syncope evaluation and management - ohio state …：晕厥的评估和管理-俄亥俄州…

SYNCOPEEVALUATION AND MANAGEMENT,Jayne Barr, MDClinical Assistant ProfessorThe Ohio State University,Case #1,42 year old femaleChief complaint: passing out at workWorks in a pharmaceutical lab. Was sitting at her desk, felt nauseated and knew she was going to pass out.Per witnesses, was slump over chair and was unconscious for a few seconds.,Case continues,No chest pain, palpitations, shortness of breathSimilar episodes 10 years ago.No family history of sudden cardiac deathNo medications.No smoking. No alcohol. No drugs.,Case #2,82 year old male.Found unresponsive by his sonPast medical historyHTNMedicationsHCTZ ExamBP 160/98. P 70. Now alert and oriented. Facial contusions. Otherwise normal exam.Q: How would you manage these 2 patients?,Syncope: Definition,Abrupt and self-limited loss of consciousness associated with absence of postural toneRelatively rapid onset. Variable warning symptoms. Followed by rapid and complete recovery. Last only a few minutes.Absence of prolonged confusionPresyncope-prodromal symptom of fainting and typically has the same work up as syncope.,Significance of Syncope,“The only difference between syncope and sudden death is that in one you wake up”. 1 -anonomymous,Syncope: Epidemiology,20-50% of adults experience at least one episode of syncope during their lifetime.Explained 53-62%Infrequent, unexplained 38-47%500,000 new syncope patients each year. 3-5% of ER visits.6% of hospital visits.More common in the elderly.Up to 23% in age 70 years.,Syncope: Economic Burden,Per recent data, the overall cost per hospital admission was estimated to be about $10,600.One study found to be $17,000 of “unnecessary” testing to diagnosis vasovagal syncopeOverall cost in US estimated to be in excess of $1 billion.,Costs of TestTroponin$78EKG$221Telemetry$255/dHead CT$1545MRI brain$2216Carotid US$1294EST$2492Echocardiogram$809EEG$1115,Causes of Syncope,Morbidity and Mortality,Most cases benign.Syncope of cardiac origin has the highest morbidity and mortality.1 year mortality of 18-33%Recurrence in the elderly population is 30%Syncope of unknown origin.1 year mortality of 6-12%.,Syncope in Children,Generally a benign event.Most common causesVasovagal (40%)Simple faint (29%)Breathholding (4%)Unknown (15%),Rare but serious causes of syncope in children Hypertrophic cardiomyopathyAnomalous origin of left coronary arteryMyocarditisLong QT syndromeCystic medial necrosisWPW,Syncope: Pathophysiology,Decreased cerebral perfusion is common to all causes of syncopeCessation of cerebral perfusion for as little as 3-5 seconds can result in syncopeDecreased cerebral perfusion may occur as a result of decreased cardiac output or decreased systemic vascular resistance.,More Pathophysiology,Bilateral hemisphere dysfunction or reticular activating system (RAS) midbrain knockout.Generally acute hypoperfusion is responsible.Regional (vasoconstriction)Systemic (global hypotension),Loss of consciousness causes loss of postural tone leading to collapse35% reduction in cerebral blood flow will cause syncope.Modifying factorsCardiac outputSystemic and local vascular resistance/occlusionBlood volumeAbility to compensate,Syncope: Etiology,Mnemonic: PASSOUTP-ressue (hypotensive causes)A-rrthymiasS-eizuresS-ugar (hypo/hyper glycemia)O-utput (cardiac)/ O2 (hypoxia)U-nusual causesT-ransient (TIAs, strokes, CNS diseases),More specifics,OUTPUTCardiacAS, PA, MS,IHSSCardiomyopathiesAtrial myoxomasCardiac tamponadeAortic dissectionMI, CHFPulmonaryPE, acute hypoxemiaPulmonary HTNCOPD exacerbationCO poisoning,UNUSUAL CAUSESAnxiety, Panic disorderMajor depressive disorderSomatization disorder (psychogenic syncope)Hyperventilation syndromeMigraine, sleep disorderTRANSIENTTIA (vertebrobasilar), CVA, subdural hematomaSubarachnoid hemorrhageCNS mass effect (tumor)Basilar artery migraine.,Syncope,CAUSES (Head-Heart-Vessels)Reflex mediatedVasovagal, carotid sinus, situationalCardiac Mechanical , arrhythmiasOrthostatic Drugs, autonomic failureCerebrovascular UnknownNonsyncopal causes,Neurally mediated reflex syncope (36-62%); average (24%),Vasovagal, carotid sinus, situationalNo increased risk for cardiovascular morbidity or mortality associated with reflex mediated syncope.,Neurally Mediated Reflex Syncope-what happens?,Stress causes an abnormal autonomic reflexNormal increased sympathetic tone replaced by increased vagal toneVariable contribution of vasodilation and bradycardia.Examples include syncope from:Pain and/or fearCarotid sinus hypersensitivity“situational” (cough, micturition, defecation syncope),Vasovagal syncope,Most common cause of syncope in young adultsPrecipitating event is often identifiableStress, trauma, pain, sight of blood, prolonged standing, heat exposure,Vasovagal Syncope,3 PHASES-ProdromeDiaphoresis, epigastric discomfort, weakness, nausea, dizzinessLasts about 2 minutes-Loss of consciousnessUsually lasts 5-20 seconds-Postsyncopal phaseNausea, dizziness, general sense of poor healthIf present, confusion which lasts no more than 30 seconds,Prevalence of VasoVagal Syncope,Prevalence poorly known (8-37% with mean of 18%)Important pointsPatients with VVS younger than Carotid sinus syndrome patientsAge range teens to elderly with mean 43 yearsPallor, nausea, sweating, palpitations are commonAmnesia for warning symptoms in older patients,Vasovagal Syncope Management,Management for Vasovagal syncope,Optimal management is source of debatePatient education, reassurance, instructionFluids (sports drinks), salt, dietTilt trainingSupport hose (waist high)Drug therapiesPacing (DDD pacing)Class II indication if positive tilt test and cardioinhibitory or mixed reflex,Drug therapies for Vasovagal syncope,Salt/volumeSalt, sports drinks, fludrocortisoneBeta-adrenergic blockers1 positive control study using atenololUse if hx of htn,DisopyramideSSRIs1 controlled studyUse if hx of depressionVasoconstrictors (eg, midodrine)1 negative controlled study (etilephrine)? Efficacy of neosynephrineUse midodrine if significant hypotension,Postural Orthostatic Tachycardia Syndrome,Upright symptoms without hypotension.Upright tachycardiaexcessive HR response to maintain a low normal BP. 500,000 Americans, usually young womenPartial dysautonomiaAntecedent infection, surgery, pregnancyTreatmentlow dose propanolol 10mg tid,Carotid Sinus Syncope,Syncope related to head turning, shaving, wearing a tight collarPathophysiologyCarotid sinus pressure causes a reflex decrease in heart rate and blood pressure,Carotid sinus massage,SiteCarotid arterial pulse just below thyroid cartilageMethodMassage, not occlusion. Right followed by left, pause betweenDuration:5-10 secondsPosture: supine and erectRisks1/5000 massages complicated by TIA,Outcome3 sec asystole and/or 50mmHg fall in systolic blood pressure with reproduction of symptoms =CAROTID SINUS SYNDROMEContraindicationsCarotid bruit, known but significant carotid arterial disease, previous CVA, MI last 3 months.,Situational Syncope,Related to micturition, defecation, swallowing or coughingInduced by baroreceptor and mechanoreceptors causing vagal stimulationCircumstances of the event are typically diagnostic,Orthostatic syncope,When vertical, blood follows gravity and pools.Increased sympathetic tone counteracts this.If the response is inadequate, syncope occurs.Drop in BP: 20 systolic or 10 diastolic within 3 minutes of standingPresent in 40% of patients over 70 years oldMay be due toDrugsVolume lossNeurologic damage,More on Orthostatic Hypotension,Volume lossAssoc. with tachycardiaMedicationsSeen in elderly 45% of timeSituationalMicturition, cough, postprandial, carotid sinus sensitivity, defecation, laughingAdrenal insufficiency,Primary autonomic diseaseIdiopathic, parkinsons disease, multisystem atrophy (Shy-Dragger)Secondary autonomic diseaseNeuropathic (dm, amyloid, alcoholism, autoimmune, vitamin deficiency, etc)CNS (cva, MS, tumors, spinal cord),Cardiac Syncope,Two basic typesDysrhythmia mediatedStructural cardiopulmonary lesionsBoth cause the heart to be unable to sufficiently increase cardiac output to meet demand,Double the risk of mortality compared with other syncopal patients. Up to 50% mortality.Patients with underlying cardiac disease are at greatest risk for cardiac syncope. Only 3% have no previous heart disease.Cardiac arrythymias especially in the elderly have high mortality.,Neurologic Syncope,Rarely the primary cause of syncopeIschemia to the RAS in the brainstem may cause “drop attacks” Results from Vertebrobasilar insufficiency due to TIA (sometimes basilar migraine)Usually accompanied by vertigo, ataxia, dysarthia, diplopiaOther examplesSubclavian stealoccurs with arm activity. Systolic BP in arms (difference of 10mmHg)Subarachnoid hemorrhage,Psychiatric causes,Most commonly associated withAnxietyPanicMajor depressive disordersVariety of mechanisms may be involvedHyperventilationIncreased vagal tone,Syncope-like States,MigraineAcute hypoxiaHyperventilationSomatization disorder (psychogenic syncope)Acute intoxication (ie alcohol)SeizuresHypoglycemiaSleep disorders,An Approach to Syncope,HISTORY,RAPID ASSESSMENTIdentify Life-Threatening causesDysrhythmiascardiac ischemiaCritical aortic stenosisAortic dissectionPulmonary embolusCVASAHToxic-metabolic derangement,HISTORY,HISTORY alone identifies the cause up to 85% of the timePOINTSPrevious episodesCharacter of the events, witnessesEvents preceding the syncopeEvents during and after the episode,HISTORY,Events preceding the syncopeProlonged standing (vasovagal)Immediately upon standing (orthostatic)With exertion (cardiac)Sudden without warning or palpitations (cardiac)Aggressive dieting Heat exposureEmotional stress,Events during and after the episodeTrauma (implication important)Chest pain (CAD, PE)Seizure (incontinence, confusion, tongue laceration, postictal behavior)Cerebrovascular syndrome (diplopia, dysarthia, hemiparesis)Associated with n/v/sweating (vasovagal),HISTORY,Associated symptomsChest pain, SOB, lightheadedness, incontinencePast medical historyIdentifying risk factorsMorbidity and mortality increases with organic causesParkinsons (orthostatic)Epilepsy (seizure)DM (cardiac, autonomic dysfunction, glucose)Cardiac disease,MedicationsAntihypertensives, diuretics (orthostatic)Antiarrthymics (cardiac syncope)TCA, Amiodarone (cardiac/prolonged QT)Family historySudden death (cardiac syncope/prolonged QT or Brugada),PHYSICAL EXAM,Vital signsOrthostaticsmost importantDrop in BP and fixed HR -dysautonomiaDrop in BP and increase HR - volume depletion/ vasodilatationInsignificant drop in BP and marked increase in HR - POTSTemperatureHypo/hyperthermia (sepsis, toxic-metabolic, exposure),Heart rateTachy/brady, dysrhythmiaRespiratory rateTachypnea (pe, hypoxia, anxiety)Bradypnea (cns, toxicmetabolic)Blood pressureHigh (cns, toxic/metabolic)Low (hypovolemia, cardiogenic shock, sepsis),PHYSICAL EXAM,HEENTTenderness/deformity (trauma)Papilledema (increased icp, head injury)Breath (alcohol, dka)NECKBruitsJVD (chf, mi, pe, tampnade),HEARTMurmur (valves, dissection)Rub (pericarditis, tamponade)LUNGSSounds may help distinguish chf, infection, pneumothorax,PHYSICAL EXAM,ABDOMENPulsatile mass; AAATendernessOccult blood lossPELVISBleeding, hypovolemiaTenderness (PID, ectopic, torsion, sepsis),SKINSigns of trauma, hypoperfusionEXTREMITESParalysis (CNS)Pulses unequal (dissection, embolus, steal),PHYSICAL EXAM,NEUROLOGICMental status; toxic metabolic; organic disease; seizure; hypoxia.Focal findings (hemorrhagic/ischemic stroke, trauma, tumor, or other primary neurologic disease,Cranial nervesCerebellar testing,Seizure or Not?,SEIZUREFrothing at mouthTongue bitingDisorientation/ postictalAge 45 years,Ancillary Studies,EKG-Cornerstone of workupArrhythmia, long qt, WPW, conduction abn.Routine Blood worklimited valueRadiology-limited value except if abnormal examOther testsdepending of history and examGlucose-hemoglobin -troponinUa/culture-CK (syncope vs seizure),Starting the “Workup”,If young adult and No comorbid conditions or symptomsMost likely VASOMOTOR or ORTHOSTATIC .*Clinicians may forego the EKG in young, healthy patients with an obvious cause of syncope.,Normal EKG,If Normal EKG:Check orthostaticsCheck hemoglobinIf low-AnemiaIf normal or high-Volume loss, dehydration, drug induced,Young adult, no comorbidity, normal EKG, absent orthostatics,VasomotorTry carotid massage(+) carotid sinus sensitivity(-) reflex or neurocardiogenicMetabolicCheck chemistry. R/O hypoglycemia, adrenal insufficiency,NeurologicCT head (tia, cva, sah)EEG (if suspect Sz)CardiovascularIf Outflow obstruction, check CT chest, Echo (PE, valvular, HOCM)If venous return, check HCG, Echo (pregnancy, tamponade),The EKGKey Points,Guidelines recommend EKG in the evaluation of all patients with syncope.Exception: young healthy patients with an obvious cause of syncopeAbnormal EKG in 90% of patient with cardiac syncopeOnly 6% of patients with reflex mediated syncope have abnormal EKG.Syncopal patient with negative cardiac history and normal EKGunlikely to have a cardiac cause,The EKG patient older, +comorbid signs/symptoms,If Abnormal EKGIschemia/injuryDysrhythmiaSinus brady, BBB, AV block, prolonged QT, WPW, HOCM, BrugadaIf Normal EKGConsider holter or event recorder if dysrhythmia suspected,WPW,sinus bradycardia,ventricular tachycardia 3 or more beats,Prolonged QT interval,Other: sinus pause 2 sec, SVT, afib, 2nd or 3rd AV block, PM malfunction,Summary of the CardiovascularDiagnostic Pathway,Holter Monitoring,24-48 hour monitorlimited value because of intermittent nature of arrhythmiasEvent recordermore helpful. Patient must be conscious in order to activate unit.Establishes diagnosis in only 2-3% of patients with syncope if EKG is normal.Indicated in patients at highest risk for arrhythmia ie, abnormal ekg, palpitations, cad history, syncope when supine or with exertion, +FH,Holter results-summary,PACs and PVCsUsually not significantException: ie 3 consecutive 3 PVCs at 100 bpmBigeminymay be significantAV block-is importantBradycardia-if signs and symptoms correlate,Loop Event Recorders,Provides longer monitoringweeks to monthsCan activate the monitor after symptoms occur, thereby freezing in its memory the readings from the previous 2-5 minutes and the subsequent 1 minuteIn patients with recurrent syncope, arrhythmias were found during symptoms in 8-20%.Limitations: compliance, use of device, transmission,ECHOCARDIOGRAM,Access structural causes of cardiac syncopeAS, MS, HOCM, atrial myoxomaUnlikely to be helpful in the absence of known cardiac disease or an abnormal ekg.INDICATIONSAbnormal EKG-history of heart diseaseMurmur -exercise assoc. syncope,Structural Heart Disease,Aortic StenosisMost common structural lesion associated with syncope in the elderlyHypertrophic Obstructive CardiomyopathyVasodilatation (drugs/hot bath) can induce syncopeObstruction to Right Ventricular OutflowPE, pulmonary stenosis, pulmonary htn,EXERCISE STRESS TEST,Syncope during exercise is more likely to be related to an arrhythmiaPost-exertional syncope is usually neurally mediated.Echocardiogram should be done prior to EST to r/o structural abnormality.INDICATIONSyncope during or shortly after exercise (exertional syncope),EPSIntracardiac EPS,Rarely indicated in patients with structurally normal hearts and normal ekg.Diagnostic yield greatest in patients with known heart disease but non-diagnostic ekg monitoring.Heart disease-50-80%No heart disease-18-50%,Difficult to correlate spontaneous events and laboratory findingsIneffective for assessing bradyarrhythmiasOften must settle for an attributable causeAbnormal finding on EPS does not guarantee that this was what caused the patients syncope. EPS is abnormal in 18-68% of patients with syncope of unknown cause.,EP testingUseful Diagnostic findings,Inducible monomorphic VTSinus node response time 3000 ms or carotid sinus response time 600 msInducible SVT with hypotensionHV interval 100ms (especially in absence of inducible VT)Pacing induced infra-nodal block,TILT TABLE TEST,Changes in position to reproduce symptoms of the syncopal event.Positive tilt table testInduction of bradycardia and hypotensionConsidered diagnostic for vasovagal syncope,Indications for Tilt table test,Unexplained recurrent syncope or syncope associated with injury in absence of structural heart ds.Unexplained recurrent syncope or syncope associated with injury in setting of organic heart disease after exclusion of potential cardiac cause of syncope,Identification of neurally mediated syncope could alter treatmentEvaluation of recurrent unexplained falls.Evaluation of near syncope or dizziness,Tilt Table Test,Unmasks Vasovagal syncope susceptibilityReproduces symptomsPositive Tilt Test*Prophylaxis treatmentbeta blockers or disopyramide as well as SSRIs *Recurrent symptoms and bradycardia may require pacemaker,NEUROLOGIC TESTING,Tend to be overusedIncludes EEG, CT head, MRI head, Carotid dopplersIn contrast, Cardiovascular tests are underused.INDICATIONOnly if history and physical exam suggests a neurologic cause or testing for other causes is complete.,EEG,Not a first line of testingTo differentiate syncope from seizureAbnormal EEG in the interval between two attacks - EpilepsyNormal EEG - does not tell us anything,Tests and Diagn