Distinguishing Cardiac from Non- Cardiac Syncope
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1 10 th Annual International SADS Foundation Conference Toronto Distinguishing Cardiac from Non- Cardiac Syncope Shubhayan Sanatani, MD, FRCPC Head, Division of Cardiology, BC Children s Hospital Director, Heart Rhythm Service Pediatric Lead, BC Inherited Arrhythmia Program
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3 Soteriades NEJM 2002
4 Goals for today What are the red flags not to be missed when seeing a child with syncope Review the features of benign transient loss of consciousness episodes How to use the ECG rationally in syncope
5 Case 14 year old boy presents to the ER with an episode of loss of consciousness Previously well, felt unwell when stood up, dizzy, nauseated, lost consciousness, unwitnessed In ER, another episode when getting up to go to the bathroom HR 40, BP 80/40, pale
6 Case (cont d) Received fluid and gradually feeling better Normal cardiac exam Cardiologist dismisses this as vasovagal, suggests patient should go home to rest Patient has another episode of bradycardia and hypotension while lying in bed Is this typical vasovagal syncope?
7 Vasovagal syncope Aka Reflex mediated, neutrally mediated, common faint Mechanism: Sympathetic surge prompts a vagal response Combination of vasodilatation and decreased cardiac output
8 Cerebral autoregulation Slide courtesy of V Claydon 1.2 Adult control Adult syncope Paediatric control Paediatric syncope Autoregulation Index p<0.05 p< Protheroe et al (2013) JOVE
9 Vasovagal Syncope what is the trigger? Vasoconstriction and tachycardia suddenly switch to vasodilatation and bradycardia Abnormal baroreflex? Ventricular Receptors? Cerebral Trigger?
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14 Table: History and Physical DOI: Copyright 2016, Canadian Cardiovascular Society
15 87/146 families (60%) completed survey average 16 years at time of CA, 69% male 72% reported to have at least one CVS symptom before CA fatigue (44%) near-syncope/lightheadedness (30%) 24% >1 (ave 2.6; range, 1-10) syncope or unexplained seizure that remained undiagnosed J Am Board Fam Med 2012
16 Drezner 2012 (cont d) Parents reported that cardiovascular symptoms first occurred 30 months on average (19-71 mos) before CA A symptom was brought to the attention of the child s physician in 41% of cases 27% reported a family member had suffered sudden death before age 50 because of a heart condition
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18 Do hormones affect syncope? Hormones drive sexual, physical and behavioral development of adolescence during puberty Females have a lower orthostatic tolerance compared to males 5:1 female to male predominance of POTS 4-5x the incidence of syncope in young females Based on Coupal 2017
19 Pubertal hormone changes cause vasodilation and impair reflex vasoconstrictor responses Decreases Increases
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21 Sudden Infant Death Syndrome Moon Lancet 2007
22 Times of change SIDS Rapid growth phase Lot of autonomic changes Hormonal influences Stressful time Fatal Low familial recurrence rate SYNCOPE Rapid growth phase Lot of autonomic changes Hormonal influences Stressful time Not fatal Common
23 Previous cardiac symptoms were present in 69% of cardiac arrest patients compared to 43% of family members (P = 0.001). History can be live saving! Approximately 70% of victims of sudden death have a warning event and many have a positive family history.
24 Is the common faint genetic?
25 Is the common faint genetic?
26 Case 5 year old girl referred for syncope 1 st episode one year ago, dance class, no obvious trigger, self resolved 2 nd episode during swimming lesson, unresponsive, instructor helped out of water 3 rd episode, playing at recess, fell, chin laceration ER recommends activity restriction due to possible concussion
27 Case (cont d) No further symptoms Referred to cardiology by neurology
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31 ECG in Syncope Van Dorn Pediatr 2011
32 When to do an ECG in Syncope History is not diagnostic of VVS. No prodrome before syncope. Mid-exertional event (e.g., swimming). Syncope triggered by loud noise or startle Family history of sudden death or heart disease in young individuals. Abnormal cardiac exam New medication with potential cardiac side effects (e.g., DOI: Copyright 2016, Canadian Cardiovascular Society
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