Cardiology for the Non-Cardiologist 2018

SyncopeFinding and treating the cause

Andreas Westib M.D., Cardiology

Clinical LecturerTotalCardiology of CalgaryandLIBIN Cardiovascular Institute of Calgary

Cardiology for the Non-Cardiologist 2018

Faculty Presenter Disclosure

Cardiology for the Non-Cardiologist

Faculty: Andreas Westib

Relationships with Financial Sponsors:

- Grants or Research Support:

- Speakers Honoraria:

- Consulting Fees:

- Patents:

- Other:

Cardiology for the Non-Cardiologist 2018

Disclosure of Financial Support

Cardiology for the Non-Cardiologist has received financial support from the following Pharmaceutical companies; Bayer, Bristol-Meyers Squibb/Pfizer, Servier, Novartis, Amgen, AstraZeneca and Merck in the form of unrestricted educational grants.

Potential Conflicts of Interest: none

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• While we have received unrestricted educational grants from several pharmaceutical companies, most presentations have no mention of specific products and are unrelated to the supporting companies or their products. No specific presentations will be supported or sponsored by a specific company.

• Information on specific products will be presented in the context of an unbiased overview of all products related to treating patients.

• All scientific research related to, reported or used in this CME activity in support or justification of patient care recommendations conforms to the generally accepted standards.

• Clinical medicine is based in evidence that is accepted within the profession.

Mitigating Potential Bias

Click to edit Master title stylePearls

• Def: REFLEX (vasovagal or situational), Orthostatic Hypotension, Cardiac

• Very common problem (1-3% of all ER visits)

• Most are benign but syncope tends to come back – even with PPM !!

• Up to 23% of patients presenting to ER have a serious 30 day outcome, half evident after ER disposition!

• Decrease in cardiac output is most common reason (ABCD)

• Simple workup is commonly sufficient

• Risk stratification scores perform no better than clinical judgement – except the CSRS?

• Reassurance and “life style” advice is very appropriate in most cases

• High risk presentations “easy” to pick out - those Pts we need to find, they may have poor outcome!

Click to edit Master title styleSurvival with syncope by

cause

Sorteriades, ES, Evans, JC, Larson, MG, et al. Incidence and prognosis of syncope. N Engl J Med 2002;

347:878.

Cardiology for the Non-Cardiologist 2018

Future perspectives

Click to edit Master title styleOur Case

• 55 year old male, fit

• First fainting episode while driving to work, minor damage to car going into the ditch, no injury

• no preceding palpitations, CP, nausea, pain, “external” triggers etc. (“non-provoked”)

• No comorbidities, no previous cardiac symptoms(no SOB, CP, presyncope, palpitations)

• No FHx (premature CVD, SCD, Syncope, PPM, Cardiomyopathy)

• In ER normal O/E (check carotid artery bruit too), BP 122/80 mmHg, pulse 69 regular, Temp. 36.9

• Telemetry: NSR, occasional PVC

• Standard blood work pending …

Click to edit Master title styleWas it a syncope?

Usually

eyes

closed!

Occurs in

Syncope too,

~ 20 sec.,

asymmetric

Click to edit Master title style

Click to edit Master title styleWhat risk level is this presentation?

A. low risk

B. neither low nor high risk

C. high risk

D. We need more info

Click to edit Master title styleWhat more info do we need?

A. CT head

B. EEG

C. Echo

D. ECG

E. More blood work

F. others

G. A combination of above?

Click to edit Master title styleRecommended workup in ERACC 2017 – ESC 2018

A. ECG

B. Carotid sinus massage in patients > 40 years if etiology remains unclear but compatible with reflex mechanism

C. Postural BP (Active standing or Tilt testing)

D. Targeted blood testing- e.g. epigastric pain and Hx of PUD- D-Dimer > 60 years + Wells score? Cave: 25%

of PE +ve patients do not tachycardia, tachypnoea etc.

E. BNP + Trop class IIb recommendation !!

Click to edit Master title styleTesting beyond the basics?

A. Echo, CMRI etc. if structural heart disease is suspected

B. Stress test if syncope/presyncope occurred during exertion

C. HR-monitoring if arrhythmia is suspected

D. Others (EEG, CT head etc.) only if clinical suspicion

Click to edit Master title styleOur Case

• ECG:

• Carotid sinus massage: normal/-ve

• Postural BP (Active standing): normal/-ve

• Targeted blood testing not indicated

• (no epigastric pain, not > 60 years etc.),

• no good evidence for BNP etc.

Click to edit Master title styleWhat risk level is this presentation now?

A. low risk

B. neither low nor high risk

C. high risk

D. We need more info

Click to edit Master title styleRisk Stratification

Syncopal

event

features

ECG

Past

medical

history

Physical

examination

Click to edit Master title styleRisk Stratification

If no structural HD,

prodrome of > 10 sec

points to reflex

mediated

Syncopal

event

features

Click to edit Master title styleRisk Stratification

Physical

examination

Click to edit Master title styleRisk Stratification

ECG

Click to edit Master title styleRisk Stratification

Past

medical

history

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Cardiology Consultation

For planning

RACC

Syncope clinic

Click to edit Master title styleOur Case

•Low risk presentation!

Click to edit Master title styleCanadian Syncope Risk Score

• Published in 2016 in CMAJ

• Large prospective syncope study with 4030 patients

• What's different to other Syncope Scores?1) Syncope specific outcomes2) Serious outcomes after disposition3) ECG variables not predetermined4) Robust statistical approach

Click to edit Master title styleCanadian Syncope Risk Score

Click to edit Master title styleCanadian Syncope Risk Score

Click to edit Master title styleSo , after all that - what is the most likely etiology for his syncope here?

A. Paroxysmal Atrial fibrillation with conversion pause?

B. Seizures?

C. Reflex syncope?

D. PE?

E. Aortic stenosis?

F. Idiopathic paroxysmal AV block / low adenosine AV block?

Click to edit Master title styleReflex Syncope

Click to edit Master title styleThank you!

Audience questions?

Further treatment presentation?

Click to edit Master title styleReally Reflex Syncope?

Reflex Syncope

without prodrome

Idiopathic

paroxysmal AV block

1)Tilt table test

2)ILR

1)Normal ECG

2)Structural normal heart

Click to edit Master title styleTreatment of Reflex Syncope

<

40

>

60

Spontaneous

or provoked

by CSM, ILR

-ve Tilt table

response is

strongest

predictor of

pacemaker

efficacy

Betablocker

age ≥ 42 ??SSRIs

Click to edit Master title styleRecommended workup in ER

ACC 2017 – ESC 2018

A. ECG

B. Carotid sinus massage in patients > 40 years if etiology remains unclear but compatible with reflex mechanism

C. Postural BP

D. Targeted blood testing- e.g. epigastric pain and Hx of PUD- D-Dimer > 60 years + Wells score? Cave: 25% of PE +ve patients do not tachycardia, tachypnoea etc.

E. BNP + Trop class IIb recommendation !!

Click to edit Master title styleDiagnosis of Orthostatic Hypotension

Click to edit Master title styleTreatment of Orthostatic Hypotension

2.5-10 mg tid 0.1-0.3 mg od w/

head up sleepin> 10 degrees