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3 dizziness and syncope. karen hauer, md

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Abdulmajid Abulsine
Abdulmajid Abulsine

This document summarizes dizziness and syncope. Dizziness is a common complaint that can have many causes including vertigo, disequilibrium, and presyncope. A careful history and exam can often determine the etiology as central, peripheral, or psychiatric. Syncope is the transient loss of consciousness and posture due to decreased brain perfusion. The evaluation of syncope focuses on identifying potentially life-threatening cardiac causes through history, exam, EKG and selected testing. Neurocardiogenic or vasovagal syncope is often diagnosed clinically without extensive testing. Admission is recommended for high risk patients but many can be safely discharged with careful evaluation.

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Dizziness and Syncope Karen E. Hauer, MD University of California, San Francisco
Dizziness and Syncope: Outline Dizziness: common etiologies Case examples Syncope Diagnosis Efficient workup Management
Dizziness ¡° There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits on learning that their patient¡¯s complaint is of giddiness [dizziness]¡± WB Matthews, 1975
Vertigo 50% Disequilibrium 2% Psychiatric 2-16% Presyncope 4-14% Single etiology 52% Kroenke, Ann Intern Med 1992 UpToDate 2005 Etiology of dizziness
Case A 72 year old woman with hypertension and migraine has 2 episodes of sudden onset dizziness. She reports ¡°side to side movement¡± lasting several hours, with left sided hearing loss, tinnitus, ear fullness, unsteadiness. Oscillopsia since.
Case A 72 year old woman with hypertension and migraine has 2 episodes of sudden onset dizziness. She reports ¡°side to side movement ¡± lasting several hours , with left sided hearing loss , tinnitus, ear fullness, unsteadiness. Oscillopsia since.
Central (15%) Brainstem infarct/ischemia Tumor Cerebellopontine angle Brainstem Migraine Vertigo: acute vestibular asymmetry Peripheral (85%) Benign positional Labyrinthitis Meniere¡¯s Otitis media
Central Gradual onset (except stroke) Persistent Neuro findings common Nystagmus any direction - changes with gaze Nystagmus not suppressable Unable to stand Vertigo: history and exam Peripheral Sudden, severe Episodic Ear symptoms common Nystagmus horizontal/torsional, no change with gaze Nystagmus suppressed with fixation Able to stand, lean to lesion
Anatomy American Academy of Otolaryngology/HNS
Dix-Hallpike maneuver: to induce positional vertigo and nystagmus Benign positional vertigo: #1 cause of peripheral vertigo Episodic symptoms Free floating debris in semicircular canals
Dix-Hallpike maneuver: diagnostic and therapeutic Positional vertigo: Vertigo/nystagmus reproduced Latency 5-15 seconds Decreases w/in 30 seconds Fatigues on repeat
Rule out tumor 1/9307 - dizziness, normal hearing 1/638 - dizziness, asymmetric hearing loss Rule out vascular compromise Indications New neuro symptoms/signs Sudden vertigo & stroke risk factors Vertigo & new severe headache Test of choice: MRI/ MRA Gizzi, Arch Neurol 1996 Vertigo: when to image?
Case: unsteadiness A 78 year old woman with coronary artery disease, type 2 diabetes, cataracts, anxiety and depression has chronic dizziness - ¡°unsteady while walking¡± Meds: insulin, lovastatin, atenolol, fludrocortisone, prozac Neuro exam: slightly wide based gait. DTRs absent in ankles. Reduced vibration sense to ankle bilaterally. Short of breath with neuro exam maneuvers.
Disequilibrium: often multifactorial Sense of imbalance -w orse with walking Contributing factors Vision, hearing impairment Peripheral neuropathy Musculoskeletal disease/gait disturbance Medications
Dizziness: a geriatric syndrome 24% of community-living elders had dizziness > 1 month Tinetti, Ann Intern Med 2000 1.31 Prior MI 1.31 Postural hypotension 1.30 > 4 meds 1.34 Impaired balance 1.27 Decreased hearing 1.36 Depression 1.69 Anxiety Relative risk Risk factor
Case: ¡°I feel like I¡¯m going to faint¡± A 30 year old woman reports episodes of feeling as if she will faint, with palpitations and lightheadedness, worse when anxious. Three episodes of syncope over past 10 years; none recently - able to avoid by lying down.
Dizziness: psychiatric etiology Young healthy patient Symptoms reproduced with hyperventilation Nystagmus suggests vestibular lesion Treat underlying anxiety/depression
Establishing Diagnosis of Syncope Presyncope & syncope: similar etiologies & workup Syncope: sudden transient loss of consciousness with loss of postural tone and spontaneous recovery Mechanism: transient hypoperfusion of brainstem or both cerebral hemispheres Differential diagnosis: coma narcolepsy seizure
Syncope: scope of the problem Common 3% Emergency Department visits 1-6% hospital admissions Costly Multiple diagnostic tests often performed Average charge for each diagnostic test ranges from $284 to $4678 Linzer, Ann Intern Med, 1997
Diagnostic Challenges History often unclear Prognosis varies widely Common etiologies are benign Potentially high mortality Need to identify high-risk patient early Many available tests 40% of patients may elude diagnosis
Syncope: management questions Diagnostic challenges What is the best diagnostic test? How and when to rule out arrhythmia? How to diagnose neurocardiogenic syncope? How to decrease the # ¡°idiopathic¡±? Management dilemmas When to admit? How are the elderly different? When to resume driving?
Case Presentation 50 yo healthy woman, standing at church Becomes weak, lightheaded, & nauseated Collapses, awakens after 1 minute Feels well in ED - ¡°I want to go home¡± Normal exam, EKG, labs, CXR Diagnosis? Plan - Admit? Further testing? Glassman, Arch Intern Med, 1997
Etiology of Syncope Idiopathic 34% Neurally-mediated Vasovagal 18% Other (situational, carotid sinus) 6% Cardiac Arrhythmia 14% Mechanical 4% Neurologic 10% Orthostatic 8% Medications 3% Psychiatric 2% Linzer, Ann Intern Med, 1997
The Key to Diagnostic Evaluation History and Exam establish diagnosis in 45% History: setting, symptoms, medical hx, meds Exam: HR, BP, cardiovascular, neurologic EKG adds 5% diagnostic yield Cheap, non-invasive, readily available Can indicate important cardiac disease Prior MI, ventricular hypertrophy, long QT Bradycardia, conduction block Abnormalities guide further testing
Diagnostic Algorithm Syncope Cardiac Noncardiac Idiopathic Arrhythmia Mechanical Neurocardiogenic Orthostatic Neurologic Psychiatric
Cardiac syncope: inadequate cardiac output, arrhythmia Cardiac enzymes - only if history or EKG suggestive of MI 1-10% MI¡¯s present with syncope EKG up to 100% sensitive for MI Echo - rule out structural heart disease before stress test if obstruction suspected yield: 5-10% Exercise stress test - exertional syncope identifies exertional arrhythmia yield: low (1%) Georgeson, J Gen Intern Med, 1992 Linzer, Ann Intern Med, 1997
Arrhythmia evaluation - telemetry Indication: suspected arrhythmia palpitations, no prodrome Idiopathic syncope or underlying heart disease Routine telemetry low yield 2240 non-ICU telemetry patients 10% syncope/dizzy all syncope ICU transfer-arrhythmia 0.8% 0.4% Telemetry ¡°Helpful¡± 12.6% 16% Mortality 0.9% 0 Linzer, Ann Intern Med, 1997 Estrada, Am J Cardiol, 1995 Glassman, Arch Intern Med, 1997. Estrada, Am J Cardiol, 1995
Arrhythmia evaluation: 24 hr ambulatory (Holter) monitoring 2612 syncope/dizzy patients Symptomatic arrhythmia = positive result Diagnostic arrhythmia in 4% Symptoms without arrhythmia Arrhythmia ruled out in 15% Bottom line Benefit: monitors during usual activity Limitation: brief duration limits yield unless daily symptoms Linzer, Ann Intern Med, 1997
Arrhythmia evaluation: improving the yield Loop recorder Indication: recurrent syncope with normal heart frequent syncope -> continuous loop recorder (weeks) infrequent syncope -> implantable loop recorder (years) Electrophysiologic study Indication: syncope with organic heart disease Signal average EKG Detects late potential in QRS - substrate for VT/VF indication: normal heart, idiopathic syncope? Linzer, Ann Intern Med, 1997 Zimetbaum , Ann Intern Med, 1999
Neurocardiogenic Syncope Vasovagal Micturition Vasodepressor Neurally - mediated Reflexive Orthostatic intolerance Carotid sinus syncope Cardioneurogenic
May be predominantly Cardioinhibitory (bradycardia) Vasodepressor (hypotension) or Both Neurocardiogenic Syncope Clinical Presentation Syncope Trigger
Neurocardiogenic Syncope: Pathophysiology
Diagnosing neurocardiogenic syncope by history and exam Precipitant Vasovagal: pain, emotion, standing Situational: vagal stimulus Autonomic symptoms Rapid recovery of mental status Bradycardia, pallor may persist Carotid sinus massage >3 sec asystole or hypotension=hypersensitivity
Is Laughter Really the Best Medicine? ¡° A 63-year-old man was referred with a 20-year history of syncope preceded by intense laughter. We were able to diagnose a gelastic syncope (from the Greek ¡®gelos¡¯, laughter). Laughter-related syncope may be induced by the Valsalva manoeuvre. We advised him not to laugh so hard in the future, and when we saw him again, he had been able to follow this advice, and had suffered no further syncope.¡± Braga. Lancet 2005
Tilt table testing 60-80? Goal: provoke neurocardiogenic syncope Indication: recurrent unexplained syncope without cardiac disease Protocol: passive tilt 45-60 min positive response reproduces symptom
Tilt table testing: why the controversy? Accuracy difficult to define Gold standard? Protocol? Reproducibility 71-87% Positive tilt test with idiopathic syncope: 49% with passive tilt 66% with tilt plus isoproterenol Tradeoff: decreased specificity Kapoor, Am J Med, 1994
Neurocardiogenic syncope: treatment Indicated for frequent syncope Lifestyle modification Add salt, avoid triggers Handgrip, tense arms and legs Medications B blocker, SSRI, midodrine, fludrocortisone Repeat tilt test on therapy? Pacemaker
Vasovagal syncope: pacemakers ineffective Randomized double-blind trial DDD pacer vs. sensing-only pacer Connolly, JAMA 2003 p = NS %
¡° Idiopathic¡± syncope: improving diagnostic yield Up to 40% patients Prognosis good Potential morbidity, lifestyle implications Consider: Diagnosis Testing Neurocardiogenic Tilt table Anxiety/depression Psychiatric evaluation Arrhythmia EPS, implanted event monitor Empiric pacemaker?
Prognosis: Framingham 25 year follow up *p<0.01 NEJM 2002;347:878 1.08 Vasovagal 1.32* Idiopathic 1.54* Neurologic 2.01* Cardiac Adjusted risk of death Etiology of syncope
Prognosis: ED risk stratification ED predictors of arrhythmia or mortality Abnormal EKG Prior VT/VF History of CHF Age > 45 Martin, Ann Emerg Med, 1997
Prognosis: Guideline for admission - the San Francisco Syncope Rule Prediction rule to identify patients at risk of bad outcomes (need admit) over 30 days Death, MI, arrhythmia, PE, stroke, transfusion Syncope or related event requiring procedure, ED visit or admit First assess the patient for cause of syncope If cause unknown, apply the rule 98% sensitive 56% specific Quinn, Ann Emerg Med, 2006
C HF - history of H ematocrit <30% E CG abnormal S hortness of breath S ystolic blood pressure <90 mm Hg at triage Quinn, Ann Emerg Med, 2006 Prognosis: Guideline for admission - the San Francisco Syncope Rule
ACP Guidelines for Hospital Admission Definitely admit HPI: chest pain PMH: CAD, CHF, ventricular arrhythmia Exam: CHF, valve dz, focal neurologic deficit EKG: ischemia/MI, arrhythmia, bundle branch block Often admit HPI: age >70, exertional syncope, frequent syncope Exam: tachycardia, orthostatic hypotension, injury Cardiac dz suspected Linzer, Ann Intern Med, 1997
Guidelines for Hospital Admission: implications for practice Myth: Every syncope patient should be admitted Recommendation: Establish clear goals for admission, usually diagnostic Myth: Every syncope patient requires ¡°rule out MI¡± Recommendation: Admission not necessary with careful history ruling out symptoms of ischemia and normal EKG Myth: Telemetry improves outcomes Recommendation: One-year mortality rarely affected by 24 hours of monitoring
Syncope in the elderly: the geriatric challenge History often obscure Syncope vs. dizziness vs. fall? Often multifactorial - elderly at high risk for Situational syncope Polypharmacy, adverse drug events Cardiac, neurovascular disease Decreased physiologic reserve Atypical presentation of disease Abnormalities do not prove causation
Syncope in the elderly: a poor prognostic sign Kapoor, Am J Med, 1986
Recommendations for Driving: following the law Laws vary by state - available from DMV California law requires reporting of any loss of consciousness County health officer receives report DMV determines fitness to drive Physician can provide influential prognostic information to DMV Physicians¡¯ recommendations variable Awareness of law often poor
American Heart Association Guidelines for Driving VT/VF (treated with medical or ICD therapy ) Risk greatest 1st 6 mo, up to 10% at 1 year Resume driving: 6 months arrhythmia free Bradycardia with syncope Resume driving: 1 week after pacemaker Neurocardiogenic syncope -> risk stratify Mild: presyncope, clear warning & precipitant Resume driving: immediately Severe: syncope, no warning or precipitant, frequent Resume driving: after therapy, waiting period (duration?)
The Potentially Costly Workup Test Charge* H & P $160 EKG $90 24-hour Holter $468 Loop recorder - 30 day $284 Electrophysiology study $4678 Psychiatric evaluation $150 CT brain $888 Echo $580 Stress test $433 Tilt table test $683 *Average at 4 academic centers, Linzer, 1997
Trust the Careful History: Excess Cost of Vasodepressor Syncope 30 patients referred for ¡°undiagnosed¡± syncope All characteristic vasodepressor history Mean cost of prior testing $3763 - 1991 Majority had Holter, echo, CT Calkins, Am J Med, 1993 Calkins, Am J Med, 1991.
Case Presentation: Is typical practice cost effective? Hypothetical scenario presented to 916 MDs Becomes weak, lightheaded, & nauseated Collapses, awakens after 1 minute Feels well in ED - ¡°I want to go home¡± Normal exam, EKG, labs, CXR Diagnosis? Plan - Admit? Further testing? Glassman, Arch Intern Med, 1997
Cost-effective workup: Internists vs. cardiologists Diagnosis: vasovagal syncope Intended plan: observation +/- overnight tele Survey results: aggressive approach Cardiologists Internists YOU Admit? 79% 72% ? Mean # additional tests 2.7 2.3 ? Glassman, Arch Intern Med, 1997
Dizziness: key points Vertigo is most common etiology Positional triggers, nystagmus help confirm peripheral etiology Neuro findings, stroke risk prompt imaging Disequilibrium - commonly due to multifactorial deficits in elderly Presyncope - manage like syncope
Syncope: key points History, exam, EKG guide further testing Identify possible cardiac syncope early Admit if high risk of cardiac disease Neurocardiogenic syncope - diagnosed clinically or by tilt table Idiopathic syncope has multiple etiologies and good prognosis

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3 dizziness and syncope. karen hauer, md

  • 1. Dizziness and Syncope Karen E. Hauer, MD University of California, San Francisco
  • 2. Dizziness and Syncope: Outline Dizziness: common etiologies Case examples Syncope Diagnosis Efficient workup Management
  • 3. Dizziness ¡° There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits on learning that their patient¡¯s complaint is of giddiness [dizziness]¡± WB Matthews, 1975
  • 4. Vertigo 50% Disequilibrium 2% Psychiatric 2-16% Presyncope 4-14% Single etiology 52% Kroenke, Ann Intern Med 1992 UpToDate 2005 Etiology of dizziness
  • 5. Case A 72 year old woman with hypertension and migraine has 2 episodes of sudden onset dizziness. She reports ¡°side to side movement¡± lasting several hours, with left sided hearing loss, tinnitus, ear fullness, unsteadiness. Oscillopsia since.
  • 6. Case A 72 year old woman with hypertension and migraine has 2 episodes of sudden onset dizziness. She reports ¡°side to side movement ¡± lasting several hours , with left sided hearing loss , tinnitus, ear fullness, unsteadiness. Oscillopsia since.
  • 7. Central (15%) Brainstem infarct/ischemia Tumor Cerebellopontine angle Brainstem Migraine Vertigo: acute vestibular asymmetry Peripheral (85%) Benign positional Labyrinthitis Meniere¡¯s Otitis media
  • 8. Central Gradual onset (except stroke) Persistent Neuro findings common Nystagmus any direction - changes with gaze Nystagmus not suppressable Unable to stand Vertigo: history and exam Peripheral Sudden, severe Episodic Ear symptoms common Nystagmus horizontal/torsional, no change with gaze Nystagmus suppressed with fixation Able to stand, lean to lesion
  • 9. Anatomy American Academy of Otolaryngology/HNS
  • 10. Dix-Hallpike maneuver: to induce positional vertigo and nystagmus Benign positional vertigo: #1 cause of peripheral vertigo Episodic symptoms Free floating debris in semicircular canals
  • 11. Dix-Hallpike maneuver: diagnostic and therapeutic Positional vertigo: Vertigo/nystagmus reproduced Latency 5-15 seconds Decreases w/in 30 seconds Fatigues on repeat
  • 12. Rule out tumor 1/9307 - dizziness, normal hearing 1/638 - dizziness, asymmetric hearing loss Rule out vascular compromise Indications New neuro symptoms/signs Sudden vertigo & stroke risk factors Vertigo & new severe headache Test of choice: MRI/ MRA Gizzi, Arch Neurol 1996 Vertigo: when to image?
  • 13. Case: unsteadiness A 78 year old woman with coronary artery disease, type 2 diabetes, cataracts, anxiety and depression has chronic dizziness - ¡°unsteady while walking¡± Meds: insulin, lovastatin, atenolol, fludrocortisone, prozac Neuro exam: slightly wide based gait. DTRs absent in ankles. Reduced vibration sense to ankle bilaterally. Short of breath with neuro exam maneuvers.
  • 14. Disequilibrium: often multifactorial Sense of imbalance -w orse with walking Contributing factors Vision, hearing impairment Peripheral neuropathy Musculoskeletal disease/gait disturbance Medications
  • 15. Dizziness: a geriatric syndrome 24% of community-living elders had dizziness > 1 month Tinetti, Ann Intern Med 2000 1.31 Prior MI 1.31 Postural hypotension 1.30 > 4 meds 1.34 Impaired balance 1.27 Decreased hearing 1.36 Depression 1.69 Anxiety Relative risk Risk factor
  • 16. Case: ¡°I feel like I¡¯m going to faint¡± A 30 year old woman reports episodes of feeling as if she will faint, with palpitations and lightheadedness, worse when anxious. Three episodes of syncope over past 10 years; none recently - able to avoid by lying down.
  • 17. Dizziness: psychiatric etiology Young healthy patient Symptoms reproduced with hyperventilation Nystagmus suggests vestibular lesion Treat underlying anxiety/depression
  • 18. Establishing Diagnosis of Syncope Presyncope & syncope: similar etiologies & workup Syncope: sudden transient loss of consciousness with loss of postural tone and spontaneous recovery Mechanism: transient hypoperfusion of brainstem or both cerebral hemispheres Differential diagnosis: coma narcolepsy seizure
  • 19. Syncope: scope of the problem Common 3% Emergency Department visits 1-6% hospital admissions Costly Multiple diagnostic tests often performed Average charge for each diagnostic test ranges from $284 to $4678 Linzer, Ann Intern Med, 1997
  • 20. Diagnostic Challenges History often unclear Prognosis varies widely Common etiologies are benign Potentially high mortality Need to identify high-risk patient early Many available tests 40% of patients may elude diagnosis
  • 21. Syncope: management questions Diagnostic challenges What is the best diagnostic test? How and when to rule out arrhythmia? How to diagnose neurocardiogenic syncope? How to decrease the # ¡°idiopathic¡±? Management dilemmas When to admit? How are the elderly different? When to resume driving?
  • 22. Case Presentation 50 yo healthy woman, standing at church Becomes weak, lightheaded, & nauseated Collapses, awakens after 1 minute Feels well in ED - ¡°I want to go home¡± Normal exam, EKG, labs, CXR Diagnosis? Plan - Admit? Further testing? Glassman, Arch Intern Med, 1997
  • 23. Etiology of Syncope Idiopathic 34% Neurally-mediated Vasovagal 18% Other (situational, carotid sinus) 6% Cardiac Arrhythmia 14% Mechanical 4% Neurologic 10% Orthostatic 8% Medications 3% Psychiatric 2% Linzer, Ann Intern Med, 1997
  • 24. The Key to Diagnostic Evaluation History and Exam establish diagnosis in 45% History: setting, symptoms, medical hx, meds Exam: HR, BP, cardiovascular, neurologic EKG adds 5% diagnostic yield Cheap, non-invasive, readily available Can indicate important cardiac disease Prior MI, ventricular hypertrophy, long QT Bradycardia, conduction block Abnormalities guide further testing
  • 25. Diagnostic Algorithm Syncope Cardiac Noncardiac Idiopathic Arrhythmia Mechanical Neurocardiogenic Orthostatic Neurologic Psychiatric
  • 26. Cardiac syncope: inadequate cardiac output, arrhythmia Cardiac enzymes - only if history or EKG suggestive of MI 1-10% MI¡¯s present with syncope EKG up to 100% sensitive for MI Echo - rule out structural heart disease before stress test if obstruction suspected yield: 5-10% Exercise stress test - exertional syncope identifies exertional arrhythmia yield: low (1%) Georgeson, J Gen Intern Med, 1992 Linzer, Ann Intern Med, 1997
  • 27. Arrhythmia evaluation - telemetry Indication: suspected arrhythmia palpitations, no prodrome Idiopathic syncope or underlying heart disease Routine telemetry low yield 2240 non-ICU telemetry patients 10% syncope/dizzy all syncope ICU transfer-arrhythmia 0.8% 0.4% Telemetry ¡°Helpful¡± 12.6% 16% Mortality 0.9% 0 Linzer, Ann Intern Med, 1997 Estrada, Am J Cardiol, 1995 Glassman, Arch Intern Med, 1997. Estrada, Am J Cardiol, 1995
  • 28. Arrhythmia evaluation: 24 hr ambulatory (Holter) monitoring 2612 syncope/dizzy patients Symptomatic arrhythmia = positive result Diagnostic arrhythmia in 4% Symptoms without arrhythmia Arrhythmia ruled out in 15% Bottom line Benefit: monitors during usual activity Limitation: brief duration limits yield unless daily symptoms Linzer, Ann Intern Med, 1997
  • 29. Arrhythmia evaluation: improving the yield Loop recorder Indication: recurrent syncope with normal heart frequent syncope -> continuous loop recorder (weeks) infrequent syncope -> implantable loop recorder (years) Electrophysiologic study Indication: syncope with organic heart disease Signal average EKG Detects late potential in QRS - substrate for VT/VF indication: normal heart, idiopathic syncope? Linzer, Ann Intern Med, 1997 Zimetbaum , Ann Intern Med, 1999
  • 30. Neurocardiogenic Syncope Vasovagal Micturition Vasodepressor Neurally - mediated Reflexive Orthostatic intolerance Carotid sinus syncope Cardioneurogenic
  • 31. May be predominantly Cardioinhibitory (bradycardia) Vasodepressor (hypotension) or Both Neurocardiogenic Syncope Clinical Presentation Syncope Trigger
  • 32. Neurocardiogenic Syncope: Pathophysiology
  • 33. Diagnosing neurocardiogenic syncope by history and exam Precipitant Vasovagal: pain, emotion, standing Situational: vagal stimulus Autonomic symptoms Rapid recovery of mental status Bradycardia, pallor may persist Carotid sinus massage >3 sec asystole or hypotension=hypersensitivity
  • 34. Is Laughter Really the Best Medicine? ¡° A 63-year-old man was referred with a 20-year history of syncope preceded by intense laughter. We were able to diagnose a gelastic syncope (from the Greek ¡®gelos¡¯, laughter). Laughter-related syncope may be induced by the Valsalva manoeuvre. We advised him not to laugh so hard in the future, and when we saw him again, he had been able to follow this advice, and had suffered no further syncope.¡± Braga. Lancet 2005
  • 35. Tilt table testing 60-80? Goal: provoke neurocardiogenic syncope Indication: recurrent unexplained syncope without cardiac disease Protocol: passive tilt 45-60 min positive response reproduces symptom
  • 36. Tilt table testing: why the controversy? Accuracy difficult to define Gold standard? Protocol? Reproducibility 71-87% Positive tilt test with idiopathic syncope: 49% with passive tilt 66% with tilt plus isoproterenol Tradeoff: decreased specificity Kapoor, Am J Med, 1994
  • 37. Neurocardiogenic syncope: treatment Indicated for frequent syncope Lifestyle modification Add salt, avoid triggers Handgrip, tense arms and legs Medications B blocker, SSRI, midodrine, fludrocortisone Repeat tilt test on therapy? Pacemaker
  • 38. Vasovagal syncope: pacemakers ineffective Randomized double-blind trial DDD pacer vs. sensing-only pacer Connolly, JAMA 2003 p = NS %
  • 39. ¡° Idiopathic¡± syncope: improving diagnostic yield Up to 40% patients Prognosis good Potential morbidity, lifestyle implications Consider: Diagnosis Testing Neurocardiogenic Tilt table Anxiety/depression Psychiatric evaluation Arrhythmia EPS, implanted event monitor Empiric pacemaker?
  • 40. Prognosis: Framingham 25 year follow up *p<0.01 NEJM 2002;347:878 1.08 Vasovagal 1.32* Idiopathic 1.54* Neurologic 2.01* Cardiac Adjusted risk of death Etiology of syncope
  • 41. Prognosis: ED risk stratification ED predictors of arrhythmia or mortality Abnormal EKG Prior VT/VF History of CHF Age > 45 Martin, Ann Emerg Med, 1997
  • 42. Prognosis: Guideline for admission - the San Francisco Syncope Rule Prediction rule to identify patients at risk of bad outcomes (need admit) over 30 days Death, MI, arrhythmia, PE, stroke, transfusion Syncope or related event requiring procedure, ED visit or admit First assess the patient for cause of syncope If cause unknown, apply the rule 98% sensitive 56% specific Quinn, Ann Emerg Med, 2006
  • 43. C HF - history of H ematocrit <30% E CG abnormal S hortness of breath S ystolic blood pressure <90 mm Hg at triage Quinn, Ann Emerg Med, 2006 Prognosis: Guideline for admission - the San Francisco Syncope Rule
  • 44. ACP Guidelines for Hospital Admission Definitely admit HPI: chest pain PMH: CAD, CHF, ventricular arrhythmia Exam: CHF, valve dz, focal neurologic deficit EKG: ischemia/MI, arrhythmia, bundle branch block Often admit HPI: age >70, exertional syncope, frequent syncope Exam: tachycardia, orthostatic hypotension, injury Cardiac dz suspected Linzer, Ann Intern Med, 1997
  • 45. Guidelines for Hospital Admission: implications for practice Myth: Every syncope patient should be admitted Recommendation: Establish clear goals for admission, usually diagnostic Myth: Every syncope patient requires ¡°rule out MI¡± Recommendation: Admission not necessary with careful history ruling out symptoms of ischemia and normal EKG Myth: Telemetry improves outcomes Recommendation: One-year mortality rarely affected by 24 hours of monitoring
  • 46. Syncope in the elderly: the geriatric challenge History often obscure Syncope vs. dizziness vs. fall? Often multifactorial - elderly at high risk for Situational syncope Polypharmacy, adverse drug events Cardiac, neurovascular disease Decreased physiologic reserve Atypical presentation of disease Abnormalities do not prove causation
  • 47. Syncope in the elderly: a poor prognostic sign Kapoor, Am J Med, 1986
  • 48. Recommendations for Driving: following the law Laws vary by state - available from DMV California law requires reporting of any loss of consciousness County health officer receives report DMV determines fitness to drive Physician can provide influential prognostic information to DMV Physicians¡¯ recommendations variable Awareness of law often poor
  • 49. American Heart Association Guidelines for Driving VT/VF (treated with medical or ICD therapy ) Risk greatest 1st 6 mo, up to 10% at 1 year Resume driving: 6 months arrhythmia free Bradycardia with syncope Resume driving: 1 week after pacemaker Neurocardiogenic syncope -> risk stratify Mild: presyncope, clear warning & precipitant Resume driving: immediately Severe: syncope, no warning or precipitant, frequent Resume driving: after therapy, waiting period (duration?)
  • 50. The Potentially Costly Workup Test Charge* H & P $160 EKG $90 24-hour Holter $468 Loop recorder - 30 day $284 Electrophysiology study $4678 Psychiatric evaluation $150 CT brain $888 Echo $580 Stress test $433 Tilt table test $683 *Average at 4 academic centers, Linzer, 1997
  • 51. Trust the Careful History: Excess Cost of Vasodepressor Syncope 30 patients referred for ¡°undiagnosed¡± syncope All characteristic vasodepressor history Mean cost of prior testing $3763 - 1991 Majority had Holter, echo, CT Calkins, Am J Med, 1993 Calkins, Am J Med, 1991.
  • 52. Case Presentation: Is typical practice cost effective? Hypothetical scenario presented to 916 MDs Becomes weak, lightheaded, & nauseated Collapses, awakens after 1 minute Feels well in ED - ¡°I want to go home¡± Normal exam, EKG, labs, CXR Diagnosis? Plan - Admit? Further testing? Glassman, Arch Intern Med, 1997
  • 53. Cost-effective workup: Internists vs. cardiologists Diagnosis: vasovagal syncope Intended plan: observation +/- overnight tele Survey results: aggressive approach Cardiologists Internists YOU Admit? 79% 72% ? Mean # additional tests 2.7 2.3 ? Glassman, Arch Intern Med, 1997
  • 54. Dizziness: key points Vertigo is most common etiology Positional triggers, nystagmus help confirm peripheral etiology Neuro findings, stroke risk prompt imaging Disequilibrium - commonly due to multifactorial deficits in elderly Presyncope - manage like syncope
  • 55. Syncope: key points History, exam, EKG guide further testing Identify possible cardiac syncope early Admit if high risk of cardiac disease Neurocardiogenic syncope - diagnosed clinically or by tilt table Idiopathic syncope has multiple etiologies and good prognosis