Transcript Syncope
Syncope Common and Uncommon Causes Kelly Airey, MD, FACC, FHRS Cardiology and Electrophysiology October 1. 2016 Disclosures - Consustant/Speaker – Biosense Webster Objectives • Identify causes of syncope • Identify differences between benign and malignant forms of syncope • Identify signs and symptoms which help differentiate various types of syncope Definition Syncope is a transient loss of consciousness (TLOC) resulting from global cerebral hypoperfusion, characterized by rapid onset, brevity and spontaneous recovery EHJ. 2009;30:2631-2671 What is the physiology? Regardless of cause: • Syncope is usually the result of cerebral hypo-perfusion • Pre-syncope is a less severe manifestation of the same process • Reduced oxygen and glucose can mimic the same condition Facts 1) The most common cause of syncope regardless of age, sex or comorbidity is vasovagal. 2) The second most common is cardiac. 3) Carotid sinus and OH rarely occur in those under 40 years Circulation.2013;127:1330-1339 TLOC Cardiac Syncope Reflex Orhostaic Hypotensive Mediated Syncope Syncope Unknown Non-syncope Non-syncopal TLOC Neurologic Seizure Other Endocrine Hypoglycemia Stroke or TIA (RAS) Psychiatric Intracranial hemorrhage Pulmonary Embolism Cardiac Syncope Obstructive Arrhythmia Aortic stenosis tachycarrhythmias Hypertrophic cardiomyopathy* bradyarrhythmia Cardiac tumors Reflex Mediated Syncope Reflex Mediated situational vasovagal Carotid Hypersensitivity TLOC - Common Causes NonSyncope Other Cardiac, orthostatic Reflex and unknown What does it cost? In the US, 30-40% are admitted at an annual cost of $2.4 billion dollars. This is related to multiple low yield investigation and unnecessary hospitalizations Circulation.2013;127:1330-1339 Recurrent Syncope infrequent, unexplained: 38% to 47%1-4 explained: 53% to 62% 500,000 new syncope patients each year5 170,000 have recurrent syncope6 70,000 have recurrent, infrequent, unexplained syncope 1-4 1 Kapoor W, Med. 1990;69:160-175. 2 Silverstein M, et al. JAMA. 1982;248:1185-1189. 3 Martin G, et al. Ann Emerg. Med. 1984;12:499-504. 4 Kapoor W, et al. N Eng J Med. 1983;309:197-204. 5 National Disease and Therapeutic Index, IMS America, Syncope and Collapse #780.2; Jan 1997-Dec 1997. 6 Kapoor W, et al. Am J Med. 1987;83:700-708. Prognosis for syncope Prognosis is determined by the underlying etiology, specifically the presence and severity of cardiac disease. Untreated, can be >10% at 6 months NEJM, 2002:879-885 The Typical Syncopal Patient • 61 years of age on average • 55% are female • 43% Vasovagal • 14% Cardiac • 43% other (including unknown) After the ER presentation • 0.7% die in 30 days • 10% die within one year • 7.5% will have a non-fatal severe outcome in ER (new dx, clinical deterioration, serious injury with recurrence, require therapeutic intervention) • 4.5% will have a non-fatal severe outcome within 7-30 days What is important To identify and treat the 4.5% that will have a non-fatal severe outcome in the next 7-30 days after presentation. Benign syncope – Cause of syncope is has good prognosis and is not life-threatening (vasovagal and other reflex-mediated) Malignant syncope – Cause of syncope is life – threatening (structural heart disease, inherited conditions; tachy/brady arrhythmias) “It’s not the fall that hurts…. It’s the sudden stop at the end….” - Will Rodgers Cause of Syncope Age and Risk Considerations Young Benign Vasovagal Vasovagal Situational Orthostatic - drugs - multifactorial Psychogenic Malignant Old Inherited/Congenital disorders causing tachycarrhythmias - long QT - CPVT - ARVC - HCM - DCM Arrhythmias - bradarrhythmias - tachycarrhythmias 17 year old male presents after passing out at 4 am while urinating after waking up from a sound sleep. He was diaphoretic at the onset of urination. He woke up on the ground in the bathroom. He was alert and oriented. Long standing history of early morning light-headed episodes and syncope as a child while standing in church. 17 year old male passed out at football practice. He had just run 100 yards and started feeling light headed at 50 yds. He collapsed to the ground shortly after. Witnesses claimed that he just fell and was unresponsive for 30 seconds after with complete recovery. No seizure noted. No previous medical history. 64 year old woman with long standing, poorly controlled hypertension passed out in the kitchen after gardening in 95 degree temperatures for three hours. EKG shows LVH. Last echo showed normal EF. Medications include lisinopril/hctz; metoprolol; furosemide; asa. 63 year old woman passed out while sitting in a chair. History of anterior MI six months earlier with occluded LAD that couldn’t be opened. Class II-III heart failure symptoms with EF of 35% with anterior hypokinesis. EKG shows old anterior infarct. Medications included metoprolol, lisinopril, ASA, furosemide. Cardiac Syncope Obstructive Arrhythmia Reflex Mediated Aortic stenosis tachycarrhythmias situational Hypertrophic cardiomyopathy* bradyarrhythmia vasovagal Cardiac tumors postural hypotension Vasovagal Syncope Upright posture Venous pooling Decreased venous return Increased LV contractility Increased LV mechanoreceptor activity vagal sympathetic Medullary Cardioinhibitory Center Sinus node deceleration bradycardia Syncope Increased adrenergic stimulation Vagal Afferent activity sympathetic vagal Arterial hypotension hypotension Pathophysiological basis of the classification of reflex syncope. ANF . autonomic nervous failure; ANS . autonomic nervous system; BP . blood pressure; low periph. resist. . low peripheral resistance; OH . orthostatic hypotension. EHJ 2009;30:2631-71 Other Reflex Syncopes • Carotid hypersensitivity • Postural Tachycardia Syndrome (POTS) • Primary autonomic failure Situational Syncope • Variant of vasovagal syncope • Recognized trigger or situation • Causal link not clear (?reflex arc) • Examples include: micturition, cough, defecation, visiting the hospital Arrhythmias that Cause Syncope • VF • Polymorphic VT/Monomorphic VT • AV Block • Sinus bradycardia/pause • Hypotensive SVT VF/VT • Result of any one of a number of acquired or inherited disorders • Look for clinical clues to suggest the patient at risk for VT/VF Causes of VT/VF Inherited • Aquired Catecholaminergic • Ischemic Cardiomyopathy polymorphic VT • Non-ischemic • Long QT syndrome • Brugada Syndrome • Hypertrophic Cardiomyopathy • Dilated Cardiomyopathy • WPW Cardiomopathy • Hypertensive • Alcoholic • Fibrosis • Infiltrative One major or >1 minor - should see cardiovascular specialist within two weeks Clinical Clues TLOC EKG abnormalities …any syncopal patient with an abnormal EKG needs further investigation Syncope work up 17 year old male presents after passing out at 4 am while urinating after waking up from a sound sleep. He was diaphoretic at the onset of urination. He woke up on the ground in the bathroom. He was alert and oriented. Long standing history of early morning light-headed episodes and syncope as a child while standing in church. 17 year old male passed out at football practice. He had just run 100 yards and started feeling light headed at 50 yds. He collapsed to the ground shortly after. Witnesses claimed that he just fell and was unresponsive for 30 seconds after with complete recovery. No seizure noted. No previous medical history. 64 year old woman with long standing, poorly controlled hypertension passed out in the kitchen after gardening in 95 degree temperatures for three hours. EKG shows LVH. Last echo showed normal EF. Medications include lisinopril/hctz; metoprolol; furosemide; asa. 63 year old woman passed out while sitting in a chair. History of anterior MI six months earlier with occluded LAD that couldn’t be opened. Class II-III heart failure symptoms with EF of 35% with anterior hypokinesis. EKG shows old anterior infarct. Medications included metoprolol, lisinopril, ASA, furosemide. Thank you!