SYNCOPE Module 3 Ed Vandenberg MD CMD Geriatric

SYNCOPE Module #3 Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198 -1320 evandenb@unmc. edu Web: geriatrics. unmc. edu 402 -559 -7512

PROCESS Series of 3 modules and questions on Etiologies, Evaluation, & Management Step #1 Power point module with voice overlay Step #2 Case-based question and answer Step # 3 Proceed to additional modules or take a break

EVALUATION Etiologies: n n The evaluation requires: Comprehensive approach Step-wise progression to first rule out the most lethal causes (i. e. cardiac) and then next progressing to the other etiologies as indicated

EVALUATION First Step First step: History H &P*, EKG, Labs Suggested (CBC, electrolytes, glucose, BUN/Cr. Ca+ and Sa. O 2, cardiac enzymes) Precipitant Activities Prodrome Medications Witnesses Comorbid conditions What to ask?

Characteristics of the Three Classes of Syncope Phase Cardiac arrhythmia Vasovagal Seizure Prior to event -Any position < 5 secs warning -Precipt. absent -Palpitations rare -Aborted with lying flat -Precipt. present -Nausea -Visual changes -Any position -May have a warning or prodrome During event -Flaccid -Absent pulse -Blue, ashen skin -Incontinence rare -Motionless, relaxed tone -Rigid tone -Slow, faint pulse -Pulse: rapid -Pale, color skin BP - Pupils dilated, reactive -Rapid, complete -Fatigue after event -No retrograde amnesia -Diaphoresis & nausea Recovery -Tonic eye deviation -Frothing -Slow recovery -Disorientation -Focal neuro. findings

EVALUATION Physical -orthostatic BP & pulse (lying, sitting & standing 1 & 3 min. ) -pulmonary -cardiac -neurologic exams First Step 1 History (from patient and witness) will give diagnosis 50% of the time Physical will give diagnosis 20% of the time

EVALUATION First Step 2, 3 LAB: BMP CBC Gave diagnosis for what % of patients? 2 -3% of patients EKG Gave diagnosis for 5% of patients BUT Often gave clue to dx: e. g. (old MI, BBB, arrhythmias)

EVALUATION additional steps 4 Echocardiography yields unsuspected findings in----- < 10% of patients (should be performed pre stress test, if patient has exertional syncope to r/o cardiac obstruction; eg septal hypertrophy)

EVALUATION additional steps 5 FOR Patients with Structural cardiac abnormalities* * structural heart. Dz: (CAD, CHF, Valve dz, cong. hrt dz) or EKG abnormalities (old MI, BBB, arrhythmias, conduction syst. dz) who have: Ischemic symptoms Perform: Exercise or Pharmacologic Stress Testing

EVALUATION additional steps 6 If added: Ambulatory ECG (Holter) gave: correlation of arrhythmia with symptoms 4% of the time Ø absence of arrhythmia with symptoms 17% of the time (79% of pts. had no arrhythmia or brief arrhythmia) Ø Note: 72 hr ambulatory monitoring did not increase yield for symptomatic arrhythmias over 24 hr monitoring

EVALUATION additional steps Ambulatory loop recorders or Event monitors (“King of Hearts”): (11) Ø in patients able to operate recorder gave diagnosis 25% of time Ø in patients unable to operate recorder consider implantable loop recorder

EPS: Electrophysiologic studies 7 Indications High yield patients: ü ü structural heart disease with unexplained syncope detection of arrhythmias in ischemic heart disease Detect arrhythmias by: via by EKG, cardiac monitoring or Holter or Event monitoring Significant findings: ü NSVT, Sinus Brady, 3 degree Heart Block, Bi. Fasicular BBB

EPS meta-analysis Ann Intern Med 1997; 127: 76 -86 Patients with: EPS yield: history of Structural heart Disease 21% demonstrated ventricular tachycardia (VT) 34% demonstrated bradycardia* Total diagnostic yield: 50% in patients with OHD (14% patients had both VT and bradycardia) (N=406) Abn EKG (i. e. conduction abnormalities) 3% demonstrated VT 19% demonstrated bradycardia* *EPS has low sensitivity and specificity for bradycardia with “normal 1% VT 10% bradycardia absence of structural heart disease) Total diagnostic yield: hearts” (i. e. (N= 219) 10% in patients without OHD

EVALUATION n n n additional steps If added: CT(head) or EEG yielded diagnosis in only---- 4% of pts (12) (these tests are rarely helpful unless neurologic signs or symptoms are present) n all patients with positive scans had focal neurologic signs or witnessed seizure)

EVALUATION additional steps 8 If added: n Head-up tilt table test (HUTT): Indications: -suspect vasovagal or -unexplained syncope in those not suspect or ruled out for cardiac cause when added to above evaluation, these tests gave diagnostic yield to total of n. 60 -76% of patients n Specificity 90% n Sensitivity 66% Caveat What is false positive rate? n Can have false positives: positive tilt table in 10% of the elderly population

* Tilt table testing The Technique n 1 st Passive testing: n n Technique fasting serial BP’s in various tilt positions up to 60 degrees with patient standing still 2 nd Isoproteronol infusion: n n Technique: as above plus infusion of isoproteronol Positive: n demonstrates drop in BP> 20 mm Hg and n symptom reproduction

Review Definition List the consequences Describe the aging physiology that predisposes to syncope List the causes Describe the evaluation Sudden LOC Mortality high in cardiac Baroreceptor, B receptors, Volume MM tone P-A-S-S O-U-T R/o cardiac first H &P, EKG, Labs

How to remember the causes? “Mnemonics” n P-A-S-S O-U-T The following mnemonic reviews the etiologies of syncope, and pertinent data on each: P ressure (hypotensive causes) O utput (cardiac)/O 2 (hypoxia) A rrhythmias U nusual causes S eizures T ransient Ischemic Attacks S ugar (hypo/hyperglycemia) & Strokes, CNS dz’s

The End of Module three on 9 Evaluation of Syncope Request “Syncope Pearls” summary card from 402. 559. 3964 or kfturner@unmc. edu

Post Test n (10) A 75 -year-old woman has chronic congestive heart failure with normal systolic function. Current medications are furosemide and an angiotensin-converting enzyme (ACE) inhibitor. While sitting in a chair approximately 1 hour after eating breakfast and taking her medications, she suddenly loses consciousness and falls to the floor. On examination at the hospital, her pulse rate is 68 per minute and blood pressure is 160/72 mm Hg. A grade 3/6 midsystolic murmur is heard at the left sternal border and radiates to the carotid arteries. There are good carotid upstrokes and no carotid bruits. Complete blood cell count, serum electrolytes, cardiac enzymes, electrocardiogram, and chest radiograph are normal. One day later, blood pressure is 104/70 mm Hg 1 hour after breakfast. Which of the following is the most appropriate next step?

Which of the following is the most appropriate next step? A. Order Doppler echocardiography. B. Encourage the patient to drink two cups of coffee (250 mg of caffeine) each morning. C. Discontinue furosemide. D. Discontinue the ACE inhibitor. E. Prescribe fludrocortisone, 0. 1 mg orally every morning.

Answer: C Discontinue furosemide. This patient has postprandial hypotension, which could be exacerbated by hypotensive medications taken with breakfast. Diuretics have been shown to exacerbate postprandial and orthostatic hypotension, probably because of their preload-reducing effects. In one study, furosemide withdrawal improved postprandial hypotension in elderly patients with heart failure and preserved systolic function.

n Doppler echocardiography probably would confirm reduced early diastolic ventricular filling and normal left ventricular function, which are characteristic of diastolic heart failure. This will not change the treatment approach, however. It is possible but unlikely that the systolic murmur represents aortic stenosis or hypertrophic cardiomyopathy. Even if present, these probably are not hemodynamically significant, given the normal physical findings and electrocardiogram. Caffeine has been effective in ameliorating postprandial hypotension in some patients, but tolerance develops rapidly. ACE inhibitors may improve postprandial regulation of blood pressure. Fludrocortisone is useful for chronic orthostatic or postprandial hypotension, but it is relatively contraindicated in patients with heart failure because it causes sodium retention.

Post Test #2 (10) n n You are called to see an 80 -year-old nursing-home resident with Alzheimer’s disease, reflux esophagitis, and glaucoma who suddenly lost consciousness and fell to the floor at 9: 00 am while sitting in the dining room beginning his breakfast. He was noted by his nurse during morning rounds to be more lethargic than usual, not engaging in his usual pacing behavior before breakfast. At 8: 00 am he received docusate, omeprazole, and timolol eye drops. After his collapse the patient spontaneously regained consciousness while lying on the floor and was diaphoretic. There were no other symptoms. On examination by the nurse, his supine blood pressure was found to be 168/92 mm Hg, heart rate was regular at 96 per minute, respiration rate was 28 per minute, and axillary temperature was 37. 7°C (99. 8°F). What is the most likely diagnosis?

What is the most likely diagnosis? A. Postprandial hypotension B. Arrhythmia C. Pneumonia D. Neurally mediated syncope E. Acute myocardial infarction

Answer; C. Pneumonia n Syncope in the elderly patient is often the atypical manifestation of diseases or situations that may not be expected to result in loss of consciousness. Pneumonia is a common cause of syncope in the elderly patient, possibly as a result of hypoxemia, dehydration, or altered cardiovascular reflexes. In this case there are several signs consistent with this diagnosis. First, the patient was lethargic during morning rounds, suggesting that there was an occult illness. Also, during the nurse’s examination he had a relatively high heart rate and respiration rate, suggesting the presence of an acute respiratory illness. His axillary temperature of 37. 7°C (99. 8°F) corresponds to an oral temperature of 38. 2°C (100. 8°F).

n Although the patient was eating a breakfast meal, postprandial hypotension usually does not occur until 30 to 45 minutes after the meal. The fact that he was receiving ophthalmic timolol drops might predispose him to a bradyarrhythmia; however, his heart rate was 96 per minute following the event. Certainly an arrhythmia is possible, but this would present acutely and would not be associated with lethargy earlier in the morning. The diagnosis of neurally mediated syncope is less common in the elderly patient but does occur; usually this is preceded by a prodrome of nausea, abdominal discomfort, diaphoresis, or a stressful situation. Finally, it is possible that an acute myocardial infarction precipitated syncope; however, in the setting of lethargy, fever, and tachypnea in a nursing-home patient without prior cardiovascular disease, this diagnosis is less likely than pneumonia. End

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