Syncope Workshop

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Syncope Workshop

1

Syncope Workshop

Allan Skanes, MD for

Peter Leong-Sit, MD

Staff Electrophysiologist, London Health Sciences

Assistant Professor of Medicine, UWO

December 9, 2011


2

Conflict Disclosure Information

Peter Leong-Sit, MD

FINANCIAL DISCLOSURE

No relevant disclosures.


3

Learning Objectives

To discuss the diagnostic evaluation and management strategies of

vasovagal syncope by review of case studies

To review the Head Up Tilt Table Test and its utility as a diagnostic

tool in syncope

To discuss the utility of available and upcoming monitoring devices

for investigating syncope

To review non-pharmacological, pharmacological and pacing

indications in the management of vasovagal syncope


5

Case

65F with recurrent syncope

6 events over 17 years

PMH: high cholesterol, osteoarthritis, doctors have told her she has

occasional “atrial fibrillation”

Meds: ASA, simvastatin


6

This person first needs:

1. Pacemaker

2. AF ablation

3. Echocardiogram

4. Holter monitor

5. Detailed history

The majority of EP

diagnoses are

objective...

Syncope is one of the

exceptions where we

have to remember to

take a careful history!


7

Differential Diagnosis

Obstructive /

Structural heart ds.

Arrhythmia

Investigations

Other

History

Vasomotor

Brignole. Heart 2007.


8

Importance of History

Benign Etiology

(Vasomotor)

Malignant Etiology

Conduction ds

Heart ds

Abrupt LOC

Fam Hx SCD


9

Stepwise Diagnosis

Expensive Invasive Tests

Quick Confirm Tests

History and Physical

Undiagnosed

Cumulative Diagnosis


Diagnosis a challenge

Importance of clinical diagnosis

10

Up to 50% undiagnosed when clinically unapparent


Vasomotor Syncope

Most often upright, can occur while sitting

Should not occur when lying

Common situations:

Post-prandial, warm day, prolonged standing

Phlebotomy

Post-exertion (not during exertion)

Prodrome: fatigue, weakness, nausea, sweating, pallor,

visual disturbance, abdominal discomfort, headache,

light-headedness or vertigo

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12

Sheldon et al. Eur Heart J 2005


13

Sheldon et al JACC 2002;40(1):142


Tailor your testing

Is this life threatening?

Careful history

Talk to the bystander

You don’t solve them all

14


Back to the Case

Most events occurred after meals

One occurred after exercising

Preceded by nausea

“Not herself” for hours after event

On 3 occasions, AF was found

16


ECG following last episode

17


Approach to Syncope

Provocation

History and Physical

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Profile Testing

Monitoring

Profile Testing Options

-Blood work

-ECG

-Echo

-EEG

-Carotid dopplers

-Head CT/MRI


Diagnostic Yield (%)

Yield of Diagnostic Testing

70

60

50

40

30

20

10

0

19

Echo EP no Holter ELR Tilt

EP ILR

SHD

SHD


ECG

Inexpensive, widely available tool

Assists in separating arrhythmogenic and vasomotor causes

However, relatively low yield

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Contributory in only ~ 5%

Identifies:

Conduction disease, bradycardia

Structural disease: Q waves, LVH, arrhythmogenic RV cardiomyopathy

Conduction anomalies: WPW

Channelopathies: Long QT, Short QT, Brugada

Linzer et al. Ann Intern Med 1997.


Echocardiography

Low routine yield of 3%, however important to exclude structural

heart disease

Guided by clinical history and physical

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Aortic stenosis, mitral stenosis

LV dysfunction

Hypertrophic obstructive CM

Atrial myxoma


Other Profiling Tests

Blood work

EEG

22

Routine use yield < 1%

CT / MRI head

Carotid doppler

CXR

Coronary angiography

All low yield tests

Order these tests

based on clinical

suspicion


Back to Case: Echo

Normal LVEF

No structural heart disease

Now what about the role for provocative or monitoring tests?

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Approach to Syncope

Provocation

History and Physical

24

Profile Testing

Monitoring

Suspect VVS

- provocation testing

(tilt table)

Suspect Arrhythmia

- ambulatory monitoring

(Holter, external loop, ILR)


Provocative Testing: Tilt Table

Recreates Vasomotor (Vasovagal Syncope)

Orthostatic stress

Tilt angle 60-80˚

Duration 30-45 minutes

Pharmacologic stress

Isoproterenol

Nitroglycerine

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Head-Up Tilt Test

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Responses to Tilt Table Testing

Cardioinhibitory

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Bradycardia

Vasodepressor

Hypotension

Mixed

Bradycardia and hypotensive


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Tilt Test

Chart notes minimum BP 80/50 mm Hg

Reproduces spontaneous symptoms


Pure Vasodepressor

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Cardioinhibitory / Mixed

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Post Test Probability

Intermediate Pre-test Probability

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positive tilt

negative tilt

Pre Test Probability

Sensitivity 75%

Specificity 85%


Suspect an Arrhythmia?

Abrupt loss of consciousness (Stokes-Adams attacks)

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No warning or prodrome

“found myself on the ground when I woke up – not sure how I get there”

No post-syncopal symptoms – “awoke feeling normal”

Is there conduction disease or structural heart disease?

ECG: Bundle branch block, Q waves (previous MI), WPW

Echo: Low ejection fraction, cardiomyopathy (HCM, RV cardiomyopathy)

If yes, esp with abrupt loss of consciousness – refer to Specialist


Suspect an Arrhythmia?

Diminishing role of EP testing

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ICD for EF


Monitoring – which one?

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Patients (%)

Holter for Syncope and Presyncope

35

70

60

50

40

30

20

10

0

symptom and

arrhythmia

Pooled analysis of 8

studies involving 2612

patients

symptoms no

arrhythmia

no symptoms

with arrhythmia

no symptoms no

arrhythmia

Linzer Ann Int Med 1997;127:76


Loop vs Holter Randomized Trial

More symptoms during Loop vs Holter

Majority of episodes during Loop captured

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Sivakumaran Am J Med. 2003;115(1):1-5


Importance of a Proper Patient Diary

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Feel OK. Have my lunch, head clear...

Going to the Manor to see Frank

Bedtime... Going to bed, still feeling fine. Not much

to record.

Doing my wash, nothing to report.

Can’t imagine what made me so dizzy last

Thursday.

Hope I have this done OK.


Loop Recorder Schematic

38

recording

onset

presyncope

Time

recording

syncope

device

activation

end of

recording


Implantable ECG Monitoring Systems

Implanted

Device

39

Base Station

Activator

Monitoring

Center

Physician


Implantable loop recorders

Suited when syncope is infrequent

Battery life: 18-24 months

Implanted in left chest

Memory of event is frozen using applicator

Also has automatic detection

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Tachy, brady, and pauses


Randomized Assessment of Syncope Trial

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“Monitoring”=ILR vs. “Conventional”=echo/tilt/ELR

$2731 / patient

$5852 / diagnosis

$1683 / patient

$8414 / diagnosis

Krahn et al Circulation 2001;104:46

Krahn et al, JACC 2003;42(3):495


Probability of Recurrence with ILR

43

Assar et al, Am J Cardiol 2003


EF Approach to Syncope

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Back to the case...

History has a vaso-vagal flavour by history

However, association with AF – Differential diagnosis includes

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AF with rapid rates

Tachy-brady syndrome

No Structural heart disease


Case investigation

Echo: normal LV function, no structural heart disease, mild LA

enlargement

Infrequent episodes (6 over 7 years):

46

ILR implanted (rather than ELR first)


BPM

40

50

67

100

150

300

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Atrial fibrillation

Wong JA et al. PACE 20


ILR Interpretation

Vasovagal syncope

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Indicated by sinus slowing

Bystander vagally-mediated Afib

Not the cause of the syncope

How do we manage VVS?


First, reassure the patient

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Survival with Syncope

Cardiac

No syncope

Vasovagal

Neurologic Unknown

Soteriades et al. NEJM 2002.


Lifestyle Measures

Treatment of VVS is salt and water

Trigger avoidance

50

+


Counter-Pressure Maneuvers

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van Dijk et al. JACC 2006;48:1652-1657


Drug Therapy – weak evidence

Paroxetine

Single randomized trial

Fludrocortisone

Anecdotal conflicting evidence

Midodrine

Decreases syncope and presyncope

Randomized studies; open and blinded

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Ward et al Heart 1998; 116; 79: 45

Sra et al JCE 1997; 82: 42

Perez-Lugones et al JCE 2001;12: 935


What about Pacemakers?

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Pacemakers for VVS

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Bradycardia on tilt test

Oculo-pacing reflex

Patients feel great

Pacemaker must have made the difference


RCT Evidence for PPM in VVS

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Double Blinded

Odds Ratio

0.01 0.1

1.0 10

Pacing versus Med Rx or no Control

Pacing versus No Pacing

Demonstrates that surgical placebo

is very effective at treating VVS!

Sud et al, Am J Med 2007:120:54


Case closure...

VVS plus vagally-mediated AF (bystander)

Pt reassured, usual education for VVS

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Patient has done well with general lifestyle modifications

Since AF was asymptomatic, not aggressively managed other than

ASA


Take-Home Points

Take a detailed history

Most syncope is neurocardiogenic

Testing guided by history

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Profile Testing (ECG, echo…)

o If structural heart disease – refer to specialist

o Worse the heart disease, More abrupt the syncope, more urgent

Provocative Testing has a limited role

Monitoring for symptom-rhythm correlation is key when suspecting

arrhythmia


Questions?

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Thank you.

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