Professor Rose Anne Kenny, St James Hospital &Trinity College, Dublin

Transcription

1 Syncope Presentation and Investigation in the Acute Setting Professor Rose Anne Kenny, St James Hospital &Trinity College, Dublin

2 Definition- Presentation Syncope is a syndrome consisting of a relatively short period of temporary and self limited loss of consciousness caused by transient reduction in blood flow to the brain (most often the result of systemic hypotension). Transient Spontaneous recovery

3 Synonyms - Presentation Syncope Faint Blackout Passing out Pre Syncope Near faint/ near pass out Gray out Funny do

4 Syncope in relation to real and apparent loss of consciousness.

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6 Syncope vs Epilepsy 12% tonic clonic like movements 80% myoclonic Brief After LOC Less coarse Not tonic clonic (gross flailing, random, contraction of axial muscles different to regular contractions of epilepsy) Video- Mobile phone

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8 Syncope vs TIA TIA does not cause syncope Vertebral Ischemia - rare- neurology Transient cerebral disturbances should not be included in the differential for Syncope Unnecessary Investigations

9 Causes- Investigation Neurally mediated Orthostatic Cardiac Arrhythmia Structural Heart Disease Cerebrovascular

10 Causes- Investigation Neurally Mediated Vasovagal Syncope Carotid Sinus Syncope Situational Faint Acute haemorrhage Cough, sneeze, Gastrointestinal stimulation Micturition Post exercise Other (brass instrument play, weight lifting, postprandial) Glossopharyngeal and trigeminal neuralgia

11 Causes- Investigation Orthostatic Primary Autonomic failure syndromes (PAF, MSA, PD,? POTS) Secondary Autonomic failure (DM, drugs, Alcohol Amyloid) Volume depletion (Haemorrhage, Diarrhoea, Addison's,?Age)

12 Causes- Investigation Cardiac Arrhythmias as primary cause SND AV Conduction PSVT, VT Inherited Syndromes (Long QT, Brugada) Implanted device malfunction Drug Induced Arrhythmia

13 Causes- Investigation Structural Cardiac/Cardiopulmonary Cardiac Valvular Acute MI Obstructive cardiomyopathy Atrial Myxoma Acute Aortic dissection Pericardial Pulmonary Embolus/ Hypertension Cerebrovascular Vascular Steal Syndromes

14 Causes- OPD; ED studies Vasovagal/Carotid Sinus Syndrome 35% Arrhythmia or Cardiac 10% Orthostatic Hypotension 25% (Canada, USA, UK, Italy)

15 Epidemiology Incidence Adults: 6.2 per 1000 person years : 11 per 1000 person years > per 1000 person years Soteriades NEJM 2002

16 %

17 Comparison of ages of first syncope in 443 patients with vasovagal syncope and 88 patients with syncope of other known cause. ER 1-3%, Admissions 6%

18 Syncope Presentation and Investigation in the Acute setting Admission based on Risk Stratification Short Term (7-10) Long term (1 year) Admission based on Mechanism of Syncope and its Treatment

19 Management of ShortTerm Risk: 10 days 1. STePS (ShortTerm Prognosis of Syncope JACC 2008) Abnormal ECG, trauma, absence prodrome, male, 10 day higher risk death, serious adverse event (CPR, PM, Defib implant, admit ICU) positive predictive value 11-14% low no. events

20 Management of ShortTerm Risk: 10 days 2. San Francisco Syncope Rule Ann Emer Med 2006, Abnormal ECG, SOB, Hct <30%, SBP<90mmHg, CCF 98% sens, 56% spec serious adverse event 7 days death, MI, Arrhythmia, PE, Stroke, SAH, Haem, ED return, Hospital admission 89% sens, 42% spec external validation Ann Emer Med 2007

21 Management of ShortTermRisk: 10 days High Risk important few days following index event Deaths, serious outcomes mostly related severity underlying disease > syncope Approx 1% death rate 1% death rate high risk within 1 week presentation

22 Clinical policy of the American College of Emergency Physicians Factors that lead to stratification as High Risk (Hospital Admission) Older Age* Abnormal ECG (acute ischemia, dysrhythmias, conduction abnormality) Hct<30% Hx or presence CCF, CAD, structural HD Ann Emerg Med 2007

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24 Management of Long Term Risk: 1 Year RF Syncope n=252; >45 yrs Abnormal ECG Hx Ventricular Arrhythmia Hx CCF Valid n=374 1 Year Death or Sign Arrhythmias: 0% none, 27% 3 > RFs Ann Emerg Med 1997

25 Management of Long Term Risk: 1 Year OESIL Europ Heart J 2003 >65 Risk Factor % 0 0 Hx CVD No prodrome Abn ECG

26 Management of Long Term Risk: 1 Year High Risk important 1 year Deaths, serious outcomes mostly related severity underlying disease > syncope death rate depend number risk factors Conclusion: High Risk Patients need close careful F/U, Optimal Treatment and Management No evidence immediate hospital admission improves long term outcome

27 Syncope Presentation and Investigation in the Acute setting SEEDS ( Syncope Evaluation in the ED) Syncope Observation Unit in ED Appropriate resources Multidisciplinary Approach Complete Hx, physical exam, ECG, 6h telemetry, 1h vital signs, Orthostatic BP, ECHO (abn CV exam or ECG)..HUT, CSM, EPS consult

28 SEEDS Syncope 51 Standard 52 p Presumptive Diagnosis Hospital Admission 67% 10% % 98% Beds Days Actuarial survival Survival free syncope 97% 90% ns 88% 89% ns Shen et al Circulation 2004

29 Hospital Admission ESC Syncope Guidelines Recommendations For Diagnosis Strong Recommend Suspected or known Heart Disease ECG suggest Arrhythmia Syncope during Exercise Syncope causing Injury Strong Family History Sudden Death

30 Hospital Admission ESC Syncope Guidelines Recommendations Patients without Heart Disease Occasionally may need admission Sudden onset palpitations before S Syncope Supine Worrisome Family History Significant Physical Injury Patient mild HD but suspicion cardiac syncope Suspected PM, defib problem

31 Hospital Admission ESC Syncope Guidelines Recommendations For Treatment Cardiac Arrhythmias Syncope due to Cardiac Ischemia Syncope secondary to structural Cardiac/Cardiopulmonary Disease Stroke focal neurological Disorders CI NMS PM planned

32 Morbidity- VVS Benign Driving, Occupation, interpersonal relationships, anxiety, depression, orthopaedic injuries (Linzer 91) 12% RTA 40% driving restrictions 10% fracture 37% missed 15 days (year) (Connolly RCT 2003)

33 Morbidity Older Patients Loss functional Ability- Fractures Loss Independence Institutionalisation Cognitive impairment

34 Syncope Presentation and Investigation in the Acute setting TLOC presenting ED Suspected or UnexplainedDx Dx Risk Stratification High Risk/ESC adm guidelines ED EDSyncope Unit Unit LowRisk Risk D/C D/C In Hospital Syncope Mx Out Patient syncopemx Mx

35 Syncope Presentation and Investigation in the Acute setting TLOC presenting ED Suspected or Unexplained Dx Init Eval: Hx, Exam, OBP, Blds Risk Stratification Risk Stratification High Risk/ESC adm guidelines ED Syncope Obs Unit In Hospital Sync Mx Low Risk D/C Out Patient syncope Mx ED Syncope Obs Unit: Trained personnel, Cardiac Monitor OBP checks Echo Syncope consult- HUT, CSM, Other specialist

36 Syncope Presentation and Investigation in the Acute setting Dx yield increased Reduced Hospital admissions Reduced Resource Consumption EGSYS Europ Heart J 2006, Europace 2006,

37 Syncope Presentation and Investigation in the Acute setting Risk stratification Cause Syncope Multidisciplinary

38 Syncope Presentation and Investigation in the Acute setting TLOC presenting ED Suspected or Unexplained Dx Init Eval: Hx, Exam, OBP, Blds Risk Stratification Risk Stratification High Risk/ESC adm guidelines ED Syncope Obs Unit In Hospital Sync Mx Low Risk D/C Out Patient syncope Mx ED Syncope Obs Unit: Trained personnel, Cardiac Monitor OBP checks Echo Syncope consult- HUT, CSM, Other specialist

39 An approach to the evaluation of syncope for all age groups. ATP test, adenosine provocation test; CSM, carotid sinus massage; ECHO, echocardiogram; EEG, electroencephalogram; EP study, electrophysiologic study; ECG, electrocardiogram.

40 Syncope Presentation and Investigation in the Acute setting

41 Syncope Presentation and Investigation in the Acute setting

42 Syncope Presentation and Investigation in the Acute setting

43 Syncope Presentation and Investigation in the Acute setting

44 Syncope Presentation and Investigation in the Acute setting

45 Syncope Presentation and Investigation in the Acute setting

46 Syncope Presentation and Investigation in the Acute setting

47 Syncope Presentation and Investigation in the Acute setting

48 Syncope Presentation and Investigation in the Acute setting

49 Syncope Presentation and Investigation in the Acute setting

50 Management of Long Term Risk: 1 Year STePs >65yrs Neoplasm Hx Cerebrovascular Disease Structural Heart Disease Ventricular Arrhythmia Ann Emerg Med 2007

51 Syncope Presentation and Investigation in the Acute setting Evaluation of Syncope Diagnosis Not life threatening, QOL, Injury Mechanism= Treatment= elimination cause, treat underlying predisposition Treatment- relative prognostic significance Prognosis stratify risk of future events- related syncope or underlying disease