Syncope Presentation and Investigation in the Acute Setting Professor Rose Anne Kenny, St James Hospital &Trinity College, Dublin
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
Synonyms - Presentation Syncope Faint Blackout Passing out Pre Syncope Near faint/ near pass out Gray out Funny do
Syncope in relation to real and apparent loss of consciousness.
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
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
Causes- Investigation Neurally mediated Orthostatic Cardiac Arrhythmia Structural Heart Disease Cerebrovascular
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
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)
Causes- Investigation Cardiac Arrhythmias as primary cause SND AV Conduction PSVT, VT Inherited Syndromes (Long QT, Brugada) Implanted device malfunction Drug Induced Arrhythmia
Causes- Investigation Structural Cardiac/Cardiopulmonary Cardiac Valvular Acute MI Obstructive cardiomyopathy Atrial Myxoma Acute Aortic dissection Pericardial Pulmonary Embolus/ Hypertension Cerebrovascular Vascular Steal Syndromes
Causes- OPD; ED studies Vasovagal/Carotid Sinus Syndrome 35% Arrhythmia or Cardiac 10% Orthostatic Hypotension 25% (Canada, USA, UK, Italy)
Epidemiology Incidence Adults: 6.2 per 1000 person years 70-79 : 11 per 1000 person years > 80 19 per 1000 person years Soteriades NEJM 2002
25 3 2030 20020 70%
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%
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
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
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
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
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
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
Management of Long Term Risk: 1 Year OESIL Europ Heart J 2003 >65 Risk Factor % 0 0 Hx CVD 1 0.8 No prodrome Abn ECG 2 19.6 3 34.7 4 57.1
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
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
SEEDS Syncope 51 Standard 52 p Presumptive Diagnosis Hospital Admission 67% 10% 0.001 43% 98% 0.001 Beds Days 140 64 - Actuarial survival Survival free syncope 97% 90% ns 88% 89% ns Shen et al Circulation 2004
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
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
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
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)
Morbidity Older Patients Loss functional Ability- Fractures Loss Independence Institutionalisation Cognitive impairment
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
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
Syncope Presentation and Investigation in the Acute setting Dx yield increased Reduced Hospital admissions Reduced Resource Consumption EGSYS Europ Heart J 2006, Europace 2006,
Syncope Presentation and Investigation in the Acute setting Risk stratification Cause Syncope Multidisciplinary
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
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.
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Syncope Presentation and Investigation in the Acute setting
Management of Long Term Risk: 1 Year STePs >65yrs Neoplasm Hx Cerebrovascular Disease Structural Heart Disease Ventricular Arrhythmia Ann Emerg Med 2007
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