Syncope and The
Older Patient
Debra L. Bynum, MD
Division of Geriatric Medicine
Pretest…








1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a
cardiac etiology for syncope
2. History: 75 year old man reports presyncopal symptoms that occur while he
is driving backwards out of his driveway in the morning. This suggests …
3. History: an 80 year old man reports an episode of syncope that occurred
after doing arm exercises for a rotator cuff injury. This suggest…
4. The only independent predictor of a cardiac etiology of syncope is a past
history of …
5. ____ is a neurodegenerative disease characterized by profound autonomic
insufficiency and parkinsonian features on exam
6. An 82 year old man presents with postural hypotension, an idiopathic
peripheral neuropathy, significant proteinuria and your attending orders a
rectal biopsy to look for____
7. Name 3 causes of “situational syncope”
8. Older patients are more likely to have positive a. tilt table tests b. carotid
sinus massage c. orthostatic hypotension d. all of the above
Pretest: bonus question

Sudden cardiac death in young men
(originally described in young asian men)
associated with this sign on EKG is known
as what syndrome?
Outline
What is syncope
 What are the causes of syncope
 How do you evaluate the patient with
syncope?
 How do you risk stratify the patient with
syncope?
 How do you treat?

Syncope: Definition

Transient Loss of Consciousness (T-LOC) due to global cerebral
hypoperfusion


Rapid onset, short duration, complete recovery
Other causes of T-LOC that are NOT syncope
Seizure (syncope can cause myoclonic movements…)
 Hypoglycemia, hypocapnea/hyperventilation
 Intoxication
 Vertebrobasilar TIA


Other etiologies that do not impair consciousness and are NOT
syncope

Drop attacks, falls, TIA from embolic source
Causes of Syncope
Neurally Mediated (up to 58% in some
series)
 Orthostatic/postural
 Cardiac arrhythmia (20-25%)
 Structural cardiac or pulmonary causes
 Cerebrovascular or psychiatric (1%)
 Unknown (18-30%)

Syncope in the Elderly
Usually multifactorial
 Often confounded by findings (orthostasis
and carotid hypersensitivity common and
may be found and yet not be the cause…)
 Prevalence up to 25% in nursing home
population over age 70
 Higher pretest probability of cardiac
disease or arrhythmia

Importance of History and PE

Up to 70- 85% of patients in prospective
studies had probable cause identified
based upon history, physical exam and
ecg
The History…

History of Heart Disease
 The
ONLY independent predictor of cardiac
cause (sens 95%, spec 45%)
 Absence of heart disease up to 97% specific
to rule out cardiac etiology (good NPV)
Neurally mediated (reflex)

Terms
 Vasovagal
 Vasodepressor
 Neurovascular
 Neurocardiogenic
 vasomotor
Who gets this?
We think of the young/healthy
 Older patients can (although often
complicated by comorbidities)

What is it? (Bezold-Jarisch
phenomenon)

The often repeated story
 Excessive
stimulation of mechanoreceptors due to
forceful contraction of underfilled left ventricle leading
to paradoxical signals to the CNS – causing change
from vasoconstriction to vasodilation – causing drop
in blood pressure and bradycardia

The more complicated story
 Disordered
baroreflex function, paradoxical cerebral
autoregulation, endogenous vasodilators… we don’t
really know….
Think neurally mediated…

Situations
 Warm
environment, hot bath, post-exercise,
prolonged standing, large meals, early morning,
valsalva, volume depletion, rising after prolonged
bedrest, alcohol, medications

Symptoms
 Classic


presyncopal symptoms
No underlying neurological or cardiac disease
Prior history
Neurally mediated…sort of ….
Situational syncope
 Carotid sinus hypersensitivity

Situational Syncope

Situations…







Tussive or laughter syncope


Cough
Micturition
Defecation
Swallow
Diving
pain
More common in obese men over 40, smokers with chronic
cough and COPD, children with asthma
More on micturition syncope

Older men, early morning, exacerbated by medications
Carotid Sinus Hypersensitivity

History
 Stimulation
of carotid area near barorecptor
(near bifurcation)
 Tight collar, neck pressure with head turning
or shaving/backing out of driveway
CSH…

Carotid massage
3

second pause or > 50 mm drop in SBP
Three responses
 1.
Cardioinhibitory (bradycardia/asystole)
 2. vasodepressor (hypotension)
 3. Mixed (features of both, most common)
 Cardioinhibitory
may benefit from pacing…
CSH…
Common in elderly, some concern that
massage/testing may over diagnose
 Also more likely to have positive response
in patients with other degenerative
neurological conditions such as Lewy body
disease and parkinson’s
 Pacing controversial, but may have role in
select cases…

Summary: Reflex syncope (neural)
Vasovagal (neurally mediated)
 Situational
 Carotid sinus hypersensitivity

Postural Hypotension

Orthostatic
 Volume loss
 Blood loss
 Drop in blood
pressure (SBP 20) with increase in HR

Autonomic

Common in elderly (10-30%) – presence may or
may not be the cause of syncope
Often medication related (long list…)

Autonomic Insufficiency

Clinical Features



Lack of tachycardic response; no respiratory variability of heart rate
ED, urinary retention, gastric emptying delay
Causes










Diabetes
Paraneoplastic
Amyloid
Multiple Systems Atrophy (Shy-Drager)
Primary Autonomic Failure
Toxins
Parkinson’s, Lewy body processes
Guillain-Barre syndrome
Spinal cord injury
HIV
Cardiac: Arrhythmia

Bradycardia/asystole





Sick sinus syndrome
2nd or 3rd degree AV blocks
Pacemaker malfunction
Have high suspicion in patients with bundle blocks…
Tachycardia




Ventricular tachycardia
Ventricular fibrillation
SVT
If you see afib, think sick sinus syndrome and
bradycardia/pauses…
Cardiac: Prolonged QT
QTc over 500
 Lack of QT shortening with increased
heart rate (role of standing or exertional
EKG)
 Genetic or secondary to medications…
 Torsades

Brugada Syndrome





Triad
 RBBB pattern in right precordial leads
 Transient/persistent ST elevation in v1-v3
 Sudden cardiac death
Structurally normal heart
Association with young and healthy men from southeast asia
who present with sudden cardiac death
Brugada sign may be asymptomatic
High risk of sudden cardiac death in those who have syncope or
family history of sudden death (Indication for AICD based upon
observational data)
Brugada Sign
Structural Cardiac or pulmonary
causes








Valvular disease (especially aortic stenosis)
HOCM
Cardiac masses (myxoma)
Pericardial disease (tamponade or restrictive
processes)
Prosthetic valve dysfunction
Acute aortic dissection
Pulmonary hypertension (exercise related)
PE
Subclavian Steal Syndrome









Proximal subclavian artery stenosis
Decreased blood flow to distal subclavian artery worsened with
exertion of arm
Blood from vertebral artery on opposite side goes to basilar artery
and then down ipsilateral vertebral artery, away from brainstem, to
serve as collateral for arm
Usually asymptomatic
Atherosclerosis
Symptoms of vertebrobasilar insufficiency (dizziness, vertigo,
diplopia, nystagmus)
Rare to have permanent neurological deficits
Diagnosis with dopplers, MRA
Treatment: surgical revascularization, stents
Cerebrovascular
Syncope = global hypoperfusion
 Vertebrobasilar pathology or bilateral
carotid disease…

How do you evaluate the patient
with syncope?
The Older Patient

Positive tests that are more common in the
elderly and not necessarily the cause of the
syncope:
 Orthostasis
 Positive
carotid massage
 Positive tilt table testing


Up to 54% of older patients with syncope may have positive
test…
Positive test in 10% of asymptomatic elderly!
Evaluation: History

Neurally mediated:
 Absence
of heart disease
 Long history of recurrent syncope
 Associated factor (pain)
 Prolonged standing
 Associated n/v, diaphoresis, presyncopal symptoms
 After a meal
 CSH: turning head or pressure on neck
History…

OH:
 After
standing
 Prolonged standing
 Presence of autonomic insufficiency or
parkinson’s
 Standing after exertion
History… cardiovascular







Presence of structural heart disease (especially systolic
dysfunction)
Family history of sudden death
During exertion or supine (BIG FLAG)
Swimming/diving into pool (prolonged QT)
Abnormal EKG
Syncope follows sudden onset of palpitations
EKG:




QT
Bundle blocks
Afib, AV blocks
Evidence of prior ischemia
 QRS over .12
Evaluation
EKG
 Telemetry
 Rule out ischemia (nursing home
patients…)
 Carotid sinus massage

 Contraindicated
in patients with prior
TIA/stroke, bruits or known carotid stenosis
Evaluation
Orthostatics
 Echo

Tilt table testing






Passive or Isoproterenol
Test: patient held in upright position (60-90 degrees), but
weightless to prevent muscles improving venous return;
this leads to venous pooling, decreased venous return,
and trigger of the neurally mediated reflex
Positive test: bradycardia or hypotension
Passive testing: sensitivity only 70%, specificity 90-100%
Isoproterenol: only 55% specificity
Usually does not add much to the history and physical…
In-hospital monitoring
Yield low (under 20%)
 Recommended in high risk patients

Holter Monitoring
24-48 hours (no higher yield with longer)
 Low yield (1-2%)
 May be useful if symptoms are very
frequent

External Loop recorders
Loop memory that continuously records
and deletes
 Patient activates in response to symptoms
(some devices also activated in response
to rhythm)
 Yield: ?25% when used for 4-6 weeks

Implantable Loop recorders




Duration up to 3 years
Can be activated by patient or bystander or
automatically activated by arrhythmias
May be cost effective to do earlier in the workup
than currently doing…
Some series – 50-80 % patients with prior
unexplained syncope were able to have
diagnosis
Electrophysiology Study (EP)
Underlying structural heart disease
(especially depressed LV function)
 Suspected bradycardia
 Patients with underlying bundle branch
block (look for development of His block
with incremental atrial pacing)
 Suspected tachycardia

Exercise Stress Testing
Patients with syncope with/after exertion
 Usually of low yield

Other evaluations…
Imaging, CTA
 Cardiac catheterization


Directed by history and physical…
Least useful tests…
Head CT with negative neuro exam
(history should direct whether symptoms
suggest stroke/TIA or syncope…)
 EEG
 Carotid dopplers (see above…)

Risk Stratification
High Risk









Chest pain
CHF
Valvular disease
History of ventricular arrhythmias
EKG ischemic changes
Prolonged QT c (over 500)
Trifascicular block or pauses over 2 sec
Cardiac devices
Atrial fibrillation
High risk: ESC recommended
hospitalization
Known heart disease
 Syncope during exercise
 Trauma (facial)
 Family history sudden death
 Sudden palpitations prior to syncope
 Syncope while supine
 Multiple recent episodes

Intermediate risk
Age over 50
 History of ischemic heart disease
 Family history of sudden death

Low risk
Age less than 50
 No history of CV disease
 Normal EKG and exam
 Symptoms c/w neurally mediated or
vasovagal syncope
 Prior history of recurrent syncope with
symptoms c/w vasovagal etiology

Treatment: reflex syncope and
orthostatic intolerance

Lifestyle
 Education,
reassurance
 Avoiding triggers
 Maneuvers: supine posture, physical
counterpressure, crossing legs)
 Avoiding medications, ETOH
 Increasing fluids, salt intake
Reflex syncope

Tilt training
 Raising
head of bed
 Progressively prolonged periods of upright posture
 Meds:
 Beta blockers
 SSRI
 Ephedrine
 Midodrine
 No meds work that well…
Reflex syncope: Cardiac pacing

5 major RCTs, conflicting results
 Significant
selection bias
 Likely not justified unless spontaneous
bradycardia found on prolonged monitoring
Orthostatic intolerance






Stop possible medications
Salt/fluid intake
Compression stockings (ideally include
abdominal binders, so compliance low)
Leg crossing/squatting with symptoms
Midodrine (alpha-agonist): works better than in
patients with reflex syncope…
Fludrocortisone (mineralcorticoid)
Indications for Pacing

Class I
 Third
degree of advanced second degree AV
block with symptoms
Bradycardia with symptoms
 Asystole over 3 seconds
 Escape rate less than 40 bpm
 After catheter ablation of AV junction
 Postoperative AVB

Pacing

Class II a
3rd degree AVB or type II
second degree AVB with narrow QRS (class I
if with a wide QRS)
 Syncope with AVB
 Drug refractory afib….
 Asymptomatic
AICD





Unexplained syncope and depressed LVEF
(ischemic or nonischemic)
HOCM (II a)
Brugada syndrome (II a unless high risk, such as
family history of sudden death)
Long QT
Patients with ischemic cardiomyopathy and
preserved LVEF but unexplained syncope (II b)
Back to the Pretest…








1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a
cardiac etiology for syncope
2. History: 75 year old man reports presyncopal symptoms that occur while he
is driving backwards out of his driveway in the morning. This suggests …
3. History: an 80 year old man reports an episode of syncope that occurred
after doing arm exercises for a rotator cuff injury. This suggest…
4. The only independent predictor of a cardiac etiology of syncope is a past
history of …
5. ____ is a neurodegenerative disease characterized by profound autonomic
insufficiency and parkinsonian features on exam
6. An 82 year old man presents with postural hypotension, an idiopathic
peripheral neuropathy, significant proteinuria and your attending orders a
rectal biopsy to look for____
7. Name 3 causes of “situational syncope”
8. Older patients are more likely to have positive a. tilt table tests b. carotid
sinus massage c. orthostatic hypotension d. all of the above
Answers to Pretest…









1. NPV
2. Carotid Hypersensitivity
3. Subclavian steal syndrome
4. Cardiac history
5. Multiple Systems Atrophy (shy-drager)
6. amyloid
7. micturition, defecation, cough, swallow
8. all of the above
9. bonus: brugada syndrome
Selected References








Benditt DG, VanDjjk JG, Sutton R. Syncope: Curr Prob Cardiol 2004; 29(4): 152-229
Epstein AE. An update on implantable cardioverter-defibrillator guidelines. Curr Opin
Cardiology 2004; 19(1): 23-25
Littman L et al. Brugada syndrome and Brugada sign. Am Heart J 2003; 145(5): 768778
Raj S, Sheldon RS. Role of pacemaker in treating neurocardiogenic syncope. Curr
Opinion Cardiol 2003; 18: 47-52
Gregoratos G, Cheitlin MD, Conill A. ACC/AHA guidelines for implantation of cardiac
pacemakers and antiarrthythmia devices: executive summary: a report of the
American College of Cardiology/Am Heart Assoc Task Force on Practice Guidelines.
Circulation. 1998; 97: 1325-1335
Connolly SJ et al. The North American Vasovagal Pacemaker Study. J Am Coll
Cardiol 1999; 33: 16-20
DiGirolamo et al. Effects of paroxetine on refractory vasovagal syncope. J Am Coll
Cardiol 1999; 33: 1227-30
Sutton R et al. Dual chamber pacing in the treatment of neurally mediated tilt-positive
cardioinhibitory syncope (VASIS). Circulation 2000; 102: 294-299
Selected References…






Krahn Ad et al. Use of the implantable loop recorder in
evaluation of patients with unexplained syncope
Kapoor WN. Current evaluation and management of
syncope. Circulation 2002; 106: 1606
Alboni P et al. Diagnostic Value of history in patients with
syncope. J Am Coll Cardiol 2001; 37: 1921
Kapoor et al. Evaluation and outcome of patients with
syncope. Medicine 1990; 69: 160
Linzer et al. Diagnosing syncope: part I. Ann Int med
1997; 126:989
Linzer et al. Diagnosing syncope: part II. Ann Int Med
1997; 127: 76
Primary References:




Chen, LY et al. Management of syncope in adults: an
update. Mayo Clin Proc, 2008: 83: 1280-93.
Weimer L, Pezhman Z. Neurological aspects of syncope
and orthostatic intolerance. Med Clin N Am 93 (2009)
427-449.
Strickberger et al. AHA/ACCF statement on the
evaluation of syncope, Circulation 2006.
Moya et al. Guidelines for the diagnosis and
management of syncope, task force from the ESC. Eur
Heart J (2009)30, 2631-2671.