Syncope: What are the Red Flags? Ethan Fruechte, M.D. North Memorial Heart and Vascular Institute Robbinsdale, MN

Syncope: What are the Red Flags? Ethan Fruechte, M.D. North Memorial Heart and Vascular Institute Robbinsdale, MN

Disclosures: None.

Case presentation: History 26yo woman self-referred for further eval of syncope Recurrent, associated with fatigue, stress, or migraine HA All actual syncopal episodes occurred while standing Some intermittent lightheadedness while seated Chronic chest wall pain, reproducible with palpation Anxiety and high-stress job; works for collections agency Taking sertraline, Imitrex, trazodone

Case presentation: Evaluation Echo: Normal chamber sizes and LV size / function; EF 60% Normal valvular function Holter monitor: Sinus rhythm throughout, normal rate trends No pauses or AV block No tachyarrhythmias

Case presentation: Evaluation Tilt testing: 5 minutes in: lightheaded, diaphoretic, nauseated Transient bradycardia but stable SBPs 90s-100s Immediate clinical recovery when supine Findings consistent with vagal response

Differential considerations: No cardiac history No palpitations or other cardiac symptoms No signs of structural heart disease No evidence of arrhythmia, ECG & Holter unremarkable Labwork unremarkable Occurred while standing Risk?

Risk stratification: High-risk features Abnormal ECG No warning History of heart disease Hypotension Shortness of breath Chest pain Structural heart or vascular disease CV etiology?

Question #1: What is the likelihood of a cardiovascular etiology among patients presenting with syncope (all-comers): A. 80% B. 50% C. 20% D. 5% E. Syncope is never cardiac. Call neurology or psych.

Question #2: What is the likelihood of a cardiovascular etiology among patients presenting with syncope, in the absence of cardiovascular disease at initial evaluation? A. 80% B. 50% C. 20% D. Less than 5%

Alboni et al. JACC 2001; 37:1921-8

Benditt DG, Adkisson WO. Cardiology Clinics 2013; 31:9-25

Syncope: Initial Evaluation May be challenging Events typically occur and resolve prior to arrival Wide range of causes Physical exam findings may be few History is key

Syncope: Initial Evaluation True syncope vs other causes: Accidental / mechanical falls Seizure Hypoglycemia Intoxication Vertebrobasilar TIA Psychogenic pseudosyncope

Syncope: Initial Evaluation Clinical features to suggest a specific diagnosis: Vasovagal Situational Recurrent Prodromal symptoms Mechanical / accidental History of falls Gait instability Orthostatic Positional Dehydration, anemia Other medical Diabetes mellitus Epilepsy / seizure disorder Intoxication

Syncope: Initial Evaluation ECG Echocardiogram Labwork: Basic metabolic panel Hemoglobin / hematocrit

Benditt DG, Adkisson WO. Cardiology Clinics 2013; 31:9-25

Case presentation: Impression / Plan Vasovagal syncope with transient cardioinhibitory response (bradycardia) Treated by increasing oral fluid intake Fludrocortisone 0.1mg daily

Case presentation: Clinical course Became pregnant; fludrocortisone discontinued Continued episodic lightheadedness throughout pregnancy, no frank syncope Ongoing post-partum symptoms Fludrocortisone restarted; dose increased to 0.2mg daily Some improvement, though periodic recurrences

Case presentation: Clinical course ILR (loop recorder) placement pursued

Case presentation: Clinical course Dual-chamber pacemaker placed Fludrocortisone discontinued Occasional lightheadedness; pt attributes to anxiety No further syncope

Summary: History is key Determine likelihood of true syncope vs other causes Determine likelihood of CV etiology Risk assessment (CV etiology = higher risk)

Summary: The majority of syncope cases are non-cv in nature (e.g. neural reflex or orthostatic) A normal ECG and echocardiogram, and the lack of any cardiac history, make the likelihood of a CV cause of syncope very low Ambulatory ECG monitoring, stress testing, implantable loop recorders, carotid sinus massage, tilt testing, and EP studies are useful additional diagnostic tools for unclear cases

Summary: High risk features include: Abrupt onset, no warning Non-positional episodes (e.g. while seated) Chest pain or dyspnea History of heart disease Abnormal ECG or echocardiogram Abnormal arrhythmia monitoring Abnormal labwork (e.g. anemia)

Thank you.