Evaluation of Syncope Jeffrey L. Williams, MD, MS, FACC, FHRS Co-Director, Heart Rhythm Center Assistant Quality and Medical Informatics Officer

Objectives

•  Be able to recognize common causes of syncope and the management of patients with syncope.

No Relevant Disclosures .

Facts About Syncope

*Syncope and collapse (ICD-9 Code: 780.2) listed as primary reason for visit. NAMCS 2006.

•  ~40% of the population will have at least one syncopal event in their lifetime1

•  10% of falls by elderly are believed due to syncope2

•  Major morbidity reported in 6%1 (e.g., fractures, motor vehicle accident)

•  Minor injury reported in 29%1

(e.g., lacerations, bruises)

1Kenny RA, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27. 2Kapoor W. Medicine. 1990;69:160-175.

Annual U.S. Emergency Dept. Visits

Syncope and Quality of Life

1Linzer M. J Clin Epidemiol, 1991;44:1037-1043. 2Linzer M. J Gen Int Med, 1994;9:181-186.

Anxiety/ Depression

Alter Daily Activities

Restricted Driving

Change Employment

100%

75%

50%

25%

Etiology of Syncope

•  Syncope remains unexplained in approximately 1/3 of cases

•  Pulmonary embolism was identified in 45 of the 355 patients (12.7%) who had an alternative explanation for syncope and in 52 of the 205 patients (25.4%) who did not.

Linzer M, et al. Ann Intern Med. 1997;126:989-996. Prandoni et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope, N Engl J Med 2016; 375:1524-1531

Unknown 34%

Cardiac abnormal rhythms, structural damage

18%

Neurologic Seizure, stroke, TIA etc.

10%

Neurally-Mediated vasovagal, carotid sinus, situational

24%

Orthostatic/ Drug-Induced ANS failure, medication

11%

What is the cost of syncope? •  In 2011, 579 Medicare patients presented to single

ER with syncope and were discharged with a primary diagnosis of syncope (ICD-9: 780.2) – 396 (68%) patients were hospitalized – Observation status (n=71 [18%]) –  Inpatient status (n=325 [82%]) – The 325 inpatients, 56% of the total cohort,

accounted for 86% of the total costs spent on patients with syncope

– The care of each inpatient resulted in an ~$1800 deficit to the hospital

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Mittal et al. AHA 2012

Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) •  Variables (score)

–  Age > 65 years (1) –  History of cardiovascular disease (1)

•  SHD, CHF, PVD, TIA/stroke –  Syncope without prodrome (1) –  Abnormal ECG (1)

•  Everything but a truly normal ECG

– 12-month all-cause mortality by score •  0:0% •  1: 0.8% •  2: 19.6% – •  3: 34.7% •  4: 57.1%

7 Colivicchi F et al. Eur Heart J 2003; 24: 811-819

Evaluation of Syncope (VANOOM) •  Vasovagal Syncope (30%): Get the history. •  Arrhythmia (20%): EKG and Echo •  Neurologic •  Orthostatic Hypotension (30%):

–  Drug Induced: 28% –  Autonomic Failure: 27% –  Age-related: 20% –  Multiple System Atrophy: 13% –  Parkinson’s disease: 5% –  Unclassified: 2%

•  Organic Heart Disease: Stenotic Valves, Cardiomyopathy (including HOCM)

•  Medications (look for BPH med changes)

Distinguishes between VVS syncope and syncope due to other causes in patients without structural heart disease. Use scoring criteria:

•  History of one of the following: bifascicular block, asystole, SVT, DM2 (-5)

•  Bystander noted patient turned blue with faint (-4)

•  Syncopal episodes started at age 35 years or older (-3)

•  Any memory of being unconsciousness (-2)

•  Pre-syncope or syncope with prolonged sitting or standing (+1)

•  Pre-syncope or syncope with pain or in medical settings (+3)

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Is it vasovagal syncope? Calgary Syncope Symptom Score

Sheldon R et al Eur Heart J 2006; 27: 344-350

If the total point score is ≥ -2, the point score correctly diagnosis patients with VVS with 89% sensitivity and 91% specificity

From CARISMA Trial

Complete Heart Block

VF Arrest

Arrhythmogenic Causes of Syncope

Neurologic Causes of Syncope •  Epilepsy: 107 adults seen in four Italian epilepsy were seen

for “possible” or “drug-resistant” epilepsy, and were assessed for recurrent syncope of unknown cause –  Overall, about 42.1% had isolated syncope, 19.6% had

isolated epilepsy, and 37.4% had coexistent syncope and epilepsy.

•  Syncope and TIA: These patients tend to be elderly males with high incidence of ischemic heart disease and hypertension. The concurrent neurologic symptoms, leading to the diagnosis, represent mainly vertebrobasilar territory ischemia.

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- Ungar A, et al. Syncope and epilepsy coexist in 'possible' and 'drug-resistant' epilepsy (Overlap between Epilepsy and Syncope Study - OESYS). BMC Neurol. 2017 Feb 28;17(1):45. -  Davidson et al, “Transient Ischemic Attack-Related Syncope,” Clin. Cardiol. 14, 141-144 (1991)

Patients at high risk for major CV events or SCD

•  Severe structural or coronary artery disease –  Heart failure; low ejection fraction; previous myocardial infarction

•  Clinical or ECG features suggesting arrhythmic syncope –  Syncope during exertion or while supine –  Palpitations at the time of syncope –  Family history of sudden cardiac death –  Non-sustained VT –  Bifascicular block –  Inadequate sinus bradycardia –  Pre-excited QRS complex; short or prolonged QT interval; RBBB pattern with ST

elevation (Brugada pattern); negative T waves in right precordial leads, epsilon waves, ventricular late potentials (suggestive of ARVC)

•  Important co-morbidities: Severe anemia or electrolyte disturbance

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- Moya et al 2009. Eur Heart J. doi:10.1093/eurheartj/ehp298

ECG Patterns in Syncope

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Long QT

Brugada Patterns

Hypertrophic CMP

RBBB/LAFB

Bifasciciular Block not just RBBB alone!!

ECG’s from Lifeinthefastlane.com

Mitral Annular Calcification •  Mitral annular calcification (MAC) is often noted on echo reports or even

visible on chest xrays. •  MAC is also associated with symptomatic bradyarrhythmias such as atrial

fibrillation and sinus node dysfunction. –  Nair et al [NAI82] examined 68 consecutive patients requiring

pacemakers and the incidence of MAC in this group was 83-93%; of these patients, 22% had AV block, 34% had atrial fibrillation with slow ventricular response, and 44% had intermittent sinus arrest.

•  MAC is associated with carotid vascular disease. [ADL98,ADL01] •  This is important because carotid sinus hypersensitivity (CSH) in elderly

patients is also associated with carotid vascular disease [OMA95] and may be associated with 45-50% of elderly patients that present with falls. [OPMA95,CRI97, SHA97]

NAI82 Nair CK, Sketch MH, Desai R, et al. High prevalence of symptomatic bradyarrhythmias due to atrioventricular node-fascicular and sinus node-atrial disease in patients with mitral anular calcification. Am Heart J 1982; 103:226. TAK83 Takamoto T, Popp RL. Conduction disturbances related to the site and severity of mitral anular calcification: a 2-dimensional echocardiographic and electrocardiographic correlative study. Am J Cardiol 1983; 51:1644. ADL01 Adler Y, Fink N, Spector D, Wiser I, Sagie A, “Mitral annulus calcification--a window to diffuse atherosclerosis of the vascular system,” Atherosclerosis, V. 155, No. 1 (March 2001), pp. 1-8. THO10 Thomsen PEB, Jons C, Raatikainen MJP, Joergensen RM, Hartikainen J, Virtanen V, Boland B, Anttonen O, Gang UJ, Hoest N, Boersma LVA, Platou ES, Becker D, Messier MD, Huikuri HV, “Long-Term Recording of Cardiac Arrhythmias With an Implantable Cardiac Monitor in Patients With Reduced Ejection Fraction After Acute Myocardial Infarction: The Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction (CARISMA) Study,” Circulation, V. 121 (September 28, 2010), pp. 1258-1264. SEI03 Seifer C and Kenny RA, “The Prevalence of Falls in Older Persons Paced for Atrioventricular Block and Sick Sinus Syndrome,” The American Journal of Geriatric Cardiology, V. 12, No. 5, (Sept/Oct 2003), pp. 298–305. SHA97 FE Shaw, RA Kenny, “The overlap between syncope and falls in the elderly,” Postgrad Med J, V. 73 (1997), pp. 635 – 639.

Carotid Sinus Hypersensitivity (20%)

•  Carotid Sinus Massage: – Absolute Contraindications:

•  MI within 3months. •  TIA/CVA within 3months.

– Relative: •  Previous VT/VF •  Presence of carotid bruit

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- Kenny and Perry, “Syncope-related falls in the elderly,” J Geriatric Cardiology, V. 2, No. 2 (June 2005), pp. 74-83.

Orthostatic Hypotension (30% of syncope):

•  Drug Induced: 28% •  Autonomic Failure: 27% •  Age-related: 20% •  Multiple System Atrophy: 13% •  Parkinson’s disease: 5% •  Unclassified: 2%

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Medications Associated with Syncope •  Polypharmacy is associated with falls in the

elderly. •  Common offenders: BPH meds, Nitrates,

Calcium channel and beta blockers. •  Consider temporal relation of these

medications and prolonged standing.

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Yields of Testing Options

*(Based on mean diagnosis time of 5.1 mos.) 2

1.  Kapoor WN. Diagnostic evaluation of syncope. Am J Med. January 1991;90(1):91-106. 2.  Krahn AD, Klein GJ, Yee R. Recurrent syncope. Experience with an implantable loop recorder. Cardiol Clin. May 1997;15(2):313-326. 3.  Krahn AD, Klein GJ, Yee R, et al. Cost implications of testing strategy in patients with syncope (RAST). J Am Coll Cardiol. August 6, 2003;42(3):495-501. 4.  Kapoor WN. Evaluation and outcome of patients with syncope. Medicine (Baltimore). May 1990;69(3):160-175. 5.  Kapoor WN. Evaluation and management of the patient with syncope. JAMA. November 11, 1992;268(18):2553-2560. 6.  Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 2: Unexplained syncope. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. July 1,1997;127(1):76-86. 7.  Krahn AD, Klein GJ, Yee R, Norris C. Final results from a pilot study with an implantable loop recorder to determine the etiology of syncope in patients with negative noninvasive and invasive testing. Am J Cardiol. July 1, 1998;82(1): 117-119. 8.  Krahn AD, Klein GJ, Yee R, Takle-Newhouse T, Norris C. Use of an extended monitoring strategy in patients with problematic syncope. Reveal Investigators. Circulation. January 26, 1999;99(3):406-410.

Test/Procedure Yield* ECG 2-11%1

Holter Monitoring 2%2

External Loop Recorder 20%3

Tilt Table 11-87%4,5

EP Study without structural heart disease 11%6

EP Study with structural heart disease 49%4

Neurological (CT scan, carotid doppler) 0-4%5

Loop Recorder (studied with Reveal) 43-88%3,7,8

Randomized Assessment of Syncope Trial

Methods:

• Combining primary strategy with crossover, the diagnostic yield was 52% for ILR only versus 19% for conventional only

• Cost/diagnosis of ILR was 26% less than conventional testing

•  60 patients with unexplained syncope and LV EF >35% were randomized to conventional testing or a Reveal ILR

•  If patients remained undiagnosed after their assigned strategy, they were offered a crossover to the alternate strategy

Results:

Krahn AD. Cost implications of testing strategy in patients with syncope. JACC. 2003;42(3):495-501.

Outcomes of Primary Diagnostic Strategy

“Although the cost of monitoring was greater than that of conventional testing, the cost/diagnosis was reduced because of the greater diagnostic yield (p < 0.0001).”

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- Thanks to Dr. Suneet Mittal, MD, Director, Electrophysiology Laboratory The Arrhythmia Institute at The Valley Hospital