1. Pediatric syncope it is not just vasovagal
Dr Neeraj Aggarwal
Pediatric Cardiologist
Department of Pediatric Cardiac sciences
Sir Ganga Ram Hospital

2. Case
A 8 years old girl is brought to OPD for evaluation of a fainting episode during morning school assembly
She describes feeling very warm, nauseated and light-headed
The loss of consciousness lasted for 20 to 30 seconds.
Witnessed describe her as extremely pale before passing out
Past history of similar episodes during assembly and she now knows the prodromal symptoms

3. Causes of syncope Commonly --Neurally mediated syncope(vasovagal)
Cardiovascular syncope
Primary/structural heart diseases
Obstructive lesions- Aortic stenosis ,Pulmonary Stenosis
Pulmonary hypertension/Eisenmenger syndrome
Hypertrophic Cardiomyopathy
Arrhythmias
Tachyarrhythmias-Long QT syndrome,Brugada syndrome (familial ventricular fibrillation),Supraventricular tachycardia,Ventricular tachycardia
Bradyarrhythmias -Sick sinus syndrome,Heart block

4. Diagnostic aims Distinguish true syncope from syncope mimics
Determine site of origin –vasovagal or cardiac

5. Syncope Mimics Seizures Sleep disorders
Somatization disorder (psychogenic)
Acute intoxication (e.g., alcohol)
Trauma/concussion
Hypoglycemia
Hyperventilation
Munchausen syndrome by proxy ( factitious disorder)

6. Diagnostic Inventory Initial Examination-must in all
Detailed patient history and exam
Supine and upright blood pressure
ECG
Additional Cardiac work up
Echocardiography
-Holter
Event Recorder
Insert-able Loop Recorder (ILR)
Special Investigations
Head-up tilt test (HUTT)
Electrophysiology study
24 hr blood pressure monitoring

7. Diagnostic Assessment: Yields

8. Common Causes of Syncope
Neurally mediated - vaso vagal syncope , situational –church ,rock concert, post micturition ,cough
Orthostatic hypotension-drug induced,Autonomic dysfunction
Cardiac arrhythmias –long QT syndrome, brady or tachy arrhythmias
Structural heart diseases – PAH ,Aortic stenosis ,Hypertrophic cardiomyopathy

9. Detailed history Position (supine, sitting, or standing)
Activity: rest, change in posture,, during or immediately after urination, defecation, cough or swallowing,during or after exercise

10. Relation to exercise History Implications
During exercise or with exertion
Arrhythmias ,PAH,HCM,AS
During swimming/loud noise
LQTS until proved otherwise
Prolonged motionless standing
Vaso-vagal
Vaso vagal syncope that is associated with exercise does exist, but a more serious cardiac cause should always be eliminated in exercise-related syncope
For exercise-induced syncope, an Exercise Stress Test is mandatory to look for ST-T wave changes (coronary insufficiency and catecholamine- sensitive dysrhythmias)

11. History
Predisposing factors (e.g. crowded or warm places, prolonged standing, postprandial period)
4. Precipitating events (e.g. fear, intense pain, position)

12. Triggers Of vaso- vagal syncope In The Young
Emotional circumstances and pain, such as venipunctures, immunizations ,blood sight
Prolonged motionless standing, especially in combination with warm temperature, confined spaces, crowded rooms (‘church syncope,school assembly ’)
Fasting, lack of sleep, fatigue, menstruation, illness with fever
Micturition ,hair cutting

13. Remember :Trigger may change in a patient from time to time
Post exercise (i.e., after termination of long runs or vigorous bursts of activity during competitive sports)
Hyperventilation and straining (self-induced syncope)
Stretching -- shaving with hyperextended neck
Standing up quickly or arising from squatting

14. Other history History Implications
Family history of early sudden death, congenital arrhythmogenic heart disease.
LQTS, Familial Cardiomyopathy
Surgery for congenital heart disease
Arrhythmias
Sensorineural deafness
LQTS
Associated with medications (antihypertensive, antidepressant agent, antiarrhythmic, diuretics, and QT prolonging agents)
LQTS prolonging drugs,hypotension,hypoglycemia)

15. Red flag signs Chest pain, dyspnoea, palpitations
History of heart disease/cardiac surgery
Syncope during exercise, with swimming, with loud noise or in sleep is typical of long QT syndromes.
Family history of deafness.
Family history of sudden unexpected death (young age ,previous sib)
Prolonged loss of consciousness > 5 min
Severe headache, focal neurological
deficits, diplopia, ataxia, or dysarthria before the syncope

16. Physical Examination
Goal - To check for orthostatic hypotension To rule out a significant heart lesion

17. Detailed examination with special attention to CVS and CNS
Vital signs in supine and then after standing for 3 to 5 minutes
Palpate:
Displaced apex - lift/heave
RV lift/heave
Thrills
Palpable S2
Murmurs of outflow obstruction-usually loud
Loud P2 indicative of pulm HTN ? soft sign

18. Orthostatic hypotension
Fall in systolic of 20 mm Hg or of 10 mm Hg in diastolic (within 3 minutes of standing from the sitting or supine position)
Postural tachycardia syndrome-
Supine to standing –HR increase of >35 beats/min , within 10 minutes of standing

19. Investigations
ECG

20. WPW

21. WPW

22. CHB

24. Long QTc -Bazett’s Correction= QT/√R-R interval
Female => 460 ms
Male => ms
(95th percentile values)
>470 and >480 (99th percentile) almost prove LQTS in absence of secondary causes

25. Stepwise approach to correct measurement of the QT interval
Use lead II.
Use lead V5 alternatively if lead II cannot be read.
Draw a line through the baseline (preferably the PR segment)

26. If the T wave is broad, the tangent is drawn

27. If the T wave has two positive deflections, the taller deflection should be chosen

28. If the T wave is biphasic, the end of the taller deflection should be chosen

29. The QT interval starts at the beginning of the QRS interval and ends where the tangent and baseline cross

30. We have diagnosed long QTc- will genetic tests help
Management will change
Prediction of recurrence in next child

32. Further Evaluation or Not?
If history is typical, exam and ECG are normal, then further testing &/or referral not necessary (eye witness accounts)
Explanation
Reassurance
No risk of Sudden death, benign & temporary
Start simple therapy –postural ,avoid holding up toddlers
Video recording the event

33. Other Diagnostic Tests
Echocardiogram
Head-Up Tilt (HUTT) Test
Includes drug provocation (NTG, isoproterenol)
Ambulatory ECG
Holter monitoring
Event recorder
Intermittent vs. Loop
Insertable Loop Recorder (ILR)
Electrophysiology Study (EPS)

34. Other Diagnostic Tests
If history is not typical for vasovagal syncope
Any of the red flag signs present

35. Case
A 3 yr old child ,having syncopal event while climbing and having early tiredness
Examination shows loud 3/6 ejection systolic murmur in left 2 ICS
ECG –Left ventricular hypertrophy
Next step –ECHO must

36. left ventricular hypertrophy: R wave in V6 = 32mm

37. case ECHO –severe valvular aortic stenosis, bicuspid aortic valve
Underwent Balloon aortic valvotomy

39. Holter Monitoring Cases in which an arrhythmia is suspected
to eliminate frequent ectopy, VT, SVT, bradycardia, intermittent WPW, Heart block or pauses

40. Endless-loop recorders – event recorders
Used to capture and save episodes even minutes after they have occurred
Time interval recorded before the button is pushed is often programmed

41. Implanted loop recorders
If difficult to capture an episode with an external loop recorder or if the episodes are quite far apart
Automatically or can be triggered by the patient to save an event

42. Role of Head up tilt table test
Sensitivity low – %
Specificity high %
So valuable to prove a vasovagal syncope (which can be done by a basic history ,exam and ECG)
To rule out a life threatening illness –ECHO more useful

43. Summary Chest pain, dyspnoea, palpitations ,history of heart disease
A careful history and examination including blood pressure and heart rate measured lying and standing, along with ECG is generally the only evaluation required
Presence of Red flag signs – needs a cardiac work up
Chest pain, dyspnoea, palpitations ,history of heart disease
Syncope during exercise, with swimming, with loud noise or in sleep is typical of long QT syndromes.
Family history of deafness/sudden unexpected death
Prolonged loss of consciousness > 5 min

44. Thanks Dr Neeraj Aggarwal Pediatric Cardiologist Sir Ganga Ram Hospital