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Syncope:UPDATE Clinical Evaluation & Management of Syncope:UPDATE 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope Developed in Collaboration with the American College of Emergency Physicians and Society for Academic Emergency Medicine Endorsed by the Pediatric and Congenital Electrophysiology Society © American College of Cardiology Foundation, American Heart Association, and the Heart Rhythm Society GHASSAN S. KIWAN,MD,MBA.FACP,FRCPC,FACC. Chief of Cardiology service. Director Bellevue International Training Center/American Heart Association. BELLEVUE MEDICAL UNIVERSITY CENTER USJ-School Of Medicine-Affiliated Teaching Hospital. Classification of Transient Loss of Consciousness (TLOC) Real or Apparent TLOC Syncope Disorders Mimicking Neurally-mediated reflex Syncope syndromes – With loss of consciousness, i.e., seizure Orthostatic hypotension disorders, concussion Cardiac arrhythmias – Without loss of consciousness, i.e., Structural cardiovascular disease psychogenic “pseudo-syncope” Brignole M, et al. Europace, 2004;6:467-537. Syncope – A Symptom, Not a Diagnosis Self-limited loss of consciousness and postural tone Relatively rapid onset Variable warning symptoms Spontaneous, complete, and usually prompt recovery without medical or surgical intervention Underlying mechanism is transient global cerebral hypoperfusion. Brignole M, et al. Europace, 2004;6:467-537. Causes of Syncope Morbidity and Mortality •Most cases benign. •Syncope of cardiac origin has the highest morbidity and mortality. 1 year mortality of 18-33% •Recurrence in the elderly population is 30% •Syncope of unknown origin. 1 year mortality of 6-12%. Syncope: Pathophysiology • Decreased cerebral perfusion is common to all causes of syncope • Cessation of cerebral perfusion for as little as 3-5 seconds can result in syncope • Decreased cerebral perfusion may occur as a result of decreased cardiac output or decreased systemic vascular resistance. General Principles Syncope Initial Evaluation *See relevant terms and definitions in Table 3. Colors correspond to Class of Recommendation in Table 1. This figure shows the general principles for initial evaluation of all patients after an episode of syncope. ECG indicates electrocardiogram. An Approach to Syncope •RAPID ASSESSMENT •HISTORY alone identifies the cause up Identify Life-Threatening to 85% of the time causes Dysrhythmias cardiac ischemia •POINTS Critical aortic stenosis HISTORY Previous episodes Aortic dissection Pulmonary embolus Character of the events, witnesses CVA Events preceding the syncope SAH Toxic-metabolic Events during and after the episode derangement •Events preceding the syncope • Events during and after the Prolonged standing (vasovagal) episode – Trauma (implication important) Immediately upon standing (orthostatic) – Chest pain (CAD, PE) With exertion (cardiac) – Seizure (incontinence, confusion, Sudden without warning or palpitations tongue laceration, postictal (cardiac) behavior) – Cerebrovascular syndrome Aggressive dieting (diplopia, dysarthia, hemiparesis) Heat exposure – Associated with n/v/sweating Emotional stress (vasovagal) •Associated symptoms Chest pain, SOB, lightheadedness, • Medications incontinence – Antihypertensives, •Past medical history diuretics (orthostatic) Identifying risk factors – Antiarrthymics (cardiac Morbidity and mortality increases syncope) with organic causes – TCA, Amiodarone Parkinsons (orthostatic) Epilepsy (seizure) (cardiac/prolonged QT) DM (cardiac, autonomic dysfunction, glucose) • Family history Cardiac disease – Sudden death (cardiac syncope/prolonged QT or Brugada) PHYSICAL EXAM •Vital signs Orthostatics—most important Drop in BP and fixed HR - – Heart rate >dysautonomia • Tachy/brady, dysrhythmia Drop in BP and increase HR -> – Respiratory rate volume depletion/ • Tachypnea (pe, hypoxia, vasodilatation anxiety) Insignificant drop in BP and • Bradypnea (cns, marked increase in HR -> POTS toxicmetabolic) Temperature – Blood pressure Hypo/hyperthermia (sepsis, toxic- • High (cns, toxic/metabolic) metabolic, exposure) • Low (hypovolemia, cardiogenic shock, sepsis) • HEART – Murmur (valves, dissection) – Rub (pericarditis, tamponade) • LUNGS – Sounds may help distinguish chf, infection, pneumothorax History and Physical Examination COR LOE Recommendation A detailed history and physical examination should be performed in patients I B-NR with syncope. Electrocardiography COR LOE Recommendation In the initial evaluation of patients with syncope, a resting 12-lead ECG is I B-NR useful. COR LOE Recommendations Evaluation of the cause and assessment for the short- and long-term morbidity I B-NR and mortality risk of syncope are recommended. Use of risk stratification scores may be reasonable in the management of IIb B-NR patients with syncope. •ABDOMEN •HEENT Pulsatile mass; AAA Tenderness/deformity (trauma) Tenderness Papilledema (increased icp, head Occult blood loss injury) Breath (alcohol, dka) •PELVIS Bleeding, hypovolemia •NECK Tenderness (PID, ectopic, torsion, Bruits sepsis) JVD (chf, mi, pe, tamponade) • SKIN – Signs of trauma, hypoperfusion • EXTREMITES – Paralysis (CNS) – Pulses unequal (dissection, embolus, steal) •SEIZURE •NEUROLOGIC Frothing at mouth Mental status; toxic metabolic; Tongue biting organic disease; seizure; Disorientation/ postictal hypoxia. Age < 45 year Focal findings LOC over 5 minutes (hemorrhagic/ischemic stroke, *tongue biting found only in seizure trauma, tumor, or other primary (99% specificity); absence did not exclude the possibility of a seizure (24% neurologic disease sensitivity) – Cranial • NOT A SEIZURE nerves – Sweating prior to episode – Nausea prior to episode – Cerebellar – Oriented after event testing – Age > 45 years Orthostatic Hypotension Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; OH, orthostatic hypotension. Disposition After Initial Evaluation COR LOE Recommendations Hospital evaluation and treatment are recommended for patients presenting with I B-NR syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. It is reasonable to manage patients with presumptive reflex-mediated syncope in the IIa C-LD outpatient setting in the absence of serious medical conditions. In intermediate-risk patients with an unclear cause of syncope, use of a structured ED IIa B-R observation protocol can be effective in reducing hospital admission. It may be reasonable to manage selected patients with suspected cardiac syncope in IIb C-LD the outpatient setting in the absence of serious medical condition. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope Additional Evaluation and Diagnosis Colors correspond to Class of Recommendation in Table 1. *Applies to patients after a normal initial evaluation without significant injury or cardiovascular morbidities; patients followed up by primary care physician as needed. †In selected patients (see Section 1.4). CT indicates computed tomography; CV, cardiovascular; ECG, electrocardiogram; EPS, electrophysiological study; MRI, magnetic resonance imaging; OH, orthostatic hypotension; and TTE, transthoracic echocardiography. Blood Testing Cardiovascular Testing COR LOE Recommendations COR LOE Recommendations Targeted blood tests are reasonable in the evaluation of selected patients with syncope Transthoracic echocardiography can be useful in IIa B-NR identified on the basis of clinical assessment selected patients presenting with syncope if from history, physical examination, and ECG. IIa B-NR structural heart disease is suspected. Usefulness of brain natriuretic peptide and CT or MRI may be useful in selected patients high-sensitivity troponin measurement is IIb B-NR presenting with syncope of suspected cardiac etiology. IIb C-LD uncertain in patients for whom a cardiac cause of syncope is suspected. Routine cardiac imaging is not useful in the evaluation of patients with syncope unless III: No cardiac etiology is suspected on the basis of an Routine and comprehensive laboratory B-R III: No Benefit initial evaluation, including history, physical B-R testing is not useful in the evaluation of examination, or ECG. Benefit patients with syncope. Stress Testing Cardiac Monitoring COR LOE Recommendations The choice of a specific cardiac monitor should be COR LOE Recommendation I C-EO determined on the basis of the frequency and nature of syncope events. To evaluate selected ambulatory patients with Exercise stress testing can be useful to syncope of suspected arrhythmic etiology, the establish the cause of syncope in selected following external cardiac monitoring approaches can patients who experience syncope or be useful: presyncope during exertion. IIa B-NR 1. Holter monitor 2. Transtelephonic monitor IIa C-LD 3. External loop recorder 4. Patch recorder 5. Mobile cardiac outpatient telemetry. To evaluate selected ambulatory patients with IIa B-R syncope of suspected arrhythmic etiology, an ICM can be useful. In-Hospital Telemetry Electrophysiological Study COR LOE Recommendation COR LOE Recommendations Continuous ECG monitoring is EPS can be useful for evaluation of selected useful for hospitalized patients patients with syncope of suspected arrhythmic admitted for syncope IIa B-NR etiology. evaluation with suspected cardiac etiology. B- I EPS is not recommended for syncope evaluation NR in patients with a normal ECG and normal cardiac III: No structure and function, unless an arrhythmic B-NR Benefit etiology is suspected.
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