Syncope – Catch ‘ em in
the Act’Zunida Ali
Electrophysiology and Pacemaker Unit
National Heart Institute
Kuala Lumpur
What is the syncope
Syncope is:
• A sudden temporary loss of consciousness associated with loss of postural tone
• Due to abrupt reduction or loss of cerebral perfusion1
1 Grubb, Olshansky (eds). Syncope: Mechanisms and Management. Armonk, NY: Futura Publishing Co., Inc., 1998, p.1
The only difference between
syncope and sudden death
is that in one you wake up.1
1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: 403-412
The Significance of Syncope
Cardiac Diseases and Arrhythmias:
Most serious due to high mortality rates
Arrthymias structural Heart Disease
- Brady arrhythmias - Obstruction to flow
- Tachyarrhythmias - Pump failure
- Cardiac tamponade
- Aortic dissection1 Day SC, et al. Am J of Med 1982;73:15-23.2 Kapoor W. Medicine 1990;69:160-175.3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189.4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.
Syncope Can Be A Serious Clinical
Problem
• Some causes of syncope are potentially fatal
• Causes with high mortality and major morbidity rates
– 7.5% overall1
– 18-33% mortality in patients with a cardiac cause1-4
1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997
2 Gendelman HE, et al. NY State J Med 1983
3 Day SC, et al, AM J of Med 1982
4 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175
Magnitude Of Syncope
Syncope Reported Frequency
• Individuals <18 yrs
• Military Population 17- 46 yrs
• Individuals 40-59 yrs*
• Individuals >70 yrs*
15%
20-25%
16-19%
23%
Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306.*during a 10-year period
Syncope:A Symptom…Not a Diagnosis
• Self-limited loss of consciousness and postural tone
• Relatively rapid onset
• Variable warning symptoms
• Spontaneous complete recovery
“Not So Normal” ECG
0%
20%
40%
60%
80%
100%
Anxiety/
DepressionAlter Daily
Activities
Restricted
Driving
Change
Employment
11Linzer, Linzer, J J ClinClin EpidemiolEpidemiol, 1991., 1991.22Linzer, Linzer, J Gen J Gen IntInt MedMed, 1994., 1994.
Impact of Syncope
Syncope: Etiology
• Neurally-• Mediated
OrthostaticCardiac
Arrhythmia
StructuralCardio-
Pulmonary
Non-Cardio-
vascular
1• Vasovagal• Carotid
Sinus• Situational
�Cough�Post-
micturition
2• Drug Induced
• ANSFailure�Primary�Secondary
3• Brady
�Sick sinus�AV block
• Tachy�VT�SVT
• Long QT
Syndrome
4 • Aortic
Stenosis
• HOCM• Pulmonary
Hypertension
5• Psychogenic• Metabolic
e.g. hyper-ventilation
• Neurological
24% 11% 14% 4% 12%
Unknown Cause = 34%
DG Benditt, UM Cardiac Arrhythmia Center
CardiologistInternist
NeurologistEntry Points
1 Reveal Syncope Validation Project (RSVP) Clinical Summary, Medtronic data on file
Emergency
and make multiple physician visits10.2 Visits per year1
3.2 Different Specialists
Patients May Enter The Healthcare System At Multiple Points
Family/General Practitioner
History and Physical Exam Surface ECG
Neurological Testing
• Head CT Scan
• Carotid Doppler
• MRI
• Skull Films
• Brain Scan
• EEG
CV Syncope Workup
• Holter
• ELR or ILR
• Tilt Table
• Echo
• EPS
Other CV Testing
• Angiogram
• Exercise Test
• SAECG
Psychological Evaluation
ENT Evaluation Endocrine Evaluation
Unexplained Syncope Diagnosis
Adapted from: W.Kapoor.An overview of the evaluation
and management of syncope. From Grubb B, Olshansky B (
Syncope: Mechanisms and Management.
Armonk, NY: Futura Publishing Co., Inc.1998.
Syncope Diagnostic Objectives
• Distinguish ‘True’ Syncope from other ‘Loss of
Consciousness’ spells:
� - Seizures
� - Psychiatric disturbances
• Establish the cause of syncope with sufficient certainty to:
� - Assess prognosis confidently
� - Initiate effective preventive treatment
•5/24/2005 0KMF15.ppt 10
Management Strategy of Evaluation
� Initial evaluation(history, physical exam, ECG, BP
supine and upright)� Laboratory investigations guided by
the initial evaluation
� Re-appraisal
� TreatmentEurropean Socciiettyy off Carrdiiollogyy Tasskk Forrcce on Managementt off Syynccope
Diagnostic examinations
Epilepsy and TIA
Epilepsy and TIA
Epilepsy and TIA
Cardiac
Cardiac
Cardiac
Co-morbidities
EEG
CT scan & MRI
Carotid Doppler
Coronary angiography
Pulmonary scintigraphy
CXR
Abdominal ultrasound
Rarely useful
NMS
NMS
Cardiac
Cardiac
Cardiac
Cardiac
NMS and Cardiac
Carotid sinus massage
Tilt testing
Echocardiogram
Holter/loop monitoring
Electrophysiological test
Exercise stress testing
Implantable loop recorder
Useful
Suspected diagnosisTest
12-Lead ECG
• Normal or Abnormal?
– Acute MI
– Severe Sinus Bradycardia/pause
– AV Block
– Tachyarrhythmia (SVT, VT)
– Preexcitation (WPW), Long QT, Brugada
• Short sampling window (approx. 12 sec)
In developmentWireless (internet) Event Monitoring
•Useful for infrequent events
•Implantable type more convenient (ILR)
Loop Recorder
•Useful for infrequent events
•Limited value in sudden LOC
Event Recorder
Useful for frequent eventsHolter (24-48 hours)
CommentsMethod
Ambulatory ECG
Holter Monitoring
• Rarely useful unless
syncope is frequent
• Diagnostic yield 0-4%
Event Recorder
Loop recorder
External Loop Recorder - KOH
How to catch it in the act ?
Syncope
episode
Regained
conscious
3 min 3 min 2 min
Programmed - Pre 4 min
- post 1 min Total recording 5 min
External Loop Recorder - KOH
• Programmed and fixed to the patient appropriately.
• Educate patient on how to fix it and taken care of the device.
External Loop Recorder - KOH
• Teach patient on how
and when to activate
the device recorder.
• Show the correct way
to send the recorded
eventMouth piece
Patient ActivatorReveal® Plus ILR Programmer
Implantable Loop Recorder
Implantable loop recorder
Role of ILR
• ESC recommends use of ILR when:
– an arrhythmia is suspected, but standard monitoring has not documented an arrhythmia (Class I recommendation), and
– the interval between episodes of syncope is measured in months or years.
EHJ. 2001;22:1256-1306.
Quick Look Screen @ Follow-up
Syncopal episode 2 weeks post-Reveal DX implant
Symptom-Rhythm Correlation
Auto Activation Point Patient
Activation Point
Reveal recording
Implantable loop recorder
Advantages:
• Longer event can be recorded
• Auto triggered and patient triggered
• No mess with electrode and cables
• No worry about daily activities
• High diagnostic yield to capture symptom ECG correlation
Implantable loop recorder
Disadvantages:
• Only diagnostic tool
• Need minor surgical procedure
• Lack of concurrent diagnostic datas like physiologic parameter eg. blood pressure
• Higher upfront cost / expensive device
Implantable loop recorder
Important:
• Proper device programming• Educate patient and family
- event activation- When to come to hospital?
• Others such as - wound care- activator
Tilt Testing is Indicated for
Diagnostic Purposes
• In cases of unexplained single syncopal episodes or recurrent episodes in the absence of organic heart disease.
• In the presence of organic heart disease, after cardiac causes of syncope have been excluded.
• For evaluating patients with
recurrent unexplained falls.
When an understanding of the haemodynamic pattern in syncope may alter the therapeutic approach
To differentiate syncope with jerking movements from Epilepsy
To assess recurrent presyncope.
Role of Tilt table
• Objectives
–Enhance Orthostatic Tolerance
–Diminish Excessive Autonomic Reflex Activity
–Reduce Syncope Susceptibility / Recurrences
• Technique
–Prescribed Periods of Upright Posture
–Progressive Increased Duration
Tilt Table Test
60-80o
Tilt Table Test in IJN
• NBM 6hr prior test
• ECG
• Blood pressure
• Carotid Massage – Supine / tilt up
• Tilt 70 degrees for 30 min.
• Isoproterenol 1-5mcg/min
Positive Tilt table test.
Tilt Table Test - Result
• Cardio inhibitory – ( HR )
• Vasodepressor - ( BP )
• Mixed Typed
Carotid Sinus Massage
• Site:
– Carotid arterial pulse just below thyroid
cartilage
• Method:– Right followed by left, pause between
– Massage, NOT occlusion
– Duration: 5-10 sec
– Posture – supine & upright
Carotid Sinus Massage
• Outcome:
� 3 sec asystole and/or 50 mmHg fall in systolic
blood pressure with reproduction of symptoms =
Carotid Sinus Syndrome (CSS)
• Contraindications
� Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months
• Risks
�1 in 5000 massages complicated by TIA
Conventional EP Testing in Syncope
• Limited utility in syncope evaluation
• Most useful in patients with structural heart disease
– Heart disease……..50-80%
– No Heart disease…18-50%
Relatively ineffective for assessing bradyarrhythmias
Brignole M, Alboni P, Benditt DG, et al. Eur Heart Journal 2001; 22: 1256-1306.
EP Testing in Syncope:Useful Diagnostic Observations
• Inducible monomorphic VT
• Inducible SVT with hypotension
• SNRT > 3000 ms or CSNRT > 600 ms
• HV interval ≥ 100 ms (especially in absence of inducible VT)
• Pacing induced infra-nodal block
Conventional Diagnostic Methods/Yield
65-88% 6, 7• Insertable Loop Recorder
(up to 14 months duration)
2-11% 2ECG
20% 7• External Loop Recorder
(2-3 weeks duration)
0-4% 4,5,8,9,10
Neurological †
(Head CT Scan, Carotid Doppler)
2% 7• Holter
Ambulatory ECG Monitors:
11-87% 4, 5Tilt Table Test (without SHD)
49% 3Electrophysiology Study with SHD
11% 3Electrophysiology Study without SHD*
49-85% 1, 2History and Physical
(including carotid sinus massage)
Yield(based on mean time to diagnosis of 5.1 months7
Test/Procedure
* Structural Heart Disease† MRI not studied
1 Kapoor, et al N Eng J Med, 1983.
2 Kapoor, Am J Med, 1991.
3 Linzer, et al. Ann Int. Med, 1997.
4 Kapoor, Medicine, 1990.
5 Kapoor, JAMA, 1992
6 Krahn, Circulation, 1995
7 Krahn, Cardiology Clinics, 1997.
8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.
9 Day S, et al. Am J Med. 1982; 73: 15-23.
10 Stetson P, et al. PACE. 1999; 22 (part II): 782.
Typical Diagnostic Pathway
Syncope
History and Physical
ECG
KnownSHD
NoSHD
Echo
EPS
+
Treat
> 30 days; > 2 Events
Tilt ILR
Tilt Holter/ ELR
ILR
Tilt/ILR
< 30 days
-
Adapted from:
Linzer M, et al. Annals of Int Med, 1997. 127:76-86.
Syncope: Mechanisms and Management. Grubb B, Olshansky B (eds) Futura Publishing 1999
Zimetbaum P, Josephson M. Annals of Int Med, 1999. 130:848-856.
Krahn A et al. ACC Current Journal Review,1999. Jan/Feb:80-84.
Diagnostic Limitations
� Difficult to correlate spontaneous events and laboratory findings
� Require frequent settlement for an attributable cause
� Unknown remain 20-30% 1
1Kapoor W. In Grubb B, Olshansky B (eds) Syncope: Mechanisms and Management. Armonk NY; Futura Publishing Co, Inc:
1998; 1-13.
Conclusion
Syncope is a common symptom,
often with dramatic consequences,
which deserves thorough investigation
and appropriate treatment of its cause.
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