SyncopeThe Diagnosis and Management
Angel R. León, MD
Division of Cardiology
Emory University School of Medicine
Arrhythmia that cause Syncope
� Sinus arrest with long pauses
� Asystole following conversion from AF
� High degree AV block
� Hypotensive ventricular tachycardia
� Ventricular fibrillation
� SVT with hypotension
Three Questions in Syncope
1. Is there any structural heart disease2. Is there any structural heart disease3. Is there any structural heart disease
Diagnostic Exercises for SyncopeHistory & physical examECGEchocardiogram w DopplerHolterTilt table testingEvent recorderEP studyInsertable loop recorderNeurologic evaluationPsychiatric evaluation
The ECG in Evaluating Syncope
Identifies:
� Q-waves from previous MI or ST changes associated with ischemia
� Hypertrophic cardiomyopathy
� Bundle branch or bifascicular block
� Prolonged (short) QTc, Brugada pattern
Echocardiogram in Syncope
Assessment of left ventricular size and functionSegmental wall abnormalities and thinningDiffusely dilated and dysfunctional LVHypertrophic cardiomyopathy with or without LV
outflow obstructionAortic stenosis, valvular or sub-valvularLV inflow obstruction: Mitral stenosis or myxomaRight ventricular abnormalities: ARVD
Holter Monitor in Syncope
What is the probability that your patient will experience syncope or near syncope during the 24hr recording?
Does nocturnal bradycardia (HR 35-40) constitute a diagnostic finding?
The 24hr Holter in Syncope Work-up
Gibson, et al., retrospectively analyzed 7,364 patients undergoing 24-hour Holter during 5-year period.
Of these, 21% had been referred because of syncope.
Gibson TC. Am J Cardiol. 1984;53:1013-1017.
The 24hr Holter in Syncope Work-up
Gibson, et al., retrospectively analyzed 7,364 patients undergoing 24-hour Holter during 5-year period.
Of these, 21% had been referred because of syncope.
Yield: < 2% had syncope during an arrhythmia
Gibson TC. Am J Cardiol. 1984;53:1013-1017.
30 day Event
Recorder in
Syncope
Linzer M. Am J Cardiol. 1990;66:214-219.
*Asterisk denotes event marker
30 day Event
Recorder in
Syncope
Linzer M. Am J Cardiol. 1990;66:214-219.
*Asterisk denotes event marker
Tilt Table Test for Syncope
Used to test for neurally-mediated, neuro-cardiogenic, vasodepressor, cardio-inhibitory syncope
Measure heart rate and blood pressure in supine & 80° head-up tilt positions
Pharmacologic challenge (NTG or Isoproterenol)
Bezold-Jarisch Reflex
Chang-Sing P. Cardiol Clinics. 1991;9(4):641-651.
Inotropy
Contractility
Catechols
BPReflex
Venous Return
Tilt
HR
Vasodilation
BPSyncope
VagalEfferen
tSmall Ventricle
Vagal
Afferent BrainStem
SympatheticWithdrawal
EP Evaluation in Syncope
Structural Heart Disease present:Conduction system disease: AV blockMI scar: Ventricular TachycardiaCardiomyopathy: VF or VTIon-channel abnormalities
No obvious structural heart disease: ?????
Neurologic Tests in Syncope
Carotid ultrasound and Doppler?RAS: Dual circulation
Brain MRI?EEG foe epileptic focus?Sleep disorder testing?
Suggested Algorithm for Diagnosing Syncope
Linzer M, Yang EH, Estes M, et al. Ann Intern Med. 1997;127:76-86
Syncope
A
Treat
Diagnostic
Treat
Organic Heart Disease –
– +
+
TreatTreat
+
Branch 1 Organic Heart
Disease
ECG and treadmill test
Holtergo to A
Branch 3 No suspectedheart disease
Stop workupTilt test, psych evaluation
Non-diagnosticConsider EP studies
Recurrent First episode
NSR w/ symptomsStop workup for
arrhythmia
Arrhythmia w/
symptoms
Branch 2 Age ≥ 60y
Carotid massage
ECG and treadmill test
–
Stop workup
Loop monitor, tilt test,
psych eval
Tilt test, psych eval
InfrequentFrequent First episode
Organic Heart Disease +
Specific Testing–
Unexplained SyncopeSuggestive
Suggested Algorithm for Diagnosing Syncope
Linzer M, Yang EH, Estes M, et al. Ann Intern Med. 1997;127:76-86
Unexplained Syncope
–+
TreatTreat
+
Branch 1 Organic Heart Disease
ECG and treadmill test
Holter
Stop workupTilt test, psych
evaluation
Non-diagnosticConsider EP studies
Recurrent First episode
NSR w/ symptomsStop workup for
arrhythmia
Arrhythmia w/ symptoms
–Stop
workup
Loop monitor, tilt
test, psych eval
Tilt test, psych eval
Infrequent
Frequent
First episode
Suggested Algorithm for Diagnosing Syncope
Linzer M, Yang EH, Estes M, et al. Ann Intern Med. 1997;127:76-86
* Performed in office setting only in the absence of bruits, a history of ventricular tachycardia, recent stroke, or recent myocardial infarction.
Branch 2 Age ≥ 60 yrs
Loop monitor, tilt test,
psych eval
Organic Heart Disease –
Holter
Branch 3 No suspected heart disease
Carotidmassage*
ECG and treadmill test
Stop workup
Tilt test, psych eval
InfrequentFrequent First episode
Organic Heart Disease +
Unexplained Syncope
Diagnostic Exercises for SyncopeHistory & physical examECGEchocardiogram w DopplerHolterTilt table testingEvent recorderEP studyInsertable loop recorderNeurologic evaluationPsychiatric evaluation
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