Medical Conditions, Sudden Incapacitation and Assessing Syncope & Unexplained Loss of Consciousness

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1 Medical Conditions, Sudden Incapacitation and Assessing Syncope & Unexplained Loss of Consciousness Kurt T. Hegmann, MD, MPH Professor and Center Director Dr. Paul S. Richards Endowed Chair in Occupational Safety and Health Rocky Mountain Center for Occup. & Env. Health University of Utah 1 3 Broad Categories of Syncope/Sudden Incapacitation 1.Reflex Syncope (neurally mediated) 2.Orthostatic Hypotension Syncope 3.Cardiac Syncope Syncope/Sudden Incapacitation (e.g.) Neurally-mediated Cough/sneeze Hypovolemia (N/V/D) Any cause weak muscles Environmental Heat Stress Autonomic failure (MS, Parkinson s, DM) Severe anemias Cardiovascular Atherosclerotic Dysrhythmias Carotid sinus hypersens. Endocrine Diabetes mellitus Electrolyte disturb s Neoplasia (e.g., insulinoma) Pharmaceuticals Anti-hypertensives Hypoglycemics Dys/rhythmics Illicit Neurological Syncope TIA, Stroke Vascular occlusions AVM Trauma/TBI Idiopathic Infectious Psychogenic; Pseudosyncope 1

2 Epidemiology 40% lifetime cumulative incidence 6.2/1000py annual incidence (Soteriades 02) Neurally mediated is most common Vasovagal Cough/sneeze/swallow/defecate/micturation/visceral pain Carotid sinus hypersensitivity Glossopharyngeal neuralgia Neurally mediated usual occurrence(s) in youth. 50% of females vs. 25% of males in lifetime Cardiac, orthostatic, postprandial causes in elderly. Elevated mortality over 1 year, mostly driven by cardiac (Martin 97) Epidemiology 40% lifetime cumulative incidence Neurally mediated is most common Vasovagal Cough/sneeze/swallow/defecate/micturation/visceral pain Carotid sinus hypersensitivity Glossopharyngeal neuralgia Neurally mediated usual occurrence(s) in youth. 50% of females vs. 25% of males in lifetime Cardiac, orthostatic, postprandial causes in elderly Moya 09; Brignole 2004: Reflex/Neurally mediated 35 48% Cardiac 5 21% Orthostatic 4 24% Epidemiology Recurrence rates high, regardless of cause (Reed 11; Grimm 97; Sheldon 96; Marikainen 11; Ungar 10) up to 54% recurrence rates (Grimm 97; Sheldon 96; Brignole 09; Moazez 91; Aydin 09) Recurrence rates (Ungar 10) Neurally mediated 9.8%/yr Idiopathic 4.1%/yr. 2

3 Kaplan Meier's survival curves in the different syncope forms. Andrea Ungar et al. Eur Heart J 2010;31: Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oxfordjournals.org. Kaplan Meier's survival curves by syncope form. Andrea Ungar et al. Eur Heart J 2010;31: Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oxfordjournals.org. Poor Prognoses (Rosanio 11) 1. Age EKG abnormalities 3. Heart failure, ischemic heart disease, ventricula dysrhythmias 4. Lack of warning symptoms /signs before syncope 5. B natriuretic peptide 300+pg/mL 3

4 Evaluation 1. Careful History and Physical 2. Orthostatic blood pressure and heart rate 3. EKG, rhythm strips a. (?)Signal averaging Evaluation 1. Careful History and Physical 2. Orthostatic blood pressure and heart rate 3. EKG, rhythm strips a. (?)Signal averaging IF above insufficient, H&P helps direct; may consider: 1. Electrolytes, CBC 2. Fasting glucose, Glucose tolerance testing 3. Tilt table testing 4. Carotid sinus massage, Holter, adenosine test, Echo, ETT, etc. 5. EEG, carotid Doppler, MRI Figure 1. Flow chart for the diagnostic approach to the patient with syncope. Strickberger et al. Circulation. 2006;113: Copyright American Heart Association, Inc. All rights reserved. 4

5 Prognosis: Neurogenic Better prognosis if Normal EKG Normal Ejection Fraction Normal cardiac structure No Recurrence Consider return to safety work after 1 month for above. Consider permanent exclusion from safety work if 2 syncopal episodes in 2 years. Prognosis: Orthostatic Hypotension Syncope Better prognosis if due to anti HTN medication and can change it Better prognosis if Normal EKG, Ejection Fraction, Normal cardiac structure No Recurrence no autonomic dysfunction Worse prognosis if Autonomic failure Consider return to safety work after 1 month for negative workup and no recur Consider permanent exclusion from safety work if 2 syncopal episodes in 2 years Prognosis: Cardiac Effective Treatment: Reduces risk 50% (Ungar 10) Return to work dependent on treatableremediable causes ICDs have high inadvertent discharge rates that preclude use in safety sensitive jobs Includes recent, more modern devices 5

6 Prognosis: Idiopathic Evaluations: Cardiovascular, Neurological, Internal Medicine IF: Normal EKG, Ejection Fraction >40%, Normal cardiac structure Normal EEG No autonomic dysfunction No Recurrence Consider return to safety work after 1 year for negative workup and no recur Consider permanent exclusion from safety work if 2 syncopal episodes in 2 years. Conclusions 1. Syncope incidence 18 40/1000/yr. a. Higher incidence in elderly 2. Associated with higher fatality. 3. Recurrence rates substantially lower if avoidable and/or treatable cause. 4. Cardiac causes have relatively poor prognoses, unless clearly treatable/preventable 5. Syncope of unknown etiology has relatively poor prognosis. 6. Some consensus guidance for RTW has been provided 6