The 5 Most Important Things to Know About Syncope. Brian Crandall, M.D. March 9 th, 2015

Transcription

1 The 5 Most Important Things to Know About Syncope Brian Crandall, M.D. March 9 th, 2015

2 Cost of Syncope Recently lost beloved member of the medical community in car accident due to syncope

3 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:

4 Syncope Reported Frequency Individuals <18 yrs 15% Military Population yrs 20-25% Individuals yrs* 16-19% Individuals >70 yrs* 23% Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: *during a 10-year period

5 The Significance of Syncope infrequent, unexplained: 38% to 47% 1-4 explained: 53% to 62% 500,000 new syncope patients each year 5 170,000 have recurrent syncope 6 70,000 have recurrent, infrequent, unexplained syncope Kapoor W, Med. 1990;69: Silverstein M, et al. JAMA. 1982;248: Martin G, et al. Ann Emerg. Med. 1984;12: Kapoor W, et al. N Eng J Med. 1983;309: National Disease and Therapeutic Index, IMS America, Syncope and Collapse #780.2; Jan 1997-Dec Kapoor W, et al. Am J Med. 1987;83:

6 Syncope: Etiology Neurally- Mediated Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary Non- Cardiovascular 1 Vasovagal Carotid Sinus Situational Cough Postmicturition 2 Drug Induced ANS Failure Primary Secondary 3 Brady Sick sinus AV block Tachy VT* SVT Long QT Syndrome 4 Aortic Stenosis HOCM Pulmonary Hypertension 5 Psychogenic Metabolic e.g. hyperventilation Neurological 24% 11% 14% 4% 12% Unknown Cause = 34% DG Benditt, UM Cardiac Arrhythmia Center

7 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.

8 The Significance of Syncope Some causes of syncope are potentially fatal Cardiac causes of syncope have the highest mortality rates 25% Syncope Mortality 20% 15% 10% 5% 0% Overall Due to Cardiac Causes 1 Day SC, et al. Am J of Med 1982;73: Kapoor W. Medicine 1990;69: Silverstein M, Sager D, Mulley A. JAMA. 1982;248: Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:

9 Red Flags of Syncope Syncope during exercise Abnormal ECG or structural heart disease Syncope resulting in injury Syncope in the supine position Family history of sudden death Patient with a pacer or ICD Frequent episodes

10 Syncope Basic Diagnostic Steps Detailed History & Physical Document details of events Assess frequency, severity Obtain careful family history Heart disease present? Physical exam ECG: long QT, WPW, conduction system disease Echo: LV function, valve status, HOCM Follow a diagnostic plan...

11 Conventional Diagnostic Methods/Yield Test/Procedure Yield (based on mean time to diagnosis of 5.1 months 7 History and Physical (including carotid sinus massage) 49-85% 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 (2-3 weeks duration) Insertable Loop Recorder (up to 14 months duration) 20% % 6, 7 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

12 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) New device 83% smaller than older devices

13 Reveal Plus Insertable Loop Recorder Patient Activator Reveal Plus ILR 9790 Programmer

14 Value of Event Recorder in Syncope *Asterisk denotes event marker Linzer M. Am J Cardiol. 1990;66:

15 47 year old male with recurrent EKG showed LBBB syncope with exericise Echo with low normal EF Event monitor was unremarkable EP study was done and was normal

16 Stage 4 of a Bruce Protocol

17 21 year old with syncope- broken wrist from fight

18 Echo showed Dilated CM- EF 30 EPS showed inducible VT

19 5 Most Important Things Syncope is common Know the history Know the EKG (Try to get it recorded during an episode Know the Echo Beware of the Red flag issues with syncope