1. SYNCOPE Tim Evans July 30, 2014

2. Syncope Background Syncope Podcast—Steve Carroll, DO Syncope—Saklani P, Circulation. 2013;127:1330-1339 Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope—ACEP Clinical Policies Subcommittee, Ann Emerg Med. 2007;49:431-444 AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, etc, Circulation. 2006;113:316-327

11. A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE—Kapoor WN, et al: N Eng J Med 1983; 309: 197-204 Results 204 patients evaluated and followed for up to more than one year— 97 patients never found to have an etiology of syncope identified Tests performed Labs in every patient—no cause for syncope found ECG in every patient—12 causes for syncope found, Sinus bradycardia (2) Complete heart block (3) Pacemaker malfunction (1) MI (2) Sinus pause (1) V Tach (3)

12. A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE Results (continued) Tests performed Prolonged electrocardiographic monitoring—190 patients, 29 causes for syncope found Sinus pauses greater than 2 seconds (8) Symptomatic sinus bradycardia (1) V Tach (14) A fib (2) Symptomatic SVT (2) Mobitz II AV block (2) Electrophysiologic Studies—23 patients, 3 inducible V Tach patients identified Cardiac cath—25 patients, 5 with aortic stenosis, 2 with pulmonary hypertension Cerebral angiography—11 patients, 2 with subclavian steal EEG—101 patients, 3 with abnormalities, 1 perhaps causing seizures CT scan head—65 patients, no cause of syncope found

13. A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE Diagnostic Studies that Determined Cause of Syncope H+P—52 ECG—12 ECG monitoring—29 Electrophysiologic studies—3 Cardiac cath—7 Cerebral angiography—2 EEG--1

14. A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE Cardiovascular Cause for Syncope—53 patients V Tach—20 Sick Sinus—10 Aortic Stenosis—5 SVT—3 Complete heart block—3 Bradycardia—2 Mobitz II AV block—2 MI—2 Pulm HTN—2 PE—1 Pacer malfunction—1 Carotid Sinus Syncope—1 Aortic Dissection--1 Non-cardiovascular Cause for Syncope—54 patients Situational Syncope—15 Orthostatic Syncope—14 Vasodepressor Syncope—10 Drug Induced—6 TIA—3 Seizure—3 Subclavian Steal-2 Conversion--1

15. Deaths During the Follow up Period Cardiovascular cause (N=53) Non cardiovascular cause (N=54) Unknown Cause (N=97) Sudden Death1123 Non sudden cardiovascular death 200 Death due to other underlying diseases 343 Mortality at 12 months 30126.4

16. The only difference between syncope and sudden death is that in one you wake up.

17. Detailed Patient history Circumstance of recent event Eyewitness account What was patient doing at time of event? Symptoms at onset of event—was there a prodrome? Position during event Sequelae Circumstance of prior events Past Medical History Cardiac Neurologic Family History Cardiac Sudden Cardiac Death Medications

18. Drugs Commonly implicated in Syncope Antihypertensives Beta Blockers Cardiac glycosides Diuretics Antidysrhythmics Nitrates Antipsychotics Antidepressants Phenothiazines Antiparkinsonism Alcohol Cocaine

20. Physical Exam Vital signs Orthostatic hypotension Cardiovascular exam—murmurs? Heart failure? Neurologic exam—focal deficits? Evidence of trauma? Carotid Sinus Massage

25. Risk Stratification tools for syncope Bottom Line—no single decision rule is sufficiently sensitive or specific to use in the ED But not useless—provide framework for clinical decision making

26. Decision Rules Martin and Kapoor—history of arrhythmias, abnormal ecg, hx of chf, age>45 San Francisco Syncope Rule—CHESS-hx chf, hct < 30, ecg with changes or non-sinus rhythm, sbp<90, sob Osservatorio Epidemiolgicalao sulla Sincope nel Lazio (OESIL)—age>65, hx cardiovascular dx, syncope without prodrome, abnormal ecg—if 2 positive increased risk of sudden death Risk Stratification of Syncope in ED (ROSE)—bnp>300, brady <50, gi blood, anemia, cp, O2 sat <94—if one positive admit Boston Syncope Criteria-signs and symptoms of cad, cardiac hx, persistent abnormal vital signs in ED, volume depletion, conduction abnormalities, valvular heart disease by history or exam Evaluation of Guidelines in Syncope Study (EGSYS)— abnormal ecg, heart disease, palpitations before syncope, syncope with effort or supine, no prodrome, no precipitants

27. High Risk Criteria Abnormal ECG—Bundle branch block or ivcd, bradycardia or 1 st degree block in absence of beta blockers or physical training, short PR, short or long QT, ischemia, infarction Suspicion of structural heart disease –hx or signs/symptoms of MI, CHF, valvular heart disease SOB Syncope during exertion or with recumbency SBP < 90 HCT < 30 Family hx of sudden cardiac death—particularly if under age 50 Advanced age

29. Brugada Syndrome

30. Wolff Parkinson White

33. Syncope--Summary Do thorough H+P—this is where the diagnosis will be made Do an ECG—look for the obvious and the not so obvious—infarcts, abnormal intervals, right heart strain Limit labs—HCG in fertile females, not much else Don’t do CT unless abnormal neuro or looking for traumatic injury

34. Is it true syncope? Transient LOC with return to baseline neurologic function History, examination, investigation of other symptoms, ECG Yes No (e.g.seizure, stroke, head trauma, other) Appropriate management Diagnosis established? Yes No Syncope with clear cause Unexplained syncope Risk stratification Serious cause? Appropriate management; admission Likely discharge Cardiac syncope  Arrhythmia  Myocardial infarction  Pericardial effusion  Pulmonary embolism  Neurologic syncope  Subarachnoid hemorrhage  Subclavian steal syndrome  Transient ischemic attack Significant hemorrhage  GI/GU/Gyn bleed  Trauma Neurocardiogenic/vasovagal  Vasomotor syncope  Carotid hypersensitivity  Situational syncope Medication related Orthostatic hypotension High-risk Criteria* Low risk and asymptomatic Discharge with follow-upAdmission for evaluation and cardiac monitoring *High-risk criteria:  Abnormal ECG  Suspicion of structural heart disease, especially a history of CHF  HCT <30  Shortness of breath  SBP <90 mmHg  Family history of sudden cardiac death  Advanced age** **There is no discrete age limit, and other factors such as cardiovascular risk play a greater role; age <45 appears to clearly be low risk if no other factors are present