Syncope. Charles DeBerardinis, DO Iredell Health Systems
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1 Syncope Charles DeBerardinis, DO Iredell Health Systems
2 Syncope Syncope loss of consciousness Vertigo sensation of motion Drop attacks fall without loss of consciousness seizure
3
4 Syncope Constatino n=670 Short term (with in 10 days) outcomes Multi-variant Analysis Abnormal EKG Trauma Absence of previous symptoms Male gender
5 Syncope Long term (1year) outcomes Mortality 6% Severe outcome 3.3% Multi-variate Analysis Age >65
6 From: Prognosis Among Healthy Individuals Discharged With a Primary Diagnosis of Syncope J Am Coll Cardiol. 2013;61(3): doi: /j.jacc Table Title: One-Year Mortality HRs Stratified by Age Groups Adjusted for Sex, Age, Comorbidity, and Pharmacotherapy Date of download: 3/24/2015 Copyright The American College of Cardiology. All rights reserved.
7 From: Prognosis Among Healthy Individuals Discharged With a Primary Diagnosis of Syncope J Am Coll Cardiol. 2013;61(3): doi: /j.jacc Table Title: Long-Term Mortality HRs Stratified by Age Groups Adjusted for Sex, Age, Comorbidity, and Pharmacotherapy Date of download: 3/24/2015 Copyright The American College of Cardiology. All rights reserved.
8 From: Prognosis Among Healthy Individuals Discharged With a Primary Diagnosis of Syncope J Am Coll Cardiol. 2013;61(3): doi: /j.jacc Figure Legend: Cumulative Incidence Plot of Long-Term All-Cause Mortality in the Age Group 45 to 74 Years: Syncope Versus Control Group A significant difference in the risk of all-cause mortality in the age group 45 to 74 years indicates that this age group may have syncope as a first symptom of future cardiovascular disease and adverse outcome. Date of download: 3/24/2015 Copyright The American College of Cardiology. All rights reserved.
9 From: Prognosis Among Healthy Individuals Discharged With a Primary Diagnosis of Syncope J Am Coll Cardiol. 2013;61(3): doi: /j.jacc Figure Legend: Competing Risk Model of Patients With Syncope Compared With Control Subjects and the Cumulative Incidence of Cardiovascular Hospitalization A significant difference in the risk of future cardiovascular hospitalization across all age groups indicates that syncope in healthy individuals may be the first symptom of future cardiovascular disease and increased hospitalization compared with the background population. Date of download: 3/24/2015 Copyright The American College of Cardiology. All rights reserved.
10 From: Prognosis Among Healthy Individuals Discharged With a Primary Diagnosis of Syncope J Am Coll Cardiol. 2013;61(3): doi: /j.jacc Figure Legend: Competing Risk Model of Patients With Syncope Compared With Control Subjects and the Cumulative Incidence of Implantation of a Pacemaker or ICD There was a significant difference in the risk of insertion of a pacemaker (PM) or implantable cardioverter-defibrillator (ICD) when comparing syncope patients and control subjects. The increase in risk was particularly dramatic within the first year after discharge for syncope, after which the curves became parallel. Date of download: 3/24/2015 Copyright The American College of Cardiology. All rights reserved.
11 From: Prognosis Among Healthy Individuals Discharged With a Primary Diagnosis of Syncope J Am Coll Cardiol. 2013;61(3): doi: /j.jacc Figure Legend: Competing Risk Model of Patients With Syncope Compared With Control Subjects and the Cumulative Incidence of Stroke Stroke as an indicator of future cardiovascular disease was significantly increased across all age groups in the healthy syncope population compared with the control population. Date of download: 3/24/2015 Copyright The American College of Cardiology. All rights reserved.
12 Freeman Baroreflex
13 Standing cc blood displaced to splanchnic, lower extremity circulation (1/4-1/3 volume) Decreased venous return to heart Decreased cardiac output Decreased blood pressure
14 Freeman Baroreflex
15 Baroreceptor Activation Sympathetic Outflow Vagal N activity PVR VR CO BP HR
16 Standing Contraction of leg/calf muscles VR Transmural capillary pressure Fluid filtration into tissue Steady state approximately 30min
17 Neurocardiogenic Syncope System failure Cardiac hyper contractile state Mechanoreceptors Normally respond only to stress Paradoxic bradycardia & PVR
18 Reflex Syncopes Neurocardiogenic Trigger - Prolonged standing, fear, emotional distress, pain, standing in hot areas. Situational - Micturition, defecation, cough Carotid sinus hypersensitivity
19 Reflex Syncopes Prodrome - Lightheadedness,nausea, diaphoresis, headache, weakness, flushing Sudden, brief LOC Rapid recovery (weak, fatique) Caveat * 1/3 patients, especially elderly-no prodrome
20 Cardiac Causes of Syncope LV outflow obstruction - AS, HOCM, LA Myxoma, MS RV/Pulmonary flow obstruction - PE, PS, RA Myxoma Pump failure/lv dysfunction Cardiac tamponade Aortic dissection Congentital HD ARVD
21 Cardiac Causes of Syncope Brady dysrthymias Tachy dysrythmias Long QT syndrome Brugada syndrome Torsades De Pointes Electrolyte abnormalities
22 History Situation LOC duration Recovery Volume status Disorders of autonomic nervous system Medications Blood loss Diabetic?blood sugar?
23 Prodrome Neck pain Coat hanger headache Dyspnea - Ischemia to trapezius & neck muscles - V/Q mismatch Chest pain - Impaired myocardial perfusion does not necessarily indicate CAD
24 Cardiac Related History Palpitations Prior/known cardiac meds Cardiac meds (anti-arrhythmics, diuretics) Phenothiazines/tricyclics OTC meds Exertional??? Family History of sudden/unexplained death
25 EKG Rhythm & AV conduction - Bradycardia, tachycardia, BBB, higher degree AVB QRS complex - Delta wave, QT segment Ischemia ARVD Brugada syndrome
26
27 Exam Carotid bruits Pulses symmetry?? Murmur - Aortic stenosis - Duration/peak - S2/P2 Dynamic murmur
28 Echo LV function Valvular heart disease HOCM Congentital heart disease ARVD Pulmonary embolus
29 Targeted diagnostics Targeted therapy
30 Conclusions Know what you are looking for Know correct, directed questions to ask Start at the top History - Prodrome/ situation - Duration LOC - Recovery Cardiac testing driven by history & PE findings
31 Conclusions Exertional syncope is BAD!!!!
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