SYNCOPE 2007: Some Principles and Some Cases Mark Linzer, M.D. General Internal Medicine UW-Madison.
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Transcript of SYNCOPE 2007: Some Principles and Some Cases Mark Linzer, M.D. General Internal Medicine UW-Madison.
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SYNCOPE 2007:Some Principles and Some Cases
Mark Linzer, M.D.
General Internal Medicine
UW-Madison
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Financial Disclosure
• No external support for this talk
• Prior grant support: – Instromedix, Inc. (loop ECG recorders)– Mellon Foundation (EP studies) – Dutch Heart Assn. (QOL)
• Recent talk at International Syncope Symposium supported by Blackwell Publishing Company
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Objectives
• Know the diagnostic categories
• Recognize the value of history taking
• Learn to choose among diagnostic tests
• Know that cardiac syncope carries high risk; when to think of AICDs, pacemakers
• Be adept at listening to a syncope case and knowing what to do!
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Diagnostic categories
• Vasovagal (neurocardiogenic); including situational
• Orthostatic hypotension
• Meds, Psychiatric
• Neurologic
• Cardiac (VHD, PE, MI, arrhythmia)
• SUO
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History is everything (or just about)*
• Sudden syncope
• Warmth, nausea, diaphoresis
• Positional
• Anxiety, mood disturbance, multiple sx
• Seizure activity, neuro sx
• Exertion, chest pn, palpitations, injury• SOB *Linzer M. Ann Intern Med 1997; 126;989-96; 127;76-86. and Van
Dijk N, Wieling W. Dutch FAST trial: watch for pubs!
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In the presence of heart disease…
• Take a full history• Examine• Check ECG (incl. QT) • Test aggressively • Admit• If CHF, think AICD (Knight B. JACC. 1999;33:1964-70)
• If BBB or SND with normal LV, think pacemaker
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Diagnostics
• Labs: not much value (acidosis, sz)
• ECG: in just about everyone; CSM?
• Neuro tests: only if signs or sx• Echo: assess substrate(Sarasin F. Heart. 2002;88:363-7);
IHSS, CoCM, CAD, AS: refer.
• Stress test: exertional sx; ? in elderly (echo first)
• Holter: background arrhythmias
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More tests
• EP studies: OHD, BBB.
• Loop ECG recording: infrequent LOC or palpitations without OHD– Ambulatory loop (Linzer M, AJC. 1990;66:214-19)
– Implantable Loop (ILR) (Krahn A. JACC 2003;42:495-501)
• Tilt test: r/o vasovagal/reflex syncope
• Psychiatric evaluation
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When to admit*
• OHD
• ECG abnormalities (e.g. CAD, long QT, SND, BBB)
• Exertional sx; palpitations; injury; chest pn; dyspnea
• FH sudden death• Severe OH (*From European Task Force on Syncope.
Europace. 2004;6:467-537).
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Quality of Life, driving issues
• Syncope has serious impact on QOL (Van Dijk N.
J Cardiovasc Electrophys. 2006;17:998-1003)
• Driving should often be restricted (European Task Force. Europace. 2004;6:467-537)
– Private vs. vocational drivers– Duration of restriction related to etiology and
when sx occurred– Often 3-12 months
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Case 1*
• Case 1 (#22): A 23 yo man with GERD and syncope while swallowing
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA. 2006.
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Giada F, Raviele A. Swallow syncope associated with asystole. In: Syncope Cases. Garcia-Civera R, Baron- Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 62.
Case 1
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Case 2*
• Case 2 (#28): A 23 year old woman with recurrent vasovagal-like episodes. How to diagnose?
*From Garcia-Civera R. Syncope Cases. Blackwell Futura.
Malden, MA. 2006.
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Romero N, Baron Esquivias G, Gomez Moreno S, et al. Long-term follow-up of vasovagal syncope with a long asystolic pause. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 79.
Case 2
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Case 3*
• Case 3 (#29): A 28 yo man with recurrent vasovagal episodes. How to treat?
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
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Krediet CTP, van Dijk N, Wieling W. Averting a vasovagal faint with a combination of leg crossing and muscle tensing. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 82.
Case 3
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Case 4*
• Case 4 (#42): A 20 yo man with lightheadedness and syncope shortly
(5-10 sec) after standing.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
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van Dijk N, Harms MPM, Wieling W. Initial orthostatic hypotension as a cause of syncope in an adolescent. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 118
Case 4
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Case 5*
• Case 5 (#52): A 73 yo man with HBP and multiple positional (orthostatic) episodes of syncope
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA. 2006.
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Daga Calejero B, Gutierrez Ibanez E, Carmona Ainat A, Sanchez Val A, et al. Orthostatic hypotension and syncope in a patient with pheochromocytoma. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 148.
Case 5
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Case 6*
• Case 6 (#53): A 28 yo man with unprovoked syncope and a borderline ECG.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
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Garcia Civera R, Ruiz Granell R, Morell Cabedo S, Sanjuan Manez R. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 153.
Case 6
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Garcia Civera R, Ruiz Granell R, Morell Cabedo S, Sanjuan Manez R. In: Syncope Cases. Garcia-Civera R,Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 154.
Case 6
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Case 7*
• Case 7 (#59): A 16 yo boy who collapsed during a soccer match 6 years ago; his brother recently died suddenly.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
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Wilde AAM, Simmers TA. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 170.
Case 7
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Wilde AAM, Simmers TA. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 171.
Case 7
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Case 8*
• Case 8 (#86): a 48 yo smoker with discomfort and dizziness while driving, and syncope after exiting the car (who then drove to the hospital).
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
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Sanchez Gonzalez A, Fournier Andray JA, Ballesteros Pradas SM, Diaz de la Llera LS, Villa Gil-Ortega M. Syncope as an isolated manifestation of left main coronary artery occlusion. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 247.
Case 8
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Case 9*
• Case 9 (#91): A 45 yo man with two syncopal spells, LBBB, EF 30%, neg cath, NSVT on Holter, and neg EPS.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
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Case 10*
• Case 10 (#99): A 50 yo man with a 3/6 SEM and syncope while walking to work.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA. 2006.
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Tornos P. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 286.
Case 10
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Tornos P. Syncope in aortic stenosis. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 287.
Case 10
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Case 11*
• Case 11 (#105): a 68 yo woman with HBP, chest and back pain, then syncope.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
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Sanjuan Manez R, Blasco ML, Martinez Leon J, Ruiz Granell R. Syncope in acute aortic dissection. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 305.
Case 11
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Case 12*
• Case 12 (#106): an 86 yo woman with breast Ca, hx of PE, and two episodes of syncope.
*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.
2006.
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Montagud Balaguer V, Pelaez Gonzalez A, Aguar Carrascosa P, Tuzon Segarra MT, Salvador Sanz A. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 308.
Case 12
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Montagud Balaguer V, Pelaez Gonzalez A, Aguar Carrascosa P, Tuzon Segarra MT, Salvador Sanz A. Pulmonary embolism presenting as syncope. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 308.
Case 12
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In summary:
• Syncope can be diagnosed.
• Syncope can be treated.
• Heart disease means serious syncope.
• The history, physical exam and ECG mean a lot!