Syncope: from admission to risk stratification

Giorgio Costantino, MDNicola Montano, MD, PhD

Cardiovascular Neuroscience Lab,Department of Biomedical and Clinical SciencesUniversity of MilanDepartment of Medicine Fondazione Policlinico, Milan

European School of Internal Medicine 2015Muravera, Sardinia, June 7-13

Non indicato nei pazienti con episodisincopali isolati e con chiare caratteristicheneuromediate desumibili dallanamnesi

Intro Less than 5% of syncopes may be

considered related to emergencyconditions

Impossible to consider all syncopalevents as emergency conditions

However, unrecognize those that hideemergent conditions may lead to dramatic consequences

What is the main problem with syncope?

Mrs. Silvana Admitted to the ER

after after a syncopalepisodes triggered by a relevant emotionalstress.

AP 100/60 mmHg; HR 110 b/m r

Miss Giulia Admitted to the ER

after after a syncopalepisodes triggered by a relevant emotionalstress.

AP 100/60 mmHg; HR 110 b/m r

Mrs. Silvana 78 years old, known

hypertensive under therapy

Syncope occurredwithout any prodromesafter being informedthat the mammographyshe underwent for a mammary nodule waspositive for breastcancer.

Miss Giulia 19 years old, silent

medical hystory Syncope occurred,

without any prodromes, after being informedthat she did not pass the test for the admission to the School of Medicine.

Mrs. Silvana Admitted to the clinical

ward for pulmorayembolism

Miss Giulia Discharged, in good

health

A 66 years-old woman

is admitted to the ER for a syncopal episodeoccurred during walking, without prodromes, followed by a head trauma.- Hypertensive, under ACEi tretment- She referred an episode of unclear bradycardia(no documentation provided) 5 years before.- In ER: negative CSM, negative telemetric ECG monitoring, few asymptomatic episodes of sinustachycardia.

.she underwent:

. Doppler Echocardiogram (normal),

. telemetric continuous monitoring (negative), .

. Holter ECG (negative).

- Discharged with diagnosis of UnexplainedSyncope.

admitted to the ward

Questions

What was her risk? Was admittance to the clinic

useful?

ER approach to Syncope

Recognize high-risk vs low-risk patients;

Do not discharge a patients at risk of a major

event;

Do not admit a patient who doesnt need.

Definition

Syncope is a transient loss of consciousness (T-LOC) due to a transient global cerebral hypoperfuzion characterized by:

rapid onset short duration spontaneous complete recovery

ESC Guidelines 2009

Syncope - Pathophysiology

ESC Guidelines 2009

Epidemiology

ESC Guidelines 2009

Soteriades, ES et al. NEJM 2002

Syncope - Survival

N=7814 patients mean follow-up 17 yrs

Initial evaluation

1. Is it Syncope?

2. Is syncope immediately evolving

3. What is the cause?

4. Is it a high-risk syncope?

Main clinical tools

Medical history Physical examination Lying and standing BP measurement ECG Other exams

MEDICAL HISTORY, PHYSICAL EXAMINATION AND ECG LEAD TO

DIAGNOSIS IN ABOUT 70% OF SYNCOPAL EPISODES.

VIM (Very Important Message)

Mrs Marta..

83 years-old, living alone Found at home lying down on the floor,

doesnt remember how did it happen She said she slipped down without being

able to get up for a very painful leg She doesn t remember how long she

stayed down on the floor

Is this Syncope?

Without witnesses, consider it as a

syncopal event (especially in the elderly).

Anamnestic Grid

Number of episodes Prodromes Associated symptoms Occurring circumstances Medical history of CAD Relevant comorbidities in medical history Episodes consequences Therapy

Mrs Hilary.

67 years old, is admitted to the ER for a syncopal episodes occured while she wasstanding still in the church

She refers a 20 years of history of recurrentsyncopale episodes, of short duration, both in orthostatism and sitting positions.

Nothing relevant in the medical history

NUMBER OF EPISODES

Recurrency over a short-term have usuallya negative prognostic meaning.

Recurrency over a long-term have usually a positive prognostic meaning.

First episode: variable, usually benign

Initial evaluation

1. Is it Syncope?

2. Is syncope immediately evolving

3. What is the cause?

4. Is it a high-risk syncope?

Mr Giancarlo..

64 years old, admitted to the ER for a syncopalepisodes without prodromes.

No overt cardiovascular diseases

During the triage, slightly confused.

Normal vital parameters.

.

Green code (medium severity) assigned The patient was waiting to undergo an

operation for cerebral aneurysm in the nextdays.

He waited 4 hour before being visited and during the medical visit fainted afterreferring a sudden acute headache.

Syncope associated with Emergent conditions

Pulmonary Embolism Hypertensive Pneumothorax

Aortic Dissection Major Cardiac Arrhythmias

Internal Hemorrhage Ectopic Pregnancy

Abdominal Aorta Aneurysm Subarachnoid Hemorrage

Myocardial Infarction Carotid Dissection

Cardiac Tamponade Fat Embolism

Alerting symptoms

PainDyspneaDisability (neurological signs and symptoms) tachycardia (unexplained)

VIM

The presence of at least one of thesesigns/symptoms allows to hypothesize the presenceof a life-threatening disease as the cause of the syncopal episode.

Thus, medical history, physical examination and diagnostic approch must be performed to exclude it.

Main clinical tools

Medical history Physical examination Lying and standing BP measurement ECG Other exams

12-leads ECG signs Sinus bradycardia; AV node blocks (II o III degree); AV block Mobitz 2 type tipo; Bundle branch block; Long or short QT; Specific ischemic repolarization signs; Signs of right heart overload; Arrhythmogenic dysplasia of the right ventricle /Brugada

syndrome; Signs of pericarditis or electrical alternans; Left or right ventricular hypertrophy.

VIM

MEDICAL HISTORY AND AN ECG NEGATIVE FOR CARDIAC DISEASES RULE OUT UP TO

97% A CARDIAC CAUSE FOR SYNCOPE

Main clinical tools

Medical history Physical examination Lying and standing BP measurement ECG Other exams

Other exams CSM in patients > 40 yrs Echocardiogram: if a cardiomyopathy is known or

suspected Continuous ECG monitoring: if an arrhythmis

syncope is supected Head-up Tilt Test: if syncope occurred while standing

or there is suspicion of a neuromediated Neurologic examination and blood exams: only if

there is suspicion of a non-syncopal T-LOC.

Initial evaluation

1. Is it Syncope?

2. (Is syncope immediately evolving)

3. What is the cause?

4. Is it a high-risk syncope?

Why stratify the risk in syncope?

Mortality: 1%

Major adverse events or major procedures: 5-

10%

Signs/Symptoms related to high risk Dyspnea Pain Dysability (neurological signs) Clinostatic syncope During exercise Without prodromes or with palpitations With severe trauma With structural cardiomyopathy or ECG anomalies Low EF, previous MI

Prognostic scoresOESIL RISK SCORE

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

age > 65 anni = 1 pointcardiovascular disease history = 1 pointsyncope without prodromes = 1 pointECG alterations = 1 point

score 0-1: mortality risk at 1 year 0-0.8%score 2-4: mortality risk at 1 year 19.6-57.1%admission suggested for a score 2

SAN FRANCISCO SYNCOPE RULE(Quinn JV et al. Ann Emerg Med 2006;47:448-454)

ECG alterationsdyspneaheart failure historyhematocrit < 30%systolic arterial pressure < 90 mm Hg

Sn 98%, Sp 56% ( 1 factor) for mortality or morbidity within 1 month from the eventadmission when present at least 1 factor

Open question

Majority of prognostic scores assess the mortality associated with syncope within 6-12 months after the events.

Prognostic factors of long-term mortalityare the same of the short-term one?

676 patients admitted to the ER for syncope 4 major metropolitan hospitals 6-months enrollment 1-year follow Mortality and major adverse events (procedures and

readmittance for syncope) within 10 days and 1 year

JACC, 2008

JACC, 2008

Are scores for syncope RS useful?

Adverse events at 10 days

SERIOUS OUTCOME 10 days Sensitivity [95%CI] Specificity [95%CI]

CJ (n=6) 0.95 [0.91 - 0.97]

0.55 [0.44 - 0.65]

OESIL (n=5)

0.78 [0.69 - 0.85]

0.56 [0.49 - 0.63]

SFSR (n=4)

0.76 [0.64 - 0.85]

0.53 [0.34 - 0.70]

0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1

VIMs

Risk factors vs risk scores Further studies needed Need to define the acceptable risk Importance of using risk scores to reduce

errors, mostly in stressful conditions(overcrowding) or by syncope non-expertphysicians

Summary what to do

1. Recognize the patient with syncope

2. Exclude rapidly evolving diseases as cause of syncope (DPD) and confirm other diagnosis

3. Monitoring

4. Stratify risk (risk factors or score)

Low Risk

Young patient (< 40), without comorbidities, with a likely vasovagal syncope

Perform ECG (mandatory!) No other exams Discharge or eventually short observation in

ER (3-6 hours)

High Risk

Patients with syncope but suspicion of cardiogenic syncope or relevant comorbidities+ likely cardiogenic syncope (ischemiccardiomyopathy, low EF, COPD, ECG alterations, clinostatic syncope)

ECG, blood exams, chest X-ray, ECG monitoring , echocardiogram

Admit to the ward

Intermediate Risk

Not high, not low (ie. Relevant comorbiditiesbut likely vasovagal syncope)

ECG, ECG monitoring, exams and chest-X-ray, eventually

Monitoring in the ER for 24 hours ??

Exams to perform

All patients: ECG

In selected cases: ECG monitoring for 3/6 hours Carotid Sinus Message Blood exams BGA Echocardiogram

Do not perform

Head TC scan (unless suspect of epilepsy or patients with head trauma)

SAT Echodoppler (unuseful)

Neurologic visit (unles with a specific question epilepsy?)

Thanks!

Syncope: from admission to risk stratificationDiapositiva numero 2IntroWhat is the main problem with syncope?Diapositiva numero 5Diapositiva numero 6A 66 years-old womanadmitted to the wardQuestionsER approach to SyncopeDefinitionSyncope - PathophysiologyEpidemiologyDiapositiva numero 14Initial evaluationMain clinical toolsMEDICAL HISTORY, PHYSICAL EXAMINATION AND ECG LEAD TO DIAGNOSIS IN ABOUT 70% OF SYNCOPAL EPISODES. Mrs Marta..Is this Syncope? Anamnestic GridMrs Hilary.NUMBER OF EPISODESInitial evaluationMr Giancarlo...Diapositiva numero 26Diapositiva numero 27Diapositiva numero 28Diapositiva numero 29Diapositiva numero 30Main clinical tools12-leads ECG signsVIMMain clinical toolsOther examsInitial evaluationWhy stratify the risk in syncope?Signs/Symptoms related to high riskDiapositiva numero 39Open questionDiapositiva numero 41Diapositiva numero 42Are scores for syncope RS useful?Adverse events at 10 daysVIMsSummary what to doLow RiskHigh RiskIntermediate RiskExams to performDo not performDiapositiva numero 52