Syncope. Philip B Vaidyan MD, FACP Department of Medicine St. Mary's Health Center

Transcription

1 Syncope Philip B Vaidyan MD, FACP Department of Medicine St. Mary's Health Center

2 I have no conflicts of interest to disclose

3 Definition Syncope is a symptom, the defining clinical characteristics of which are: Transient Self- limited loss of consciousness Loss of postural tone Onset is relatively rapid Recovery is spontaneous, complete, and usually prompt The underlying mechanism is a transient global cerebral hypoperfusion

4 Prevalence and Impact What we do know 40% of the adult population has experienced a syncopal episode 1 1% of ER visits 2 Up to 5% of admissions Annual healthcare costs estimated at $2.4bn 2 Cost per inpatient work up $5,400 1 Soteriades ES, N Engl J Med Sun BC, Am J Cardiol 2005

5 What we do know Incidence and rate of hospitalization increases with age 1 Soteriades ES, N Engl J Med 2002

6 What does this do to our patients? Functional impairment on par with RA, chronic low back pain, and depressive disorders. 80% 70% 60% 50% 40% 30% 20% 10% 0% Change ADLs Linzer M, J Clin Epidemiol 1991 Limit Driving Change Employment

7 Causes of Syncope Neurocardiogenic / Vasovagal Most Common Pain/Noxious Stimuli Situational (micturation, cough, defecation) Carotid Sinus Hypersensitivity (CSH) Fear Prolonged standing / heat exposure

8 Causes of Syncope Cardiovascular Most Dangerous Structural heart disease is the most important predictor of total mortality and sudden death in patients with syncope. Arrhythmia Bradycardia Sick sinus, AV block Tachycardia Ventricular tachycardia, supraventricular tachycardia, Wolff- Parkinson- White Long QT syndrome, Brugada syndrome Structural Aortic stenosis, mitral stenosis Hypertrophic obstructive cardiomyopathy Ischemia

9 Causes of Syncope Orthostatic Hypotension D A A D Drugs: BP meds, Diuretics, TCAs Autonomic Insufficiency (Parkinsons, Shy- Dragger, DM, Adrenal Insufficiency) Alcohol Dehydration

10 Diagnosis Initial evaluation (History, physical exam, EKG, BP supine and upright) (History,9hysical exam, ECG & BP supine/upright) ysical exam, ECG & BP supine/upright)

11 Ways to provide High Value, Cost Conscious Care

12 New Concepts in the Assessment of Syncope. JACC 2012 Brignole M, J Am Coll Cardiol 2012

13 How do we assess risk? Parry SW, BMJ 2010

14 Red Flags San Francisco Syncope Rule Congestive heart failure history Hematocrit < 30% EKG changes Shortness of breath Systolic Blood Pressure < 90 mm Hg at triage No to all = Low risk for serious outcome at 7 days Quinn J, Ann Emerg Med 2004

15 Recap of Risk Factors Age Known cardiac disease Abnormal ECG Lack of prodrome Associated chest pain or shortness of breath

16 Diagnostic Yield in Older Patients Test Obtained Abnormal Affected Dx Etiology Management ECG 2081 (99) 438 (21) 147 (7) 72 (3) 153 (7) Telemetry 2001 (95) 314 (16) 212 (11) 95 (5) 245 (12) Enzymes 1991 (95) 108 (5) 31 (2) 9 (0.5) 29 (1) Head CT 1327 (63) 138 (10) 28 (2) 7 (0.5) 28 (2) TTE 821 (39) 516 (63) 35 (4) 13 (2) 36 (4) Postural BP 808 (38) 230 (28) 142 (18) 122 (15) 202 (25) Carotid US 267 (13) 122 (46) 2 (1) 2 (0.8) 6 (2) EEG 174 (8) 68 (39) 2 (1) 1 (0.6) 2 (1) Head MRI 154 (7) 46 (30) 20 (13) 3 (2) 19 (12) Stress Test 129 (6) 53 (41) 13 (10) 2 (2) 12 (9) Mendu ML, Arch Intern Med 2009

17 Diagnostic Yield in Older Patients Test Obtained Abnormal Affected Dx Etiology Management ECG 2081 (99) 438 (21) 147 (7) 72 (3) 153 (7) Telemetry 2001 (95) 314 (16) 212 (11) 95 (5) 245 (12) Enzymes 1991 (95) 108 (5) 31 (2) 9 (0.5) 29 (1) Head CT 1327 (63) 138 (10) 28 (2) 7 (0.5) 28 (2) TTE 821 (39) 516 (63) 35 (4) 13 (2) 36 (4) Postural BP 808 (38) 230 (28) 142 (18) 122 (15) 202 (25) Carotid US 267 (13) 122 (46) 2 (1) 2 (0.8) 6 (2) EEG 174 (8) 68 (39) 2 (1) 1 (0.6) 2 (1) Head MRI 154 (7) 46 (30) 20 (13) 3 (2) 19 (12) Stress Test 129 (6) 53 (41) 13 (10) 2 (2) 12 (9) Mendu ML, Arch Intern Med 2009

18 Test EEG $32,973 Head CT $24,881 Cardiac Enzymes $22,397 *Troponin I alone $4,818 Carotid Ultrasound $19,580 Head MRI $8,678 Stress Test $8,415 Echo $6,272 ECG $1,020 Telemetry $710 Postural Blood Pressure $17 Cost per test result affecting management Mendu ML, Arch Intern Med 2009

19 What is NOT helpful? EEG Head CT Cardiac Enzymes Carotid US

20 What does work? Thorough history with collateral information from witness Physical examination Postural blood pressure ECG Cost = $435

21 Take a good history! 5 Ps Precipitants Prodrome Palpitations Position Post- event phenomena Appearance Abnormal Movements Mental State Incontinence/Tongue Biting Chronic medical issues Family history of SCD Parry SW, BMJ 2010

22 ECG and Telemetry ECGs are relatively cheap and informative Structural Heart Disease Q- waves (infarct) ST segment changes (ischemia) Conduction System Disease Bundle branch block Atrioventricular (AV) block Electrical Disease Wolff- Parkinson- White (WPW) syndrome Brugada syndrome Long QT syndrome Marine JE, J Electrocardiol, 2013

23 Outpatient ECG Monitoring Holter Monitor daily syncopalepisodes Event Recorder weekly syncopalepisodes Implantable Loop Recorder monthly syncopalepisodes

24 Postural Blood Pressure Have the patient lie supine for 10 minutes Measure blood pressure and pulse Have the patient stand Inquire about symptoms Repeat blood pressure after 1 and 3 minutes Classical Orthostatic Hypotension is defined by: Drop in SBP >20 mm Hg or DBP >10 mm Hg within 3 minutes of standing

25 Post - H&P, ECG, and Postural BP You should be able to answer: Syncope or not? Etiology determined based on the above? High risk of cardiovascular events or death?

26 Advanced Cardiac Testing Stress testing and Left Heart Catheterization If concern for ischemia EP study If concern for tachyarrhythmia Tilt test For diagnostic dilemma or if it will affect treatment

27 Echocardiogram and Syncope Echo is helpful to confirm or refute suspicion of cardiac disease after the basics Not indicated for syncope without suspicion of cardiac disease Must have 2 nd diagnosis

28 General Concepts Perform a comprehensive history and physical examination using evidence based tools Routinely obtain an ECG Utilize EEG, Head CT, or MRI only with clinical suspicion of focal neurological deficit or seizure Consider Holter, event recorder, or implantable loop recorders if any arrythmia is suspected, depending on frequency of events Utilize cardiac imaging only with clinical suspicion of structural or valvular heart disease Perform invasive EP study only with clinical suspicion of a tachyarrhythmia Obtain a Tilt test only for diagnostic dilemma and if it will affect treatment and/or outcome

29 Do s and Don ts Do every time: H&P, ECG, Postural Blood Pressure Try to avoid: EEG, Cardiac Enzymes, Head CT, Carotid US Other testing as indicated based on findings Try to avoid the shot gun approach

30 Bibliography Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version 2009): the task force for the diagnosis and management of syncope of the European Society of Cardiology (ESC). Eur Heart J 2009;30: Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, et al. Incidence and prognosis of syncope. N Eng J Med 2002;347: Sun BC, Emond JA, Camargo CA Jr. Direct medical costs of syncope- related hospitalizations in the United States. Am J Cardiol2005;95: Linzer M, Pontinen M, Gold DT, Divine GW, Felder A, Brooks WB. Impairment of physical and psychosocial function in recurrent syncope. J Clin Epidemiol 1991;44: Rosanio S, Schwarz ER, Ware DL, Vitarelli A. Syncope in adults: systematic review and proposal of a diagnostic and therapeutic algorithm. IntJ Cardiol 2013;162(3): Parry SW, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ 2010;340:c Radack KL. Syncope. Cost- effective patient workup. Postgrad Med 1986;80(8): Simpson CS, KrahnAD, Klein GJ, Yee R, Skanes AC, Manda V, Norris C. A cost effective approach to the investigation of syncope: relative merit of different diagnostic strategies. Can J Cardiol 1999;15(5): Strickberger, SA, Benson DW, Biaggioni I, Callans DJ, Cohen MI, Ellenbogen KA, et al. AHA/ACCF scientific statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 2006;113(2): Brignole M, Hamdan MH. New concepts in the assessment of syncope. J Am Coll Cardiol 2012;59(18): Sheldon R, Rose S, Connolly S, Ritchie D, Koshman ML, Frenneaux M. Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur Heart J 2006;27(3): Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short- term serious outcomes. Ann Emerg Med 2004;43(2): Colvicchi F, Ammirati F, Melina D, Guido V, Imperoli G, Santini M, et al. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J2003;24: Mendu ML, McAvay G, LampertR, Stoehr J, Tinetti ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med 2009; 164(14): Nguyen- Michel VH, Adam C, Dinkelacker V, Pichit P, Boudali Y, BaulacM, et al. Characterization of seizure- induced syncopes: EEG, ECG, and clinical features. Epilepsia 2014;55(1): Grossman SA, Fischer C, Bar JL, Lipsitz LA, Mottley L, Sands K, et al. The yield of head CT in syncope: a pilot study. Intern Emerg Med 2007;2(1):46-9. Lagi A, Cuomo A, Veneziani F, CencettiS. Copeptin: a blood test marker of syncope. IntJ ClinPract 2013;67(6): Langer- Gould AM, Anderson WE, Armstrong MJ, Cohen AB, Eccher MA, et al. The American Academy of Neurology s top five choosing wisely recommendations. Neurology 2013;81(11): Marine JE. ECG features that suggest a potentially life- threatening arrhythmia as the cause for syncope. J Electrocardiol 2013;46(6):561-8.

31 Syncope Philip B Vaidyan MD, FACP Department of Medicine St. Mary's Health Center