DIZZINESS

1
DIZZINESS SYNCOPEEvaluation Treatment

• John M. Fedor, M.D.

2

• 55-year old fell off couch while eating a
  pretzel, apparently lost consciousness
• Father had similar event in Tokyo

3
Choices

• A. MRI of Brain
• B. ENT Consultation
• C. Electrophysiology Study
• D. Psychiatric/Neurological Consult
• E. Drug Screen

4
(No Transcript)
5
Syncope A SymptomNot a Diagnosis

• Self-limited loss of consciousness and postural
  tone
• Relatively rapid onset
• Variable warning symptoms
• Spontaneous complete recovery

6
Goal of Syncope Evaluation

• Establish cause with sufficient confidence to
• Assess prognosis and recommend treatment strategy

7
Self-limited fall or collapse
Psychogenic
Nuerovascular
Transient loss of consciousness
Accidents
Pseudo-syncope

• Stroke
• TIA

• Sleep disorder
• Seizure
• Intoxication
• Metabolic disorder

• Concussion
• Fracture
• Trip Fall

Syncope
8
Conditions Mistaken For Syncope

• Dizziness
• Vertigo
• Drop Attacks
• Falls
• Psychogenic syncope
• Hypoglycemia

• TIA
• Sleep disorder
• Hyperventilation
• Acute intoxication
• Seizures

9
Syncope Basic Diagnostic Steps

• Detailed History Physical
• Document details of events
• Assess frequency, severity
• Obtain careful family history
• Heart disease present?
• Physical exam
• ECG long QT, WPW, conduction system disease
• Echo LV function, valve status, HOCM
• Ambulatory monitoring

10
Syncope Evaluation and Differential Diagnosis
History What to Look for

• Complete Description
• From patient and observers
• Type of Onset
• Duration of Attacks
• Posture
• Associated Symptoms
• Sequelae

11
Diagnostic Tests

• EKG
• Echocardiogram
• ETT

12
12-Lead ECG

• Normal or Abnormal?
• Acute MI
• Severe Sinus Bradycardia/pause
• AV Block
• Tachyarrhythmia (SVT, VT)
• Preexcitation (WPW), Long QT, Brugada
• Short sampling window (approx. 12 sec)

13
Diagnostic Tools

• Ambulatory monitoring
• 1. Holter
• 2. King of Hearts Event Recorder
• Insertable Loop Recorder
• EP Studies Structural Heart Disease
• Autonomic Function Test
• Tilt table
• Carotid Massage

14
Typical Diagnostic Pathway
Syncope
History and Physical ECG
KnownSHD
NoSHD
gt 30 days gt 2 Events
lt 30 days
Echo
EPS
-

Adapted from Linzer M, et al. Annals of Int Med,
1997. 12776-86. Syncope Mechanisms and
Management. Grubb B, Olshansky B (eds) Futura
Publishing 1999 Zimetbaum P, Josephson M. Annals
of Int Med, 1999. 130848-856. Krahn A et al. ACC
Current Journal Review,1999. Jan/Feb80-84.
Treat
Tilt/ILR
15
Head-up Tilt Test (HUT)

• Unmasks VVS susceptibility
• Reproduces symptoms
• Patient learns VVS warning symptoms
• Physician is better able to give prognostic /
  treatment advice

16
NMS Basic Pathophysiology
Benditt DG, Lurie KG, Adler SW, et al.
Pathophysiology of vasovagal syncope. In
Neurally mediated syncope Pathophysiology,
investigations and treatment. Blanc JJ, Benditt
D, Sutton R. Bakken Research Center Series, v.
10. Armonk, NY Futura, 1996
17
Head-Up Tilt Test (HUT)
DG Benditt, UM Cardiac Arrhythmia Center
18
Tilt-Table Testing

• May reproduce patients symptoms
• May provide mechanistic information
• Positive in up to 65 of syncope patients (10-80
  of controls)
• Sensitivity unknown specificity unclear
• Day-to-day variability is common

19
(No Transcript)
20
Tilt-Table Findings

• Neurocardiogenic- hypotension with or
  without bradycardia
• Dysautonomic- gradual decline in BP
• POTS- excessive HR response to mildly low BP
• Cerebral Syncope- cerebral vasoconstriction in
  absence of hypotension
• Psychogenic- no change in HR, BP, EEG, nor
  cerebral blood flow

21
(No Transcript)
22
Causes of Orthostatic Syncope

• Drug-induced
• Diuretics, vasodilators, ETOH, etc.
• 1 Autonomic failure
• Parkinsons
• 2 Autonomic failure
• DM, ETOH, bed rest
• Inappropriate sinus tachycardia, HRgt100 at rest
  or minimal activity

23
(No Transcript)
24
Causes of Orthostatic Syncope

• Drug-induced
• Diuretics, vasodilators, ETOH, etc.
• 1 Autonomic failure
• Parkinsons
• 2 Autonomic failure
• DM, ETOH, bed rest
• Inappropriate sinus tachycardia, HRgt100 at rest
  or minimal activity

25
Treatments that may workOrthostatic Hypotension

• Volume/salt
• TED Hose
• Midodrine
• Florinef
• DDAVP
• Clonidine
• Strengthening muscles

26
Ambulatory ECG
27
Value of Event Recorder in Syncope
Asterisk denotes event marker
Linzer M. Am J Cardiol. 199066214-219.
28
(No Transcript)
29
EP Testing SyncopeAbnormalities of greatest
diagnostic value

• Induced PSVT or VT
• Abnormal sinus node
• Abnormal conduction

30
Conventional Diagnostic Methods/Yield
9 Day S, et al. Am J Med. 1982 73 15-23. 10
Stetson P, et al. PACE. 1999 22 (part II) 782.
5 Kapoor, JAMA, 1992 6 Krahn, Circulation, 1995 7
Krahn, Cardiology Clinics, 1997. 8 Eagle K,, et
al. The Yale J Biol and Medicine. 1983 56 1-8.
1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J
Med, 1991. 3 Linzer, et al. Ann Int. Med, 1997. 4
Kapoor, Medicine, 1990.
Structural Heart Disease MRI not studied
31
16-year old female

• Recurrent syncope and palpitations
• Standing causes episodes of persistent sinus
  tachycardia (HRgt130) and near syncope

32
What is this?

• A. Psychogenic
• B. Cardiac arrhythmia
• C. Neurocardiogenic
• D. Orthostatic intolerance

33
POTSorthostatic intolerance with greater than
120/min increase in HR

• Typically young patients
• Onset often associated with acute illness or
  surgery
• Mechanisms unknown
• Possible denervation lower extremities
• Loss of fluid to interstitial space
• Increased baroreceptor response to orthostatic
  stress
• Inadequate norepi re-uptake transport

34
POTS - Rx

• salt/volume
• physical rehabilitation (tilt table, resistance
  training
• beta blockers, midodrine, pyridostigmine
• psychologic assistance
• Usually improves in 3 years

35
Neurally Mediated Reflex Syncope

• Vasovagal syncope
• Carotid sinus syncope
• Situational syncope
• post micturition
• cough
• swallowing
• defecation
• blood drawing

36
Neurocardiogenic SyncopeTreatment Options

• Lifestyle avoidance, salt load, support hose
• Drugs little controlled data
• Tilt training gt90 effective
• Dual chamber (DDDR rate drop response)

37
Neurocardiogenic SyncopeDrug Therapies

• Beta blockers
• SSRIs
• Anticholinergics (disopyramide, scopolamine)
• Theophylline
• Midodrine
• Fludrocortisone
• Erythropoietin

38
55-year old man

• 55-year old man who is referred for the
  evaluation of syncope. He has a 10-year history
  of hypertension treated with lisinopril 5 mg. He
  had no prodrome prior to the syncopal episode and
  he regained consciousness in less than a minute.
  There is no history of prior MI, angina, dyspnea,
  orthopnea or edema, physical exam normal

39
(No Transcript)
40
55-year old man

• A cardiac catheterization showed diffuse global
  hypokinesis with an ejection fraction of 35-40.
  There was 1 MR. The RCA had a 30 proximal
  stenosis, the LAD had luminal irregularities and
  there was a 60 stenosis in a moderate sized 2nd
  obtuse marginal. At this point you would

41
55-year old male

• Order a Cardiolite Stress Test
• Dilate the 60 OM stenosis
• Perform an EP test
• Place a pacemaker
• Place an ICD
• Order an event recorder

42
55-year old man

• EP testing revealed an HV interval of 70 msec
  (normallt55 msecs) and ventricular fibrillation
  induced with double ventricular extrastimuli. At
  this point you would
• Recommend a dual chamber pacemaker
• Recommend a dual chamber ICD
• Recommend a biventricular pacemaker
• Recommend a biventricular ICD
• Provide an event recorder

43
92-year old woman

• 92-year old woman referred for the evaluation of
  syncope. She has had 2 syncopal episodes without
  prodrome both while sitting. She regained
  consciousness within 20-30 seconds on both
  occasions. She has a history of hypothyroidism
  and takes Synthroid 50 mcg qd. There is no
  history of hypertension or coronary artery disease

44
92-year old woman

• On physical exam her BP is 140/85. HR is 80. The
  heart is regular with a 1/6 systolic murmur and
  frequent extrasystoles. AN ECG shows NSR, left
  axis and isolated unifocal PVCs. An Echo shows
  an EF of 45 with mild LVH and mitral annular
  calcification. A Holter monitor shows the
  following

45
(No Transcript)
46
92-year old woman

• At this point you would recommend
• Pacemaker placement
• ICD placement
• EP testing
• Tilt table testing
• Event recorder monitor

47
(No Transcript)
48
Syncope Etiology
Orthostatic
Cardiac Arrhythmia
Structural Cardio- Pulmonary
Non- Cardio- vascular
Neurally- Mediated

• 1
• Vasovagal
• Carotid Sinus
• Situational
• Cough
• Post-
• micturition

• 2
• Drug
• Induced
• ANS
• Failure
• Primary
• Secondary

• 3
• Brady
• Sick sinus
• AV block
• Tachy
• VT
• SVT
• Long QT Syndrome

• 4
• Aortic Stenosis
• HOCM
• Pulmonary
• Hypertension

• 5
• Psychogenic
• Metabolic
• e.g. hyper-
• ventilation
• Neurological

24
11
14
4
12
Unknown Cause 34
DG Benditt, UM Cardiac Arrhythmia Center
49
SUMMARY

• Syncope TLOC due to inadequate cerebral
  perfusion
• All syncope warrants evaluation not just
  high-risk cases
• Objective
• Establish cause,
• Prognosis,
• Best therapy
• Use Diagnostic Tests Responsibly