SYNCOPE A DIAGNOSTIC AND TREATMENT STRATEGY PRESENTATION OVERVIEW

Transcription

1 SYNCOPE A DIAGNOSTIC AND TREATMENT STRATEGY PRESENTATION OVERVIEW I. Prevalence & Impact II. Etiology III. Diagnosis & Evaluation Options IV. Treatment Options V. Quiz

2 SECTION I: PREVALENCE AND IMPACT

3 THE SIGNIFICANCE OF SYNCOPE The only difference between syncope and sudden death is that in one you wake up. 1 1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: THE SIGNIFICANCE OF SYNCOPE 1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, Blanc J-J, L her C, Touiza A, et al. Eur Heart J, 2002; 23: Day SC, et al, AM J of Med Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:

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5 SECTION II: ETIOLOGY SYNCOPE: A SYMPTOM NOT A DIAGNOSIS Self-limited loss of consciousness and postural tone Relatively rapid onset Variable warning symptoms Spontaneous complete recovery

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7 NEURALLY MEDIATED REFLEX SYNCOPE --WHAT HAPPENS? Stress causes an abnormal autonomic reflex Normal increased sympathetic tone replaced by increased vagal tone Variable contribution of vasodilation and bradycardia. Examples include syncope from: Pain and/or fear Carotid sinus hypersensitivity situational (cough, micturition, defecation syncope)

8 Syncope Mortality THE SIGNIFICANCE OF SYNCOPE Some causes of syncope are potentially fatal Cardiac causes of syncope have the highest mortality rates 25% 20% 15% 10% 5% 0% 1 Day SC, et al. Am J of Med 1982;73: Kapoor W. Medicine 1990;69: Overall Due to Cardiac Causes 3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248: Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13: IMPACT OF SYNCOPE 100% 80% 73% 1 71% 2 60% 2 60% 40% 37% 2 20% 0% Anxiety/ Depression Alter Daily Activities Restricted Driving Change Employment 1 Linzer, J Clin Epidemiol, Linzer, J Gen Int Med, 1994.

9 SECTION III: DIAGNOSIS AND EVALUATION OPTIONS

10 INITIAL EVALUATION (CLINIC/EMERGENCY DEPT.) Detailed history Physical examination 12-lead ECG CSM if age > 40 years

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14 CONVENTIONAL DIAGNOSTIC METHODS/YIELD History and Physical Test/Procedure (including carotid sinus massage) Yield (based on mean time to diagnosis of 5.1 months % 1, 2 ECG 2-11% 2 Electrophysiology Study without SHD* 11% 3 Electrophysiology Study with SHD 49% 3 Tilt Table Test (without SHD) 11-87% 4, 5 Ambulatory ECG Monitors: Holter 2% 7 External Loop Recorder 20% 7 (2-3 weeks duration) Insertable Loop Recorder 65-88% 6, 7 (up to 14 months duration) Neurological (Head CT Scan, Carotid Doppler) 0-4% 4,5,8,9,10 1 Kapoor, et al N Eng J Med, Kapoor, Am J Med, Linzer, et al. Ann Int. Med, Kapoor, Medicine, Kapoor, JAMA, 1992 Day S, et al. Am J Med. 1982; 73: Krahn, Circulation, 1995 Stetson P, et al. PACE. 1999; 22 (part II): Krahn, Cardiology Clinics, Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8. * Structural Heart Disease MRI not studied

15 CAROTID SINUS MASSAGE Firm, longitudinal massage for 5 seconds over right carotid sinus Between the superior border of the thyroid cartilage and the angle of the mandible. Some authors recommend continuing CSM for 10 seconds if there is no asystole after 5 seconds.

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17 AMBULATORY ECG Method Holter (24-48 hours) Comments Useful for infrequent events Event Recorder Loop Recorder Wireless (internet) Event Monitoring Useful for infrequent events Limited value in sudden LOC Useful for infrequent events Implantable type more convenient (ILR) In development

18 HEAD-UP TILT TEST (HUT) Unmasks VVS susceptibility Reproduces symptoms Patient learns VVS warning symptoms Physician is better able to give prognostic / treatment advice HEAD-UP TILT TEST (HUT)

19 SECTION IV: TREATMENT OPTIONS

20 ISOMETRIC COUNTER PRESSURE MANEUVER Each of these maneuvers might boost blood pressure sufficiently to delay symptoms.

21 TILT TRAINING Stand with your back lightly against a wall while your heels are about six inches (15 centimeters) from the base of the wall. Do this for 3-5 minutes without moving, twice a day. Every few days, add a minute or so to the standing time until you can do 20- to 30-minute sessions without feeling faint. After that, try to do 20 minutes of wall standing three to four times a week. It's best to do this in a carpeted room, and to have someone with you in case you faint.

22 SECTION V: QUIZ

23 QUIZ 1 28-year-old man presents with an 8-year history of recurrent syncope occurring about two times per year. Prior to losing consciousness, he notices his chest is pounding. History and physical are unremarkable. His resting ECG and echocardiogram are normal. QUIZ 1 Which of the following tests is most likely to yield a diagnosis? A. Loop recorder. B. Signal-averaged ECG. C. EP study. D. Stress test. E. Tilt table testing

24 QUIZ 2 55 YOM, syncope while sitting at the dinner table. BP of 110/80 mm Hg and a heart rate of 80 bpm. There was an LV thrust, a quiet, single second heart sound, and a grade III/IV systolic ejection murmur at the base, which peaked in mid-systole and radiated into the carotids. The upstroke velocity of the carotid pulse was only slightly slowed. ECG : RBBB and left axis deviation. PR interval 0.24 sec. QUIZ 2 Which of the following is the most likely explanation for the patient's syncope? A. Aortic stenosis. B. Neurally mediated, vasodepressor syncope. C. Ventricular tachycardia. D. Third-degree AV block. E. Postprandial syncope

25 28-year-old man presents with an 3-month history of recurrent syncope occurring about two times per month. PE - WNL LONG QT SYNDROME Congenital Adenergic dependent Acquired Bradycardia dependent Electrolyte imbalance Drugs

26 Congenital Long QT s Swimming r Ringing Sleeping Genetic AD : Romano-Ward and Timothy syndromes AR: Jervell Lange-Nielsen syndrome Rx : Betablocker (esp. in LQTS1) AICD in 2 nd prevention 28-year-old man presents with an 3-month history of recurrent syncope occurring about two times per month. PE - WNL

27 SHORT QT SYNDROME First report by Gussak in 2000 (Now 23 case) QTc < 300 ms T wave abnormalities tall and peaked T asymmetrical T (rapid descending limb) Genetic analysis for confirm diagnosis Clinical : AF, VT/VF Rx : Unknown, ICD 2 nd prevent 28-year-old man presents with an 3-month history of recurrent syncope occurring about two times per month. PE - WNL

28 28-year-old man presents with an 3-month history of recurrent syncope occurring about two times per month. PE - WNL CLASSIFICATION Type in Brugada ECG pattern Wilde AAM, Antzelevitch C, Borggrefe M, et al: Proposed diagnostic criteria for the Brugada syndrome. Eur Heart J 23: , 2002

29 Wilde AAM, Antzelevitch C, Borggrefe M, et al: Proposed diagnostic criteria for the Brugada syndrome. Eur Heart J 23: , 2002 DIAGNOSIS CRITERIA Wilde AAM, Antzelevitch C, Borggrefe M, et al: Proposed diagnostic criteria for the Brugada syndrome. Eur Heart J 23: , 2002

30 V1 V2 V3 Lead II I IIa IIb III ICD for Brugada syndrome with previous Expectation of survival > 1 year I I IIa IIb III IIa IIb III ICD for Brugada syndrome with spontaneous abnormal ECG with with or without mutations gene Expectation of survival > 1 year ICD for Brugada syndrome with Expectation of survival > 1 year

31 I IIa IIb III for electrical storm I IIa IIb III for electrical storm I IIa IIb III in asymptomatic with spontaneous ST elevation with or without a mutation in the SCN5A gene. 28-year-old man presents with an 3-month history of recurrent syncope occurring about two times per month. PE - WNL

32 ARVC AD trait with variable age-related penetrance AR (Naxos disease) 28-year-old man presents with an 3-month history of recurrent syncope occurring about two times per month. PE - WNL

33 28-year-old man presents with an 3-month history of recurrent syncope occurring about two times per month. PE - WNL THANK YOU