Syncope:Syncope: DistinguishingDistinguishing thethe VanillaVanilla FaintFaint FromFrom aa SuddenSudden CardiacCardiac DeathDeath WarningWarning SignSign JohnJohn Rogers,Rogers, MD,MD, FACCFACC Director, Cardiac Pacing and Tachyarrhythmia Device Therapy Scripps Clinic April 4, 2012 SYNCOPESYNCOPE AA TransientTransient LossLoss ofof ConsciousnessConsciousness TheThe primaryprimary purposepurpose ofof thethe evaluationevaluation ofof thethe patientpatient withwith syncopesyncope isis toto determinedetermine whetherwhether thethe patientpatient isis atat increasedincreased riskrisk forfor death.death. IfIf thesethese diagnosesdiagnoses cancan bebe excluded,excluded, thethe goalgoal thenthen becomesbecomes identificationidentification ofof thethe causecause ofof syncopesyncope inin anan attemptattempt toto improveimprove thethe qualityquality ofof thethe patientpatient’’ss lifelife andand toto preventprevent injuryinjury toto thethe patientpatient oror others.others. PrevalencePrevalence andand ImpactImpact TheThe SignificanceSignificance ofof SyncopeSyncope TheThe onlyonly differencedifference betweenbetween syncopesyncope andand suddensudden deathdeath isis thatthat inin oneone youyou wakewake up.up.1 1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: 403-412. TheThe SignificanceSignificance ofof SyncopeSyncope 1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997 2 Blanc J-J, L’her C, Touiza A, et al. Eur Heart J, 2002; 23: 815-820. 3 Day SC, et al, AM J of Med 1982 4 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175 SyncopeSyncope ReportedReported FrequencyFrequency Individuals <18 yrs 15% Individuals 17- 46 yrs 20-25% Individuals 40-59 yrs* 16-19% Individuals >70 yrs* 23% *during a 10-year period Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306. TheThe SignificanceSignificance ofof SyncopeSyncope infrequent, unexplained: 38% to 47% 1-4 explained: 53% to 62% 500,000 new syncope patients each year 5 170,000 have recurrent syncope 6 70,000 have recurrent, infrequent, unexplained syncope 1-4 1 Kapoor W, Med. 1990;69:160-175. 4 Kapoor W, et al. N Eng J Med. 1983;309:197-204. 2 Silverstein M, et al. JAMA. 1982;248:1185-1189. 5 National Disease and Therapeutic Index, IMS America, Syncope and Collapse #780.2; Jan 1997-Dec 1997. 3 Martin G, et al. Ann Emerg. Med. 1984;12:499-504. 6 Kapoor W, et al. Am J Med. 1987;83:700-708. TheThe SignificanceSignificance ofof SyncopeSyncope Some causes of syncope are potentially fatal Cardiac causes of syncope have the highest mortality rates 25% 20% 15% 10% Syncope Mortality Syncope 5% 0% Overall Due to Cardiac Causes 1 Day SC, et al. Am J of Med 1982;73:15-23. 2 Kapoor W. Medicine 1990;69:160-175. 3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189. 4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504. ImpactImpact ofof SyncopeSyncope 100% 1 73% 71% 2 s t 80% n 2 e 60% i t a P 60% f o 37% 2 n o i t r 40% o p o r P 20% 0% Anxiety/ Alter Daily Restricted Change Depression Activities Driving Employment 1Linzer, J Clin Epidemiol, 1991. 2Linzer, J Gen Int Med, 1994. EtiologyEtiology NotNot SoSo SeriousSerious CausesCauses FortunatelyFortunately OneOne ofof TheThe MoreMore CommonCommon CausesCauses ofof SyncopeSyncope SeriousSerious CausesCauses HankHankHank GathersGathersGathers 23 yo Loyola Marymount University NBA prospect Syncopal spell shooting free throw 12/9/89 Workup includes thallium and cath apical defect EPS induces PMVT Treated with beta-blocker: ICD refused UnusualUnusual CausesCauses ofof SyncopeSyncope Syncope:Syncope: EtiologyEtiology Structural Non- Cardiac Neurally- Orthostatic Cardio- Cardio- Arrhythmia Mediated Pulmonary vascular 1 2 3 4 5 • Vasovagal • Drug • Brady • Aortic/Mitral • Psychogenic • Carotid Induced Sick sinus Stenosis • Metabolic Sinus • ANS AV block • HOCM • Tachy e.g. hyper- • Situational Failure • Pulmonary VT/VF* ventilation Cough Primary Hypertension Post- Secondary SVT • Neurological micturition • Long QT • Bleeding Syndrome 24% 11% 14% 4% 12% Unknown Cause = 34% SpectrumSpectrum ofof “““Malignant”MalignantMalignant”” CardiacCardiac SyncopeSyncope CHDCHD18%18% IVF LQTS Neuro-Neuro- 1o ED (26%) cardiogeniccardiogenic SyncopeSyncope DCM HCM ARVD Cardiomyopathies (54%) “…“…cardiaccardiac syncopesyncope cancan bebe aa New England harbingerharbinger ofof suddensudden death.death.”” Journal of Medicine Study of survival rates with and without syncope Cardiac syncope carried a 6-month mortality rate of greater than 10% Cardiac syncope doubled the risk of death Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347(12):878-885. [Framingham Study Population] ““PeoplePeople whowho’’veve hadhad aa heartheart attackattack havehave aa suddensudden deathdeath raterate thatthat’’ss 44--66 timestimes thatthat ofof thethe generalgeneral population.population.””11 1American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex.: American Heart Association; 2002. TimeTime DependenceDependence ofof MortalityMortality RiskRisk PostPost--MI:MI: Prediction of Sudden Cardiac Death After Myocardial Infarction in the Beta-Blocking Era1 700 post-MI patients; ~95% on beta blockers two years after discharge. – Arrhythmia events or SCDs did not concentrate early after the index event, but most of them occurred more than 18 months post- MI. 1Huikuri H, et al. J Am Coll Cardiol 2003; 42: 652-8. DiagnosisDiagnosis andand EvaluationEvaluation OptionsOptions SyncopeSyncope DiagnosisDiagnosis AHA/ACC Scientific Statement on the , Labs Evaluation of Syncope: Tilt Table Test “This approach (ILRs) is more likely to identify the mechanism of syncope than is a conventional approach that uses Holter or event monitors and EP testing and is cost- effective.” A. Strickberger et al. Circulation 2006; 113: 316-327 InitialInitial EvaluationEvaluation (Clinic/Emergency(Clinic/Emergency Dept.)Dept.) Detailed history Physical examination Laboratory examination 12-lead ECG Echocardiogram – to determine if structural heart disease is present “Don’t Blow Off a Blackout” EXERTIONAL/AUDITORY/EXERTIONAL/AUDITORY/ POSTPARTUMPOSTPARTUM SYNCOPE/SEIZURESSYNCOPE/SEIZURES MAYMAY BEBE POTENTIALPOTENTIAL SUDDENSUDDEN DEATHDEATH WARNINGWARNING SIGNS!!SIGNS!! Syncope:Syncope: DiagnosticDiagnostic MethodsMethods andand YieldsYields Test/Procedure Yield* ECG 2-11% 1 Holter Monitoring 2% 2 External Loop Recorder 20% 2 Tilt Table 11-87% 3,4 EP Study without structural heart disease 11% 5 EP Study with structural heart disease 49% 3 Neurological (CT scan, carotid doppler) 0-4% 3,4 SQ Implantable Cardiac Monitor ( ICM) 43-88% 6,7,8 *(Based on mean diagnosis time of 5.1 mos.) 2 1 Kapoor, Am J Med, 1991. 5 Linzer, Ann Intern Med, 1997. 2 Krahn, Cardiol Clinics, 1997. 6 Krahn, Am J Cardiol, 1998. 3 Kapoor, Medicine, 1990. 7 Krahn, Circ, 1999. 4 Kapoor, JAMA, 1992. 8 Krahn, JACC, 2003. AmbulatoryAmbulatory ECGECG Method Comments Holter (24-48 hours) Useful for frequent events (ie. Episodes every 24 - 48 hours. Event Recorder (up to 4 weeks) Useful for infrequent events ( ie. Weekly – monthly episodes) Limited value in sudden LOC Loop Recorder (up to 4 weeks) Useful for infrequent events Limited value in sudden LOC (auto detect better) Implantable Cardiac Monitor (3 yrs) Implantable type (ICM) more convenient Useful for infrequent events HeadHead--upup TiltTilt TestTest (HUT)(HUT) Unmasks VVS susceptibility Reproduces symptoms Patient learns VVS warning symptoms Physician is better able to give prognostic / treatment advice May be helpful in assessing effectiveness of treatment of neurocardiogenic syncope (ie repeat tilt testing) HeadHead--UpUp TiltTilt TestTest (HUT)(HUT) Note that BP tends to fall in advance of the bradycardia component IMPLANTABLEIMPLANTABLE CARDIACCARDIAC MONITORSMONITORS ((ICMsICMs)) AA MajorMajor AdvanceAdvance inin thethe EvaluationEvaluation ofof SyncopeSyncope andand HeartHeart RhythmRhythm DisordersDisorders TheThe ““BlackBlack BoxBox”” forfor thethe HumanHuman BodyBody RhythmsRhythms DuringDuring RecurrentRecurrent SyncopeSyncope Bradycardia 36% Normal Sinus Rhythm Normal Sinus Rhythm 58% 58% Tachyarrhythmia 6% Krahn A, et al. Circulation. 1999; 99: 406-410 TheThe GOLDGOLD StandardStandard DocumentDocument HeartHeart RhythmRhythm atat TimeTime ofof SymptomsSymptoms SeemsSeems aa SimpleSimple TaskTask……ButBut…… ...NOT...NOT SOSO EASY:EASY: RhythmRhythm disordersdisorders areare oftenoften •• Unpredictable/infrequentUnpredictable/infrequent •• BriefBrief duration,duration, difficultdifficult toto recordrecord •• TransientlyTransiently disabling,disabling, fear,fear, faintfaint •• NotNot perceivedperceived •• DuringDuring sleepsleep •• TooToo briefbrief •• MisinterpretedMisinterpreted byby patient/bystanderpatient/bystander (e.g.,(e.g., ““fallsfalls””)) •• NotNot severe,severe, butbut ““markermarker”” ofof seriousserious consequencesconsequences WhatWhat isis anan ImplantableImplantable CardiacCardiac MonitorMonitor (ICM)(ICM) ?? Offers up to 3 years of continuous, leadless ECG monitoring Minimally invasive, outpatient procedure High diagnostic yield (65-88%) symptom-rhythm correlation High patient compliance Patient and auto triggered to capture ECG Programmable to store up to 49 minutes of ECG HowHow isis anan ICMICM Placed?Placed? 22 cmcm SubcutaneousSubcutaneous ElectrodesElectrodes Front electrode Back electrode SymptomSymptom RhythmRhythm