Syncope – Catch ‘ em in

the Act’Zunida Ali

Electrophysiology and Pacemaker Unit

National Heart Institute

Kuala Lumpur

What is the syncope

Syncope is:

• A sudden temporary loss of consciousness associated with loss of postural tone

• Due to abrupt reduction or loss of cerebral perfusion1

1 Grubb, Olshansky (eds). Syncope: Mechanisms and Management. Armonk, NY: Futura Publishing Co., Inc., 1998, p.1

The only difference between

syncope and sudden death

is that in one you wake up.1

1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: 403-412

The Significance of Syncope

Cardiac Diseases and Arrhythmias:

Most serious due to high mortality rates

Arrthymias structural Heart Disease

- Brady arrhythmias - Obstruction to flow

- Tachyarrhythmias - Pump failure

- Cardiac tamponade

- Aortic dissection1 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.

Syncope Can Be A Serious Clinical

Problem

• Some causes of syncope are potentially fatal

• Causes with high mortality and major morbidity rates

– 7.5% overall1

– 18-33% mortality in patients with a cardiac cause1-4

1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997

2 Gendelman HE, et al. NY State J Med 1983

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

Magnitude Of Syncope

Syncope Reported Frequency

• Individuals <18 yrs

• Military Population 17- 46 yrs

• Individuals 40-59 yrs*

• Individuals >70 yrs*

15%

20-25%

16-19%

23%

Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306.*during a 10-year period

Syncope:A Symptom…Not a Diagnosis

• Self-limited loss of consciousness and postural tone

• Relatively rapid onset

• Variable warning symptoms

• Spontaneous complete recovery

“Not So Normal” ECG

0%

20%

40%

60%

80%

100%

Anxiety/

DepressionAlter Daily

Activities

Restricted

Driving

Change

Employment

11Linzer, Linzer, J J ClinClin EpidemiolEpidemiol, 1991., 1991.22Linzer, Linzer, J Gen J Gen IntInt MedMed, 1994., 1994.

Impact of Syncope

Syncope: Etiology

• Neurally-• Mediated

OrthostaticCardiac

Arrhythmia

StructuralCardio-

Pulmonary

Non-Cardio-

vascular

1• Vasovagal• Carotid

Sinus• Situational

�Cough�Post-

micturition

2• Drug Induced

• ANSFailure�Primary�Secondary

3• Brady

�Sick sinus�AV block

• Tachy�VT�SVT

• Long QT

Syndrome

4 • Aortic

Stenosis

• HOCM• Pulmonary

Hypertension

5• Psychogenic• Metabolic

e.g. hyper-ventilation

• Neurological

24% 11% 14% 4% 12%

Unknown Cause = 34%

DG Benditt, UM Cardiac Arrhythmia Center

CardiologistInternist

NeurologistEntry Points

1 Reveal Syncope Validation Project (RSVP) Clinical Summary, Medtronic data on file

Emergency

and make multiple physician visits10.2 Visits per year1

3.2 Different Specialists

Patients May Enter The Healthcare System At Multiple Points

Family/General Practitioner

History and Physical Exam Surface ECG

Neurological Testing

• Head CT Scan

• Carotid Doppler

• MRI

• Skull Films

• Brain Scan

• EEG

CV Syncope Workup

• Holter

• ELR or ILR

• Tilt Table

• Echo

• EPS

Other CV Testing

• Angiogram

• Exercise Test

• SAECG

Psychological Evaluation

ENT Evaluation Endocrine Evaluation

Unexplained Syncope Diagnosis

Adapted from: W.Kapoor.An overview of the evaluation

and management of syncope. From Grubb B, Olshansky B (

Syncope: Mechanisms and Management.

Armonk, NY: Futura Publishing Co., Inc.1998.

Syncope Diagnostic Objectives

• Distinguish ‘True’ Syncope from other ‘Loss of

Consciousness’ spells:

� - Seizures

� - Psychiatric disturbances

• Establish the cause of syncope with sufficient certainty to:

� - Assess prognosis confidently

� - Initiate effective preventive treatment

•5/24/2005 0KMF15.ppt 10

Management Strategy of Evaluation

� Initial evaluation(history, physical exam, ECG, BP

supine and upright)� Laboratory investigations guided by

the initial evaluation

� Re-appraisal

� TreatmentEurropean Socciiettyy off Carrdiiollogyy Tasskk Forrcce on Managementt off Syynccope

Diagnostic examinations

Epilepsy and TIA

Epilepsy and TIA

Epilepsy and TIA

Cardiac

Cardiac

Cardiac

Co-morbidities

EEG

CT scan & MRI

Carotid Doppler

Coronary angiography

Pulmonary scintigraphy

CXR

Abdominal ultrasound

Rarely useful

NMS

NMS

Cardiac

Cardiac

Cardiac

Cardiac

NMS and Cardiac

Carotid sinus massage

Tilt testing

Echocardiogram

Holter/loop monitoring

Electrophysiological test

Exercise stress testing

Implantable loop recorder

Useful

Suspected diagnosisTest

12-Lead ECG

• Normal or Abnormal?

– Acute MI

– Severe Sinus Bradycardia/pause

– AV Block

– Tachyarrhythmia (SVT, VT)

– Preexcitation (WPW), Long QT, Brugada

• Short sampling window (approx. 12 sec)

In developmentWireless (internet) Event Monitoring

•Useful for infrequent events

•Implantable type more convenient (ILR)

Loop Recorder

•Useful for infrequent events

•Limited value in sudden LOC

Event Recorder

Useful for frequent eventsHolter (24-48 hours)

CommentsMethod

Ambulatory ECG

Holter Monitoring

• Rarely useful unless

syncope is frequent

• Diagnostic yield 0-4%

Event Recorder

Loop recorder

External Loop Recorder - KOH

How to catch it in the act ?

Syncope

episode

Regained

conscious

3 min 3 min 2 min

Programmed - Pre 4 min

- post 1 min Total recording 5 min

External Loop Recorder - KOH

• Programmed and fixed to the patient appropriately.

• Educate patient on how to fix it and taken care of the device.

External Loop Recorder - KOH

• Teach patient on how

and when to activate

the device recorder.

• Show the correct way

to send the recorded

eventMouth piece

Patient ActivatorReveal® Plus ILR Programmer

Implantable Loop Recorder

Implantable loop recorder

Role of ILR

• ESC recommends use of ILR when:

– an arrhythmia is suspected, but standard monitoring has not documented an arrhythmia (Class I recommendation), and

– the interval between episodes of syncope is measured in months or years.

EHJ. 2001;22:1256-1306.

Quick Look Screen @ Follow-up

Syncopal episode 2 weeks post-Reveal DX implant

Symptom-Rhythm Correlation

Auto Activation Point Patient

Activation Point

Reveal recording

Implantable loop recorder

Advantages:

• Longer event can be recorded

• Auto triggered and patient triggered

• No mess with electrode and cables

• No worry about daily activities

• High diagnostic yield to capture symptom ECG correlation

Implantable loop recorder

Disadvantages:

• Only diagnostic tool

• Need minor surgical procedure

• Lack of concurrent diagnostic datas like physiologic parameter eg. blood pressure

• Higher upfront cost / expensive device

Implantable loop recorder

Important:

• Proper device programming• Educate patient and family

- event activation- When to come to hospital?

• Others such as - wound care- activator

Tilt Testing is Indicated for

Diagnostic Purposes

• In cases of unexplained single syncopal episodes or recurrent episodes in the absence of organic heart disease.

• In the presence of organic heart disease, after cardiac causes of syncope have been excluded.

• For evaluating patients with

recurrent unexplained falls.

When an understanding of the haemodynamic pattern in syncope may alter the therapeutic approach

To differentiate syncope with jerking movements from Epilepsy

To assess recurrent presyncope.

Role of Tilt table

• Objectives

–Enhance Orthostatic Tolerance

–Diminish Excessive Autonomic Reflex Activity

–Reduce Syncope Susceptibility / Recurrences

• Technique

–Prescribed Periods of Upright Posture

–Progressive Increased Duration

Tilt Table Test

60-80o

Tilt Table Test in IJN

• NBM 6hr prior test

• ECG

• Blood pressure

• Carotid Massage – Supine / tilt up

• Tilt 70 degrees for 30 min.

• Isoproterenol 1-5mcg/min

Positive Tilt table test.

Tilt Table Test - Result

• Cardio inhibitory – ( HR )

• Vasodepressor - ( BP )

• Mixed Typed

Carotid Sinus Massage

• Site:

– Carotid arterial pulse just below thyroid

cartilage

• Method:– Right followed by left, pause between

– Massage, NOT occlusion

– Duration: 5-10 sec

– Posture – supine & upright

Carotid Sinus Massage

• Outcome:

� 3 sec asystole and/or 50 mmHg fall in systolic

blood pressure with reproduction of symptoms =

Carotid Sinus Syndrome (CSS)

• Contraindications

� Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months

• Risks

�1 in 5000 massages complicated by TIA

Conventional EP Testing in Syncope

• Limited utility in syncope evaluation

• Most useful in patients with structural heart disease

– Heart disease……..50-80%

– No Heart disease…18-50%

Relatively ineffective for assessing bradyarrhythmias

Brignole M, Alboni P, Benditt DG, et al. Eur Heart Journal 2001; 22: 1256-1306.

EP Testing in Syncope:Useful Diagnostic Observations

• Inducible monomorphic VT

• Inducible SVT with hypotension

• SNRT > 3000 ms or CSNRT > 600 ms

• HV interval ≥ 100 ms (especially in absence of inducible VT)

• Pacing induced infra-nodal block

Conventional Diagnostic Methods/Yield

65-88% 6, 7• Insertable Loop Recorder

(up to 14 months duration)

2-11% 2ECG

20% 7• External Loop Recorder

(2-3 weeks duration)

0-4% 4,5,8,9,10

Neurological †

(Head CT Scan, Carotid Doppler)

2% 7• Holter

Ambulatory ECG Monitors:

11-87% 4, 5Tilt Table Test (without SHD)

49% 3Electrophysiology Study with SHD

11% 3Electrophysiology Study without SHD*

49-85% 1, 2History and Physical

(including carotid sinus massage)

Yield(based on mean time to diagnosis of 5.1 months7

Test/Procedure

* Structural Heart Disease† MRI not studied

1 Kapoor, et al N Eng J Med, 1983.

2 Kapoor, Am J Med, 1991.

3 Linzer, et al. Ann Int. Med, 1997.

4 Kapoor, Medicine, 1990.

5 Kapoor, JAMA, 1992

6 Krahn, Circulation, 1995

7 Krahn, Cardiology Clinics, 1997.

8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.

9 Day S, et al. Am J Med. 1982; 73: 15-23.

10 Stetson P, et al. PACE. 1999; 22 (part II): 782.

Typical Diagnostic Pathway

Syncope

History and Physical

ECG

KnownSHD

NoSHD

Echo

EPS

+

Treat

> 30 days; > 2 Events

Tilt ILR

Tilt Holter/ ELR

ILR

Tilt/ILR

< 30 days

-

Adapted from:

Linzer M, et al. Annals of Int Med, 1997. 127:76-86.

Syncope: Mechanisms and Management. Grubb B, Olshansky B (eds) Futura Publishing 1999

Zimetbaum P, Josephson M. Annals of Int Med, 1999. 130:848-856.

Krahn A et al. ACC Current Journal Review,1999. Jan/Feb:80-84.

Diagnostic Limitations

� Difficult to correlate spontaneous events and laboratory findings

� Require frequent settlement for an attributable cause

� Unknown remain 20-30% 1

1Kapoor W. In Grubb B, Olshansky B (eds) Syncope: Mechanisms and Management. Armonk NY; Futura Publishing Co, Inc:

1998; 1-13.

Conclusion

Syncope is a common symptom,

often with dramatic consequences,

which deserves thorough investigation

and appropriate treatment of its cause.