Title: Syncope and The Older Patient
1Syncope and The Older Patient
- Debra L. Bynum, MD
- Division of Geriatric Medicine
2Pretest
- 1. The ECG has the greatest value in its (NPV or
PPV) in the diagnosis of a cardiac etiology for
syncope - 2. History 75 year old man reports presyncopal
symptoms that occur while he is driving backwards
out of his driveway in the morning. This
suggests - 3. History an 80 year old man reports an episode
of syncope that occurred after doing arm
exercises for a rotator cuff injury. This
suggest - 4. The only independent predictor of a cardiac
etiology of syncope is a past history of - 5. ____ is a neurodegenerative disease
characterized by profound autonomic insufficiency
and parkinsonian features on exam - 6. An 82 year old man presents with postural
hypotension, an idiopathic peripheral neuropathy,
significant proteinuria and your attending orders
a rectal biopsy to look for____ - 7. Name 3 causes of situational syncope
- 8. Older patients are more likely to have
positive a. tilt table tests b. carotid sinus
massage c. orthostatic hypotension d. all of the
above
3Pretest bonus question
- Sudden cardiac death in young men (originally
described in young asian men) associated with
this sign on EKG is known as what syndrome?
4Syncope Definition
- Sudden and temporary loss of consciousness with
inability to maintain postural tone, followed by
spontaneous recovery
5Causes of Syncope
- Neurally Mediated (up to 58 in some series)
- Orthostatic/postural
- Cardiac arrhythmia (20-25)
- Structural cardiac or pulmonary causes
- Cerebrovascular or psychiatric (1)
- Unknown (18-30)
6Syncope in the Elderly
- Usually multifactorial
- Often confounded by findings (orthostasis and
carotid hypersensitivity common and may be found
and yet not be the cause) - Prevalence up to 25 in nursing home population
over age 70 - Higher pretest probability of cardiac disease or
arrhythmia
7Importance of History and PE
- Up to 70 of patients in prospective studies had
probable cause identified based upon history,
physical exam and ecg
8The History
- History of Heart Disease
- The ONLY independent predictor of cardiac cause
(sens 95, spec 45) - Absence of heart disease up to 97 specific to
rule out cardiac etiology (good NPV)
9The History
- Position
- Supine cardiac until proven otherwise
- Upon sitting/standing orthostasis
- Prolonged standing venous pooling/orthostasis/vas
ovagal - Presyncopal symptoms
- Presence suggests vasovagal, but does not rule
out arrhythmia - Lack of suggests arrythmia (up to 65 with sudden
syncope) - Dyspnea (Pulmonary embolus)
- Focal neurologic symptoms (TIA, seizure)
- Seizure like activity (including loss of bowel
and bladder control, tongue bite, postictal state)
10The history
- Recovery period
- Instant arrythmia
- Feeling hot and nauseated vasovagal
- Confusion/lethargy postictal
- Situational syncope (vasovagal)
- Cough
- Swallow (cold liquid)
- Micturition (urination)
- Defecation
- Exertional
- Ventricular tachyarrhythmia
- Aortic stenosis or HOCM
- Pulmonary Hypertension
11 The history
- Prior faint 1-4 years prior suggest vasovagal
- Age
- Medications
- Tricyclic antidepressants
- Nitrates
- Alpha adrenergic antagonists
- Diuretics
- Injury (facial suggests arrhythmia)
- Postprandial (vagally mediated)
12Specific Causes and Treatment Options for Syncope
- Postural Hypotension
- Drop in systolic blood pressure of over 20
- Medications
- Autonomic Insufficiency
- No reflex tachycardia
- Shy-Drager (multiple systems atrophy)
- Primary autonomic failure
- Parkinsons Disease
- Diabetes
- Aging
- Amyloid
- Volume Loss
- Dehydration
- Blood loss
13Autonomic Insufficiency and Orthostatic
Hypotension
- Treatment Options
- Review of medications
- Avoid volume depletion
- Arising slowly
- Tensing crossed legs while standing
- Dorsiflex feet or handgrip prior to standing
- Thigh high Jobst stockings (decreases venous
pooling) - Avoid prolonged standing (venous pooling)
- Increased salt diet
- Smaller meals to avoid postprandial drop in BP
- Fludrocortisone
- Midodrine (alpha 1 adrenergic agonist)
- Phenylephrine (not usually used in older
patients) - Fluoxetine
14Mechanical Cardiac Causes
- Obstruction to LV outflow
- Aortic Stenosis
- HOCM
- Left atrial myxoma
- Mitral Stenosis
- Obstruction to pulmonic flow
- Pulmonic stenosis
- Pulmonary HTN
- PE (can also have vasovagal type syncope
associated with smaller PEs) - Right atrial myxoma
15Other Mechanical Cardiac Causes
- Large MI with LV dysfunction
- CHF
- Tamponade
- Aortic dissection
16Cardiac Arrhythmias
- Bradycardia
- Sick sinus syndrome
- 2nd or 3rd degree AV block
- Pacemaker malfunction
- Tachycardia
- Ventricular tachycardia
- Ventricular fibrillation
- SVT
- If you see atrial fibrillation, think sick sinus
syndrome as potential cause of syncope
17Brugada Syndrome
- Triad
- RBBB pattern in right precordial leads
- Transient/persistent ST elevation in v1-v3
- Sudden cardiac death
- Structurally normal heart
- Association with young and healthy men from
southeast asia who present with sudden cardiac
death - Brugada sign may be asymptomatic
- High risk of sudden cardiac death in those who
have syncope or family history of sudden death
(Indication for AICD based upon observational
data)
18Brugada Sign
19Implantable Cardioverter-Defribrillator Guidelines
- AICD indicated for patients with spontaneous
Vtach with underlying heart disease or in
patients with normal heart when vtach not
amenable to other treatments
20AICD guidelines
- Ischemic Cardiomyopathy
- LVEF
- At least 1 month after MI and 3 months after
revascularization - MADIT-II trial
- Multicenter Automatic Defibrillator Implantation
Trial - 5.6 ARR in mortality over 4 years
- Results support prophylactic AICD, but not
considered cost wise - Based upon subset analysis, Current
recommendation in those with QRS 120 ms - Unclear result those with ICDs had 5 absolute
increased risk of hospitalization for CHF (19 vs
14) ?artifact, ?due to living longer?,
?detrimental
21AICD guidelines
- Syncope in patients with advanced structural
heart disease - High risk of sudden cardiac death
- Inducible Vtach with structural heart disease
- Inducible Vtach with normal heart that is not
amenable to ablation therapy
22Subclavian Steal Syndrome
- Proximal subclavian artery stenosis
- Decreased blood flow to distal subclavian artery
worsened with exertion of arm - Blood from vertebral artery on opposite side goes
to basilar artery and then down ipsilateral
vertebral artery, away from brainstem, to serve
as collateral for arm - Usually asymptomatic
- Atherosclerosis
- Symptoms of vertebrobasilar insufficiency
(dizziness, vertigo, diplopia, nystagmus) - Rare to have permanent neurological deficits
- Diagnosis with dopplers, MRA
- Treatment surgical revascularization, stents
23 Cerebrovascular Disease
- Less common cause of true syncope
- Vertebrobasilar disease (presyncope)
- Drop Attacks
24Vasovagal/Neurocardiogenic syncope
- Situational Syncope
- Micturition
- Defecation
- Cough
- Swallow
- Recurrent Neurocardiogenic Syncope
- Posprandial
- The FAINT
25Vasovagal Syncope
- Presyncopal symptoms
- Setting (procedure, pain, anxiety)
- Prior history
26Neurally Mediated Syncope
- Cardiac sensory receptors in LV stimulated by
stretch - Increased neural discharge to vasomotor center in
medulla - Increased parasympathetic tone and decreased
sympathetic activity - Sudden bradycardia and hypotension
27Recurrent Neurocardiogenic Syncope
- Upright posture lead to pooling of blood in lower
extremities - Decreased venous return
- Normal response reflex tachycardia and forceful
LV contraction and vasoconstriction - Susceptible individuals activation of
mechanoreceptors triggers reflex bradycardia and
hypotension - Response triggered by forceful LV contraction
with prolonged standing or with increased
catecholamines (anxiety, fear, panic, pain)
28Treatment of Recurrent Neurocardiogenic Syncope
- Medications
- Paroxetine
- Only agent shown effective in RCT
- Midodrine
- Alpha adrenergic agonist
- Small studies
- Fludrocortisone
- No good study
- Beta blockers
- Often used, mixed evidence in studies
29Pacemakers in the treatment of Recurrent
Neurocardiogenic Syncope
- 3 large RCTs of permanent pacing
- North American Vasovagal Pacemaker Study (VPS-1)
- Patients with over 6 episodes, positive tilt
table test with significant bradycardia - Significant decrease in recurrence with pacer (HR
.087) - Vasovagal Syncope International Study
- 5 recurrence with pacemaker vs 61 without (19
patients) - Syncope Diagnosis and Treatment Study
- Pacemaker vs atenolol
- 93 patients 4.3 recurrence vs 26
30Pacemakers and neurocardiogenic syncope
- Problems with trials
- Small numbers of patients
- Not blinded
- Highly selected patients
- Patients had profound bradycardia on tilt table
testing and multiple episodes
31Pacers and neurocardiogenic syncope
- Bottom line
- May benefit patients with recurrent episodes of
clear neurally mediated syncope, associated with
significant bradycardic response, who have a
decreased QOL otherwise (injuries, driving, etc)
32Carotid Sinus Hypersensitivity
- ?Role of Carotid Sinus Massage
- Some recommend if no bruits, recent MI, cva or
history of vtach - ?monitor
- Positive response 3 sec pause
- In literature, but most cardiologists would not
recommend - High yield of carotid massage in elderly (up to
40 over the age of 75 may have a positive
response), but not specific in identifying this
as the cause of syncope (PPV not known) - History syncope/presyncope with turning neck,
backing up in car, wearing tight collar
33Evaluation of Syncope
- When a cause of syncope is identified, history
and physical lead to etiology in up to 85 cases - The only independent predictor of a cardiac cause
of syncope is the presence of underlying heart
disease (95 sens, only 45 spec)
34Orthostasis
- May be confounder in older patients
- Up to 25 of older patients may have orthostasis
when tested, the presence of orthostasis may be
true, true and unrelated
35The ECG
- Prolonged QT
- Bradycardia, AVN disease, MI, HOCM, Brugada
- Only 2-10 will have diagnostic abnormality
- Up to 50 of patients with syncope have abnormal
EKG - Greatest use in NPV (negative predictive value)
of NORMAL ECG
36The Holter Monitor
- 24-48 hours continuous ECG
- No added yield with 72 hours
- Low yield unless frequent symptoms
- Up to 70 of Holter studies negative for
diagnosis - One series only 5 of studies had arrhythmia
that correlated with symptoms - Probably good NPV if symptoms documented with
benign rhythm
37Event or Loop Monitors
- Higher yield than holter (up to 55 positive
yield of symptom-arrhythmia correlation in some
series) - Problem with patient education and ability to
activate monitor correctly (25 of patients have
difficulty) - May be especially problematic in the very elderly
or those with dementia
38Implantable Loop Recorder
- Prolonged monitoring for those with syncope of
unclear etiology despite workup, especially for
those in whom cardiac etiology is suspected - Several small studies suggest that in very
selected patients, may increase yield of
diagnosis to almost 85
39Other Cardiac Tests
- Echo
- Exercise or Functional Tests
- EP studies
- Most useful when history or physical suggests
specific further testing to be done
40Tilt Table Testing
- Passive or Isoproterenol
- Test patient held in upright position at 40-90
degrees and observed for symptoms and hypotension
or bradycardia - Passive testing sensitivity of 70, specificity
of 90-100 - Isoproterenol only 55 specificity
- Overall little to add to history and PE lack of
sensitivity with passive testing and lack of
specificity with induced testing limits
usefulness of test
41Lab tests
- The basics (anemia)
- ?BNP some studies report usefulness as a marker
for cardiac cause of syncope sensitivity of 82
and specificity of 92, Likelihood ratios of pos
and neg tests probably not more useful than
pretest probability of underlying heart disease
based upon history and physical exam - CK, MB and Troponins
- More useful if positive (greater PPV) than neg
- One series up to 10 nursing home patients
presenting with syncope had positive enzymes
42The Least Useful Tests
- CT head with negative neurological exam
- EEG with no neurological symptoms
- Carotid Artery Dopplers (useful for evaluation of
CVA or TIA, not useful for evaluation of syncope
without vertebrobasilar symptoms)
43The Older Patient
- Positive tests that are more common in the
elderly and not necessarily the cause of the
syncope - Orthostasis
- Positive carotid massage
- Positive tilt table testing
- Up to 54 of older patients with syncope may have
positive test - Positive test in 10 of asymptomatic elderly!
44Algorithm for diagnosing syncope
Linzer, M. et. al. Ann Intern Med 199712776-86
45Summary of Charges for Diagnostic Tests in
Syncope
Linzer, M. et. al. Ann Intern Med 199712776-86
46Summary
- Syncope in the older patient usually
multifactorial - Tailor tests based upon history and physical exam
- Elderly more likely to have positive tests that
may be confounders - Elderly more likely to have underlying heart
disease and higher pretest probability of a
cardiac etiology - Use algorithms in older, complicated patients
with great caution!!!
47Back to the Pretest
- 1. The ECG has the greatest value in its (NPV or
PPV) in the diagnosis of a cardiac etiology for
syncope - 2. History 75 year old man reports presyncopal
symptoms that occur while he is driving backwards
out of his driveway in the morning. This
suggests - 3. History an 80 year old man reports an episode
of syncope that occurred after doing arm
exercises for a rotator cuff injury. This
suggest - 4. The only independent predictor of a cardiac
etiology of syncope is a past history of - 5. ____ is a neurodegenerative disease
characterized by profound autonomic insufficiency
and parkinsonian features on exam - 6. An 82 year old man presents with postural
hypotension, an idiopathic peripheral neuropathy,
significant proteinuria and your attending orders
a rectal biopsy to look for____ - 7. Name 3 causes of situational syncope
- 8. Older patients are more likely to have
positive a. tilt table tests b. carotid sinus
massage c. orthostatic hypotension d. all of the
above
48Answers to Pretest
- 1. NPV
- 2. Carotid Hypersensitivity
- 3. Subclavian steal syndrome
- 4. Cardiac history
- 5. Multiple Systems Atrophy (shy-drager)
- 6. amyloid
- 7. micturition, defecation, cough, swallow
- 8. all of the above
- 9. bonus brugada syndrome
49Selected References
- Benditt DG, VanDjjk JG, Sutton R. Syncope Curr
Prob Cardiol 2004 29(4) 152-229 - Epstein AE. An update on implantable
cardioverter-defibrillator guidelines. Curr Opin
Cardiology 2004 19(1) 23-25 - Littman L et al. Brugada syndrome and Brugada
sign. Am Heart J 2003 145(5) 768-778 - Raj S, Sheldon RS. Role of pacemaker in treating
neurocardiogenic syncope. Curr Opinion Cardiol
2003 18 47-52 - Gregoratos G, Cheitlin MD, Conill A. ACC/AHA
guidelines for implantation of cardiac pacemakers
and antiarrthythmia devices executive summary
a report of the American College of Cardiology/Am
Heart Assoc Task Force on Practice Guidelines.
Circulation. 1998 97 1325-1335 - Connolly SJ et al. The North American Vasovagal
Pacemaker Study. J Am Coll Cardiol 1999 33
16-20 - DiGirolamo et al. Effects of paroxetine on
refractory vasovagal syncope. J Am Coll Cardiol
1999 33 1227-30 - Sutton R et al. Dual chamber pacing in the
treatment of neurally mediated tilt-positive
cardioinhibitory syncope (VASIS). Circulation
2000 102 294-299
50Selected References
- Krahn Ad et al. Use of the implantable loop
recorder in evaluation of patients with
unexplained syncope - Kapoor WN. Current evaluation and management of
syncope. Circulation 2002 106 1606 - Alboni P et al. Diagnostic Value of history in
patients with syncope. J Am Coll Cardiol 2001
37 1921 - Kapoor et al. Evaluation and outcome of patients
with syncope. Medicine 1990 69 160 - Linzer et al. Diagnosing syncope part I. Ann Int
med 1997 126989 - Linzer et al. Diagnosing syncope part II. Ann
Int Med 1997 127 76