Fainting may cause physical injury, lead to hospitalization and be a sign of an underlying cardiac disorder. Our cardiac electrophysiologist will review the causes of fainting, tell who's at risk, and discuss methods to minimize the chances of fainting. Presentation by Summit Medical Group Cardiologist Roy Sauberman, MD FACC
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Fainting: Causes and Ways to Minimize Risk
1. FAINTING Causes and Ways to Minimize Risk Roy Sauberman, MD FACC Summit Medical Group
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5. 1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997 2 Gendelman HE, et al. NY State J Med 1983 3 Day SC, et al, AM J of Med 1982 4 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175
30. No Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
36. +/- Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1% * 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
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38. Diagnostic Gold Standard for Arrhythmias ECG strip recorded during clinical symptoms ECG Monitoring
43. ECG Monitoring Options ILR MCOT External Loop Recorder Event Recorder Holter Monitor 12-Lead 2 Days 7 Days 30+ Days 36 Months 10 Seconds ILR = insertable loop recorder MCOT= mobile cardiac outpatient telemetry
44. Mobile Cardiac Outpatient Telemetry (MCOT) Patient Indicates symptoms on PDA. Abnormal ECG transmitted automatically PDA or cell phone stores ECG data and symptom status. Wireless transmission capability provided. Monitor center receives, reviews and transmits data to physician. Pre-determined ‘urgency’ criteria determine timing of physician alerts Physician receives and acts upon data as medically appropriate
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47. Implantable Loop Recorder • Battery longevity up to 36 months • Gold standard (symptom – rhythm correlation) • High diagnostic yield for patients with infrequent events • High patient compliance
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51. Krahn, Circ. 1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and clinical assessment) Rhythm strip useful in diagnosis of 132 patients (64%) 206 Patients with Syncope Diagnostic Yield
52. 64% Diagnostic Yield Krahn, Circ. 1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and clinical assessment) Rhythm strip useful in diagnosis of 132 patients (64%) 206 Patients with Syncope Diagnostic Yield
53. ILR Advantages • The less frequent the symptoms are . . . – The less likely conventional testing will yield a diagnosis – The more testing will be required – The more costly the attempts to diagnose will be – The longer the diagnostic process – The more frustrated the patient and clinician become – The more likely the patient may be in harm’s way • Breaks the costly & time consuming diagnostic cycle
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55. “ Those who suffer from frequent and severe fainting often die suddenly.” Hippocrates, 1000 BC
56. MicroVolt T Wave Alternans (MTWA) Even Beats Odd Beats Mean V alt V alt
57. Mechanism Linking MTWA to Ventricular Arrhythmias Long APD Short APD Long APD Short APD Action Potential Alternans Leads to T-Wave Alternans Long APD Region Short APD Region Spatially Discordant Alternans Leads to Dispersion of Recovery, Wave Front Fractionation, and Reentry
67. Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration
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70. Intracardiac Recordings PA = Intra-atrial Conduction Interval A = Atrial Electrical Activity AH = Atria-His Bundle Conduction Interval H = His Bundle Electrical Activity HV = His Bundle-Ventricle Conduction Interval V = Ventricular Electrical Activity Surface ECG High Right Atrium IEGM His Bundle IEGM CS IEGM RV Apex IEGM PR Basic Sinus Cycle Length QRS A V V
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74. Sudden Death Risk High Coronary Risk Post M I Heart Failure/ EF < 35%) Previous VF / VT Syncope / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)
75. Sudden Death Risk High Coronary Risk Post M I Heart Failure/ EF < 35%) Previous VF / VT Syncope / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)
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77. Leading Causes of Death in the US 1 National Vital Statistics Report , Vol 49 (11), Oct. 12, 2001 2 MMWR . State-specific mortality from sudden cardiac death – US 1999.Feb 15, 2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers
78. Leading Causes of Death in the US 1 National Vital Statistics Report , Vol 49 (11), Oct. 12, 2001 2 MMWR . State-specific mortality from sudden cardiac death – US 1999.Feb 15, 2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers Only ALL cancers combined cause more deaths each year than sudden cardiac arrest!!
Transient Loss of Consciousness, or TLOC, is just that—as is illustrated here. It can be as simple as a benign ‘faint’ or a symptom of an underlying disease that may lead to sudden death. Or it may not be syncope at all.
This slide provides a simple classification of the principal causes of syncope. This scheme lists the causes of syncope from the most commonly observed (Left) to the least common (Right). This ranking may be helpful in thinking about the strategy for evaluating syncope in individual patients. Within the boxes,the most common causes of syncope are indicated for each of the major diagnostic groups. VVS—Vasovagal Syncope CSS—Carotid Sinus Syndrome ANS—Autonomic Nervous System HCM—Hypertrophic Cardiomyopathy
This slide provides a simple classification of the principal causes of syncope. This scheme lists the causes of syncope from the most commonly observed (Left) to the least common (Right). This ranking may be helpful in thinking about the strategy for evaluating syncope in individual patients. Within the boxes,the most common causes of syncope are indicated for each of the major diagnostic groups. VVS—Vasovagal Syncope CSS—Carotid Sinus Syndrome ANS—Autonomic Nervous System HCM—Hypertrophic Cardiomyopathy
WPW—Wolff Parkinson White syndrome HCM—Hypertrophic Cardiomyopathy
Carotid sinus massage (CSM) is an often overlooked, yet highly cost effective test, especially in older syncope patients. CSM must be applied with care, and the method described here has proven both safe and effective. Note that an abnormal response to CSM (i.e., Carotid Sinus Hypersensitivity, CSH) is not diagnostic of Carotid Sinus Syndrome (CSS). Reproduction of symptoms is a crucial diagnostic element. To achieve symptom reproduction, it may be useful to conduct CSM with the patient in the upright posture. If the latter is to be done, the patient should be safely secured to a tilt-table in order to prevent injury from a fall. Note: May perform during tilt-table test. *Munro N, McIntosh S, Lawson J, et al. Incidence of complications after carotid sinus massage in older patients with syncope. J Am Geriatr Soc . 1994;42:1248-1251.