1. Syncope Priya Victor M.D

2. Introduction ► Syncope is defined as transient loss of consciousness and postural tone ► Accounts for 3% of all ER visits and 6% of all hospital admissions ► Could be the manifestation of benign neurocardiogenic or the first manifestation of an occult lifethreatening condition

3. Objective ► To determine the utility of various diagnostic tests in the evaluation syncope  CT scans  Echo  EKG  Holter monitor  EEG  Tilt table test

4. Methods ► Retrospective study ► 100 patients from the RCRMC ER admissions with a diagnosis of syncope were identified ► Chart review was performed with attention to the cause of syncope, investigations and results of further testing.

5. Results of CT scans

6. Echo cardiogram

7. EKG

8. Other tests ► 24 hr holter monitor two were done, both normal. ► One adenosine cardiolyte – normal. ► One ETT – normal. ► Two tilt table test, both were positive for hypotension. ► One dobutamine stress test – normal.

9. Causes of syncope ► vasovagal 23 ► Orthostatic hypotension 9 ► Hypoglycemia 6 ► Secondary to medications 3 ► Sick sinus syndrome 2 ► Symptomatic bradycardia 2 ► PSVT 2 ► BPV 1 ► Iron defi anemia 1 ► Seizures 1 ► Afib with RVR 1 ► Neck mass 1 ► Unknown etiology 48

10. Discussion ► ► Of patients visiting ER with syncope: (Alboni et al JACC 2001;37:1921) Cardiac (often arrhythmia) 23% Neurally mediated 58% Neuro-psychiatric 1% Unexplained 18% ► ► Of patients with cardiac syncope, 24% subsequently develop Sudden Death (Kapoor, Medicine (Baltimore) 1990;69:160)

11. Approach ► ► Accurate diagnosis of etiology is possible from history, examination, basic lab & ECG in 2/3 of patients. ► ► Of those who require detailed work-up: Clinically targeted: Dx. Reached by work-up in 73% Not targeted: Dx. Reached by work-up in 25% (Sarasin et al Am J Med 2001;111:177) ► ► Work-up depends on duration of symptoms,frequency of attacks, known pre- existing disease, and age of the patient.

12. Neurologic testing ► ► EEG (Hyperventilation, Sleep-deprived, Nasopharyngeal) ► ► Brain CT / MRI ► ► Carotid Duplex Some test is done in over half pts with syncope Rarely useful, except in very well-selected cases Pires et al. Arch Int Med 2001;161:1889

14. CONCLUSION ► Of all the tests performed, EKG was of greatest yield. ► The most common etiology was vasovagal. ► Even though vasovagal syncope was a common diagnosis, the tilt table test was only ordered for a minority of patients.

15. CONCLUSION ► Of currently available diagnostic tests, the initial clinical history provides the greatest yield. ► A broad range of specialized tests can be performed for patients with syncope whose initial history and physical examination do not provide a diagnosis.