1. Syncope in the older patient: ECGs you must know Dr Steve W Parry Clinical Senior Lecturer and Honorary Consultant Physician Falls and Syncope Service, Royal Victoria Infirmary and Institute for Ageing and Health, Newcastle University

2. Copyright ©2010 BMJ Publishing Group Ltd. Parry SW, Tan MP BMJ 2010;340:c880 Fig 1 Causes of syncope by age

3. Streamlining and Risk Stratification: Initial Evaluation True syncope from “non-syncopal” disorders Cardiac from non-cardiac syncope Clinical features and basic investigations suggesting a diagnosis or route of referral

4. Basic Evaluation History –Witness account –Clues to underlying diagnosis Stokes-Adams presentation VVS, CSS, OH Familial sudden death syndromes Seizures, psychiatric disorders Subclavian steal, CVD Examination –Cardiovascular, neurological 12 lead ECG –Normal: low risk of cardiac syncope –Abnormal: independent predictor of increased mortality Lying/standing blood pressure measurement

5. Syncope: Certain diagnosis based on symptoms, signs and ECG findings Classical vasovagal syncope Precipitating events (fear, pain, emotional distress, instrumentation, prolonged standing) associated with typical prodromal/post event symptoms Situational syncope Micturition, defaecation, cough, swallowing Orthostatic hypotension Syncope or pre-syncope documented during orthostatic fall in blood pressure

6. Certain diagnosis based on symptoms, signs and ECG findings Cardiac ischaemia related syncope Arrhythmia-related syncope Clear ECG evidence of symptom-rhythm correlation (Mobitz II, 3 rd degree AVB, SVT/VT, sinus pauses >3 sec etc) Suggestive from history or ECG

7. Brugada syndrome

8. Arrhythmogenic right ventricular dysplasia T inversion in right precordial leads Epsilon wavesVentricular late potentials

9. Ventricular tachycardia

10. Ventricular fibrillation

11. Normal ECG

12. Long QT c QT c = QT/√R-R

13. Torsade de Pointes VT

14. Mobitz I AVB (Wenckebach)

15. Mobitz II AV block

16. Complete heart block

18. Bifascicular block: RBBB with LAFB (LAD broadened QRS)

19. Trifascicular block: RBBB with 1st degree AVB and LAD

20. Sinus node dysfunction with junctional bradycardia

21. Early repolarisation as normal variant

22. Wolff Parkinson White Syndrome

23. PR depression in pericarditis

24. ECG abnormalities suggesting arrhythmic syncope RBBB, LBBB Very prolonged PR interval Previous MI Chronotropic incompetence –cf trend on 24 hour ECG

25. When is syncope scary?

26. Red flags in transient loss of consciousness Prolonged unconsciousness, post-event confusion and/or neurological signs, lateral tongue biting Unheralded syncope with prompt recovery (Stokes Adams attack) or other features suggesting life- threatening arrhythmias Family history of premature sudden cardiac or unexplained death Syncope during exercise Supine syncope

27. Red flags in transient loss of consciousness Chest pain, breathlessness Palpitations preceding syncope Syncope in patients with heart failure or established heart disease Frequent and/or injurious syncope Syncope while driving ECG abnormalties –Long QTc, SCD, sinus brady <50, broad QRS Anaemia Electrolyte imbalance

28. Risk prediction tools Attempts to quantify risk and identify those at most risk following presentation Predominantly A&E based and developed OESIL, EGSYS, Boston Syncope Rule, ROSE rule San Francisco Syncope Rule (Quinn et al Ann Emerg Med 2004) –Recent meta-analyses and systematic reviews (Serrano et al Ann Emerg Med 2010) suggest SFSR is most promising –Problems in older patients None have gained wide acceptance Comparison with clinician best judgement shows equivalent risk prediction (Quinn et al Am J Emerg Med 2005)

29. San Francisco Syncope Rule (Quinn et al Ann Emerg Med 2004, 2006) –History of congestive heart failure –Haematocrit <30% –Abnormal ECG or cardiac monitoring –Systolic BP <90mmHg at triage –BNP >300pg/ml –Bradycardia <50 bpm –PR exam with faecal occult blood (if GIB suspected) –Anaemia –Chest pain –ECG with q wave –Sats <94% on room air ROSE (Risk Stratification of Syncope in the ED) (Reed et al EMJ 2007)