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  1. 1. SYNCOPE<br />Nathan Mjos, D.O. PGY4<br />ARMC Emergency Dept<br />July 20, 2011<br />
  2. 2. Defined as as a transient loss of consciousness and postural tone characterized by rapid onset, short duration and spontaneous recovery due to global cerebral hypoperfusion that most often results from hypotension <br />Syncope:<br />
  3. 3. Accounts for 1-3% of annual ER visits<br />Accounts for 6% of hospitalizations<br />Highest incidence in elderly population as well as highest morbidity <br />Distinct entity from dizziness or vertigo<br />Incidence<br />
  4. 4. Reflex:Cardiac: Dysrhythmias<br />Vasovagal Structural cardiopulmonary disease Bradyarythmias<br />Situational Valvular heart disease Stokes-Adams <br />Carotid sinus syndrome Aortic/tricuspid/mitral stenosis Sinus node disease<br />Orthostatic hypotensioncardiomyopathy 2nd or 3rd degree block<br />Psychiatric Pulmonary HTN Pacemaker malfunction<br />Neurologic: Congenital heart disease Ventricular tachycardia<br />TIA MyxomaTorsades de pointes<br />Subclavian steal Pericardial disease SVT<br />Migraine Aortic dissection Atrial fibrillation<br />Medications Pulmonary embolism Atrial flutter<br />Breath Holding (peds) Myocardial ischemia<br />Causes<br />
  5. 5. AntihypertensivesPhenothiazines<br />B-blockers Nitrates<br />Cardiac glycosides Alcohol<br />Diuretics Cocaine<br />Antidysrhythmics Antipsychotics<br />Antipsychotics<br />Antiparkinsonism drugs<br />Common Drugs Implicated<br />
  6. 6. EKG findings<br />
  7. 7. Diagnostic rate of 20-50% in the ER<br />Definitive diagnosis in 15-30% of inpatients after thorough work-up<br />Framingham Heart Study reported 822 episodes of syncope in 7814 patients over 17 year period1:<br />Vasovagal (21%)<br />Cardiac (10%)<br />Orthostatic (9%)<br />Unknown (37%)<br />
  8. 8. Orthostatic hypotension defined as fall in SBP of 20 mm Hg upon assuming upright position<br />5 – 55% of patients with orthostatic hypotension also have other identifiable causes of syncope2<br />Asymptomatic orthostatic hypotension found in 40% patients > 70 years old<br />Orthostatics (and IM)<br />
  9. 9. The emergency physician must identify those relatively few patients with life-threatening processes (e.g., dysrhythmias, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, acute coronary syndromes) and those other patients who may benefit from intervention (e.g., patients with bradycardia, medication-induced orthostatic hypotension)<br />ACEP 2007 recommendations<br />
  10. 10. Martin et al 19973:<br />252 syncope patients <br />Validated cohort 374 patients<br />Predictors of arrhythmia or 1-year mortality:<br />Abnormal EKG<br />h/o ventricular arrhythmia<br />h/o CHF<br />Age > 45<br />End point arrhythmia or death at 1 year 0% with 0 risk factors and 27% with 3-4 risk factors<br />Study Support<br />
  11. 11. Colivicchi et al 2007<br />The OsservatorioEpidemiologicosullaSincopenel Lazio (OESIL) score<br />270 syncope patients, validated with 328 patient cohort<br />End point was death at 1 year<br />Sensitivity 95%, Specificity 31%<br />Found that age, abnormal EKG, lack of prodrome, h/o cardiovascular disease, and heart failure are all reliable predictors of adverse events at 1 year in syncope patients<br />
  12. 12. 684 patients with syncope<br />Adverse events recorded at 7 days<br />0 factors considered low risk<br />Sensitivity 86%, Specificity 49%<br />C – CHF<br />H – Hematocrit < 30%<br />E – abnormal EKG (new changes or nonsinus rhythm) <br />S – systolic BP < 90<br />S – Shortness of breath<br />San Francisco Syncope Study<br />
  13. 13. History, history, history…<br />Vitals: persistent hypotension suggestive of another disease process<br />EKG: diagnostic in < 5%<br />Continuous cardiac monitoring: predictors of arrhythmia in 72 monitor – initial abnormal EKG, male sex, age > 65, h/o heart disease<br />Diagnostic Testing<br />
  14. 14. Laboratory testing: little diagnostic value other than hematocrit (less than 30% associated with poor outcome)5<br />Routine CT of the head NOT recommended<br />Independent testing scores result in higher admission rates (SFSR 40%, OEDIL 43%) than clinical judgement alone (34%)6<br />
  15. 15. Soteriades ES, Evans JC, Larson MG, et al: Incidence and prognosis of syncope. New Engl J Med 347:878, 2002.<br />Atkins D, Hanusa B, Sefcik T, et al: Syncope and orthostatic hypotension. Am J Med 91:179, 1991.<br />Martin TP, Hanusa BH, Kapoor WN. Risk stratification of patients with syncope. Ann Emerg Med. 1997;29:459-466.<br />ColivicchiF, Ammirati F, Melina D, et al. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J. 2003;24:811-819.<br />Quinn JV, Stiell IG, McDermott DA, et al. Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004;43:224-232. 23. Calkins H, Shyr Y, Frumin H, et al.<br />Serrano LA, Hess EP, Bellolio F, et al. Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2010;56:362-373.<br />References<br />