M A R T H A S O S A - J O H N S O N , M . D.
HS CLINICAL PROFESSOR OF MEDICINE- DIVISION OF INTERNAL MEDICINE
D I V E R S I T Y C O N S U LTA N T, S O M M E D I C A L E D U C AT I O N D E PA R T M E N T
U C I R V I N E H E A LT H
Objectives
1. Definition of syncope
2. Epidemiology of syncope
3. Approach to Syncope
5. Classification of Syncope
6. Diagnostic studies
Epidemiology of syncope
Incidence:
Framingham Heart Study followed 7814 men and women
Followed for 17 years
11% reported syncopal episodes
Similar in men and women*
3-5% of ER visits
1% of hospital admissions
Up to Date June 2015
Both slides: Vasovagal most common cause followed by cardiac and unknown about 30%
Classifications of Syncope
Causes of Syncope
Reflex/Neurally
Mediated
Cardiac Syncope
Vasovagal, Situational
Structural heart disease
Orthostatic
Arrhythmias
Carotid Sinus Hypersensitivity
Neurologic
Other/unexplained
Syncope
Syncope
Seizures, TIA, stroke
APPROACH TO SYNCOPE
Approach to Syncope
*Syncope is a SYMPTOM
*Determining cause allows us to choose interventions or recommend treatments.
*Recall that evaluation of patients with syncope is the same as that for pre-syncope, which is the
prodromal symptom of fainting
Approach to Syncope
Initial Evaluation of patient presenting with
transient loss of consciousness should include:
1. Careful history:
Clinical features associated with syncopal episode can
help determine cause of syncopal episode
2. Physical examination, including orthostatic
blood pressure measurements
3. ECG
In *study of 650 ED patients:
History, PE including carotid massage, ECG and basic labs
established a suspected cause of syncope in 69% of patients.
*e.g. Vitals , Cardiac exam for murmurs, loud P2 may
suggest Pulmonary HTN, physiologic maneuvers for
HOCM e.g., unilateral abnormalities on neuro exam
could suggest CNS etiology, +stool guaiac
*e.g. conduction blocks( i.e. bifascicular blocks),
bradycardia, tachycardia, ST elevations, TWI, Q
waves,
European Society of Cardiology Guidelines (2009)
*UTD reference- Sarasin FP, Louis-Simonet M., Carballo D, et al: Prospective evaluation of
patients with syncope. Am J Medicine 2001; 111:177.
CLINICAL CASES
Mrs. P:
69 yr old with HTN and high cholesterol who is scheduled to see you in your
Continuity Clinic because she “fainted 2 days ago” while Ballroom dancing
You are getting ready to see her but before you
go in you take a moment to ponder:
Definition of Syncope
1. Onset is abrupt/sudden.
Was this episode of
“fainting” a syncopal event?
2. Loss of consciousness is transient and of
short duration
3. Absence of postural tone.
4. Recovery is spontaneous and usually no
sequelae.
Up to Date June 2015
Mrs. P:
69 yr with HTN and high cholesterol is scheduled to see you in Continuity Clinic
because she “fainted 2 days ago” while Ballroom dancing
HPI:
She enjoys ballroom dancing and goes dancing 1-2 times a week at the Senior Center.
Over the last few months she had noticed that she has been more short of breath while
dancing and felt more tired than usual afterwards. She thought it was just her “age
catching up to her”. She had no problems with light housekeeping at home.
She recalls feeling short of breath while dancing. She doesn’t know exactly what
happened next but she found herself laying on the floor. Her dancing partner told her
she had “passed out” and he had caught her. Apparently, she did not respond for about
2 minutes but then opened her eyes.
Mrs. P’s History- What else do you want to know?
Before LOC:
Days before episode:
Didn’t recall chest pain, back pain, arm pain,
lightheaded, feeling sweaty, dizzy, numbness in her
body or had any nausea.
No diarrhea, fevers, chills, nausea , “had been feeling well”
Months before episode:
She had been feeling more short of breath with dancing.
After LOC
*aware of her surroundings.
Medications
*recognized her friends
Cozaar 50 mg/day
*denied B/B incontinence, tongue biting
Atorvastatin 40 mg/day
*felt embarrassed about event
Calcium +Vit D twice a day
*She declined them calling paramedics despite their
suggestions as she felt okay.
Levothyroxine 75mcg/day
*Did call to make an appointment for today.
(Not on blood thinners, diuretics or seizure meds)
Mrs. P- Physical Exam and Labs
BP 128/78 Pulse 76, afebrile , RR= 16 , O2 Sat RA= 98%
BP sitting: 136/84 , P= 80 Standing: 140/88, P=88
No recent labs.
GEN:
NAD, cooperative, looking younger than stated age
HEENT: atraumatic, PERRL, EOMI; pharynx was clear
What would you order?
Neck: supple, no cervical lymph nodes, thyroid normal
CV:
RRR nl S1S2 , 3/6 SEM heard best at RUSB with
radiation to carotids, PMI laterally displaced
CMP , CBC : Normal
Pulses: 2+ carotid, radial and 1+ DP bilaterally
EKG: NSR with nl intervals
Lungs: Moving air well, CTA
ABD: Soft, NTTP, no HSM, active bowel sounds
Skin:
no abrasions, bruises noted
Neuro: CN3-12 intact, BUE/BLE strength WNL, normal
sensory and reflexes
LVH with strain pattern
EKG Findings in
Left ventricular hypertrophy with strain pattern (ST depression with inverted T waves)
With history, PE findings, ECG and labs obtained, what are your thoughts about what
might have caused her episode of syncope?
History:
*Sudden onset without prodrome (nausea, pallor,
diaphoresis, warmth associated with vasovagal) is more
common among patients with cardiac syncope.
*Exertional syncopeConsider obstruction from aortic stenosis, hypertrophic
cardiomyopathy or ventricular tachycardia
Exam:
Vitals : No orthostatic hypotension
CV: RRR nl S1S2 , 3/6 SEM heard best at RUSB with
radiation to carotids, PMI laterally displaced
EKG: NSR with nl intervals,
LVH with strain pattern
Arrhythmias:
AF, Sinus node dysfunction, AV node conduction blocks,
SVT, VT, VF, drug induced bradycardia
* Most common cardiac cause
Structural heart disease
AS, ACS, Hypertrophic, Cardiomyopathy, Cardiac masses,
tamponade, congenital anomalies of coronary arteries,
prosthetic valve dysfunction
Mrs. P : What do you do next?
*What is your concern?
*What intervention/study does she need?
*Inpatient evaluation?
*Outpatient evaluation?
Presently stable. On exam, no CHF, 3/6 SEM with radiation to carotid
EKG: no acute ischemia changes
Supportive family and will not be alone.
Advise no further strenuous activities until further testing completed.
Mrs. P- Outcome
Called Cards Fellow
*Presented history/PE findings/EKG
*Discussed concerns given risk stratification
* Cards Fellow approved urgent Echo
* Echo done following morning revealed
Aortic valve area= .8 cm2
EF%= 60% with normal wall motion
>> Referred to CT surgery for discussion
regarding Aortic valve replacement
Approach to Syncope:
Case # 2: Mrs. Williams
You have been an R2 for several months and are
doing your Emergency Medicine rotation.
Did she have a syncopal episode?
1.Abrupt
*58 yr old female presenting to ED with
complaint of having passed out at the movies
and brought in by paramedics for further
evaluation.
2. Loss of consciousness
3. Absence of postural tone
4. Followed by rapid spontaneous recovery
HPIMrs. Williams
58 yr old with h/o HTN (on HCTZ 25mg/day) who had been in her USOH when she went to the movies
earlier that evening. She recalls beginning to feel warm and then felt nauseated. At one point, she
felt like she might vomit and told her husband that she needed to go outside. He followed her out
because he was not sure what was wrong with her. When got outside theater, she began to have “
cold sweats and felt light-headed”. She recalls reaching for the railing and then woke up on the floor.
Her husband provided history that she lost consciousness for about 1-2 minutes. He was barely able
to catch her as she slumped forward.
She remembers everything up to the point of losing consciousness. Her husband did not see any
convulsions. On awakening she had not bitten her tongue and recognized her husband and
surroundings. One of the theater staff has also seen her fall and had called paramedics. She was still
feeling lightheaded and with some mild nausea and so agreed to go to ED.
Of note, her father and sister were sick that week with flu-like illness with gastrointestinal symptoms.
She had a few loose stools without blood 1-2 days before. She had felt a little tired and had not eaten
much but had no more diarrhea today.
No family history of heart attacks or strokes.
Mrs. Williams
History- What else do you want to know?
Before LOC:
Days before episode:
Denied shortness of breath, chest pain, back
pain, arm pain, DOE, headache, numbness in
face or body.
“few loose stools without blood 1-2 days before.
After LOC
*aware of her surroundings.
*recognized her husband
*denied tongue biting
*still felt lightheaded and with some nausea
She had felt a little tired had not eaten much but
had no more diarrhea today”.
+family members had been ill with “flu-like
symptoms.
Medications
HCTZ 25mg/day
Calcium +Vit D BID
(Not on blood thinners, or seizure meds)
Mrs. Williams: PE and labs
Vitals: Supine BP = 122/74 Pulse 88,
T: 98.2 F| RR: 18
Standing BP= 104/68 Pulse 108
Gen: Alert and oriented x 3, converses appropriately
HEENT: PERRLA, EOMI, sclera anicteric, oropharynx clear
CBC: WBC 9.5 (78% PMN), Hgb 13.5, plt =230
Neck: Supple, no cervical lymphadenopathy, no bruits
BMP: K 3.2, otherwise normal
Heart: RRR, normal S1, S2, no murmurs/rubs/gallops, no JVD
CK: 81
Lungs: Clear to auscultation bilaterally
Trop: < 0.03
Abd: Soft, non-tender, non-distended, no guarding, No HSM
NEURO: CN II-XII grossly intact ;BUE and BLE : 5/5 strength, normal
sensory, reflexes and gait
SKIN: no rashes or bruises
EXT: Warm, no clubbing/cyanosis/edema,
Pulses: RP/DP 2+ and no C/C/E
UA: normal
EKG today: NSR= 92 with nl axis, intervals and
otherwise Normal
Mrs. PWith history, PE findings ,ECG, and labs, what are your thoughts about what might have caused
her episode of syncope?
Causes of
Syncope
Reflex syncope
Vasovagal
Situational
Cardiac Syncope
Neurologic
Unknown
Carotid Sinus
Hypersensitivity
Orthostatic
UP To Date June 2015
Reflex -mediated Syncope
Vasovagal:
Prodromal symptoms of nausea, warmth, pallor,
lightheadedness and diaphoresis
Distress, fear, pain, **instrumentation, phobias,
or orthostatic stress can trigger an event
Symptoms correlate with increased vagal tone
(increased signal in the vagus nerve supplying
the heart), which acts to momentarily slow the
heart and/or dilate (widen) the blood vessels in
the body, leading to a reduction in blood flow to
the brain >> loss of consciousness as the brain
becomes deprived of oxygen.
Clues in Mrs. Williams history:
*Prodrome: warm, felt nauseated, lightheaded,
and experienced cold sweats
*mild diarrhea for 1-2 days
*decreased po intake few days
* HCTZ
*PE: WNL except for Orthostatic BP values
Orthostatic: SBP decreases by 20 mmHg and/or DBP
decreases by 10 mmHg or Pulse increases by 20 on
going from supine to standing position
(Borderline decrease in SBP/DBP values but her
pulse did increase by 20 points on standing up)
Mrs. Williams
Treatment
1. Replete with one liter of IVF
2. Replete KCL orally
Outcome:
*Diagnose her with Vasovagal syncope and discharge home.
*Mrs. Williams seen in Pav 3 one week later for ED follow up.
*She was doing well.
SYNCOPE
SEIZURE
Usually begins in standing position
Can occur in any position
Often associated with prodromal symptoms of
nausea, warmth, pallor, lightheadedness and
diaphoresis with reflex/neurally mediated
syncope
May be preceded by aura or occur
without warning
Jerking motion of limbs usually not present
Jerking motions during period of
unconsciousness
Consciousness regained spontaneously and fully
aware of surroundings
Post-ictal period of confusion and
drowsiness
Approach to Syncope- Diagnostic Studies
Additional testing is based on results of
initial evaluation (History, Physical Exam
findings and EKG).
No diagnostic test to evaluate syncope
other than clinical evaluation.
2009 European Society of Cardiology Testing
Strategy Guidelines:
- Carotid Sinus Massage
-Echo if previous known heart disease or data suggestive of
structural heart disease or syncope secondary to CV cause
-ECG monitoring if suspicion for arrhythmia
-Orthostatic challenge (Tilt table) when suspicion of reflex
mechanism
-Less specific testing (e.g. Neurological evaluation)
indicated only when suspicion is for non-syncopal transient
LOC
Additional Testing2009 European Society of Cardiology guidelines
1. Carotid Sinus Massage
> 40 years of age
Should be avoided in pts with h/o of TIA or stroke
within past 3 months and in patients with carotid
bruits (unless have Doppler studies that excludes
significant stenosis)
Diagnostic if syncope is reproduced with asystole
longer than 3 seconds and/or fall in SBP>50 mmHg
2009 European Society of Cardiology guidelines
Orthostatic challenge- Tilt Table Testing
Tilt Table Testing
Reflex syncope (Vasovagal) triggered by
standing
Characterized by:
*initial normal reflex to standing
*followed by rapid fall in venous return and
*vasovagal reaction (reflex bradycardia and
vasodilation)
**Commonly performed but test has limited
specificity, sensitivity and reproducibility**
UpToDate June 2015
2009 European Society of Cardiology guidelines
ECG monitoring
External Event Recorder
1. In-hospital
◦ Recommended in pts with structural heart disease
◦ Yield is low, about 16%.
2. Holter (24-48 hour of continuous monitoring)
◦ Value is limited because of intermittent nature
of syncope
◦ Establishes a diagnosis in only 1-3 % of patients
with syncope
◦ Reccs: Indicated for patients who have clinical or
ECG features suggesting an arrhythmic syncope
◦ Somewhat more helpful than Holter
◦ Limitations in that patient must be conscious
to activate unit and record rhythm when
symptomatic
◦ Some models (intermittent) can store several
minutes of recording which pt can activate on
regaining consciousness.
◦ Reccs- Indicated for patients who have clinical
or ECG features suggesting an arrhythmic
syncope
2009 European Society of Cardiology guidelines
Implantable Loop Recorder (ILR)
-Subcutaneous device usually implanted in left
parasternal or pectoral region with battery life
of 18-24 months
-Activated by programmed criteria or by
patient manually activates it with placement
of magnet
-Most useful in pts with infrequent symptoms,
noninvasive testing negative or inconclusive
Recommended:
◦ patients with recurrent syncope of uncertain
origin and without significant structural or
coronary artery disease
◦ In patients with significant structural or CAD in
whom a comprehensive evaluation did not
reveal a cause of syncope
◦ To assess on presence of bradycardia before
initiating cardiac pacing in patients with
suspected or confirmed reflex syncope with
frequent or traumatic syncopal episodes
Evaluation of Syncope in Adults: UTD June 2015
Summary Points
1. Definition of Syncope: abrupt onset, Transient LOC, absence of postural tone with rapid recovery.
2. Initial Evaluation (history, PE and ECG) can often help identify cause for syncope.
3. Clinical features associated with syncopal episode can help determine cause of syncopal episode.
4. Classifications of syncope
◦
Reflex (vasovagal/situational/carotid sinus sensitivity/orthostatic) – about 50% of causes
◦
Cardiac (Arrhythmias and structural) – about 20% of causes
◦
Neuro- Infrequent, but important to distinguish between seizure and syncope
◦
Unknown cause in about 1/3 of cases
Summary Point #5:
7.
Summary Points
6. Additional Diagnostic Testing based on 2009 ESC guidelines
- Carotid Sinus Massage
-Echo if previous known heart disease or data suggestive of structural heart disease or syncope
secondary to CV cause
-ECG monitoring if suspicion for arrhythmia
-Orthostatic challenge (Tilt table) when suspicion of reflex mechanism
-Less specific testing (e.g. Neurological evaluation) indicated only when suspicion is for nonsyncopal transient LOC