Lee Chee Wan. Senior Consultant Pacing and Cardiac Electrophysiology. GP Symposium 2 nd April 2016

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1 Lee Chee Wan Senior Consultant Pacing and Cardiac Electrophysiology GP Symposium 2 nd April 2016

2 Objectives Definition of syncope Common causes of syncope & impacts How to clinically assess patient with syncope What are the high risk features Practical tips for GP

3 This is a divider page place Guidelines your heading for the here diagnosis and management of syncope (version 2009) The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)

4 What is Syncope? Total loss of consciousness due to transient global cerebral hypoperfusion Rapid onset Short duration Spontaneous complete recovery

5 This is a divider page place your heading here Aetiology and impacts

6 Causes of True Syncope Neurally- Mediated/ reflex Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary 1 VVS CSS Situational Cough Post- Micturition 2 Drug- Induced ANS Failure Primary Secondary 3 Brady SN Dysfunction AV Block Tachy VT SVT Long QT Brugada 4 AMI Aortic Stenosis HCM Pulmonary Hypertension Aortic Dissection Unexplained Causes = Approximately 20-30% DG Benditt, UM Cardiac Arrhythmia Center

7 Pretenders.

8 Pretenders Seizures Somatization disorder (psychogenic pseudosyncope) Falls Trauma/concussion Hypoglycemia Hyperventilation Cataplexy Vertebrobasilar TIA Acute intoxication (e.g., alcohol).

9 Summary 1 Syncope is transient loss of consciousness (T-LOC) due to global cerebral hypoperfusion NOT all loss of consciousness = syncope Common causes include vasovagal, orthostatic hypotension and cardiac arrhythmia

10 Impact of syncope Affects all age groups with peak incidence at 20 and 80 years of age 40% will experience syncope at least once in a lifetime % do not recur 1% ED attendance 3 and 1-6% of hospital admissions 2 Major morbidity reported in 6% 1 eg, fractures, motor vehicle accidents Estimated costs exceeded $10 billion US 1 3 Blanc JJ, et al. Eur Heart J. 2002;23:815-20

11 Impact of syncope % 1 71% 2 60% % Anxiety/ Depression Alter Daily Activities Restricted Driving Change Employment

12 Overall Survival of Syncope Soteriades, E. et al. N Engl J Med 2002;347:

13 Summary 2 Syncope is a common problem that affects all age group Associated with significant financial cost, injury, morbidity and in some cases increased mortality

14 This is a divider page place your heading here A clinical approach to assessment

15 Diagnosis Clinical approach to assessment History Clinical examination ECG Further tests

16 Assessment Objectives Was it a true syncopal attack? Are there high risk features? Any injury & future risk of injury Can one establish diagnosis with reasonable confidence to predict prognosis and guide treatment

17 ?syncope ESC guideline 2009

18 ESC guideline 2009 History & Aetiological diagnosis Posture Provocation Prodrome The attacks Any injury? Post attack PMH/Background

19 Physical Examination HR, rhythm BP postural (?highest yield) RR, Oxygen Sat Heart sound (AS, HOCM) Neurological deficit?injury Doesn t predict aetiology or seriousness of the aetiology, but influences urgency of management

20 ECG Normal or abnormal AF, SVT, VT, sinus tachy Sinus brady < 50 (40), sinus pause > 3s (recurrent) Bifascicular block, alternating BBB, AV block Pre-excited ECG Long QTc, Brugada pattern Q wave (not isolated in III), poor R wave Abnormal T inversion (ARVC, HCM)

21 Bifascicular Block and Prolonged PR

22 Complete Heart Block

23 VT

24 Further Assessment (mostly hospital based) CXR, blood tests Carotid sinus massage (> 40 yo) Echocardiogram Exercise/stress testing Tilt table (limited reproducibility) Electrophysiological study Coronary angiogram Neurological testing is rarely helpful in true syncope

25 ECG monitoring Inpatient telemetry has low yield even in high risk patients (more of reassurance) OP 24 hour holter has very low yield (?over use) External recorder (non loop not useful for syncope; loop recorder has low compliance)

26 Implantable loop recorder (ILR) Infrequent attacks Other tests inconclusive Highest yield (in no obvious cause) Cost effective Lasts > 2 years Programmed criteria Patient activated

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28 Summary 3 History is the cornerstone of assessment Supported by clinical examination, ECG and other tests Aim is to establish diagnosis with reasonable confidence in order to predict prognosis and guide treatment

29 This is a divider page place your heading here Management

30 Goals of management Reduce mortality, morbidity/injury and recurrence Identify underlying cause and treat accordingly But not always possible

31 Management/Treatment Neurally- Mediated/ reflex Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary 1 VVS CSS Situational Cough Post- Micturition 2 Lifestyle modification Avoid Drug-Induced provocative situation ANS or Failure factors Ensure hydration/salt Primary intake?medication Secondary?Ted stocking?conditioning/ training PPM 3 Revascularisation Brady Surgery/TAVI SN Medication/surgery Dysfunction disease /ICD AV Block Tachy to avoid injury VT SVT Long QT Brugada Adjust medication Control underlying Lifestyle measures PPM if not AMI reversible Aortic Medication Stenosis Ablation HCM ICD Pulmonary Hypertension Avoid sodium channel blocker Aortic and Dissection treat fever Minimizes injury DG Benditt, UM Cardiac Arrhythmia Center

32 Practical Tips

33 What should I do in clinic now? Do I need to send this patient to ED now? Syncope with injury Syncope with high risk features Do I need to refer this patient to a specialist OP clinic? True syncope other than vasovagal syncope and simple postural hypotension

34 High Risk Features Significant structural heart disease or CAD Abnormal ECG suggestive of arrhythmia Syncope during supine or exercise (not after) Association with palpitation/cp Absence of prodrome Clinical injury Family history of SCD (or aborted one) or HCM or channelopathy Severe electrolytes disturbance or significant anaemia (<9) or BNP > 300

35 Online Calculator

36 Driving?

37 Conclusion Syncope is a common problem that affects all age group It is associated with significant cost and morbidity, reduced quality of life, and in some increased mortality Key in management is to reduce injury, morbidity, recurrence and mortality Diagnosing and treating underlying cause where possible, and lifestyle measures Identify those need urgent and intensive assessments Despite advances and improved diagnosis, management remains challenging in some

38 Visiting Consultant National Heart Centre TTSH