Syncope The Diagnosis and Management Angel R. León, MD Division of Cardiology Emory University School of Medicine

Transcription

1 Syncope The Diagnosis and Management Angel R. León, MD Division of Cardiology Emory University School of Medicine

2 Disclosures None

3 Syncope Death is just prolonged syncope J. Willis Hurst MD

4 Causes of Syncope Cardiac Non-cardiac Arrhythmic Non-arrhythmic Aortic stenosis Orthostasis Drugs

5 Arrhythmia that cause Syncope Sinus arrest with long pauses Asystole following conversion from AF High degree AV block Hypotensive ventricular tachycardia Ventricular fibrillation SVT with hypotension

6 Three Questions in Syncope 1. Is there any structural heart disease 2. Is there any structural heart disease 3. Is there any structural heart disease

7 Diagnostic Exercises for Syncope History & physical exam ECG Echocardiogram w Doppler Holter Tilt table testing Event recorder EP study Insertable loop recorder Neurologic evaluation Psychiatric evaluation

8 The ECG in Evaluating Syncope Identifies: Q-waves from previous MI or ST changes associated with ischemia Hypertrophic cardiomyopathy Bundle branch or bifascicular block Prolonged (short) QTc, Brugada pattern

9 The Long QT Syndrome 28yo woman survives sudden cardiac death

10 31yo Man with Syncope: ARVD

11 12yo Boy with Near Syncope: HCM

12 Echocardiogram in Syncope Assessment of left ventricular size and function Segmental wall abnormalities and thinning Diffusely dilated and dysfunctional LV Hypertrophic cardiomyopathy with or without LV outflow obstruction Aortic stenosis, valvular or sub-valvular LV inflow obstruction: Mitral stenosis or myxoma Right ventricular abnormalities: ARVD

13 Holter Monitor in Syncope What is the probability that your patient will experience syncope or near syncope during the 24hr recording? Does nocturnal bradycardia (HR 35-40) constitute a diagnostic finding?

14 The 24hr Holter in Syncope Work-up Gibson, et al., retrospectively analyzed 7,364 patients undergoing 24-hour Holter during 5-year period. Of these, 21% had been referred because of syncope. Gibson TC. Am J Cardiol. 1984;53:

15 The 24hr Holter in Syncope Work-up Gibson, et al., retrospectively analyzed 7,364 patients undergoing 24-hour Holter during 5-year period. Of these, 21% had been referred because of syncope. Yield: < 2% had syncope during an arrhythmia Gibson TC. Am J Cardiol. 1984;53:

16 30 day Event Recorder in Syncope *Asterisk denotes event marker Linzer M. Am J Cardiol. 1990;66:

17 30 day Event Recorder in Syncope *Asterisk denotes event marker Linzer M. Am J Cardiol. 1990;66:

18 Tilt Table Test for Syncope Used to test for neurally-mediated, neurocardiogenic, vasodepressor, cardioinhibitory syncope Measure heart rate and blood pressure in supine & 80 head-up tilt positions Pharmacologic challenge (NTG or Isoproterenol)

19 Tilt Bezold-Jarisch Reflex Venous Return Small Ventricle Vagal Efferen t HR BP Catechols Inotropy Reflex Vagal Afferent Brain Stem Sympathetic Withdrawal Vasodilation BP Syncope Contractility Chang-Sing P. Cardiol Clinics. 1991;9(4):

20 EP Evaluation in Syncope Structural Heart Disease present: Conduction system disease: AV block MI scar: Ventricular Tachycardia Cardiomyopathy: VF or VT Ion-channel abnormalities No obvious structural heart disease:?????

21 Intra-His Conduction Delay

22 Induction of VT

23 Neurologic Tests in Syncope Carotid ultrasound and Doppler? RAS: Dual circulation Brain MRI? EEG foe epileptic focus? Sleep disorder testing?

24 Suggested Algorithm for Diagnosing Syncope Syncope Diagnostic Suggestive Unexplained Syncope Treat Specific Testing + Treat go to A Branch 1 Organic Heart Disease ECG and treadmill test + Holter Organic Heart Disease + Branch 2 Age 60y Carotid massage ECG and treadmill test Branch 3 No suspected heart disease NSR w/ symptoms Stop workup for arrhythmia Arrhythmia w/ symptoms Non-diagnostic Consider EP studies + Organic Heart Disease A Recurrent First episode Treat Treat Frequent Infrequent First episode Tilt test, psych evaluation Stop workup Loop monitor, tilt test, psych eval Tilt test, psych eval Stop workup Linzer M, Yang EH, Estes M, et al. Ann Intern Med. 1997;127:76-86

25 Suggested Algorithm for Diagnosing Syncope Unexplained Syncope Branch 1 Organic Heart Disease NSR w/ symptoms Stop workup for arrhythmia Recurrent Holter First episode + Arrhythmia w/ symptoms Treat ECG and treadmill test + Treat Non-diagnostic Consider EP studies Frequent Infrequent Loop monitor, tilt test, psych eval Stop workup Tilt test, psych evaluation Stop workup First episode Tilt test, psych eval Linzer M, Yang EH, Estes M, et al. Ann Intern Med. 1997;127:76-86

26 Suggested Algorithm for Diagnosing Syncope Unexplained Syncope Branch 2 Age 60 yrs Carotid massage* Branch 3 No suspected heart disease ECG and treadmill test Organic Heart Disease + Organic Heart Disease Frequent Infrequent First episode Holter Loop monitor, tilt test, psych eval Tilt test, psych eval Stop workup * Performed in office setting only in the absence of bruits, a history of ventricular tachycardia, recent stroke, or recent myocardial infarction. Linzer M, Yang EH, Estes M, et al. Ann Intern Med. 1997;127:76-86

27 Diagnostic Exercises for Syncope History & physical exam ECG Echocardiogram w Doppler Holter Tilt table testing Event recorder EP study Insertable loop recorder Neurologic evaluation Psychiatric evaluation

28 Practical Workup for Syncope Take a careful history looking for: Demographics: Age, family history Vagal symptoms-situational syncope History of MI, valve disease, CHF Seizure, syncope, other rare birds Two tests: ECG and Echocardiogram