TLOC - What are the red flags? John Dean March 2018

Transcription

1 TLOC - What are the red flags? John Dean March 2018

2 What is TLOC? Transient loss of consciousness It is very common It accounts for 5% of ED attendances It accounts for 6% of hospital admissions It consumes a lot of the healthcare budget

3 Syncope or Seizure? Fit or faint?

4 Types of syncope Reflex Neurocardiogenic (vasovagal) Carotid sinus syndrome Situational Orthostatic Primary autonomic failure Volume depletion Cardiac

5 Types of syncope Cardiac Arrhythmia Bradycardia Tachycardia Structural Fixed obstruction (Aortic stenosis, pulmonary embolus) Dynamic obstruction e.g., Hypertrophic cardiomyopathy (HOCM) Others Hypoglycaemia, pseudosyncope

6 Induced syncope 56 of 59 subjects 90% myoclonus 79% head turns, oral automatisms, righting movements 60% visual and auditory hallucinations Eyes open in the majority (initial upward gaze common) Lempert T et al, Annals of Neurology vol 36, , August 1994

7 Historical criteria that distinguish syncope from seizures 671 pts with T-LOC diagnosis secure in epilepsy 52 complex partial 50 generalised 437 syncope 267 vasovagal 90 ventricular tachycardia 80 other Sheldon et al J Am Coll Cardiol. 2002;40(1):

8 Historical criteria that distinguish syncope from seizures Criteria Regression Coefficient (SE) P value Points Cut tongue 6.85 (2.03) Abnormal Behaviour 3.82 (1.37) T-LOC with emotional stress 3.97 (1.30) Postictal confusion 3.52 (1.33) Head turning during T-LOC 3.67 (1.43) Prodromal déjà vu/jamais vu 2.75 (1.43) Any pre-syncope (1.34) T-LOC with prolonged standing/sitting (1.71) Diaphoresis prior to T-LOC (1.80) Score > 1 favours epilepsy, < 1 favours syncope Sheldon et al J Am Coll Cardiol. 2002;40(1):

9 A simple algorithm for distinguishing syncope from seizure

10 Vasovagal syncope vs arrhythmia 418 pts with syncope Structurally normal heart 323 diagnosis established Tilt table test +ve 235 Arrhythmia 88 Sheldon et al, Eur Heart J 2006;27:344-50

11 Vasovagal syncope vs arrhythmia Criteria Points Abnormal ECG or arrhythmia history -5 Witnessed cyanosis -4 Age > 35 years -3 Some recall -2 T-LOC with prolonged sitting/standing 1 Sweating or warm feeling prior to TLOC 2 T-LOC with medical procedure 3 VVS likely if score > or = -2 Sheldon et al, Eur Heart J 2006;27:344-50

12 Making the diagnosis ECG during symptoms 24 hour ECG Cardiocall Patch monitors Smartphone apps Implantable loop recorders

13 24 hour ECG Cheap Poor yield for infrequent episodes Potentially clinically irrelevant data Diagnostic assumptions

14 Cardiocall (loop recorder) Event recording only Available in primary care 7 days monitoring 20 min data Can be used without electrodes Cheap Reusable device costs x AA batteries and electrode pads/week

15 Patch monitors 14 days monitoring Waterproof Disposable Automatic and activated recording Cost 100

16 Smartphone apps Cost 100 Watch battery lasts months Reusable (Ebay) Loop system available

17 Implantable loop recorder (ILR) Subcutaneous implant Up to 3 years monitoring Automatic and activated recording Home monitoring Cost 1800 (more than a simple pacemaker) Disposable

18 Implantable (?) loop recorder

19

20

21 Misdiagnosis of epilepsy the REVISE study 103 pts with epilepsy 69% diagnosed by neurologist 4% definite seizures TTT and ILR 21% had profound bradycardia on ILR 14% had a +ve TTT but no correlation with ECG findings on ILR Petkar et al Europace (2012) 14,

22 When syncope and epilepsy coexist

23

24

25

26 When syncope and epilepsy coexist Ictal bradycardia Complex partial seizures Usually temporal lobe Linked to SUDEP Usually require pacemaker

27 ECG of 39 year man post VF cardiac arrest

28 Brugada Syndrome SUDS or SUNDS Phillipines bangunut (scream & die) Laos non-laitai Thailand lai-tai (death during sleep) Japan pokkuri (to pop off)

29 Brugada ECG s

30 CD

31 CD

32 CD QT =680ms QTc = 669ms

33 AB 59 y/o man syncope Admitted to hospital ECGs normal Overnight monitoring no arrhythmia CTPA ve Discharged for cardiology OPD

34 AB Walking from station to bank Indigestion On day of syncope late for work rushing Bad indigestion Exercise ECG

35

36 AB Critical stenosis in circumflex Treated with PCI No more indigestion or syncope

37 What are the red flags? Chest pain No warning FH of sudden death Abnormal CVS examination Abnormal ECG