Approach to Syncope(1)_fde7fdca-1b42-4be1-a4ff-77d5da4bba84.pptx

syncope

1. Approach to syncope Pressenter : Dr. Santosh Pokhrel Moderator : Dr. Sonali Nayak

2. Cases 1 A 65-year-old man presents to the emergency department after experiencing a brief loss of consciousness while walking uphill. He did not experience any warning signs and collapsed suddenly. There was no tonic-clonic activity, tongue biting, or incontinence. He regained consciousness within 1 minute and no post ictal confusion present. He has a history of hypertension and increasing exertional dyspnea over the past few months. There was systolic ejection murmur heard best at the second right intercostal space. ECG shows left ventricular hypertrophy. A. Vasovagal syncope B. Seizure C. Aortic stenosis D. Orthostatic hypotension E. Hypoglycemia

3. Case 2 A 42-year-old woman presents after a brief loss of consciousness early in the morning. She reports that it happened shortly after she stood up from bed. She recalls waking up on the floor feeling very tired and slightly confused. Her husband says he heard a thud and found her lying unresponsive for about a minute. There was no tongue bite. She denies any chest pain, palpitations, or presyncopal symptoms. She is otherwise healthy, with no regular medications. What would you like to do ? A. Tilt-table testing to assess for orthostatic hypotension B. Ambulatory ECG (Holter monitor) to assess for cardiac arrhythmia C. MRI brain with EEG to evaluate for seizure D. Reassure and discharge with outpatient follow-up

4. Syncope The transient self limited loss of consciousness due to the acute global impairment of cerebral blood flow Onset is rapid Duration is brief recovery is spontaneous and rapid

5. Causes of Syncope

6. Pathophysiology Brain receives the 750ml/min blood and is 15% of cardiac output cessation of blood flow for 6_8sec will result in loss of consciousness and blood flow is less than 25ml/sec per 100gm brain tissue

7. NEURALLY MEDIATED SYNCOPE Causes 1.Vasovagal syncope: Provoked fearr,pain,anxiety 2.situational: a.Pulomonary Cough, wind instrument players ,sneeze b.Urogenital post micturition urogenital tract instrumentation,prostatic massage c.Gastrointestinal Swalllow syncope, glossopharyngeal neuralgia Gastrointestinal instrumentation, rectal examination ,defecation syncope

8. d.Carotid sinus: Carotid sinus sensitivity, carotid sinus massage e.ocular : ocular pressure,ocular examination,ocular surgery

9. Orthostatic Hypotension Primary autonomic failure due to idiopathic central and peripheral neurodegenerative diseases Lewy body disease Parkinsonism Pure autonomic failure Multiple system atrophy(shy dragger syndrome)

10. Secondary autonomic failure due to autonomic peripheral neuropathies Daibetes Hereditary amyloidosis Primary amyloidosis Hereditary sensory and autonomic neuropathies Idiopathic immune mediated autonomic neuropathy Autoimmune autonomic gangliopathy Sjogrens syndrome HIV neuropathy

11. Cardiac syncope Arrhythmias: a.Sinus node dysfunction b.Atrioventricular dysfunction c.Supraventricular tachycardias d.Ventricular tachycardias e.Inherited channelopathies :

12. Cardiac structural disease a.Valvular disease b.Myocardial ischaemia c.Obstructive and other cardiomyopathies d.Atrial myxoma e.Pericardial effusion and tamponade

13. Approach to patient I was standing in line for a long time. Suddenly I felt hot, my vision blurred, and next thing I knew, I was on the floor." "I fainted when I saw blood during my blood draw." "I fainted in the bathroom while straining to pass stool." "I was urinating early in the morning when everything went black." "I was coughing hard and then I just collapsed." "It happened after swallowing a big pill." "I fainted right after getting out of bed." "Whenever I stand for a while, I feel dizzy and sometimes blackout." "I was vomiting for two days, and when I stood up to go to the bathroom, I fainted."

14. "I was just sitting and talking to someone, and suddenly I lost consciousness. "I felt my heart race, then everything went dark for a few seconds." "They told me I passed out in the middle of my sentence." "I fainted while walking uphill. I had some chest tightness just before." "I get dizzy every time I climb stairs or walk fast."

15. History Prodrome : Lightheadedness? Visual changes? Nausea? Palpitations? Position: Standing (suggests orthostatic or vasovagal) Supine (suggests cardiac) Sitting (less common but possible with arrhythmias) Post-event: Confusion (suggests seizure) Quick recovery (more likely syncope) Injury (severity and location)

16. Red flag signs Sudden syncope during exertion Family history of sudden cardiac death Palpitations prior to syncope Syncope with chest pain or dyspnea Age >60 with cardiac comorbidities

17. Examination Vitals: Supine → sitting → standing BP & HR (orthostatic hypotension) Pulse deficit or bradycardia? (suggest arrhythmia) Cardiac Exam: Murmur? (AS, HCM) Irregular rhythm (AF, complete heart block) Carotid Sinus Massage: Only in patients >40 years with negative workup and suspected reflex syncope

18. Differential diagnosis SEIZURE HYPOGLYCEMIA CATAPLEXY PRESYNCOPE

19. E xamination i . Head up tilt- table testing : Positioning patient supine on a padded table that is then tilted to 60-70 degree for upto 45 min,monitoring BP and ECG. ii . Carotid sinus massage : Should be avoided if there is presence of carotid bruit. Positive test is characterized by ECG showing sinus pause of 3 sec and fall in systolic blood pressure of more than 50 mmhg .

20. Autonomic Nervous System Testing Includes assessment of parasympathetic autonomic nervous system function (eg: heart rate variability to deep respirations and a Valsalva maneuver), sympathetic cholinergic function (eg: thermoregulatory sweat response and quantitative sudomotor axon reflex test) and sympathetic adrenergic function test (BP response to Valsalva maneuver ) Tilt table test - useful in distinguishing orthostatic hypotension due to autonomic failure from the hypotensive bradycardic response of the neurally mediated syncope

21. BLOOD PRESSURE MONITORING To rule out orthostatic hypotension: Monitor BP after 3 minute of standing In case of orthostatic hypotension there is reduction of systolic BP of atleast 20mmhg and diastolic BP of atleast 10mmhg

22. ECG monitoring: may show feature of non sustained VT,sinus bradycardia,high degree AV node block - It is diagnostic when there is correlation between syncope and documented arrythmia -Absence of arrythmias during syncope excludes arrythmic syncope

23. -Some arrythmias are likely the cause of syncope even if they are not correlated with a syncopal episode a. Mobitz II or 3 rd degree AV block b. Ventricular pause>3 sec c. Rapid prolonged paroxysmal VT/SVT Ion channelopathies such as QT prolongation:Romano wardsyndrome

24. Holter monitoring is recommended for patients who experiences frequent syncopal episodes one or more episodes in week Echocardiography:Its indicated if structural heart disease is suspected or if other examination fails daignosis

25. 4. Neurological evaluation: to exclude the causes of loss of consciousness other than syncope CT scan or MRI of brain, EEG can be done 5.Psychiatric evaluation

26. TREATEMENT OF SYNCOPE

27. Patient in syncope Patient kept in left lateral position Secure airway, breathing and circulation (loosen any tight clothings around the neck; peripheral stimulation) Monitor blood sugar level vasovagal Identification the cause of syncope orthostatic cardiac

28. 1. NEUROGENIC SYNCOPE Counsel the patients to take steps to avoid injury by being aware of prodromal symptos and maintaining horizontal position at those times. Avoid known precipitants and maintain adequate hydration Employ isometric muscle contraction during prodrome to abort episodes. Fludrocotisone vasoconstricting agents and beta adrenoreceptors antagonist are widely used by experts to treat refractory patients. Though the trial and evidence regarding the use of d rug is less likely

29. 2.0RTHOSTATIC HYPOTENSION : Adequate hydration and elimination of offending drugs. Salt supplementation compressive stocking counselling on standing slowly midodrine and fludrocortisone can help by increasing systolic BP and expanding plasama volume respectively.

30. 3. CARDIOVASCULAR(ARRYTHMIA OR MECHANICAL) Treatment of underlying disorders(valve replacement,antiarrythmic agent,coronary revascularization) Cardiac pacing for sinus node dysfunction or high degree AV block Catheter ablation procedures in selected with syncope associated with SVT. Discontinuation of QT prolongation drugs ICD for ion channelopathies and other conditions if needed.

31. Case 1 A 65-year-old man presents to the emergency department after experiencing a brief loss of consciousness while walking uphill. He did not experience any warning signs and collapsed suddenly. There was no tonic-clonic activity, tongue biting, or incontinence. He regained consciousness within 1 minute and no post ictal confusion present. He has a history of hypertension and increasing exertional dyspnea over the past few months. There was systolic ejection murmur heard best at the second right intercostal space. ECG shows left ventricular hypertrophy. A. Vasovagal syncope B. Seizure C. Aortic stenosis D. Orthostatic hypotension E. Hypoglycemia

32. This patient experienced exertional syncope without prodrome, suggestive of cardiac syncope. The presence of a systolic murmur, exertional symptoms, and left ventricular hypertrophy is classic for aortic stenosis. Aortic stenosis limits cardiac output during exertion, leading to transient cerebral hypoperfusion and sudden syncope. Vasovagal syncope typically has a prodrome (nausea, lightheadedness). Seizure often involves postictal confusion, tongue biting, or incontinence. Orthostatic hypotension would present after standing, not during exertion.

33. A 42-year-old woman presents after a brief loss of consciousness early in the morning. She reports that it happened shortly after she stood up from bed. She recalls waking up on the floor feeling very tired and slightly confused. Her husband says he heard a thud and found her lying unresponsive for about a minute. There was no tongue bite. She denies any chest pain, palpitations, or presyncopal symptoms. She is otherwise healthy, with no regular medications. What would you like to do ? A. Tilt-table testing to assess for orthostatic hypotension B. Ambulatory ECG (Holter monitor) to assess for cardiac arrhythmia C. MRI brain with EEG to evaluate for seizure D. Reassure and discharge with outpatient follow-up

34. Though the event occurred after standing, the post-event confusion and lack of orthostatic BP drop or prodrome raise suspicion for seizure. No tongue bite does not rule out seizure. Cardiac syncope is less likely due to absence of palpitations, chest pain, or cardiac history. Tilt-table test is used when vasovagal or orthostatic causes are suspected and initial workup is unrevealing. EEG ± MRI is essential when there is suspicion of first unprovoked seizure or unexplained LOC with neurological features.

35. Take Home Message Other causes of transient loss of consciousness should be distinguished from syncope Appropriate history, physical examination, special investigations and a cardiac evaluation is necessary in patients presenting with syncope

36. References Harrison's Principle and Practice of Internal Medicine Hutchison's Clinical Methods, 25th Edition

37. THANK YOU!