10/12/2016. Disclosures. Objectives. Not for the Faint of Heart: Evidence-Based Evaluation & Management of Syncope. None

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1 Not for the Faint of Heart: Evidence-Based Evaluation & Management of Syncope Zachary Hartsell, MHA, PA-C Wake Forest School of Medicine PA Program Disclosures None Objectives Describe the pathophysiologic mechanisms that lead to syncope Identify and appropriately apply clinical scoring rules to patients with syncope Employ evidence based recommendations to determine who requires in-hospital evaluations 1

2 Definition Transient loss of consciousness Loss of postural tone Spontaneous return to baseline neurologic function No resuscitative efforts Presyncope = prodrome Underlying mechanism Global hypoperfusion BL cerebral cortices Focal hypoperfusion reticular activating system Prevalence Approximately 1% of ED visits 30-40% admitted $2.4 billion annual costs Multiple expensive, low yield diagnostics Impacts patients on medical, economical and social basis 1/3 of people will pass out in their lives 1/3 of those will have a recurrence 1/3 will injure themselves (requiring treatment) Youtube.com 2

3 Rates of Syncope The incidence rates of syncope per 1000 person-years of follow-up increased with age among both men and women. The increase in the incidence rate was steeper starting at the age of 70 years. Syncope rates were similar among men and women. Soteriades, ES, Evans, JC, Larson, MG, et al. Incidence and prognosis of syncope. N EnglJ Med 2002; 347:878. Presumed Etiology of Syncope Mosquedo-Garcia Etiology Neurally-mediated (Reflex) Vasovagal Carotid sinus Situational Idiopathic Cardiac Orthostatic hypotensive Hypoadrenergic Neurologic Psychogenic 3

4 Diagnosis Study of 121 patients Cause determined in 13 (11%) $23,000 cost for each diagnosed Study of 341 patients 58% neurally-mediated cause 23% cardiac cause (brady- or tachyarrhythmia) 1 % neurologic or psychiatric cause 18% unexplained cause Triaging Syncope Life-threatening Cardiovascular syncope Acute blood loss Pulmonary embolism ICH Consider (but not true syncope) Stroke Seizure Life-Threatening Causes Cardiovascular Syncope Arrhythmia Ventricular tachycardia Brugadasyndrome Bradycardia Ischemic Acute coronary syndrome Structural Valvular heart disease (AS, MS) Cardiomyopathy (ischemic, dilated, hypertrophic) Atrial myxoma Cardiac tamponade 4

5 Life-Threatening Causes Blood loss Trauma with significant blood loss Gastrointestinal bleeding Tissue rupture Pulmonary embolism Saddle embolus Intracranial hemorrhage Not Immediate Life-Threatening Causes Neurally-mediated Neurocardiogenic(vasovagal) Carotid sinus hypersensitivity Orthostatic hypotensive Medication-related Neurally-Mediated Syncope Hypotension and vasodilatation + relative or absolute bradycardia Abrupt withdrawal of sympathetic tone and increase in parasympathetic tone Triggered by orthostatic stress 5

6 Neurally-Mediated Syncope Vasovagal theory: Baroreceptors cause sympathetic activation in response to decreased BP Increased cardiac inotropy, chronotropyand peripheral vasoconstriction Reduced ventricular filling and preload Excessive wall tension activates ventricular mechanoreceptors (similar to HTN) Compensatory bradycardia and vasodilatation Neurally Mediated Syncope Neurally-Mediated Syncope Carotid sinus hypersensitivity Elderly Neck stretching or head turning Can occur without triggers Carotid baroreceptor hypersensitivity Confirm by carotid sinus massage? 6

7 Neurally-Mediated Syncope Situational (poorly understood) Strong emotion or physical pain Distention of hollow viscera Esophagus, bladder, rectum Activates sensory-proprioceptive or specialized afferent nerves Neurally-Mediated Syncope Orthostatic Hypotensive Volume loss Autonomic dysfunction Primary vssecondary Deconditioning, prolonged bed rest 7

8 Orthostatic Hypotensive Insufficient peripheral vasoconstriction Response to orthostatic stress Decrease in SBP >20mmHg or DBP >10mmHg Within 3 minutes of standing Medication-Related Vaso-active medications Anti-HTNs,αand β-blockers, CCB, nitrates, diuretics, ED medications Medications affecting conduction Antiarrhythmics, digoxin Medications affecting the QT interval Antiemetics, antipsychotics, antidepressants Clinical Presentation Dizziness Lightheadedness Nausea/vomiting Warmth Pallor Diaphoresis Chest pain Vertigo Unsteadiness LOC 8

9 History History and physical exam led to the cause of syncope in 45%. Number of episodes Position (erect vs. supine to erect vs. supine) Preceding events Duration of symptoms Recovery Past medical history Medications Etiology History Prodrome During Postdrome Vasovagal Carotid sinus syndrome Situational Triggered by pain Recent procedure Prolonged standing Hot/Crowded surroundings After exertion Neck extension Neck tie +/- head turning Shaving Swallowing Cough Micturition Defecation Warmth Diaphoresis Nausea Ringing in ears Abdominal pain Pallor Diaphoresis Retrograde amnesia (elderly) Fatigue Nausea Somnolence Cardiac During exertion Sudden noise Strongemotion Associated cardiac ds Family history Palpitations Brief Absent Cyanosis Rapid recovery mentation Physical Exam Vitals HR Orthostatic BP Cardiovascular Signs of heart failure Valvular disease Carotid auscultation Respiratory Signs of heart failure PE Neurologic Focal deficits 9

10 Further Evaluation Let the history and physical guide you Lab ECG Echocardiography Neurodiagnostics Imaging EEG Carotid ultrasound CT Scan Several studies have shown little benefit 2014 Review >1000 patients with syncope reviewed Syncope with normal neurological exam - none had abnormal head CT Insufficient evidence to recommend routine head CT in patients with normal neurologic exam and syncope Downs et al., 2014 Echo Structural heart disease and cardiopulmonary disease account for approximately 5% of syncopal episodes Echo frequently performed in evaluation of syncope Indications New murmur 10

11 Electrocardiographic Monitoring Monitoring during event provides direct evidence confirming or disproving arrhythmia ECG Telemetry Holter monitoring External loop recorder Implantable Loop Recorder Subcutaneous monitoring device (left chest) Device is automatically activated according to programmed criteria Patient can activate device to record Useful in patients with: Suspected cardiac etiology Non-invasive testing negative or inconclusive Infrequent symptoms 32 Implantable Loop Recorder Lowers average cost of diagnosis No change in outcomes from traditional methods Cardiology Referral Minor surgical procedure 11

12 What About Tilt Table Testing? What is Tilt Table Testing? Tilt Table Test Useful in patients who are: Young and otherwise healthy and neurocardiogenic syncope is suspected Older and the cause of syncope is unclear but neurocardiogenic syncope is suspected Monitored in supine position for five minutes to obtain baseline BP and HR Positioned in a head-up tilt position and passively moved from a supine position to a head-up position between 60º and 90º 35 Tilt Table Test BP, HR, and symptoms are recorded every 3-5 minutes ECG is recorded continuously If the patient experiences LOC or is unable to maintain posture in association with a significant fall in BP or HR, he or she is returned to a supine position, and the test is considered positive. If, after a period of minutes, no symptoms have developed, the patient is returned to the supine position

13 Tilt Table Test 37 Tilt Table Utility? Not helpful for obvious vasovagal syncope by other criteria Sensitivity for vasovagal syncope 26%-80% Specificity 90% Confirms diagnosis May be able to provide strategies for avoidance Cost v. Benefit Test Cost Diagnostic Yield EKG $100-$500+ 7% Troponin $95 3% External Event Recorder $200 38% * Telemetry (inpatient) $2000 3% Tilt test $600 58% Holter Monitor $300 21% Internal Loop Recorder $ % EP Study $20, % Echo $1000 3% Krahnet al,

14 Acute Diagnosis and Management Three Questions 1. Is this truly syncope? 2. If syncope, is there a life threatening cause 3. If syncope, and not immediately life threatening, is the patient at high risk? Risk Stratification Many different risk stratification systems developed Each has their benefits and limitations San Francisco Rule OESIL Martin et al 1997 ACEP San Francisco Rule 684 consecutive syncope patients CHESS75 CHF HCT <30 EKG Abnormal SBP<90 SOB secondary to CHF history Age >75 Predictive of 7 day mortality Quinn et al,

15 OESIL Osservatorio Epidemiologico sulla Sincope nel Laszio Italian Study looked at 1 year mortality 4 predictive factors Abnormal EKG History of CAD or HF Age >65 Syncope without a prodrome Colivicchi 2003 Martin et al 350 consecutive syncope patients Predict arrhythmia and death at 1 year Risks Age >45 History of VT or VF History of heart failure Abnormal EKG Martin et al, 1997 ACEP Risk Stratification - High Abnormal EKG (Ischemia, infarction, arrhythmia, conduction abnormalities) History of Cardiac Disease SBP<90 SOB during evaluation HCT<30 Older age Family history of sudden cardiac death 15

16 International Meta-analysis 45,000 patients over 20 years 3% of all admissions 42% of patients admitted to the hospital 1 month risk of death 4.4% Statistically significant risk factors Palpitations preceding syncope Exertional syncope History of HF or CAD Evidence of bleeding D Ascenzo et al, 2013 ED Observation Units Randomized trial, 5 EDs, 124 patients Intermediate-risk adults (age 50 or older) ED observation syncope protocol Inpatient admission Primary outcomes Inpatient admission rate Length-of-stay ED Observation Unit Lower inpatient admission rate Shorter hospital length-of-stay Lower cost Serious outcomes similar for 2 cohorts 16

17 SEEDS Trial RCT Evalof patients with syncope at intermediate risk of cardiac cause Standard care Syncope unit Diagnostic yield higher in syncope unit Lower admission rates and length of stay decreased No difference in all-cause mortality or syncope recurrence Cochrane 2011 Insufficient evidence to support any recommended treatment (drugs or device) for the management of syncope Cochrane 2011 Treatment Treat underlying cause Education 17

18 Take Home Points Often times the etiology of syncope goes undiagnosed, however healthcare costs related to admission for syncope are high Most common etiology is vasovagal Work-up focuses on ruling out life-threatening causes Decision to admit based on risk stratification Observational units may be optimal alternative to inpatient admission Questions? 18