Transcript Module 2 - 108 KB

SYNCOPE
Module #2
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
981320 UNMC
Omaha, NE 68198-1320
[email protected]
Web: geriatrics.unmc.edu
402-559-7512
PROCESS
Series of 3 modules and questions on
Etiologies, Evaluation, & Management
Step #1 Power point module with voice
overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or
take a break
Etiologies
P-A-S-S O-U-T
(mnemonic)







P
A
S
S
ressure (hypotensive causes)
rrhythmias
eizures
ugar (hypo/hyperglycemia)
O utput (cardiac)/O2 (hypoxia)
U nusual causes
T ransient Ischemic Attacks & Strokes
B) A rrhythmias
TYPES:




Bradyarrhythmias
Tachyarrhythmia’s
SVT, NSVT, A.F.,
pacemaker malfunctions
DIAGNOSIS
 1st step:

HISTORY:



sudden onset
associated with known
heart disease,
quick post event
recovery of
consciousness
EKG
Continuous cardiac
monitor (Inpatient vs.
Holter)
or

—>Event Monitor or
Stress Testing (Exercise
vs DSE)
or

 Electro-physiologic
study ( EPS)
C)
Seizures1
HISTORY----is the key to
diagnosis
Compared to young patients;



Many more occur with
out warning
Many more have
atypical prodrome
POST-ICTAL sx’s:
-longer than any other
cause of syncope
(second only to death: JOKE!)
DIAGNOSIS:
“The Gold Standard”:
 EEG positive and
appropriate
symptoms witnessed




The “Fall-Back
Position”
EEG negative and
appropriate
symptoms witnessed
Gave dx in: < 2 %
Question:2
Can decreased CNS perfusion
causes seizures ?



Decrease CNS perfusion by 35%
SYNCOPE
Decrease in CNS perfusion for:
>10 secs------>SYNCOPE
>15 secs.----->Seizure (possible)
PEARL:
EEG —>of no use in ABSENCE OF
SEIZURE ACTIVITY by history
D) Sugar
(hypo/hyperglycemia)
hypoglycemia from D.M. with
hypoglcemic therapy ONLY
 hyperglycemia from DM and not enough
therapy
Tips:
 Don’t look for hypoglycemia in the NONDiabetic
 GTT doesn’t add diagnostic information

E) Output (cardiac)/O2
(hypoxia)
History:
 usually sudden onset
(exception in CHF),
 Associated cardiac
sx’s:
-dyspnea
-chest pain
-tachypnea
Causes:
 CARDIAC
 PULMONARY (O 2)
E) Output (cardiac)/O2
Causes:
Name some causes of
impaired cardiac output:
E) Output (cardiac)/O2
Causes:
CARDIAC :

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


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Aortic or Mitral or Pulmonic
Stenosis
Hypertrophic Cardiomyopathy
Cardiomyopathies:
(Restrictive or Dilated)
Atrial Myxoma
Cardiac Tamponade
Aortic Dissection
MYOCARDIAL INFARCT
CHF
PULMONARY (O 2
Related)




Pulmonary embolii
Pulmonary Hypertension
Carbon monoxide
COPD exacerbation ( add
 PCO2)
E) Output (cardiac)/O2
The DIAGNOSIS:
Tests:

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SaO2 +/- ABG’s
EKG
CXR
Echo?
CT chest?
NOTE:
 ECHO: helpful in 5
% of all syncopes
Therefore:
use Echo in:
 structural heart dz,
 heart murmurs
 hx of : impaired
cardiac output
symptoms
F) U nusual causes
Causes:
 Anxiety
 Panic disorder
 Somatizations
disorder
 Major Depressive
disorder
 Hyperventilation
syndrome
History
 Psychiatric history
 Symptoms don’t fit
 Diagnosis -sometimes
by exclusion
“The Good News”
 infrequent in the
elderly
G) Transient Ischemic Attacks
& Strokes (and other CNS causes)
Causes:
 CVAs
 TIAs (vertebro-basilar)
 Subarachnoid
hemorrhage
 Subdural hematoma



Basilar artery migraine
Subclavian steal
CNS mass effect: tumor,
edema, AVM
Diagnosis;
Neuroimaging

(“Aren’t you glad you
live in the New
Millennium?”)
The End of Module two on
3
Evaluation of Syncope
Post Test4

A 72-year-old man is hospitalized following a syncopal
episode that occurred while he was walking to the
library. Cardiac monitoring reveals sick sinus syndrome
with short periods of paroxysmal atrial fibrillation and
prolonged episodes of sinus bradycardia with occasional
sinus pauses of up to 3.2 seconds. The patient takes no
medications and has been well except for an episode of
dizziness that occurred while he was walking down the
hall at home. Cardiac telemetry at that time revealed a
3.0-second sinus pause. The patient tells you that he is
not concerned about dying but does want to remain
alert, functional, and able to walk to the library. Which of
the following should you recommend?
Which of the following should you recommend?
A. Exercise stress test
B. Electrophysiologic study (EPS)
C. Dual-chamber pacemaker
D. Ventricular pacemaker
E. Ventricular pacemaker and amiodarone
therapy
Answer: C. Dual-chamber pacemaker

This patient clearly meets the criteria for sick sinus
syndrome; further diagnostic testing is not needed. The
symptomatic sinus pause is an indication for pacemaker
therapy. Although coronary artery disease can cause sick
sinus syndrome in elderly patients, it most often is
caused by degeneration and fibrosis of the sinus node.
Several large, randomized, controlled trials have
investigated the best pacing mode for elderly patients
with symptomatic bradycardias. This patient is less
concerned about mortality than quality of life; therefore,
a pacing mode that will eliminate his symptoms, permit
continued social function, and prevent stroke and
recurrent atrial fibrillation is most desirable. In the
Pacemaker Selection in the Elderly (PASE) study, both
ventricular and dual-chamber pacing were found to
improve overall quality of life in patients with sinus
bradycardia, but nearly one quarter of those assigned to
ventricular pacing developed pacemaker syndrome and
eventually required dual-chamber pacing.

During the 18-month follow-up period, dual-chamber
pacing was found to result in moderately better quality
of life and cardiovascular function. Studies have shown
no effect of pacing mode on overall survival. In another
study, 1474 elderly patients (average age 73 ± 10 years)
with symptomatic bradycardia were randomly assigned
to either ventricular or dual-chamber pacing. No overall
effect of pacing mode on stroke or death from
cardiovascular causes was reported. However, in a
subgroup of patients aged 74 and under, a significant
reduction in both outcomes was seen with dual-chamber
pacing. The study also showed an 18% reduction in the
risk of atrial fibrillation. Treatment with amiodarone is
not indicated at this time. End
REFERENCES
1. Ramsay ER, Rowan JA, Pryor FM. Special considerations in treating
the elderly patient with epilepsy. Neurology 2004; 62:S24-S29
2. Davis TL, Freemon FR. Electroencephalography should not be routine
in the evaluation of syncope in adults. Arch Int Med 1990; 73:593598
3. Bush D. Syncope. In: Geriatric Review Syllabus: A Core Curriculum in
Geriatric Medicine, 5th Edition (Cobbs EL, Duthie EH, Murphy JB,
eds.), Blackwell Publishing for the American Geriatrics Society,
Malden, MA, Chapter 24, pp 165-169, 2002
4. Used with permission from Murphy JB, et. al. Case Based Geriatrics
Review: 500 Questions and Critiques from the Geriatric Review
Syllabus, AGS 2002, New York, NY