4/2/2014. Karli Urban, MD Department of Family and Community Medicine MU Health Care

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1 Karli Urban, MD Department of Family and Community Medicine MU Health Care I do not have a financial interest, arrangement or affiliation with a commercial organization that may have a material interest in the subject matter of my presentation I will not discuss the unapproved or off label use of a medical device, biologic or pharmaceutical Participants will have an understanding of the causes of syncope Participants will be aware of the risk stratification tools that are available to aid physicians in determining the short term risk of death and potential need for hospitalization Participants will have an understanding of the recommended history, physical examination and diagnostic evaluation recommended. This includes introduction to algorithms which are available to guide evaluation. 1

2 American Academy of Family Physicians: Transient and abrupt loss of consciousness with complete return to preexisting neurological function Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC) Rapid onset loss of consciousness of short duration as a result of global cerebral hypoperfusion with loss of postural tone, which is followed by spontaneous and complete recovery AAFP: Transient and abrupt loss of consciousness with complete return to preexisting neurological function ESC: Rapid onset loss of consciousness of short duration as a result of global cerebral hypoperfusion with loss of postural tone, which is followed by spontaneous and complete recovery 2

3 Cumulative incidence: 3 6% over 10 years Similar gender distribution, but women more frequent at extremes of age Compared to those years old: Incidence increases two fold in those Incidence increases three fold in those >80yo Soteriades et al. Incidence and Prognosis of Syncope. N Engl J Med 2002; Vol. 347, No. 12 Up to 44% of patients do not seek evaluation after syncopal event Patients typically present to a primary practice rather than to the emergency room 9.3 vs 0.7 per 1000 patient years Who does present to the ED? Older patients and those with a higher prevalence of cardiovascular disorders 3

4 Neurally mediated Cardiac Neurologic Orthostatic Psychogenic Unknown Neurally mediated 24% Vasovagal 18% Situational 5% Carotid sinus 1% Cardiac 18% Arrhythmia 14% Structural disease 4% Neurologic 10% Orthostatic 8% Psychogenic 2% Unknown 34% No increased risk of death or CV events if due to orthostatic or neurally mediated causes (32%) Goal to improve patient s quality of life and prevent injury to patient or others Increased risk of death Patients with syncope have increased risk of death by any cause (hazard ratio of 1.3) and increased risk of CV events (hazard ratio 1.3) When syncope is secondary to cardiac etiology: Risk of death from any cause is more than two fold 4

5 Soteriades et al. Incidence and Prognosis of Syncope. N Engl J Med 2002; Vol. 347, No. 12 Pediatric and young patients Neurally mediated syncope, conversion reactions, primary arrhythmia Middle age Neurally mediated Increasing frequency of syncope secondary to micturition, defecation, cough, orthostasis and panic disorders Elderly Higher frequency of syncope secondary to obstructions to cardiac output Aortic stenosis Pulmonary emboli Arrhythmias secondary to heart disease Parry S, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ 2010; 340:c880 5

6 20 50% of patients still have unexplained syncope after intensive evaluation Use combination of history, physical examination, and risk stratification guides History Physical Exam Risk Stratification Steps in evaluation A detailed history and exam can provide the initial diagnosis in 66% of patients with syncope One study showed that history and exam established the diagnosis more often than EKG, holter monitor, electrophysiology or echocardiogram Regarded as the most critical step in obtaining the correct diagnosis Use the rule of the 5 P s Precipitating factors Prodrome Position before syncope Postsyncope Preexisting disease 6

7 Neurally mediated Environment Warm/crowded environment Emotional distress or fear Dehydration Coughing, urination, defecation, eating Activity Head movement, tight collar, shaving Cardiac Etiology Exercise or exertion Neurally mediated Lightheaded, dizziness, vertigo, blurred vision Nausea, diaphoresis, abdominal pain Cardiac etiology Chest pain Dyspnea Fluttering or palpitations Neurologic Focal neurologic deficit Tonic clonic movements Aura Neurally mediated Prolonged standing Cardiac etiology Supine Orthostatic Sudden change in posture Prolonged sitting 7

8 Neurally mediated Nausea, vomiting, fatigue Myoclonic movements Cardiac etiology Immediate complete recovery Chest pain, dyspnea Bradycardia Neurologic Focal neurologic event Tonic clonic movements or posturing Prolonged confusion Incontinence Cardiac etiology Cardiomyopathy Structural heart disease Arrhythmias Family history of sudden cardiac death Orthostatic Diabetes mellitus Parkinsons Alcoholism Renal insufficiency History Physical Exam Risk Stratification Steps in evaluation 8

9 Primary focus Vital signs Orthostatic hypotension, autonomic dysfunction Cardiovascular Carotid bruit Carotid sinus massage New/change in murmur Neurological exam Changes in gait, cognition, strength Medication review Antiarrhythmic or antihypertensives Over the counter Technique Lie supine for 10 minutes and record baseline blood pressure and heart rate Stand for 3 minutes and repeat vitals, inquire about symptoms Interpretation Orthostatic hypotension defined by: Drop in SBP of 20mmHg OR DBP of 10mmHG Clinically important if original symptoms are reproduced Expect heart rate increase, but by <30 bpm Excessive increase in heart rate >30 bpm or to a rate >120 bpm can be suggestive of postural orthostatic tachycardia syndrome Lack of heart rate response suggests autonomic failure, rate limiting drugs or chronotropic incompetence Parry S, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ 2010; 340:c880 History Physical Exam Risk Stratification Steps in evaluation 9

10 Used as an aid, although none have been widely accepted for use in the clinic or ER ROSE: Risk Stratification of Syncope in the Emergency Department SFSR: San Francisco Syncope Rule B R A C E S BNP: levels >300 ng/l Bradycardia: <50 bpm Rectal examination: positive FOBT Anemia: hemoglobin <9 g/dl Chest pain with syncope ECG: Presence of Q waves (not in lead III) Oxygen saturation <94% on room air Sensitivity of 87.2% Specificity of 65.5% NPV of 98.5% for one month serious outcomes Abnormal EKG Shortness of breath SBP <90mmHg Hematocrit <30% Congestive heart failure Sensitivity of 98% (vs closer to 90%) Specificity of 56% NPV of of 99.7% for one month serious outcomes 10

11 Similarities between tools: EKG changes Suggestion of CHF (BNP > 300 ng/l) Anemia (Hgb <9 g/dl or Hct <30%) History Physical Exam Risk Stratification Steps in evaluation Completion of history, physical exam and risk stratification All patients should have the following standardized tests: 12 lead EKG with assessment of QT interval Basic lab testing: CBC for anemia BNP for evaluation of cardiac etiology BMP for electrolyte abnormality Pregnancy test if female of child bearing age These steps alone can identify the etiology of syncope in up to 69% of patients with a later identified known cause 11

12 Most identified algorithm for use was published in 2006 in Circulation AHA/AACF Scientific Statement on the Evaluation of Syncope Input from: American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke Quality of Care and Outcomes Research Interdisciplinary Working Group American College of Cardiology Foundation Heart Rhythm Society Strickberger et al. AHA/AACF Scientific Statement on the Evaluation of Syncope. Circulation. 2006; 113: Gauer, Robert. Evaluation of Syncope. Am Fam Physician. 2011; 84(6):

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14 Completion of history, physical exam and risk stratification All patients should have the following standardized tests: 12 lead EKG with assessment of QT interval Basic lab testing: CBC for anemia BNP for evaluation of cardiac etiology BMP for electrolyte abnormality Pregnancy test if female of child bearing age Study published in Archives of Internal Medicine Review of 2, 106 consecutive patients >65 years of age admitted for evaluation of syncope Designed with goal of determining the frequency and yield of tests that were ordered Evaluated the cost per test yield Specifically evaluated if use of the SFSR improved test yield Mendu et al. Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients. Arch Intern Med July 27; 169(14): Patient characteristics: Mean age: 79 Female 53% Most common pre existing health conditions: HTN, HLD, CAD 90% of patients admitted to Internal or Family Medicine service; 6% to cardiology; 3% to neurology No significant differences in testing pattern or frequency 14

15 Test Ordered Abnormal findings Affected diagnosis Helped determine etiology EKG 99% 21% 7% 3% Telemetry 95% 16% 11% 5% Cardiac enzymes 95% 5% 2% 0.5% Head CT 63% 10% 2% 0.5% Echocardiogram 39% 63% 4% 2% Postural blood pressure 38% 28% (55%) 18% (26%) 15% (21%) Test Ordered Abnormal findings Affected diagnosis Helped determine etiology EKG 99% 21% 7% 3% Telemetry 95% 16% 11% 5% Cardiac enzymes 95% 5% 2% 0.5% Head CT 63% 10% 2% 0.5% Echocardiogram 39% 63% 4% 2% Postural blood pressure 38% 28% (55%) 18% (26%) 15% (21%) Test Ordered Abnormal findings Affected diagnosis Helped determine etiology EKG 99% 21% 7% 3% Telemetry 95% 16% 11% 5% Cardiac enzymes 95% 5% 2% 0.5% Head CT 63% 10% 2% 0.5% Echocardiogram 39% 63% 4% 2% Postural blood pressure 38% 28% (55%) 18% (26%) 15% (21%) 15

16 Test Ordered Abnormal findings Affected diagnosis Helped determine etiology EKG 99% 21% 7% 3% Telemetry 95% 16% 11% 5% Cardiac enzymes 95% 5% 2% 0.5% Head CT 63% 10% 2% 0.5% Echocardiogram 39% 63% 4% 2% Postural blood pressure 38% 28% (55%) 18% (26%) 15% (21%) Test Ordered Abnormal findings Affected diagnosis Helped determine etiology EKG 99% 21% 7% 3% Telemetry 95% 16% 11% 5% Cardiac enzymes 95% 5% 2% 0.5% Head CT 63% 10% 2% 0.5% Echocardiogram 39% 63% 4% 2% Postural blood pressure 38% 28% (55%) 18% (26%) 15% (21%) Test Cost per test Cost per test affecting diagnosis or management EKG $75 $1020 Telemetry $87 $710 Cardiac enzymes $121 $22,397 Head CT $525 $24,881 Echocardiogram $275 $6272 Postural blood pressure $5 $17 16

17 Application of SFSR improved yields and lowered costs by appropriately identifying patients in need of further evaluation Extrapolating results nationally, yearly costs obtained with the most commonly obtained tests nears 6 BILLION dollars Bottom line: Many unnecessary tests are obtained in the evaluation of syncope. Prioritize tests based on history and exam. Often the cheapest tests (history, physical examination and orthostatic blood pressures) are the most helpful. Gauer, Robert. Evaluation of Syncope. American Family Physician. 2001; 84(6): Strickberger et al. AHA/AACF Scientific Statement on the Evaluation of Syncope. Circulation. 2006; 113: Mendu et al. Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients. Arch Intern Med July 27; 169(14): Parry S, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ 2010; 340:c880. Soteriades et al. Incidence and Prognosis of Syncope. N Engl J Med 2002; Vol. 347, No. 12. Sarasin FP, Louis Simonet M, Carballo D, et al. Prospective evaluation of patients with syncope: a population based study. Am J Med. 2001; 111(3): Sarasin FP, Junod AF, Carballo D, et al. Role of echocardiography in the evaluation of syncope: a prospective study. Heart. 2002; 88(4): Assar MD, et al. Optimal duration of monitoring in patients with unexplained syncope. Am J Cardiol. 2003; 92 (10): Quinn et al. Derivation of the San Francisco Syncope Rule to Predict Patients with Short Term Serious Outcomes. Annals of Emergency Medicine. 2004; 43:2. Moya et al. Guidelines for the diagnosis and mangement of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). European Heart Journal. 2009; 30, Reed et al. The ROSE (Risk Stratification of Syncope in the Emergency Department) Study. Journal of the American College of Cardiology. 2010; Vol. 55, No 8. Karli Urban, MD Department of Family and Community Medicine MU Health Care 17