Mary Agnes Ostick DNP, CRNP Villanova University II To discuss the definition and presentation of syncope
To present the classifications of syncope
To discuss the necessary history and physical for syncope
To discuss clinical practice guidelines of syncope Syncope is an abrupt and transient loss of consciousness caused by cerebral hypoperfusion which results in lost of postural tone
Cerebral blood flow falls below half normal value
Duration short Trigger affects parasympathetic system which affects vagal tone-relaxation
While withdraw of sympathetic-loss of compensatory mechanisms
Vasodilation and bradycardia
Fainting occurs
Studies report as much as 41% of US population will have episode
Recurrent syncope 13.5%
Females 22%, males 15%
In teens, incidence of >1 syncopal episode is 40% by age 21 1-1.5% of all ED visits/year
250,000 annual admissions
Median hospital cost $2,500 /day Mortality is low 0.7% at 10 days 1.6% at 30 days 8.4% at 1 year (1/3 of deaths are cardiac) h ot o b y U n k n o w n A ut h or is li c e ns e d u n d er C C B Y- N C - N D Lightheadedness Palpitations Weakness Dimming or blurred vision Nausea, epigastric distress Feeling warm or cold Facial pallor May manifest similar symptoms of prodrome
Lasts few seconds: nearly “blackout”
Younger age with fewer comorbidities Seizures
Sleep disturbances
Metabolic disorders
Psychogenic disorders
Acute intoxication Neurally mediated
Orthostatic hypotension
Cardiac Vasovagal
Situational
Carotid sinus syndrome Most common form, 45%
Benign
Prodrome symptoms
TLOC (30 seconds) with full recovery
Normal vital signs
No hypoxia
No signs anemia
No EKG abnormalities No further testing needed
Avoid triggers
Good hydration Micturation or post micturation syncope
Defecation, cough, swallow
“Sitcom syncope” 1% of all syncope, affects older patients
Pressure on carotid sinus baroreceptor, vagus nerve mediated bradycardia
Diagnosis by carotid sinus massage
“Minister's disease” 15% of ED fainting cases
Normal response to gravitational stress ( cardiac output and cerebral perfusion ) becomes inadequate Medication induced most common cause
Volume depletion
Postural tachycardia syndrome (POTS)
Primary and secondary autonomic failure
Post prandial hypotension Orthostatic vital signs (OVS)
Drop in systolic BP >= 20 mm Hg or diastolic > or =10 mm Hg with position change
A 50% decrease will lead to presyncope or syncope Orthostatic hypotension is common in ED patients with syncope 12-24% of ED visits
OVS alone cannot be the only measurement to determine cause of syncope because some cardiac patients will show OH ( 2018 Journal of Emergency Medicine ) POTS : form of orthostatic intolerance characterized by increase in HR, without hypotension that occurs on standing
500,000 Americans
Common in young :15-45 years old
Women > men 4.5:1 Cause? Number of abnormalities
Symptoms : dizziness , lightheadedness, blurred vision, fatigue with standing , GI symptoms
Hallmark is exaggerated heart rate in response to postural changes Diagnosis: Tilt Table
Sustained HR greater than 130 beats/ min or increase to 120 beats/min within 10 minutes of tilt
No orthostatic hypotension Optimal treatment is uncertain
Non- pharmacologic: Exercise ,high salt diet and oral volume expansion
Medications Fludrocortisone combined with diet and volume
20 % of all syncope cases are cardiac
Decreased cardiac output and diminished cerebral perfusion
6 month mortality with proven cardiac syncope is 10%or greater
Framingham study :those with syncope 2x as likely to die during the 17 year study Arrhythmia
Structural cardiac disease
Obstructive cardiomyopathy Onset during exertion Palpitations at onset
History cardiac disease Chest pain
EKG Changes Occurs while supine
Lack of prodrome Family history of sudden death
>60 years old Bradycardia VT , SVT’s Sick sinus syndrome Wolf Parkinson White Atrial arrhythmias 2nd and 3rd degree heart blocks Brugada syndrome Pacemaker dysfunction Brugada syndrome: pattern on EKG pseudo- Rt bundle branch block and ST elevation in V1-V3
Pre-excitation syndrome: Wolff- Parkinson White
Ventricular tachycardia Ventricular repolarization disorder characterized by long Qt interval that can lead to ventricular arrhythmias or sudden cardiac death
Symptoms: syncope, seizures, cardiac arrest
Can be congenital or acquired
Acquired : drug therapy (fluoroquinolones and CP450 inhibitors) electrolyte imbalance (eating disorders) anti psychotics
Diagnosis : presenting symptom of syncope personal and family history
Due to decrease cardiac output secondary to structural defect
In young : hypertrophic cardiomyopathy predisposing to tachycardia arrhythmias
In elderly : chest pain & SOB, R/O aortic stenosis Hypertrophic MI or ischemia obstructive cardiomyopathy Acute aortic dissection
Saddle pulmonary Pulmonary embolus hypertension
Valvular diseases
Genetic heart muscle disease caused by mutation in genes are rare < 200,000/year
Affects young
Characterized by LVH causing • LV outflow obstruction • Diastolic and systolic dysfunction • Myocardial ischemia • Mitral regurgitation Symptoms : • Presyncope or syncope • Fatigue • Dyspnea • Chest pain • Palpitations Prone to atrial and ventricular arrhythmias can be asymptomatic and can lead to sudden cardiac death( SCD) Treatment: cardio-defibrillator Most will be neurally mediated
Syncope during exertion deserves a cardiology workup: HOCM, ion channel disorders or arrhythmias Heat illness (exercise associated collapse) occurs after running a race or workout due to abrupt decrease in venous return causing athlete to collapse
Heat stroke: collapse with altered mental status , seizure or coma. Different from syncope by elevated core temp tachycardia, hypotension, nausea vomiting Conversion disorder
Can be associated with anxiety or depression
Females more frequently
Can report syncope and falls without injury and lasting longer than a typical syncopal event Seizures , metabolic, intoxication, subclavian steal syndrome
Syncope: Can cause a transient hypoxia that causes myoclonic jerking involuntary, brief, mimics seizures
No post-ictal obtundation in syncope
2017 Clinical practice guidelines American College of Cardiology American Heart Association Heart Rhythm Society
2018 (ESC) European Society of Cardiology Recommendations
EKG
Complete history and physical
Orthostatic vital signs Prodrome Setting: trigger? Hydration? Syncope without warning : cardiac Past history : structural heart disease? Metabolic diseases Medications Family history sudden death Circumstances at time of syncope
Witnessed?
Neurally mediated • Vasovagal: Precipitated by fear with prodrome of pallor, sweating, nausea
• Situational : urinating, coughing defecating
• Carotid sinus hypersensitivity - turning neck Orthostatic hypotension • After or prolonged standing • Change or start of medication
Cardiac • During exertion or supine • Sudden palpitations followed by syncope True syncope lasts 1-2 minutes • Can have persistent nausea post syncopal episode
Prolonged LOC • seizure or conversion reaction
Arrhythmias may recover quickly
Confusion or neurological changes during recovery may be attributed to seizure or stroke Vital signs Heart rate; check for arrhythmia Hypoxia or tachypnea, consider PE Orthostatic BP’s
Cardiovascular exam
Neuro exam Vertigo, nystagmus, ataxia
If anemia suspected; rectal exam EKG
Labs only if indicated by history Pregnancy, CBC, comprehensive panel Glucose
D- dimer or CT angiography for PE
Cardiac Echo if structural heart condition
Only if head trauma or CVA ->CT head Tilt table for postural or recurrent neurally mediated syncope If cardiac arrhythmias suspected
Holter monitor 24-48 hour Event monitor Implantable loop recorder
Implantable loop recorder
POTS and Neurocardiogenic syncope 450 charts reviewed 39 -4 episodes of syncope past 6 months 33 women (20-46)
ALL had prior Holter or event monitors with INCONCLUSIVE results
Implantable loop recorders placed All subjects had >6 sec asystole or bradycardia <30/min
15 subjects >10 sec asystole with prolonged and convulsive syncope San Francisco syncope rule
Consider admission if 1 or more present
Abnormal EKG CHF history Hematocrit < 30% Dyspnea Systolic BP <90 High risk • Arrhythmias : syncope during exercise; • with palpitations; without prodrome • Comorbidities; anemia, electrolyte imbalance • EKG changes • Family hx of sudden death • Hypotension ( less than 90 systolic) • Older age • Structural heart disease , CHF, or CAD Disposition after evaluation
Additional evaluations
Cardiac monitoring and EPS testing
Neurological testing
Arrhythmias
Driving after syncope
Athletes
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