Syncope

Abdul Gofir
Blok 18
Syncope (Greek – to interrupt)

 Syncope is the sudden

transient loss of
consciousness and
postural tone with
spontaneous recovery.
 Loss of
consciousness occurs
within 10 seconds of
hypoperfusion of the
reticular activating
system in the mid brain.
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
Syncope: scope of the problem
 Common
 3% Emergency Department visits
 1-6% hospital admissions
 Costly
 Multiple diagnostic tests often performed
 Average charge for each diagnostic test ranges
from $284 to $4678
Linzer, Ann Intern Med, 1997
 Diagnostic Challenges
 History often unclear
 Prognosis varies widely
 Common etiologies are benign

 Potentially high mortality

 Need to identify high-risk patient early

 Many available tests

 40% of patients may elude diagnosis
 Syncope: management questions

Diagnostic challenges
 What is the best diagnostic test?

 How and when to rule out arrhythmia?

 How to diagnose neurocardiogenic syncope?

 How to decrease the # “idiopathic”?

Management dilemmas
 When to admit?

 How are the elderly different?

 When to resume driving?

Case Presentation
 50 yo healthy woman, standing at church
 Becomes weak, lightheaded, & nauseated

 Collapses, awakens after 1 minute

 Feels well in ED - “I want to go home”

 Normal exam, EKG, labs, CXR

 Diagnosis?
 Plan - Admit? Further testing?
Glassman, Arch Intern Med, 1997
Etiology of Syncope
Idiopathic 34%
Neurally-mediated
Vasovagal 18%
Other (situational, carotid sinus) 6%
Cardiac
Arrhythmia 14%
Mechanical 4%
Neurologic 10%
Orthostatic 8%
Medications 3%
Psychiatric 2%
Linzer, Ann Intern Med, 1997
The Key to Diagnostic Evaluation

History and Exam establish diagnosis in 45%

 History: setting, symptoms, medical hx, meds
 Exam: HR, BP, cardiovascular, neurologic
EKG adds 5% diagnostic yield

 Cheap, non-invasive, readily available

 Can indicate important cardiac disease
 Prior MI, ventricular hypertrophy, long QT

 Bradycardia, conduction block

Abnormalities guide further testing

Diagnostic Algorithm
Syncope

Cardiac Noncardiac Idiopathic

Arrhythmia Neurocardiogenic
Mechanical Orthostatic
Neurologic
Psychiatric
 Cardiac syncope:
inadequate cardiac output, arrhythmia
Cardiac enzymes - only if history or EKG suggestive of MI
– 1-10% MI’s present with syncope
– EKG up to 100% sensitive for MI
Echo - rule out structural heart disease
– before stress test if obstruction suspected
– yield: 5-10%
Exercise stress test - exertional syncope
– identifies exertional arrhythmia
– yield: low (1%)
Georgeson, J Gen Intern Med, 1992
Linzer, Ann Intern Med, 1997
 Arrhythmia evaluation - telemetry
 Indication: suspected arrhythmia
 palpitations, no prodrome

 Idiopathic syncope or underlying heart disease

 Routine telemetry low yield

 2240 non-ICU telemetry patients

 10% syncope/dizzy

all syncope
ICU transfer-arrhythmia 0.8% 0.4%
Telemetry “Helpful” 12.6% 16%
Mortality 0.9% 0
Estrada, Am J Cardiol, 1995
Linzer, Ann Intern Med, 1997
Estrada, Am J Cardiol, 1995
 Arrhythmia evaluation:
24 hr ambulatory (Holter) monitoring

2612 syncope/dizzy patients

• Symptomatic arrhythmia = positive result

• Diagnostic arrhythmia in 4%

• Symptoms without arrhythmia

• Arrhythmia ruled out in 15%

Bottom line
• Benefit: monitors during usual activity

• Limitation: brief duration limits yield unless daily

symptoms
Linzer, Ann Intern Med, 1997
Arrhythmia evaluation: improving the yield

– Loop recorder
– Indication: recurrent syncope with normal heart

– frequent syncope -> continuous loop recorder (weeks)

– infrequent syncope -> implantable loop recorder (years)
– Electrophysiologic study
– Indication: syncope with organic heart disease

– Signal average EKG

– Detects late potential in QRS - substrate for VT/VF

– indication: normal heart, idiopathic syncope?

Linzer, Ann Intern Med, 1997

Zimetbaum , Ann Intern Med, 1999
 Reflexive
Vasodepressor
Micturition
Orthostatic
intolerance

Neurocardiogenic
Syncope
Vasovagal
Carotid sinus syncope
Neurally - mediated
Cardioneurogenic
 Neurocardiogenic Syncope
Clinical Presentation
140 Trigger
May be predominantly 120
 Cardioinhibitory
100
 (bradycardia)
80 Blood
 Vasodepressor pres sure
60 Pulse
 (hypotension) or
40
 Both Syncope
20
0
2 4 6 8
time (minutes)
Neurocardiogenic Syncope:
Pathophysiology
Decreased venous return

Increased LV contractility

Mechanoreceptor
Stimulation

Inhibits Increases
Sympathetic tone Vagal tone

Vasodilation Bradycardia/
Asystole

Hypotension SYNCOPE

SYNCOPE
 Diagnosing neurocardiogenic
syncope by history and exam

 Precipitant
 Vasovagal: pain, emotion, standing
 Situational: vagal stimulus
 Autonomic symptoms
 Rapid recovery of mental status
 Bradycardia, pallor may persist
 Carotid sinus massage
 >3 sec asystole or hypotension=hypersensitivity
Neurocardiogenic syncope: treatment

Indicated for frequent syncope

 Lifestyle modification
 Add salt, avoid triggers

 Handgrip, tense arms and legs

 Medications
 B blocker, SSRI, midodrine, fludrocortisone

 Repeat tilt test on therapy?

 Pacemaker
 Is Laughter Really the Quic kT i me™ and a
T IFF (U nc ompres s ed) dec ompres s or
are needed t o s ee thi s pi c ture.

Best Medicine?
 “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.
 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.”
Braga. Lancet 2005
 Tilt table testing
• Goal: provoke
neurocardiogenic syncope

• Indication: recurrent
unexplained syncope
without cardiac disease

60-80˚ • Protocol: passive tilt 45-60 min

• positive response reproduces
symptom
Tilt table testing:
why the controversy?
 Accuracy difficult to define
 Gold standard?
 Protocol?
 Reproducibility 71-87%

 Positive tilt test with idiopathic syncope:

 49% with passive tilt
 66% with tilt plus isoproterenol
 Tradeoff: decreased specificity

Kapoor, Am J Med, 1994

Vasovagal syncope: pacemakers ineffective

Randomized double-blind trial

DDD pacer vs. sensing-only pacer
100
90
80
70
% 60
50 p = NS DDD pacer
placebo
40
30
20
10
0
syncope presyncope
Connolly, JAMA 2003
 “Idiopathic” syncope:
improving diagnostic yield
 Up to 40% patients
 Prognosis good
 Potential morbidity, lifestyle implications
 Consider:
Diagnosis Testing
Neurocardiogenic Tilt table
Anxiety/depression Psychiatric evaluation
Arrhythmia EPS, implanted event monitor
 Empiric pacemaker?
 Prognosis:
Framingham 25 year follow up

Etiology of syncope Adjusted risk of

death
Cardiac 2.01*
Neurologic 1.54*
Idiopathic 1.32*
Vasovagal 1.08

*p<0.01
NEJM 2002;347:878
 Prognosis:
ED risk stratification

 ED predictors of Arrhythmia or death

at one year
arrhythmia or
80%
mortality 70%
60%
 Abnormal EKG
50%
 Prior VT/VF 40%
30%
 History of CHF 20%
10%
 Age > 45 0%
0 1 2 3 or 4
Number of
Martin, Ann Emerg Med, 1997 risk factors
 Prognosis:
Guideline for admission - the San
Francisco Syncope Rule
 Prediction rule to identify patients at risk of bad
outcomes (need admit) over 30 days
 Death, MI, arrhythmia, PE, stroke, transfusion

 Syncope or related event requiring procedure, ED

visit or admit
 First assess the patient for cause of syncope
 If cause unknown, apply the rule
Quic k Ti me™ and a

 98% sensitive
T IFF (Unc om pres s ed) dec om pres s or
are needed to s ee t his pic t ure.

 56% specific

Quinn, Ann Emerg Med, 2006

Prognosis:
Guideline for admission - the San
Francisco Syncope Rule

 CHF - history of
QuickTime™ and a
TIFF ( Uncompressed) decompressor

 Hematocrit <30% are needed to see this pictur e.

 ECG abnormal
 Shortness of breath
 Systolic blood pressure <90 mm
Hg at triage
Quinn, Ann Emerg Med, 2006
ACP Guidelines for Hospital
Admission

Definitely admit Often admit

 HPI: chest pain  HPI: age >70,
exertional syncope,
 PMH: CAD, CHF,
frequent syncope
ventricular arrhythmia
 Exam: tachycardia,
 Exam: CHF, valve dz, orthostatic hypotension,
focal neurologic deficit injury
 EKG: ischemia/MI,  Cardiac dz suspected

arrhythmia, bundle
branch block Linzer, Ann Intern Med, 1997
 Guidelines for Hospital Admission:
implications for practice
 Myth: Every syncope patient should be admitted
 Recommendation: Establish clear goals for admission,
usually diagnostic

 Myth: Every syncope patient requires “rule out MI”

 Recommendation: Admission not necessary with careful
history ruling out symptoms of ischemia and normal EKG

 Myth: Telemetry improves outcomes

 Recommendation: One-year mortality rarely affected by 24
hours of monitoring
Syncope in the elderly:
the geriatric challenge
 History often obscure
 Syncope vs. dizziness vs. fall?

 Often multifactorial - elderly at high risk for

 Situational syncope

 Polypharmacy, adverse drug events

 Cardiac, neurovascular disease

 Decreased physiologic reserve

 Atypical presentation of disease

 Abnormalities do not prove causation

Recommendations for Driving:
following the law
 Laws vary by state - available from DMV
 California law requires reporting of any loss of
consciousness
QuickTime™ and a
 County health officer receives report TIFF (Uncompressed) decompressor
are needed to see this picture.

 DMV determines fitness to drive

 Physician can provide influential prognostic

information to DMV
 Physicians’ recommendations variable
 Awareness of law often poor
 American Heart Association
Guidelines for Driving
 VT/VF (treated with medical or ICD therapy)
 Risk greatest 1st 6 mo, up to 10% at 1 year
 Resume driving: 6 months arrhythmia free
 Bradycardia with syncope
 Resume driving: 1 week after pacemaker
 Neurocardiogenic syncope -> risk stratify
 Mild: presyncope, clear warning & precipitant
 Resume driving: immediately

 Severe: syncope, no warning or precipitant, frequent

 Resume driving: after therapy, waiting period (duration?)
Thank for attention
Reference from Lecture
Karen E. Hauer, MD
University of California,
San Francisco