Syncope Cardiac or not? Dr Jaycen Cruickshank Emergency Physician Director of Clinical Training BHS

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1 Syncope Cardiac or not? Dr Jaycen Cruickshank Emergency Physician Director of Clinical Training BHS

2 Syncope( (cardiac(or(not?( What(is(syncope?( Syncope( is( a( brief( loss( of( consciousness( that( resolves( spontaneously( and( completely.( It( is( distinct( from( vertigo,( seizures,( coma,( and( states( of( altered( consciousness.( Why$is$this$definition$so$important?( If( your( patient( is( sick( and( unstable,( your( mindset( and( diagnostic( work( up( is( completely(different.((the(syncope(lecture(helps(with(a(different(patient(group$ Syncope(+(patient(is(now(breathless(=(dyspnea(for(investigation$ Syncope(+(patient(has(chest(pain(=(chest(pain(for(investigation$ Syncope(+(headache(=(headache(for(investigation$ Syncope(+(GIT(bleeding(=(GIT(bleeding(for(investigation$ When(applying(the(rules(above,(think(serious(causes(on(your(list(of(differential( diagnoses,(and(severity(sufficient(to(cause(altered(conscious(state( Assessment(of(a(patient(post(syncopal(episode( (identify(or(stratify( A( careful( history,( obtaining( the( exact( description( of( the( events( before,( during,( and(after(the(event,(with(the(help(of(eye(witnesses,(is(paramount.(( Red( Flags:( Syncope( on( exertion,( and/or( sudden( onset( without( a( prodrome,( are( features(that(warrant(concern((cardiac(causes)(,(as(is(a(family(history(of(sudden( death.( The( two( most( common( causes( are( vasovagal( (neurocardiogenic)( syncope( and( postural(hypotension( Approximately( 30%( of( patients( will( have( no( cause( found.( The( San$ Francisco$ syncope$ rule( is( not( robust,( but( key( criteria( such( as( cardiac( failure( and( abnormal$ecg$seem(particularly(important(factors(in(predicting(poor(outcomes.( European(Guidelines(in(Syncope(Study((EGSYS)(score(will(be(reviewed.(( ECGs(not(to(miss(in(patients(who(appear(well(now,(but(had(an(episode(of( syncope( (AB 2 C(W(+(Q 2 ( Acute(coronary(syndromes( Blocks( (eg(trifascicular(block( Brugada( syndromeq( RBBB( and( ST( elevation( V1Q3( (risk( ventricular( arrhythmia( Cardiomyopathy(HOCM( (risk(of(cardiac(arrhythmias(on(exertion( W(Wolff(Parkison(White(syndrome(Short(PR(and(delta(wave((Q(( QT(Long(QT(interval( >500(msec(Q((risk(of(episodes(of(polymorphic(VT( QT( Short( QT( interval( ( <300msec( ( (inherited( risk( of( sudden( cardiac( death)( Suggested(further(reading(( ( Article:( Medscape(review(article( (

3 Syncope this is what you need to know Learning objectives To understand what is not syncope This helps with what is syncope a symptom not a diagnosis To be familiar with diagnostic approach to syncope identify or risk stratify Recognition of ECGs in between episodes of syncope he was well when I last saw him alive Refer to ED lecture series and self directed workbooks

4 AB 2 C W + WRONG QT Acute Coronary Syndrome Blocks / Brugada Cardiomyopathy WPW Long QT & Short QT

5 This is syncope Take a proper history E.g. Situational syncope, vasovagal, postural Before, during (eyewitness) and after details. Red flags Exertional, sudden onset, no prodrome Family history, recurrent, Cardiac failure Abnormal ECG

6 Case The University student

7 Case The truck driver The middle of the night collapse

8 This is not syncope (as such) Your patient is unstable and has not recovered Syncope + patient is now breathless = dyspnea for investigation Syncope + patient has chest pain = chest pain for investigation Syncope + headache = headache for investigation Syncope + GIT bleeding = GIT bleeding for investigation Think serious causes of these problems.

9 Epidemiology = pre test probability The handout has a reasonable summary Diagnostic rate of 20-50% in the ER Definitive diagnosis in 15-30% of inpatients after thorough work-up Framingham Heart Study reported 822 episodes of syncope in 7814 patients over 17 year period1: Vasovagal (21%) Cardiac (10%) Orthostatic (9%) Unknown (37%)

10 AB 2 C W + WRONG QT Acute Coronary Syndrome Blocks / Brugada Cardiomyopathy WPW Long QT

11 Episode of syncope here is his first ECG

12 Syncope ECG

13 Block trifascicular courtesy

14 Young man in 30 s with Episodic fainting episodes That ECG looks odd. What is the diagnosis?

15 Brugada syndrome

16 Brugada syndrome Brugada Syndrome is an ECG abnormality with a high incidence of sudden death in patients with structurally normal hearts. Likely gene mutation causing sodium channel abnormality Diagnosis depends on a characteristic ECG finding AND clinical criteria. Further risk stratification is controversial. Definitive treatment = ICD. Brugada sign in isolation is of questionable significance. brugada-syndrome/

17 Diagnosis Brugada This ECG abnormality must be associated with one of the following clinical criteria to make the diagnosis: Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT). Family history of sudden cardiac death at <45 years old. Coved-type ECGs in family members. Inducibility of VT with programmed electrical stimulation. Syncope. Nocturnal agonal respiration.

18 BRUGADA SYNDROME POLYMORPHIC VT 1/3 will develop 2 nd episode in 2 years Updated June

19 18 year old, syncope while playing football. Updated June

20 AB 2 C W + WRONG QT Acute Coronary Syndrome Blocks / Brugada Cardiomyopathy WPW Long QT & Short QT

21 Collapse while playing basketball Updated June

22 HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY WALL THICKNESS PREDICTOR OF DEATH SUBGROUP WITH NEED AN ICD

23 Young lady, frequent syncope episodes, now well, normal exam, and has this ECG What is the diagnosis?

24 Wolff-Parkinson White Syndrome Accessory pathway leads to episodes of SVT. See

25 Wolff-Parkinson-White Syndrome See summary in emcore blog Mohan Kamalanathan A group of disorders commonly bundled together and known as Pre-excitation Syndromes. Incidence is quite uncommon at 0.1 to 0.3 % of the population. Of these, incidence of sudden cardiac death is rare. A favourite of ECG enthusiasts as there are classical ECG changes in a number of cases, known as a delta wave at the start of the QRS complex.

26 Syncopal episode. Now well. ECG abnormal?

27 Prolonged QT corrected

28 AB 2 C W + WRONG QT Acute Coronary Syndrome Blocks / Brugada Cardiomyopathy WPW Long QT & Short QT

29 Very rare Short QT syndrome Think of it especially if family history of sudden death as an AICD may save a life. short-qt-syndrome/

30 Syncope Clinical decision rules Unfortunately none of the clinical decision rules are fully validated However they all demonstrate features which can contribute to clinical decision making

31 Martin et al 19973: 252 syncope patients Validated cohort 374 patients Predictors of arrhythmia or 1-year mortality: 1) Abnormal ECG 2) History of ventricular arrhythmia 3) History of congestive cardiac failure 4) Age > 45 End point arrhythmia or death at 1 year 0% with 0 risk factors and 27% with 3-4 risk factors

32 Further reading Colivicchi et al 2007 The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score 270 syncope patients, validated with 328 patient cohort End point was death at 1 year Sensitivity 95%, Specificity 31% Found that age, abnormal ECG, lack of prodrome, h/o cardiovascular disease, and heart failure are all reliable predictors of adverse events at 1 year in syncope patients

33 San Francisco Syncope rule It looks like it detects patients without syncope ie hypotension or dyspnea are not really back to normal 684 patients with syncope Adverse events recorded at 7 days 0 factors considered low risk Sensitivity 86%, Specificity 49% C CHF H Hematocrit < 30% E abnormal ECG (new changes or nonsinus rhythm) S systolic BP < 90 S Shortness of breath

34 AB 2 C W + WRONG QT Acute Coronary Syndrome Blocks / Brugada Cardiomyopathy WPW Long QT & Short QT

35 Summary of learning History is really important Risk stratification if diagnosis is uncertain is the aim, clinical decision rules are helpful but not perfect Knowing certain ECGs is really helpful You can approach the next patient with syncope with confidence that patient is mine thanks very much The patient who is dizzy with a fuzzy head feeling well that s for another talk. Where s Peter, he does vertigo really well.

36 References 1. Soteriades ES, Evans JC, Larson MG, et al: Incidence and prognosis of syncope. New Engl J Med 347:878, Atkins D, Hanusa B, Sefcik T, et al: Syncope and orthostatic hypotension. Am J Med 91:179, Martin TP, Hanusa BH, Kapoor WN. Risk stratification of patients with syncope. Ann Emerg Med. 1997;29: Colivicchi F, Ammirati F, Melina D, et al. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J. 2003;24: Quinn JV, Stiell IG, McDermott DA, et al. Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004;43: Calkins H, Shyr Y, Frumin H, et al. 6. Serrano LA, Hess EP, Bellolio F, et al. Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2010;56:

Death after Syncope: Can we predict it? Daniel Zamarripa, MD Senior Medical Director December 2013

Death after Syncope: Can we predict it? Daniel Zamarripa, MD Senior Medical Director December 2013 Death after Syncope: Can we predict it? Those who suffer from frequent and severe fainting often die suddenly