass instrument playing, weightlifting)
  25. 25. Orthostatic Hypotension • Fall in systolic BP by 20 mmHg or more and/or fall in diastolic BP by 10 mmHg or more or systolic BP to < 90 mmHg, when a person assumes a standing position from sitting or supine position. • Classification – Initial OH ( 0 – 30 sec) – Classical OH (30 sec – 3 min) – Delayed (progressive) OH (3 – 30 min) – Delayed (progressive) OH + Reflex syncope (3 – 45 mins)
  26. 26. • Orthostatic hypotension – Primary autonomic failure • Pure autonomic failure, Parkinson’s disease with autonomic failure, Lewy body dementia, multiple system atrophy – Secondary autonomic failure • Diabetes, amyloidosis, uremia, spinal cord injures – Drug-induced orthostatic hypotension • Alcohol, vasodilators, diuretics, antidepressants – Volume depletion • Haemorrhage, diarrhoea, vomitting
  27. 27. Reproduced From: European Heart Journal (2009) 30, 2631–2671
  28. 28. • Cardiac Syncope – Arrythmias as primary cause: • Bradycardia: – Sinus node dysfunction – AV conduction disease – Implanted device failure • Tachycardia – Supraventricular – Ventricular (idiopathic, secondary to structural heart diseases, channopathies) • Drug induced tachycardia and bradycardia
  29. 29. • Cardiac Syncope – Structural disease (Cardiac) • Valvular heart disease, Acute MI/ischemia, HOCM, Cardiomyopathy, Cardiac Mass (Atrial Myxomas, tumors), • Pericardial diseasea/tamponade, congenital anomalies of coronary arteries, prosthetic valve dysfunction – Structural disease (Extra cardiac) • Pulmonary embolus, acute aortic dissection, pulmonary hypertension
  30. 30. Reproduced From: European Heart Journal (2009) 30, 2631–2671
  31. 31. CONDITIONS MISDIAGNOSED AS SYNCOPE • With partial or T-LOC w/o global cerebral hypoperfusion – Epilepsy – Metabolic disorders including hypoglycemia, hypoxia, hyperventilation with hypocapnia – Intoxications – Vertebrobasilar TIA • W/O impairment of consciousness – Cataplexy – Drop attacks – Falls – Functional (psychogenic peudosyncope) – TIA of carotid origin
  32. 32. RISK STRATIFICATION • SAN FRANCISCO SYNCOPE RULE (SFSR) – Abnormal ECG – Congestive Cardiac Failure – Shortness of breath – Haematocrit < 30% – SBP < 90 mmHg • No risk :: score = 0 • Risk of serious events in 7 days :: score >= 1
  33. 33. DIAGNOSTIC TESTS
  34. 34. • ECG is most important investigation which helps suffice the diagnosis in most of the situations • If that does not help then, International Study On Syncope Of Unknown Etiology (ISSUE) investigators advise some further tests.
  35. 35. Carotid Sinus Massage • Indicated in patients > 40 years of age with syncope of unknown etiology after initial evaluation • Contraindicated in patients with previous TIA or stroke in prior 3 months and in patients with carotid bruits • RESULT: Diagnostic if syncope is reproduced in the presence of asystole longer than 3 seconds and/or fall in SBP > 50 mmHg
  36. 36. CAROTID SINUS MASSAGE (CSM)
  37. 37. ACTIVE STANDING
  38. 38. TILT TABLE TESTING
  39. 39. Interpretation Of Tilt Table Test (TTT) VASIS CLASSIFICATION • Type 1 – Mixed. Both HR and BP are reduced. BP reduction precedes HR reduction. HR reduction >10% but never < 40 / min • Type 2 – Cardioinhibitory. Reduction in both HR and BP. BP decrease precedes HR reduction. Minimum HR is < 40/min or ayatole > 3sec • Type 3 – Pure vasodepressor. HR does not decrease to more than 10% • Chronotrophic incompetence - no HR increase in spite of the tilt • Excessive HR rise – POTS (Positional Orthostatic Tachycardia Syndrome)
  40. 40. Reproduced from: Journal of American College Of Cardiology
  41. 41. ELECTROCARDIOGRAPHIC MONITORING • Conventional Ambulatory Holter Monitoring • In-Hospital Monitoring • Event Recorders • External or implantable loop recorders • Remote (at home) telemetry
  42. 42. In-Hospital Monitoring • Indicated only when the patient is at high risk of a life-threathening arrythmia • To be applied immediately after syncope, for a few days, to look for arrhythmic syncope • Yield only 16%
  43. 43. Holter Monitoring • Conventional 24 – 48 hour, or even 7 days, Holter recorders. • Yield may be as low as 1 – 2 %
  44. 44. External Loop Recorders • These devices have a loop memory which records and deletes ECG • When activated by the patient typically after the event, they records and saves the pre- activation 5 – 15 minutes of ECG. • Very less useful in infrequent syncope and requires high patient compliance
  45. 45. Implantable Loop Recorders (ILRs) • Life span of 36 months • Solid state loop memory that stores retrospective ECGs when activated by bystander or patient, usually after a syncopal episode, or automatically in case of an occurrence of predefined arrythmias.
  46. 46. Reproduced From: http://openi.nlm.nih.gov/
  47. 47. Reproduced From: Hall-Garcia Cardiology, Texas
  48. 48. Remote (at home) Telemetry • External and implantable device systems are available that are able to provide continuous ECG recording or 24 hour loop memory, with wireless transmission (real time) to a service center.
  49. 49. ELECTROPHYSIOLOGICAL STUDY (EPS)
  50. 50. Echocardiography • For patients suspected of having a structural heart disease
  51. 51. Psychiatric Evaluation • Various psychiatric drugs can precipitate syncope through OH and prolonging QT interval • However, disruption of anti psychotic medications may have severe psychiatric consequences • These patients may present with “Functional Attacks” of T-LOC
  52. 52. • Functional Attacks – Pseudoseizures – Pseudosyncopes
  53. 53. NEUROLOGICAL INVESTIGATIONS • Electroencephalogram • CT/MRI • Neurovascular Studies – Doppler USG
  54. 54. TREATMENT • Principal goals: – Prolong survival – Limit physical injuries – Prevent recurrences
  55. 55. TREATMENT OF REFLEX SYNCOPE • Lifestyle modifications – Aviodance of possible triggers – Early recognition of prodromal symptoms – Performing maneuvers to abort the episode • Supine position • Physical counterpressure maneuvers (PCMs)
  56. 56. Pharmacological considerations • α – agonists – Midodrine • Fludrocortisone – Some benefits in adults with reflex syncope • β – blockers • Paroxetine
  57. 57. Individual considerations • For VVS – Tilt table testing • To make patients familiarize with prodromal symptoms – PCMs (Physical Counterpressure Maneuvers) • For Situational Syncope • Carotid Sinus Syncope – Dual Chamber Cardiac Pacing
  58. 58. ORTHOSTATIC HYPOTENSION & OTHROSTATIC INTOLERANCE • Principal Goals – Expansion of ECF volume • In absence of hypertension, patient instructed to take sufficient salt and water intake (target 2 – 3 litres and 10 gm NaCl) • Rapid cool water ingestion – Orthostatic intolerance and post prandial hypotension
  59. 59. • Sleeping with head end of bed elevated (10◦) • For gravitational venous pooling – Abdominal binders or compressive stocking • Pharmacological – Midodrine – Fludrocortisone
  60. 60. Other treatment Modalities • Octreotide – Post prandial hypotension • Erythropoetin – Anaemia • Pyridostigmine • Frequent small meals • Judious use of leg and abdominal muscles
  61. 61. CARDIAC CAUSE - TREATMENT • Treat the underlying cause
  62. 62. Syncope in the elderly • Most common cause of syncope are OH, reflex syncope (especially CSS) and cardiac arrythmias • Syncope in morning favors OH • Taking multiple medications, whose withdrawal/overdose leads to syncope
  63. 63. • OH is not always repeatable in the elderly (particularly medication and age related). Therefore, orthostatic BP appraisal should be repeated, preferably in the morning and/or promptly after syncope • CSM is particularly important • Tilt testing is well tolerated and safe • Twenty-four hour ambulatory BP recordings may be helpful if instability of BP is suspected • Due to high frequency of arrythmias, an ILR may be especially useful in elderly with unexplained syncope
  64. 64. Driving and Syncope • In a large study, 9.8 % had syncope while driving, which was commonly reflex (37 %) or cardiac (12%) • The cumulative probability was only 7 % in 8 years • Risk of syncope mediated driving accidents was 0.8% per year
  65. 65. Refereneces • eMedcape Website • European Society Of Cardiology (ECS); European Heart Journal • www.dizziness-and-balance.com • Harrison’s Textbook Of Internal Medicine 17th Edition • Merck Manuals (MSD – online) • American Heart Journal • PubMed (National Institute Of Health –NIH) • Mayo Clinic websites
  66. 66. Dr. Tikal Kansara IInd Year Resident SSG Hospital & Medical College, Vadodara

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