1. Syncope …
The Right Test for
the Right Patient
(Osama Alhadramy MD, FRCP(C
*
Engel GL. 7th century

2. Objectives
 Who should be admitted?
 Who should admit/see the patient in the
ER ?(getting the right consult(
 What is the right test for your patient?
 Cases

3.  76y M with high lipids ,HTN (HCT 4 /12(
 Recurrent exersional syncope q 4 days for 2/12
 Seen by GP , D/C HCT for postural hypotension
without improvement .
 Exersional SOB for 2 y class I-III
 Nausea and Diarrhea for 2 weeks
 Multiple injuries
 O/E Obese , no CHF, no murmer

5.  84 y M with no health issues
 First episode witnessed syncope
 Minimal CP on exertion for months
 O/E B9, no murmurs
 -ve CK / Trop

8. ?Are we doing good job
WHO**
Statistical Information System**

9. Definition
 Syncope is a transient loss of
consciousness, associated with loss of
postural tone, with :
1. spontaneous return to baseline
neurologic function
2. requiring no resuscitative efforts .
*AHA/ACCF Scientific Statement on the Evaluation of Syncope
J Am Coll Cardiol 2006;47:473– 84.
*EHA statement 2004

10. Impact of Syncope
100%
73% 1 71% 2
80%
Proportion of Patients
60% 2
60%
37% 2
40%
20%
0%
Anxiety/ Alter Daily Restricted Change
Depression Activities Driving Employment
Linzer, J Clin Epidemiol, 1991.
1
Linzer, J Gen Int Med, 1994.
2

11. Syncope: Etiology
Structural Non-
Neurally- Cardiac
Orthostatic Cardio- Cardio-
Mediated Arrhythmia
Pulmonary vascular
1 2 3 4 5
• Vasovagal • Drug • Brady • Aortic • Psychogenic
• Carotid Induced Sick sinus Stenosis
AV block • Metabolic
Sinus • ANS • HOCM
• Tachy e.g. hyper-
• Situational Failure • Pulmonary
Cough Primary VT* ventilation
SVT Hypertension
Post- Secondary
• Long QT • PE
micturition
Syndrome
Unknown Cause
DG Benditt, UM Cardiac Arrhythmia Center

12. Neurally Mediated Syncope

13. Definitions
EHA executive statement
EHJ (2004( 25, 2054–2072

14. Famous MCQ in medicine
 …….. is the best tool to diagnose syncope
and to determine the etiology .
EPS
History /Physical
ILR
HM
Telemetry
King's of Heart
CT
EEG

15. How good is H/P
15 June 1997 • Annals of Internal Medicine

16. Clues in history

17. Associated symptoms
 Neurally-mediated syncope:
1. Absence of cardiac disease
2. Long history of syncope
(Chronic presentation(
3. After unpleasant sight, sound, smell or pain
4. Prolonged standing or crowded, hot places
5. Nausea, vomiting associated with syncope
6. With head rotation, pressure on carotid sinus
(as in tumors, shaving, tight collars(

18.  Syncope due to orthostatic hypotension:
1. After standing up
2. Temporal relationship with start of
medication leading to hypotension or
changes of dosage
3. Presence of autonomic neuropathy or
Parkinsonism

19. Things suggestive of seizure
 Prodrome (aura)
 Episode of abrupt onset associated with injury
 Presence of a tonic phase before the onset of rhythmic clonic
activity
 Head deviation or unusual posturing during the episode
 Tongue biting (particularly involving the lateral aspect of the
tongue)
 Loss of bladder or bowel control
 Prolonged postictal phase during which the patient is confused
and disoriented.
.J Am Coll Cardiol 2002 Jul 3;40(1):142-8

20. Are there predictors for
?cardiac syncope

21. Predictors of cardiac syncope
all comers
Am J Med 2001 Aug 15;111(3(:177-84

22. Predictors in patients with SHD
JACC Vol. 37, No. 7, 2001 June 1,2001:1921– 8

23. Patients without SHD
JACC Vol. 37, No. 7, 2001 June 1, 2001:1921–8

24. Absence of Pre-syncope
 The sudden loss of consciousness without
warning (pre-syncope( is most likely to
result from an arrhythmia (bradycardia or
tachycardia(.

25. American Heart Journal 818 Krahn et al May 2001

26. Duration of symptoms
 A prolonged loss of consciousness may
indicate a seizure or aortic stenosis.
 By comparison, arrhythmias and
neurocardiogenic syncope are often
associated with a brief period of syncope,
since the supine position reestablishes
some blood flow to the brain and can
therefore result in the restoration of
consciousness

27. Recovery
 Persistence of nausea, pallor, and
diaphoresis in addition to a prolonged
recovery from the episode suggest a vagal
event.
 Significant neurologic changes or
confusion during the recovery period may
be due to a stroke or seizure.

28. PHYSICAL EXAMINATION
 Postural hypotension
 Irregular heart beats : AF
 Tachypnea : Massive PE
 Murmur
 CNS
 Rectal exam

29. work up
 Carotid sinus massage
 ECG
 Holter Monitor
 Implantable loop recorder
 Echocardiography
 Stress testing and angiogram
 Electrophysiological study
*ACC/AHA 2006

30. Carotid sinus massage
Class I in
patients above
the age of 40

31. ECG
 yield 2-10% *
 Not classified but class I (my guidelines(
* Kapoor, Am J Med, 1991.

32. Telemetry
 Class I
1. For patient with structural heart disease
2. High risk of life threatening arrhythmias.

33. Holter monitor
Yield 2-10%
Holter Monitor
15 June 1997 • Annals of Internal Medicine

34. Holter Monitor
 Class I
1. patients who have the clinical or ECG
features suggesting an arrhythmic cause
of syncope.
2. Patients with very frequent syncopes

35. ?Is one HM enough

36.  Series of 95 patients with syncope
1. 1st HM 14/95 (15%(
2. 2nd HM 9/ 81 (11%(
3. 3rd HM 3 /72 (4.2%(
Arch Intern Med. 1990 May;150(5):1073-8

37. Predictors of abnormal HM
1. age above 65 years
2. history of heart disease
3. initial none sinus rhythm
Arch Intern Med. 1990 May;150(5):1073-8

38. (Event recorders (King's of heart
 Yield 20% *
 often do not provide useful information
since the patient must be conscious in
order to activate the unit and "store" the
rhythm at the time of the symptom .
.Krahn, Cardiology Clinics, 1997*

39. Implantable loop recorder
 Yield 65-90% **
 (ILR( is a subcutaneous monitoring device
for the detection of cardiac arrhythmias.
 It stores recorded ECG strips either when
the device is activated automatically
according to programmed criteria or when
the patient manually activates it with
magnet application
Krahn, Circulation, 1995*
Krahn, Cardiology Clinics, 1997*

40. Insertable Loop Recorder
Patient Activator Reveal® Plus ILR Programmer

41. 56 y woman with syncope
accompanied with seizures.
AV Block
65 yo man with syncope.
VT and VF

42. RAST trial
Unexplained Syncope
n=60
ILR Conventional
n=30 n=30
In Follow-up Diagnosed Undiagnosed Diagnosed Undiagnosed
n=3 n=14 n=13 n=6 n=24
Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.

43. RAST Crossover Results
Unexplained Syncope
n=60
13/30 24/30
Undiagnosed after monitoring Undiagnosed after conventional
6 accepted crossover to conventional 21 accepted crossover to ILR
Diagnosed Undiagnosed Diagnosed Undiagnosed In follow-up
n=1 n=5 n=8 n=5 n=8
Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.

44. RAST - Diagnoses
14
12
number of patients
10
ILR Conventional
8
6
4
2
0
Bradycardia Tachycardia Vasovagal Seizures
Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.

45.  Class I
1. When the mechanism of syncope
remains unclear after conventional work
up.
2. Patients who have the clinical or ECG
features suggesting an arrhythmic
syncope
3. History of recurrent syncope with injury.

46. Are there patients who do
not need any cardiac
?monitor

47. No need for any monitoring
 Class III (ECG monitoring is unlikely to
be useful( :
1. Do not have the clinical or ECG features
suggesting an arrhythmic or structural
heart disease
2. No recurrent syncope( single episode(

48. Can they exclude cardiac causes of
?syncope

49.  Class I
ECG monitoring excludes an arrhythmic
cause when there is a correlation between
syncope and no rhythm variation

50. Echocardiography
 Diagnoses of underlying structural heart
disease such as left ventricular
dysfunction, hypertrophic cardiomyopathy,
or significant aortic stenosis .
 Yield 0-20%

51. Heart. 2002 Oct;88(4(:363-7.

52.  CONCLUSIONS:
 Echocardiography was most useful for
assessing the severity of the underlying
cardiac disease and for risk stratification in
patients with unexplained syncope but
with a positive cardiac history or an
abnormal ECG

53.  Class I
 ECHO is recommended if suspect
structural or coronary heart disease.

54. Upright tilt table test
 Very useful in young, and healthy patients
in whom the diagnosis of
neurocardiogenic syncope is suspected .
 Yield 11-90% ***
*PACE, Vol. 20 April 1997, Part I 875
*Kapoor, JAMA, 1992

55. Diagnosing VVS
(ACC Consensus Protocol(
 Overnight fast
 ECG
 Blood pressure
 Supine least 5 -20 min
 Tilt minimum of 20 min and a 60° 80°
maximum of 45 min

56. PACE, Vol. 20 April 1997, Part I 875

57.  Class I
1. Unexplained single syncopal episodes in
high risk settings
2. Recurrent episodes in the absence of
organic heart disease
3. In the presence of organic heart disease,
after cardiac causes of syncope have
been excluded.

58. Coronary angiogram / stress testing
 Class I
1. In patients with syncope suspected to be
due to myocardial ischemia.
2. Patients with syncope and risk factors for
CAD and symptoms of angina or angina
equivalent.
3. Syncope related to exersice

59. Electrophysiology study
 Patients who may benefit from an EP
study include those with:
1. Left ventricular dysfunction
2. Significant coronary artery disease
3. A prior myocardial infarction
4. Other structural heart disease
5. Conduction system disease (eg, bundle
branch block(
 Yield 50%
Stetson P, et al. PACE. 1999; 22 (part II): 782

60.  Class I
1. Abnormal electrocardiography
2. Structural heart disease
3. syncope associated with palpitations or
family history of sudden death

61. Can EPS role out cardiac causes of
??syncope

62. Class I
Normal electrophysiological findings can not
completely exclude an arrhythmic cause of
syncope.

63. ?What to do then

64. :Further work up
(ILR (preferred
HM
King's of heart

65. BNP
148 patients with syncope
THE AMERICAN JOURNAL OF CARDIOLOGY VOL. 93 JANUARY 15, 2004

66. ?Who should be admitted
 Abnormal ECG
 History of cardiac disease, chest pain or heart
failure
 Persistently low blood pressure (systolic <90
mmHg(
 Exersional SOB or angina
 Hematocrit <30 (if obtained(
 Older age >60
 Family history of sudden cardiac death
Ann Emerg Med. 2007 Apr;49(4):431-44
Am J Emerg Med. 2005 Oct;23(6):782-6

67. ?Why should we care

68. Prognosis
N Engl J Med, Vol. 347, No. 12 September 19, 2002

69. .AHA/ACC 2006 ©

70. Conventional Diagnostic Methods/Yield
Test/Procedure Yield
History and Physical 49-85% 1, 2
(including carotid sinus massage(
ECG 2-11% 2
Electrophysiology Study without SHD* 11% 3
Electrophysiology Study with SHD 49% 3
Tilt Table Test (without SHD) 11-87% 4, 5
Ambulatory ECG Monitors:
• Holter 2% 7
• External Loop Recorder 20% 7
(2-3 weeks duration(
• Insertable Loop Recorder 65-88% 6, 7
(up to 14 months duration(
Neurological †
(Head CT Scan, Carotid Doppler( 0-4% 4,5,8,9,10
1
Kapoor, et al N Eng J Med, 1983. 5
Kapoor, JAMA, 1992 9
Day S, et al. Am J Med. 1982; 73: 15-23.
2
Kapoor, Am J Med, 1991. 6
Krahn, Circulation, 1995 10
Stetson P, et al. PACE. 1999; 22 (part II(: 782. * Structural Heart Disease
3
Linzer, et al. Ann Int. Med, 1997. 7
Krahn, Cardiology Clinics, 1997.
8
Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.
†
MRI not studied
4
Kapoor, Medicine, 1990.

71. Bottom line
 In young patients without suspicion of
heart or neurological disease and
recurrent syncope , tilt testing should be
done first.
 Older patients, carotid sinus massage is
recommended as first step.
 Patients with evidence of structural heart
disease from H&P , palpitation,
extensional symptoms cardiac work up
should be done first .

72. ..Back to the cases

73.  76y M with high lipids ,HTN (HCT 4 /12(
 Recurrent syncope q 4 days for 2/12
 Seen by GP , D/C HCT for postural
hypotension without improvement .
 Exersional SOB for 2 y class II
 Nausea and Diarrhea for 2 weeks
 Multiple injuries
 O/E Obese , no CHF, no murmer

75.  Telemetry : no arrhythmia
 ECHO:EF 40% with segmental RWMA,
mild AV sclerosis
 MIBI: High risk Circ ischemia , EF 45%

77.  84 y M with no health issues
 First episode witnessed syncope
 Minimal CP on exertion for months
 O/E B9, no murmurs
 -ve CK / Trop

79.  EP : Pace maker
 ECHO: EF 45-50% with DD
 D/C home
 10 days later came with syncope / fall
 New ant T changes with Trop 23 , no CP

81. Thanks