Syncope: Hospital Evalua7on

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1 Syncope: Hospital Evalua7on Brad Hendricks DO Hospitalist- Riverside Walter- Read Hospital WVSOM Summer Seminar No Disclosures 1

2 Objec7ves 1. Define Syncope 2. Epidemiology 3. Types of Syncope 4. Risk Stra7fica7on 5. Explana7on of Hospital Evalua7on Objec7ves 1. Define Syncope 2. Epidemiology 3. Types of Syncope 4. Risk Stra7fica7on 5. Explana7on of Hospital Evalua7on 2

3 Defini7on Transient Loss of Consciousness Loss of Postural Tone Spontaneous Recovery Objec7ves 1. Define Syncope 2. Epidemiology 3. Types of Syncope 4. Risk Stra7fica7on 5. Explana7on of Hospital Evalua7on 3

4 Epidemiology 3% Emergency Department visits Up to 6% of Hospital Admissions Cost close to 2 Billion dollars per year Median peak of first syncope is around 15 years Sharp increase in incidence axer 70 years 5% in females ages 20 to 29 Up to 50% in females aged 80 and above Objec7ves 1. Define Syncope 2. Epidemiology 3. Types of Syncope 4. Risk Stra7fica7on 5. Explana7on of Hospital Evalua7on 4

5 Cardiovascular Types of Syncope Neurocardiogenic (many names) Orthosta7c Neurologic Cardiovascular- Structural Pulmonary embolism Pulmonary hypertension Mitral valvular stenosis Myocardial infarc7on (large) Pericardial constric7on or tamponade Aor7c ou_low tract obstruc7on Aor7c valvular stenosis Hypertrophic obstruc7ve cardiomyopathy 5

Supraventricular Tachycardia Atrial Fibrilla7on Wolff- Parkonson- White

6 Cardiovascular- Arrhythmias Bradyarrhythmias Sinus Bradycardia Sick Sinus Syndrome AV Block Pacer Malfunc7on Drug induced Tachyarrhythmias Supraventricular Tachycardia Atrial Fibrilla7on Wolff- Parkonson- White syndrome Brugada syndrome Ventricular Tachycardia Torsades de Pointes Wolff- Parkinson White Syndrome 6

7 Brugada Syndrome Torsades de Pointes 7

8 Vasovagal Neurocardiogenic Most common cause of syncope Diagnosis made with History Pathophysiology: Ini7ally response (Palp, anxiety, swea7ng) Then withdrawal (Vasodila7on) Followed by (brady,nausea) Frequently recurrent OXen preceded by presyncopal prodrome las7ng seconds to minutes. Rarely occur in supine posi7on Orthosta7c Orthosta7c Hypotension is an excessive fall in blood pressure when an upright posi7on is assumed. Defined as a drop of >20 mmhg systolic, 10 mmhg diastolic Volume Deple@on: - inadequate fluid intake - excessive volume loss Drug/medica@on induced: - etoh, vasodilators, diure7cs, β-blockers, etc. Primary Autonomic Failure: - mul7ple system atrophy, parkinson s ds, lewy body demen7a Secondary Autonomic Failure: - diabetes, amyloidosis, spinal cord injuries 8

Neurologic Rarely the primary cause of syncope. Pa@ents with loss of consciousness with persistent neurologic deficits or altered mental status are not true syncope.

9 Neurologic Rarely the primary cause of syncope. with loss of consciousness with persistent neurologic deficits or altered mental status are not true syncope. Brain- stem ischemia, subclavian steal, basilar artery migraines. Syncope mimics: Seizure Subarachnoid hemorrhage Ventricular obstruc7on Objec7ves 1. Define Syncope 2. Epidemiology 3. Types of Syncope 4. Risk 5. Explana7on of Hospital Evalua7on 9

Risk Stra7fica7on San Francisco Rule: 1) Abnormal ECG or Cardiac Monitoring 2) Systolic Blood Pressure < 90mmHg 3) Hematocrit < 30% 4) CHF (at presenta7on or history of) 5) History of Shortness of

to identify patient at low risk of short-term serious outcomes.

10 Risk Stra7fica7on San Francisco Rule: 1) Abnormal ECG or Cardiac Monitoring 2) Systolic Blood Pressure < 90mmHg 3) Hematocrit < 30% 4) CHF (at presenta7on or history of) 5) History of Shortness of Breath C- CHF hx H- Hematocrit E- ECG S- SOB S- SBP Included 12 studies with total 5316 patients Nine studies were prospective and three were retrospective Sensitivity 87%, Specificity 52% Intended to identify patient at low risk of short-term serious outcomes. Risk Stra7fica7on The ROSE Rule: (Risk Of Syncope in Emergency Department) 1) Brain Natriure7c Pep7de >300 pg/ml 2) Stool Posi7ve for Occult Blood 3) Oxygen Satura7on < 94% on room air on ini7al presenta7on 4) Hemoglobin < 90 g/l 5) Chest Pain at the 7me of syncope 6) Bradycardia (HR < 50 bpm) ED based single center study Edinburgh UK Analyzed 529 pts older than 16 yrs Prospective trial 87% Sensitivity, 66% Specificity, 99% Negative Predictive Value B- BNP R- rectal A- anemia C- CP E- ECG S- Sats 10

11 Objec7ves 1. Define Syncope 2. Epidemiology 3. Types of Syncope 4. Risk Stra7fica7on 5. of Hospital Evalua7on The primary purpose of the evalua7on of the pa7ent with syncope is to determine whether the pa7ent is at increased risk of death. Step 1: Detailed History Live neither in the past nor in the future, but let each day s work absorb your en7re energies, and sa7sfy your widest ambi7on. Sir William Osler 11

New onset vs recurrent History Prodrome Recent medica7on changes Observa7ons of onlookers Tonic- clonic/seizure like ac7vity Focal neurological changes/aura/premoni7ons/pos7c7cal

12 New onset vs recurrent History Prodrome Recent medica7on changes Observa7ons of onlookers Tonic- clonic/seizure like ac7vity Focal neurological changes/aura/premoni7ons/pos7c7cal confusion Associated with turning head/ posi7on changes History cont. Past Medical History: MI Head Trauma arrhythmia Family History Sudden Death arrhythmia Social History Drugs Alcohol 12

Evalua7on Step 2: Physical Exam Vital signs including bedside 7lt Complete cardiac/neurological examina7on To have striven, to have made the effort, to have been true to certain ideals- this

13 Evalua7on Step 2: Physical Exam Vital signs including bedside 7lt Complete cardiac/neurological examina7on To have striven, to have made the effort, to have been true to certain ideals- this alone is worth the struggle. Sir William Osler Step 3: Inexpensive Evalua7on Electrocardiogram (EKG) Informa7on on rhythm, AV conduc7on, nonsustained ectopy, etc. Diagnos7c in approximately 5% 13

Echocardiogram Few studies have evaluated its u7lity - Retrospec7ve Chart review Mean Age 58 yrs Jan 2011 through

pa7ent with normal ECG to those with abnormal ECG Echo performed Results: No pa7ents with normal ECG (235) has

14 Echocardiogram Few studies have evaluated its u7lity - Retrospec7ve Chart review Mean Age 58 yrs Jan 2011 through Mar % Men 198 Adult pa7ents met inclusion criteria 50% Hispanic Bronx, NY Results: Correla7on between NML ECG and ECHO p< Retrospec7ve Cohort: 323 consecu7ve ED observa7on pa7ents Over 18 months Presen7ng with syncope Compared pa7ent with normal ECG to those with abnormal ECG Echo performed Results: No pa7ents with normal ECG (235) has structural heart abnormali7es. Caro7d Duplex A low yield study for syncope evalua7on European Guidelines recommend against use to evaluate syncope US Guidelines recommend in serng of focal neurologic symptoms or cervical bruits. 14

Stress test For suspected Ischemia Recommended for unexplained syncope Exer7on related syncope Exer7on induced tachyarrhythmia May need to get Echo prior to stress Low Yield $326 per day Con7nuous

15 Stress test For suspected Ischemia Recommended for unexplained syncope Exer7on related syncope Exer7on induced tachyarrhythmia May need to get Echo prior to stress Low Yield $326 per day Con7nuous Telemetry 24 hour Holter Monitor - 4% Posi7ve Yield - Organic heart disease, abnml EKG, high susp for arrhythmia External Loop Recorder - 13% Posi7ve Yield, Suspicion for arrhythmia - Frequent syncope, either no organic HD or organic heart DS/abnml EKG w/ nega7ve cardiac work- up Insertable Loop Recorder - 27% Posi7ve Yield - Nega7ve cardiac work- up, infrequent syncope, nega7ve 7lt 15

with nega7ve evalua7on, the pretest probability that the diagnosis is neurocardiogenic

16 Tilt Table Tes7ng Aids to establish diagnosis of neurocardiogenic syncope Sensi7vity ranges 26-80% Specificity approximately 90% Concerns about reproducibility ( 15-35%) In pa7ents with nega7ve evalua7on, the pretest probability that the diagnosis is neurocardiogenic syncope is high, so head- up 7lt table tes7ng contributes liule to establishing the diagnosis. CT/MRI 16

17 Low Yield CT/MRI Most help if neurologic deficit or complaint, Trauma above the clavicles, or warfarin therapy. Can be difficult to differen7ate syncope from epilepsy based predominantly clinical history Over interpreta7on of clinical and neuroimaging may occur in a nonspecific approach 17

Review Detailed H&P/Exam, EKG, Orthosta7cs on every one Purpose is to iden7fy those at increased risk for death Majority don t need hospitaliza7on - Risk Stra7fica7on Tools

18 Review Detailed H&P/Exam, EKG, Orthosta7cs on every one Purpose is to iden7fy those at increased risk for death Majority don t need hospitaliza7on - Risk Stra7fica7on Tools Choose studies wisely - Caro7d Duplex not helpful - Echo typically not helpful - CT or MRI only if neurologic deficits - Stress Test- It s up to you. Thank You Happy 3 rd Birthday 18

19 References 1. Ray J, Kusumoto F, Nora G. Syncope. Journal of Intensive Care Medicine. 2016; 31:no. 2: Kenny RA, Bhangu J, King- Kallimanis B. Epidemiology of Syncopy/Collapse in Younger and Older Western Pa7ent Popula7ons. Progress in Cardiovascular Diseases. Jan- Feb 2013, Vol.55(4): Fauci A, Braunwald E, et al. Harrison s Principles of Internal Medicine. 2008, Edi7on 17: Strickberger S, Benson DW, et al. AHA/ACCF Scien7fic Statement of the Evalua7on of Syncope. Circula7on. 2006;113: Downs M, Cowan C, Campbell J. Does Head CT Assist in the Diagnosis of an Adult with Syncope? Evidence- Based Prac7ce. 2014; 17 (12): Puppala V, Dickinson O, Bendiu D. Syncope: Classifica7on and Risk Stra7fica7on. Journal of Cardiology Vol 63 (3): Saccilouo R, Nickel C, Koller M. San Francisco Syncope Rule to Predict Short- Term Serious Outcomes: A Systemic Review. Canadian Medical Associa7on Journal (15): Goldman L, Ausiello D, et al. Cecil Medicine Edi7on 23: Tin7nalli J, et al. Tin7nalli s Emergency Medicine Edi7on 7: References- cont. 10. Atoui M, Gonzalez C, Bhandari M, et.al. Echocardiogram in the Evalua7on of Pa7ents with Syncope and Normal Electrocardiogram: Do We Need It. Circula7on. 2013; 128: A Anderson K. Cardiac Evalua7on for Structural Abnormali7es May Not Be Required in Pa7ents Presen7ng With Syncope and a Normal ECG Result in Observa7on Unit Serng. Annuals Emergency Medicine. 2012; 60: Kadian - Dodov D, Papolos A, Olin J. Diagnos7c U7lity of Caro7d Artery Ultrasonography in the Evalua7on of Syncope: A Good Test for the Wrong Reason. European Heart Journal- Cardiovascular Imaging. 2014; doi: /ehjci/jeu Kapoor W. Current Evalua7on and Management of Syncope. Circula7on. 2002; 106: Grossman S, Fischer C, et.al. The Yield of Head CT in Syncope: A Pilot Study. Internal and Emergency Medicine. 2007; Vol 2: (1), pp Fauouch J, Bonaventura C, et.al. Over- Interpreta7on of Electoclinical and Neuroimaging Findings in Syncope Misdiagnosed as Epilep7c Seizures. Epilep7c Disord. 2007; 9 (2):

Index. cardiology.theclinics.com. Note: Page numbers of article titles are in boldface type.

Index. cardiology.theclinics.com. Note: Page numbers of article titles are in boldface type. Index Note: Page numbers of article titles are in boldface type. A Adenosine in idiopathic AV block, 445 446 Adolescent(s) syncope in, 397 409. See also Syncope, in children and adolescents AECG monitoring.