Syncope AHD[1]

8/8/2019 Syncope AHD[1]

1/23


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DefinitionyA transient loss of consciousness accompanied by an

inability to maintain postural tone

y Resolves spontaneouslywithout interventiony Duration seconds - minutes


3/23

Epidemiologyy In the US . . .

y 3% of ED visits

y

6% of admissionsy Costs $750 million annually

y Common in elderlyy CAD

y Polypharmacy

y Neuropathiesy Autonomic instability

y Incidence < 0.1% in children


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Mortality / Morbidityy Mortality at 1 year . . .

y 20-30% if cardiac

y 2-6% if etiology unknowny Major potential for morbidity

y Head injury

y Lacerations

y Extremity fractures


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Is it Syncope?y Dizziness, presyncope, drop attacks and vertigo: No

LOC

SEIZURE SYNCOPE

Duration ofUnconsciousness >5min

Seconds-minutes

Slowreturn to baselinemental status

Oriented immediately after

Bladder Incontinence Bladder Control Retained

Aura Prodromal Sx andcomplaints during episode


6/23

Differential Diagnosesw NeurallyMediated Syncope (24%)

w Vasovagal

w Situational

w Carotid Sinus

w Orthostatic Hypotension (10%)

w Psychiatric Disorders (2%)

w NeurologicDz (10%)

- TIA in Vertebrobasilar circ.w Cardiac Syncope

x Organic Heart Dz (4%)

x Arrhythmias (14%) UNKNOWNUNKNOWN (34(34%)%)

R/O LifeR/O Life--threateningthreateningDxDx: PE, Blood Loss,: PE, Blood Loss,Subarachnoid Hem,Subarachnoid Hem,Some CardiacSome Cardiac


7/23

Pathophysiology 101y Syncopewill result if

y blood flowis less than 20ml/100g/min

y if it stops for 3-5 secondsy Can be due to:

I. regional hypoperfusion- i.e cerebrovascconstriction/dz

II. systemic hypotension- mechanical obstruction,arrythymias, hypovolemia, dysfunctional vasovagal


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Cardiogenic Syncopey 18% of Syncope

y 1 year mortality 30%

y 2 main mechanismsy Arrhythmias

y Mechanical Obstruction- Aortic Stenosis, HypertrophicCardiomyopathy, Pulm HTN


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Arrhythmiasy Most common cardiac cause

y < 10 sec

y Usually suddenwith no prodromey Unrelated to posture or exertion


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Arrhythmiasy Tachyarrhythmias

y V-Tach

y

Torsades de pointsy Rarely SVT

y Long QT syndrome

y Bradyarrhythmiasy Sick sinus

y Blocks

y Pacemaker malfunction


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Mechanical Obstructiony Often exertional

y Right-sided outflowobstruction

y Pulmonary stenosisy PE

y Left-sided outflowobstructiony Aorticstenosis

y

Hypertrophicobstructivecardiomyopathyy Aortic dissection

y Cardiac tamponade


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Orthostatic Syncopey Most common type in elderly

y Brought on by sudden standing or prolonged standing

y Blunted baroreceptor responsewhich results in failureof cardiac compensation following hypotension

- i.e. increased vagal tone

y Decreased vasomotor toney Neuropathies

y Decreased intravascular volumey Hemorrhage, Dehydration, Sepsis, Meds


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Vasovagal Syncopey aka fainting

y MOST COMMON CAUSE OF SYNCOPE in YOUNGP

Tsy emotional/noxious stimuli

y Normal: Standing upblood pools in LE Decrease inCO, SV and BP changes compensated by symptonevasoconstrict & Tachycardia.

y Syncope: Compensatory resp. interrupted byparadoxical withdrawal of symp stimulation andreplacement by parasymp brady, vasodilation,decrease BP and cerebral perfusion


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Vasovagaly Can be prevented/reversed with supine position and

elevation of legs

y Less common in elderly because ofdecreased vagal tone and decreased B-adrenergiccontractility


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Historyy Prodrome

y Events before, during and after episode

y

Posture before episodey Stressors-blood, pain, emotional, fatigue, heat,

prolonged standing, cough/defecation/swallowing

y Duration; rate of recovery

y

Assoc. Sx: CP, palpitations, neuro

y Seizure?

y Trauma?


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PRODROMEy 70% experience a prodrome

y Pallor, diaphoresis

y

Nausea or vomitingy Faintness, dizziness

y Blurring/dimming vision, constriction of visual fields,paralysis of voluntary lateral gaze, EOM fixed

y Yawning, ringing in ears

y Parasthesias


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Medicationsy blockers

y Diuretics

y DigoxinyAntipsychotics

yAntidepressants

y Phenothiazines

yAlcohol

yAntidysrhythmics

yAntiparkinsonism drugs


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Physical ExamyVitals including orthostatics

y -Significant changes includey

Systolic 20 mm Hgy Diastolic 10 mm Hg

y Heart rate 20 bpm

y Fever

yVolume status

y CVS

- Murmurs, Carotid pulses for bruits, pressure tocarotid sinus

y CNS


19/23

Workupy 40-60% nondiagnostic

y Hx + PE should diagnose 50-60% of patients

y *Need to decide if presence/absence of structuralheart dz

y EKG in all patients

y CBC, metabolic panel, not of great utility


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Workup- IfAbn EKGy Cardiac monitor

-HM: if frequent events of arrhythmia

-Event Recorder/Loop: if infrequent events-Implantable Event Recorder: syncope 1-2x/yr

y ECHO- Diagnostic if either severe aortic stenosis or anatrial myxoma is identified

y ETT- w/exertional syncope, r/o ischemia orcathecholamine-induced arrythmias

y Cardiac Catheterization- If previous tests suggestischemia


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Workupy Tilt-Table Test

y Neurologic Studies

-lowyield- EEG, CT, MRI for

Neurologic; lowyield


22/23

TreatmentyArrhythmia, cardiac mechanical, neuro: trx underlyingyVaso-vagal:

y Orthostatic: volume repletion, compressive stockings,midodrine (alpha1-agonist), fludocortisone, high Na

diet (volume expansion). Beta-blockers often used firstline, but studies showno more effective than placebo.

y Patient Education


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Bottom Liney Syncope is a common event

yA symptom, not a diagnosis!!

y Usually benign, but missed events can be catastrophicy Biggest yield from Hx, PE, EKG

y Diagnostic in 50-80% of cases

Syncope AHD[1]

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