Syncope: Evaluation and Management

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Syncope Evaluation and Management
Clinical Management

• David Robertson
• February 8, 2004

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Cardiovascular Continuum
LBP
POTS
Normotension
Labile HBP
HBP
NMS
Bradycardia/hypotension 500,000 Americans
Orthostatic tachycardia
500,000 Americans
Orthostatic hypotension
100,000 Americans
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Cardiovascular Continuum
LBP
POTS
Normotension
Labile HBP
HBP
NMS
Bradycardia/hypotension 500,000 Americans
asymptomatic
Orthostatic tachycardia
symptomatic
500,000 Americans
Orthostatic hypotension
100,000 Americans
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Cardiovascular Continuum
LBP
POTS
Normotension
Labile HBP
HBP
NMS
Bradycardia/hypotension 500,000 Americans
Orthostatic tachycardia
500,000 Americans
Orthostatic hypotension
Severe Dysautonomias
100,000 Americans
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Orthostatic Hypotension in Autonomic Failure
52 year old male
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Therapy of Severe Dysautonomias

• FIRST LINE
• Water (40 mmHg!)
• Food (-30mmHg!)

• SECOND LINE
• Physical Maneuvers
• Exercise (in water)

• THIRD LINE
• Fludrocortisone Salt
• Pressor Drugs (midodrine)

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Cardiovascular Continuum
LBP
POTS
Normotension
Labile HBP
HBP
NMS
Bradycardia/hypotension 500,000 Americans
Mild Dysautonomias
Orthostatic tachycardia
500,000 Americans
Orthostatic hypotension
100,000 Americans
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POTS
EKG
BP
HR
Tilt Angle
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Postural Tachycardia SyndromePOTS

• Upright symptoms without hypotension
• Upright tachycardia
• 500,000 Americans usually young women
• Antecedent infection surgery pregnancy
• Partial dysautonomia
• Tx low dose (10 mg tid) propranolol

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Cardiovascular Continuum
LBP
POTS
Normotension
Labile HBP
HBP
NMS
Bradycardia/hypotension 500,000 Americans
Mild Dysautonomias
Orthostatic tachycardia
500,000 Americans
Orthostatic hypotension
100,000 Americans
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Syncope (NMS)
EKG
BP
HR
Tilt Angle
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Syncope

• Transient loss of consciousness
• with loss of postural tone
• followed by recovery

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Syncope
Swoon Emotional Dysautonomia Viral? Swallowing Sta
nding Arrhythmia
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Syncope The Problem

• Loss of consciousness is common
• Long differential diagnosis
• Most benign some fatal
• Treatment requires diagnosis

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Why Do We Faint ?

• Blood/Injury/Fear
• Pain, blood, medical procedures, fright
• After minutes or hours of upright posture
• Generally standing or quiet sitting
• Worse in heat or warm stuffy rooms
• Probably related to tilt test syncope
• Within 30 seconds of arising from sitting or
  lying
• Probably increased conductance in muscle bed
• Can occur with starting to walk after quiet
  standing
• At or immediately after peak heavy exercise

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Hypotension and Sinus Arrest During Venipuncture
100
BP (mm Hg)
80
60
40
20
ECG
0
5
10
15
20
25
30
35
40
45
50
Time (sec)
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Syncope Common Symptoms

• Frequent symptoms or signs
• Nausea
• Diaphoresis
• Pallor
• Fatigue
• Myoclonic twitches
• Frequent presyncopal spells
• Improvement on lying down

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Syncope Rate in Young Adults

• 12-48
• (usually no medical attention)

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Syncope

• 3-5 of all ER visits (35admitted)
• Syncope 1o diagnosis 1-6 of admits
• 1,000,000 new patients evaluated yearly
• Prevalence 0.7 in young 6.0 in old
• Tends to be young women and old men

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Syncope Impact

• Recurrent syncope Rheumatoid arthritis
• Maybe home schooling
• Maybe lose your job
• Maybe injury Falls 4th cause of death
• Pacemaker may make you uninsurable

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Neurally Mediated Syncope

• Recurrent (gt3) syncope
• No cardiac lesion
• Especially in young
• Rarely life-threatening
• Most gradually improve

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Case 1

• 21 year old woman
• Syncope during choir practice

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No W/U Required

• If syncope has an obvious cause
• If there is no cause for concern
• But if in facility HP plus EKG

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Case 2

• 21 year old woman
• Syncope during basketball competition

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Evaluation of Syncope I

• Is there structural heart disease ?
• Hx
• PE
• ECG
• Echo
• Monitoring (loop recorder)

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Case 3

• 21 year old woman
• Syncope during class
• Father died suddenly at 34

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Evaluation Of Syncope II

• Tilt-Table Test
• EP (Electrophysiological) Study
• Butonly BP, HR during spontaneous syncope is
  definitive.

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Tilt-Table Test Positivity

• Normal Subjects
• Syncope Patients

• 13
• 24-75

MEV Petersen, Heart 2000 84 509-514
40 normal positivity at Vanderbilt
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Therapy of Syncope

• No drug or device proven helpful
• Rate-drop pacemaker
• Drugs sometimes employed
• Propranolol
• Fludrocortisone
• SSRIs
• Yohimbine

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16 oz Water Effect on Tilt Tolerance
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Vanderbilt University Autonomic Dysfunction
Center