Syncope - American College of Physicians · Patients with classic vasovagal syncope symptoms 75%...
Transcript of Syncope - American College of Physicians · Patients with classic vasovagal syncope symptoms 75%...
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Syncope
Sri Sundaram, MD, FHRS
Sris @ southdenver.com 303-921-1754
South Denver Cardiology Associates www.southdenver.com
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Research Grant - St. Jude Medical Speaker’s Bureau – St. Jude Medical, Boston Scientific
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1. Transient loss of consciousness
2. Inability to maintain postural tone
3. Rapid and spontaneous recovery
4. Absence of clinical features of another cause
DEFINITION
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37% in USA will faint once By age 60, 42% Women and 32% Men Most that have will have by age 40 1 year recurrence rate is 25-32% Vasovagal in most common cause of passing out
Sheldon RS, et al. HRS Expert consensus statement on treatment of POTS, IST and Vasovagal Syncope. Heart Rhythm 2015
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-Demographics: Syncope by Age
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-NEJM 2002; 347: 878-885
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Neurally-mediated (24%) • Vasovagal 18% • Situational 5% • Carotid Hypersensitivity 1%
Cardiac (18%) • Arrhythmia 14% • Outflow obstruction/AMI 4%
Orthostatic/Medications 11% Neurologic (seizure) 10% Psychiatric 2%
-NEJM 2000; 343: 1856-62 -Ann Int Med 1997; 126: 989-96
• Unknown 35%
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-NEJM 2002; 347: 878-885
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Is loss of consciousness syncope or not?
Is heart disease present or absent?
Are there important clinical features in the history that suggest the diagnosis?
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History & Physical Carotid sinus massage (esp for older pts) Orthostatic BP measurement ECG, ECHO Cardiac auscultation Assessment of injuries
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Right carotid artery massaged for 5-10 sec
If no response repeat on Left Pause >3 sec or fall of SBP >50mmHg considered
abnormal and defines hypersensitivity Treatment is pacemaker
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Most accurate after ~5 minutes laying supine
Measurements of BP at 1 & 3 min
Defined as fall in SBP >20mmHg fall in DBP >10mmHg SBP <90mmHg
-Journal of the Neurological Sciences. 144(1-2):218-9, 1996 Dec.
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-Diagnostic modalities ”
Grubb B., NEJM 2005.
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-Tilt Table Responses
-Vasovagal -Dysautonomic
-Tilt
-Tilt
-Tilt -Head Down
-Head Down
-Head Down
-POTS
Heart Rate Blood Pressure
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• Evaluate a test by: 1. Sensitivity 2. Specificity 3. Reproducibility
No Gold Standard – need gold standard to determine
sensitivity and specificity.
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SENSITIVITY Patients with classic vasovagal syncope symptoms
75% had reproducible syncope during tilt
SPECIFICITY Very difficult to determine 20-40% incidence of syncope of lifetime 60-80%
should be negative. Over a lifetime, conditions can change
Wasman MB, et al. Am J Cardiol 1989,63:58-65. Agarwal R., et al. J Invasive Cardiol 1997,9:601-603.
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Good test –> should get same result everytime
Tilt is about 70-80%
reproducible
Delephine S. Am J Cardiol 2002, 90:488-491.
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• Clinical evaluation most useful.
• Order Tilt when clinical diagnosis is not clear.
• Tilt should not be the sole diagnostic modality. Results combined with other tests.
• • Positive or Negative result does not definitively rule in or rule out
vasovagal syncope.
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• Patient/family education
Avoidance of triggers
•Recognition of premonitory symptoms Lifestyle changes Increased fluid/salt intake Careful postural changes
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•First line treatment •Counsel to arise slowly and wait
a few seconds before standing Especially on first arising in the morning Perform isometric excercises before
arising
•Avoidance of hot showers or excessive heat
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•Support leotard prevents venous pooling thereby enhancing venous return
•Available in: 15-20mmHg 20-30mmHg 30-40mmHg
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Tilt training: Patient stands at 70° against wall
twice a day, initially for as long as tolerated
Duration of standing is increased slowly until 30 minutes 1-2 times per day is achieved
Effective if performed consistently
-Pacing & Clinical Electrophysiology. 21(1 Pt 2):193-6, 1998 Jan.
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Sheldon R, et al. Prevention of Syncope Trial (POST). Circulation 113;1164-1170.
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Beta Blockers &
Vasovagal Syncope
Sheldon R, et al. Prevention of Syncope Trial (POST). Circulation 113;1164-1170.
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Beta Blockers &
Vasovagal Syncope
Sheldon R, et al. Prevention of Syncope Trial (POST). Circulation 113;1164-1170.
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JAMA. 1997 Apr 2;277(13):1046-51.
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Midodrine Alpha-1 agonist
Increases peripheral vasoconstriction
First drug approved by FDA for treatment of
orthostatic hypotension Usual dosage 10mg tid (every 4 hours)
Effect usually lasts 2-4 hours following dose
JAMA. 1997 Apr 2;277(13):1046-51.
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Echo
ECG
Monitoring
EP study
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HOCM Aortic Stenosis
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EP study and
Implantable Loop Recorder
Holter Monitor
Event Monitor
-Krahn AD. Randomized Assesment of Syncope Trial. Circulation 2001.
Holter & Event Monitoring
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Time Course of Repeat Syncopal Event
•Loop Recorder battery can last up to 3 years
•Can capture
syncopal episode that conventional monitoring
missed.
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•Indicated when work up negative, including EP
study
•Symptoms are concerning for cardiac
syncope
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-KRAHN AD, KLEIN GJ, FITZPATRICK A, SEIDL K, ZAIDI A, SKANES A and YEE R. -Predicting the Outcome of Patients with Unexplained Syncope Undergoing Prolonged Monitoring. PACE 2002; 25:37–41.
Implantable Loop Recorder
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Kurichian V, et al. Heart Rhythm 2008
PACEMAKERS for Treatment of Syncope
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What’s Next - Droxidopa?
Kaufman H, et al. Droxidopa for neurogenic orthostatic hypotension. Neurology 2013;83:1-8.
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