Syncope

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Syncope
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• Syncope is a common disorder,
• affecting 30 of adults
• Syncope is responsible
• 1 to 6 of emergency department visits
• 0.6 to 1.0 of hospital admissions
• Bimodal presentation
• Peak at early adulthood
• Neurocardiogenic
• Late in life
• degenerative

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• Difficulty in diagnoses
• Episodes may be sporadic
• Multiple possible causes

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Neurocardiogenic syncope

• Normal reflex
• Venous pooling
• Drop in BP
• Increased symp drive
• Myocardial C fibres also affect vagal tone

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Neurocardiogenic syncope

• Abnormal reflex
• Increased venous pooling
• Increased symp drive
• Marked pressure effect on C fibres
• Paradoxical increase in vagal tone
• Reduces contraction
• Increases dilatation

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Diagnostic tests and yields

• ECG 2-11
• Holter Monitoring 2
• External Loop Recorder 20
• Tilt Table 11-87
• EP Study without structural heart disease11
• EP Study with structural heart disease 49
• Neurological (CT scan, carotid doppler) 0-4

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Diagnostic tests and yields

• ECG 2-11
• Holter Monitoring 2
• External Loop Recorder 20
• Tilt Table 11-87
• EP Study without structural heart disease11
• EP Study with structural heart disease 49
• Neurological (CT scan, carotid doppler) 0-4
• Implantable loop recorder 43-88

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Syncope increases mortality

• Study of survival rates with and without syncope
• Cardiac syncope carried a 6-month mortality rate
  of greater than 10
• Cardiac syncope doubled the risk of death

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Case 1

• 64yo male
• Suddenly felt unwell, strange, dizzy LOC for 2
  minutes
• ECG, Echo, 48hr Holter, Tilt, MRI and sleep
  deprived EEG all NAD
• Loop recorder inserted
• Similar episode
• 25s pause
• DDD PM inserted

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Case 1

• He collapsed again several weeks later, while
  sitting for a meal at a wedding.
• Repeat EEG
• Temporal-lobe epilepsy was diagnosed,
• Treated with oxcarbazepine.
• He remains asymptomatic at 1 year of follow-up.

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Case 1

• Ictal bradycardia is a rare manifestation of
  epileptic seizures.
• There is limited evidence of a preferential left
  temporal-lobe onset.
• Most patients are male and gt60 years of age
• This pattern of epilepsy may induce central or
  obstructive apneas as well as SCD
• Temporal-lobe epilepsy may present with feelings
  of panic and impending doom, palpitations,
  diaphoresis, dyspnea, and paresthesias.
• Hence, it is easily misdiagnosed as an anxiety
  attack.
• The discovery of a major arrhythmia without EEG
  monitoring may lead to an incorrect diagnosis
• Cardiac pacemakers may be indicated in
  symptomatic ictal bradycardia or asymptomatic
  bradycardia lasting more than 5 seconds.

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CASE 2

• 73yo male
• Under care of diabetic service
• Referred to cardiology for work-up of black-outs
• ECG, Echo, 24hr and 7 day holter normal
• Loop recorder implanted

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Case 2

• After 6 months
• will you check this mans Loop
  Recorder.........Neurologist reckons he had a 52
  second pause on an EEG
• Id say its a typo!....meant 5.2 seconds
• Loop recorder revealed no patient activated
  episodes
• Automatic episodes all later than date of EEG

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Case 2
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Case 3

• 22yo female
• Referred to Cardiology from Neurology for
  implantation of loop recorder due to syncope
• No significant medical Hx
• Admitted to previous ectasy use, smokes cannabis
  every day
• ECG, 7day Holter, Echo NAD
• MRI, CT, Sleep deprived EEG NAD
• Loop recorder inserted

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Case 3

• Presented following syncopal episode
• No awareness of onset
• When full awareness regained sitting up in
  chair
• Speaks gibberish for minutes prior to episode
• Interrogation revealed

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Case 3
4.2 second pause
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Case 3
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Case 3

• Also had one episode of speaking gibberish for
  five minutes, no syncope
• No associated arrhythmia

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Case 3

• Questions
• Would you pace this patient now
• What is the sensitivity/specificity of an EEG in
  this setting
• What is the usefulness of repeat EEG