Syncope : What tests should I do? Boon Lim Consultant Cardiologist Clinical Lead for Imperial Syncope Unit Hammersmith Hospital

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1 Syncope : What tests should I do? Boon Lim Consultant Cardiologist Clinical Lead for Imperial Syncope Unit Hammersmith Hospital

2 The most important diagnostic test is History taking

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4 Why is history taking a challenge? T-LOC differential requires knowledge of ALL causes, encompassing cardiology, neurology, general medicine, internal medicine, geriatrics and psychiatry. General medical training is now more fragmented, leading to decrease in broad skills of history taking and physical examination Reflex syncope (40% A&E attendances for T-LOC) doesn t quite fall within any speciality. Therefore specialists attempt to rule out causes in own field

5 Hammersmith audit for patients referred for head up tilt testing 460 patients in 10 months Oct 11 Jul test per patients prior to 59% echo 50% 24h Holter 13% Exercise testing 20% MRI brain 13% EEG 2.6% ILR 3.4% 24h BP Unpublished data, Hammersmith Hospital audit

6 General practitioner 5% Geriatric consultant 2% Other consultants 2% Neurologist 16% General cardiologist 36% Electrophysiologist 39%

7 Investigation outcome Echocardiography (272 pt) was abnormal in 14 patients (5.7%): 5 mild-moderate valve regurgitation 5 left ventricular hypertrophy 3 focal hypokinetic areas 1 atrial dilatation 24 hours Holter (229 pt) was abnormal in 10 patients (4.8%): 5 paroxysmal atrial fibrillation 1 frequent ventricular ectopies 2 runs of supraventricular tachycardia 1 not sustained ventricular tachycardia 1 periods of atrio-ventricular block Mobitz 2 type 1 MRI of the heart (7 pt) carotid Doppler test (7 pt) and EPS (8 pt) were all normal Unpublished data, Hammersmith Hospital audit

8 Investigation outcome 24h BP was abnormal in 3 patients (18%): for the presence of hypertension Exercise test (62 pt) was abnormal in 3 patients (4.8%): 2 with signs of ischemia 1 with supraventricular tachycardia External loop recorder (23 pt) was abnormal in 2 patients (8.6%): 1 for frequent ventricular ectopy 1 supraventricular tachycardia Internal Loop recorder (12 pt) was abnormal in 1 patient (8.3%) Non-sustained supraventricular tachycardia MRI of the brain (72), CT of the brain (26) and EEG (60) were normal in all patients Unpublished data, Hammersmith Hospital audit

9 If you go to a barbers, you get a..

10 Head up tilt test diagnostic yield HUTT reached a diagnosis in 67% of patients (308): Positive in 64% of patients (294 patients) Orthostatic hypotension in 0.65% (3 patients) POTS in 1% (5 patients) Pseudosyncope in 1.3% (6 pt) A negative outcome was observed in 28.7% (132 pt) Non diagnostic in 4.3% (20 pt): For early interruption on demand of the patient (5 pt) Suspected false positive response (15 pt) Unpublished data, Hammersmith Hospital audit

11 Does anything beat the diagnostic yield (67%) of HUTT? Esc Syncope Guidelines 2018

12 History Physical exam for what? Is the patient well or unwell? Murmur of Aortic Stenosis, structural heart disease, arrhythmia? Lying and standing BP ECG But what if I am not trained to read ECGs?

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21 The case of 80yo M with fainting Clinical history of childhood faints, stopped in 20s, typical vasovagal in assembly, church Episode that led to tilt recently was that he was out for a walk before feeling v unwell and dizzy for 5 seconds whilst walking prior to LOC. But experience on tilt test was NOT a reproduction of real life symptoms, and that the symptoms whilst walking were far more severe and abrupt and not comparable to what he had on tilt test Reported as false positive. What next?

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24 Treatment? He had pacemaker He had increased dose of beta blocker Doing well

25 27yo Lacrosse player with syncope after exercise, negative tilt, negative Holter, Normal echo, normal ECG. Therefore modified supranormal Bruce

26 27yo Lacrosse player with syncope after exercise, negative tilt, negative Holter, Normal echo, normal ECG. Therefore modified supranormal Bruce

27 27yo Lacrosse player with syncope after exercise, negative tilt, negative Holter, Normal echo, normal ECG. Therefore modified supranormal Bruce

28 27yo Lacrosse player with syncope after exercise, negative tilt, negative Holter, Normal echo, normal ECG. Therefore modified supranormal Bruce

29 Mrs DS, 41yo F, MD in company, pre-syncope x 3 daily, with syncope once weekly.

30 Mrs DS, 41yo F, head of post-sorting office, presyncope x 3 daily, with syncope once weekly. LOC

31 Mrs DS, 41yo F, head of post-sorting office, presyncope x 3 daily, with syncope once weekly. LOC 1 LOC 2

32 How to improve appropriate diagnostic testing for syncope? Education Exposure Multidisciplinary approach key encompassing neurologists, ED physicians, general medics Establish Syncope Units Online resource promotion

33 Syncopedia.org a great tool for learning for clinicians.

34 STARS resources Work in progress anchored by ESC Syncope

35 Syncope : What tests should I do? Imperial Syncope Team