1. SYNCOPE Nathan Mjos, D.O. PGY4 ARMC Emergency Dept July 20, 2011

2. Defined as as a transient loss of consciousness and postural tone characterized by rapid onset, short duration and spontaneous recovery due to global cerebral hypoperfusion that most often results from hypotension Syncope:

3. Accounts for 1-3% of annual ER visits Accounts for 6% of hospitalizations Highest incidence in elderly population as well as highest morbidity Distinct entity from dizziness or vertigo Incidence

4. Reflex:Cardiac: Dysrhythmias Vasovagal Structural cardiopulmonary disease Bradyarythmias Situational Valvular heart disease Stokes-Adams Carotid sinus syndrome Aortic/tricuspid/mitral stenosis Sinus node disease Orthostatic hypotensioncardiomyopathy 2nd or 3rd degree block Psychiatric Pulmonary HTN Pacemaker malfunction Neurologic: Congenital heart disease Ventricular tachycardia TIA MyxomaTorsades de pointes Subclavian steal Pericardial disease SVT Migraine Aortic dissection Atrial fibrillation Medications Pulmonary embolism Atrial flutter Breath Holding (peds) Myocardial ischemia Causes

5. AntihypertensivesPhenothiazines B-blockers Nitrates Cardiac glycosides Alcohol Diuretics Cocaine Antidysrhythmics Antipsychotics Antipsychotics Antiparkinsonism drugs Common Drugs Implicated

6. EKG findings

7. Diagnostic rate of 20-50% in the ER Definitive diagnosis in 15-30% of inpatients after thorough work-up Framingham Heart Study reported 822 episodes of syncope in 7814 patients over 17 year period1: Vasovagal (21%) Cardiac (10%) Orthostatic (9%) Unknown (37%)

8. Orthostatic hypotension defined as fall in SBP of 20 mm Hg upon assuming upright position 5 – 55% of patients with orthostatic hypotension also have other identifiable causes of syncope2 Asymptomatic orthostatic hypotension found in 40% patients > 70 years old Orthostatics (and IM)

9. The emergency physician must identify those relatively few patients with life-threatening processes (e.g., dysrhythmias, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, acute coronary syndromes) and those other patients who may benefit from intervention (e.g., patients with bradycardia, medication-induced orthostatic hypotension) ACEP 2007 recommendations

10. Martin et al 19973: 252 syncope patients Validated cohort 374 patients Predictors of arrhythmia or 1-year mortality: Abnormal EKG h/o ventricular arrhythmia h/o CHF Age > 45 End point arrhythmia or death at 1 year 0% with 0 risk factors and 27% with 3-4 risk factors Study Support

11. Colivicchi et al 2007 The OsservatorioEpidemiologicosullaSincopenel Lazio (OESIL) score 270 syncope patients, validated with 328 patient cohort End point was death at 1 year Sensitivity 95%, Specificity 31% Found that age, abnormal EKG, lack of prodrome, h/o cardiovascular disease, and heart failure are all reliable predictors of adverse events at 1 year in syncope patients

12. 684 patients with syncope Adverse events recorded at 7 days 0 factors considered low risk Sensitivity 86%, Specificity 49% C – CHF H – Hematocrit < 30% E – abnormal EKG (new changes or nonsinus rhythm) S – systolic BP < 90 S – Shortness of breath San Francisco Syncope Study

13. History, history, history… Vitals: persistent hypotension suggestive of another disease process EKG: diagnostic in < 5% Continuous cardiac monitoring: predictors of arrhythmia in 72 monitor – initial abnormal EKG, male sex, age > 65, h/o heart disease Diagnostic Testing

14. Laboratory testing: little diagnostic value other than hematocrit (less than 30% associated with poor outcome)5 Routine CT of the head NOT recommended Independent testing scores result in higher admission rates (SFSR 40%, OEDIL 43%) than clinical judgement alone (34%)6

15. Soteriades ES, Evans JC, Larson MG, et al: Incidence and prognosis of syncope. New Engl J Med 347:878, 2002. Atkins D, Hanusa B, Sefcik T, et al: Syncope and orthostatic hypotension. Am J Med 91:179, 1991. Martin TP, Hanusa BH, Kapoor WN. Risk stratification of patients with syncope. Ann Emerg Med. 1997;29:459-466. ColivicchiF, Ammirati F, Melina D, et al. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J. 2003;24:811-819. Quinn JV, Stiell IG, McDermott DA, et al. Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004;43:224-232. 23. Calkins H, Shyr Y, Frumin H, et al. Serrano LA, Hess EP, Bellolio F, et al. Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2010;56:362-373. References