Syncope

1
Syncope (An internist approach) Chandra S
Pemmasani, MD
2
What is syncope? 

• A sudden, brief loss of consciousness
  associated with loss of postural tone ?
  followed by a rapid and complete recovery to
  baseline neurologic function requiring no
  resuscitative efforts.
• Different from cardiac arrest
• Syncope is a symptom - not a diagnosis
• Presyncope syncope represent a spectrum of
  similar problem

3

• How big is the problem?
• 3 - 5 of all ED visits
• 1 2 all hospital admissions
• Costs gt750 million dollars/year

4
Pathophysiology? Global hypoperfusion of both
the cerebral cortices Focal hypoperfusion of
reticular activating system
5

• Etiology
• Cardiac 20
• Arrhythmias
• Obstructive
• Neurocardiogenic 24
• Orthostatic 8
• Decreased vasomotor tone
• Low intravascular volume
• Psychiatric 5
• Unexplained syncope 35

6

• Arrhythmia
• Sinus bradycardia
• Second and third degree AV block
• VT
• Long QT/torsades
• SVT
• Organised/ regular (WPW) more common
• Disorganised (AFib) - rare
• Paroxysmal and infrequent
• VF does cause syncope it causes cardiac arrest

7

• Outflow obstruction
• Left sided
• Aortic stenosis
• HOCM
• Aortic dissection
• Cardiac tamponade
• Right sided
• Massive PE pulmonary HTN

8
Neurocardiogenic Initial stimulus (stress) cause
catecholamine release
BP, HR and SVR
Increased sympathetic tone activates medullary
center which in turn lead to excessive
parasympthetic output
Hypotension and bradycardia
9

• Neurocardiogenic
• MC cause in young patients
• Prodrome of symptoms
• Low BP and HR at the scene
• Excellent prognosis
• Less common in elderly - deccreased vagal tone
  and decreased beta adrenergic cardiac
  contractility
• ExamplesCough induced syncope micturition
• Situational (blood draws) postprandial carotid
  hypersensitivity syndrome

10

• Orthostatic
• Decreased intravascular volume - diuretics GI
  blood loss etc
• Medications vasodilators
• Autonomic insufficiency -
• Parkinson's disease
• Diabetes mellitus
• Alcohol consumption - impairs vasoconstriction
• Aging - attenuation of the vestibulosympathetic
  reflex

11

• Orthostatic
• Diagnosis of exclusion
• Definition
• SBP drop of 20
• DBP drop of 10
• PR increase 20/min
• Orthostatic vitals are neither sensitive nor
  specific
• High false positive rate (meets criteria but no
  symptoms)

12

• Question
• Good history, examination and EKG gives diagnosis
  of syncope in what of pts?
• 10
• 25
• 50
• 75
• 90

13
History Prodrome - N/V/AP/Warmth/dizziness/diaph
oresis/Pallor Triggers (micturition, coughing,
swallowing, prolonged standing) Position of the
pt Prolonged standing (15-20 mts)
neurocardiogenic While getting out of bed
orthostatic While sitting or supine
arrhythmias With exertion HOCM AS tamponade
arrhythmias
14
History Duration Difficult as most pts dont
remember More than 4-5 minutes (suspect seizures
or other causes of altered MS) Associated
features Chest pain (CAD or
PE) Palpitations SOB (PE or CHF) Headache
(SAH) Other neuralgic symptoms (weakness or
paresthesiaas)
15
History Medications CCB, beta blockers,
diuretics anticholinergics nitrates alpha
blockers Previous episodes and the
circumstances Family history Sudden cardiac
death
16

• Examination
• BP in both arms if different suspect?
• Dissection
• Subclavian steal
• Orthostatic vitals signs
• Supine for 5 minutes check vitals
• Then standing for 2-3 minutes
• Hypoxic PE/CHF
• Volume status (mucus membranes skin turgor)

17

• Examination
• Oropharynx for tongue laceration
• JVD
• Bruit
• Irregular pulse a.fib
• AS or MS murmurs
• S3 or s4 gallops
• Lung exam
• Stool guaiac
• Good neuro exam to identify subtle findings of a
  stroke
• Any other signs of trauma

18

• Differential Diagnosis
• Seizures
• Hypoglycemia
• Drugs / Alcohol
• Narcolepsy
• Stroke / TIA

19

• Question
• Which of the following is most helpful in
  differentiating seizure for syncope?
• Tongue biting - yes
• Bladder incontinence no
• Postictal confusion - yes
• Unusual position of the head (head deviation)
  yes
• Aura yes
• Seizures may follow the syncope if the patient
  is prevented from lying down

20
Evaluation Rule out life threatening causes -
Cardiac (MI dissection CT arrhythmias) Blood
loss (back pain, abdominal pain) PE SAH
21
Labs EKG Bradycardia Prolonged QRS,
QTc Ischemia WPW Brugada Pulses
alterans Cardiac enzymes CBC BMP UA b-HCG CXR ECHO
suspected structural heart disease Cardiac
monitor 24-48 hrs optimal
22

• Neurological workup
• EEG provides diagnostic information in less than
  2 of cases
• - Practically all of these patients have symptoms
  suggestive of a seizure or a history of a
  convulsive disorder
• CT scan of the head provides new information in
  less than 4 of cases
• - Practically all of these patients have focal
  neurologic findings

23

• Mayo Clinic Proc. 2005 80(4) 480-488.
• Retrospective review
• ACP guidelines (Annals 1997)
• Use US (transcranial/ carotid)
• - Focal neurologic sx
• - Focal neurologic signs
• - Carotid bruits
• - We should take into account history of CVA/
  TIA/ and CAD hx (secondary to strong
  association with cerebrovascular disease)

24
Stepwise evaluation Step 1? History, Physical
Exam, ECG - DX (50) Step 2? Medication review,
R/O life threatening causes, CBC, BMP and
pregnancy test (in appropriate age group) - Dx
(50) Step 3? Elderly, SHD, Abnl Ecg,
Palpitations, Chest pain, No prodrome, Framingham
risk factors A. Suspect cardiac cause
25

• Rule out ACS
• () ? cardiology consult and treat
• Echo
• () SHD, WMA ? stress, consider EPS, Loop
  monitor ? cardiology consult and treat
• (-) SHD ? look at telemetry, consider stress,
  reevaluate hx, consider holter, loop monitor,
  consider cardiology consult
• Telemetry
• - Literature supports 24-48 hours as optimal,
  out to 72 increases diagnostic yield in certain
  patients such as elderly and patients with SHD

26
A 40-year-old truck driver is brought in after a
syncopal episode he is short of breath and
complains of chest pain. BP 110/70 and PR is
120/min. 84 on RA. Examination shows clear
lungs. His EKG is shown below
AN EKG one month ago was completely normal. What
is the diagnosis? Next step?
27
A 33-year-old male is brought in after a syncopal
episode while watching TV at 8 PM he has no
other symptoms and vital signs are normal.
Examination is unremarkable. His EKG is shown
below
What is the diagnosis?
28
A 23-year-old male developed palpitations
followed by a syncopal episode he has no other
symptoms and vital signs are normal. Examination
is unremarkable. His EKG is shown below
What is the diagnosis?
29

• An 18-year-old male is brought in because of a
  syncopal episode. Episode occurred while he was
  standing still after playing a basket ball. He
  has no prodromal symptoms. He has two similar
  episodes in the past and both occurred while
  standing still. No FH of sudden death.
  Examination and EKG are within normal limits.
  What do you do next?
• Reassurance and no workup
• Obtain ECHO and seek cardiology help

30

• A C team resident who is also an MAO had a
  syncopal episode during the rounds. He did not
  have time to eat or pee. He woke up with in 2
  minutes after leg elevation. He describes feeling
  nauseous and dizzy before the episode. Never had
  similar problems. At the time of episode his BP
  is 90/70 and PR is 40/min but after 10 minutes it
  is 120/80 and 80/min respectively. EKG and other
  examination is with in normal limits. Next step?
• Restart the rounds
• ECHO
• Holter monitor
• Admit and rule our ACS

31

• A 34-year-old woman was brought in to ER by
  colleagues after a syncopal episode. She has a
  severe headache just before the episode but no
  prior history. FH is significant for migraine.
  Vital signs and examination are with in normal
  limits. Nxt step
• Discharge from ER with sumatriptan
• Admit and workup for cardiac cause
• Obtain CT head

32

• A 65-year-old had a syncopal episode while
  hiking.
• No prior episode and had no chest pain or
  shortness of
• breath. No prodromal symptoms. He has
  hypertension
• and diabetes. No H/O CAD. His vital signs,
  examination
• and EKG are within normal limits. First set of
  cardiac
• enzymes are negative. Next step?
• Discharge from ER
• Admit ECHO and stress
• Tilt table testing
• Outpatient holter monitor

33
A 23-year-old male developed syncope with
exertion. He has had a recent URI followed by
dyspnea on exertion. His EKG is shown below

34
A 43-year-old male had s syncopal episode while
walking. He experienced palpitations prior to the
episode. He has a history of drug use and was
recently started on methadone. His EKG is shown
below