Syncope A work up for Internists and Hospitalists - PowerPoint Presentation

Slide1

Syncope

A work up for Internists and Hospitalists

Philip

Dittmar

January 31, 2014Slide2

I have no conflicts of interest to disclose.Slide3

Syncope

The current state in healthcare

Classification of syncope

Costs of a “typical” work up

Ways to provide “High Value Cost Conscious Care”Slide4

Syncope

Transient loss of consciousness due to transient global cerebral

hypoperfusion

characterized by rapid onset, short duration, and spontaneous complete recovery.

Moya A,

Eur

Heart J 2009Slide5

What we want to know?

What caused it to happen?

Will it happen again?

Is this a sign of other things?

Is it deadly?Slide6

What we do know…

40% of the adult population has experienced a

syncopal

episode

1

1% of ER

visits

2

Up to 5% of admissions

Annual healthcare costs estimated at $2.4bn

2

Cost per inpatient work up $5,400

1

Soteriades

ES, N

Engl

J Med 2002

2

Sun BC, Am J

Cardiol

2005Slide7

What we do know…

Incidence and rate of hospitalization increases with

age

1

Soteriades

ES, N

Engl

J Med 2002Slide8

What does this do to our patients?

Functional impairment on par with RA

,

chronic low back pain, and depressive

disorders.

Linzer M, J

Clin

Epidemiol

1991Slide9

Syncope

The current state in healthcare

Classification of syncope

Costs of a “typical” work up

Ways to provide “High Value Care”Slide10

Symptom not a Diagnosis

Cardiac syncope

Arrhythmia

Structural heart disease

Non-cardiac syncope

Neurally

-mediated syncope

Orthostatic hypotension

Non-syncope

Epilepsy, concussion, psychogenic

pseudosyncopeSlide11

Cardiac Syncope

Arrhythmia

Bradycardia

Sick sinus,

atrioventicular

b

lock

Tachycardia

Ventricular tachycardia, supraventricular tachycardia, Wolff-Parkinson-White

Long QT syndrome,

Brugada syndromeStructural

Aortic stenosis, mitral

s

tenosis

Hypertrophic

o

bstructive cardiomyopathy

IschemiaSlide12

Non-Cardiac Syncope

Neurally

-mediated syncope

Vasovagal

Carotid sinus

Situational – cough, sneeze, micturition

Orthostatic hypotension

Drug induced

Autonomic nervous system failureSlide13

Non-Syncope

Epilepsy

Concussion

Psychogenic

pseudosyncope

Acute intoxication

Hypoglycemia

Sleep disordersSlide14

Soteriades

ES, N

Engl

J Med 2002

Overall Survival with SyncopeSlide15

Causes of syncope by age

Parry SW, BMJ 2010Slide16

Syncope

The current state in healthcare

Classification of syncope

Costs of a “typical” work up

Ways to provide “High Value Cost Conscious Care”Slide17

Our patient

65-year-old man with history of CAD s/p stent with syncope. He does not recall any

prodrome

, but stated that symptoms started after walking across his living room. His wife was in another room and heard him crash into the coffee table. She noted some jerking movements prior to his return to full alertness. Wife called 911.Slide18

What we do (on day 0)

Thorough history with witness statement

Physical examination

ECG with telemetry

CBC, CMP, Troponin, CXR, Transthoracic Echo

CT Head

Urinalysis with Toxicology

Cost: >$1,500

https://www.healthcarebluebook.com

/Slide19

What we do (on day 1)

Stress test

Carotid

doppler

MRI/MRA

EEG

CTA chest

TSH, lipids,

Hgb

A

1

CAdditional cost for testing: >$4,250

https://www.healthcarebluebook.com

/Slide20

…and on day 2

Left heart catheterization

Send home with a

Holter

monitor

Could add an addition cost of: $7,000

1

Testing could reach: >$12,500

Average cost in US per syncope-related hospitalization: $5400

2

Average length of stay: 2.7 days

1

https://www.healthcarebluebook.com

2

Sun

BC,

Am

J

Cardiol

2005Slide21

Syncope

The current state in healthcare

Classification of syncope

Costs of a “typical” work up

Ways to provide “High Value, Cost Conscious Care”Slide22

How can we do this better?

Syncope. Cost-effective patient workup.

Radack

KL, Postgrad Med

1986.

A cost effective approach to the investigation of syncope: relative merit of different diagnostic strategies

Simpson CS,

Can J

Cardiol

1999.Slide23

AHA/ACCF Statement on the Evaluation of Syncope – 2006

Expert

Concensus

Strickberger

, SA,

Circ

& J Am

Coll

Cardiol

2006Slide24

New Concepts in the Assessment of Syncope.

JACC 2012

Brignole

M, J Am

Coll

Cardiol

2012Slide25

How do we assess risk?

Parry SW, BMJ 2010Slide26

Calgary Syncope Symptom Score

Is there a history of

bifascicular

block,

asystole

, SVT, or diabetes?

-5

Blue during faint?

-4

First episode when age 35 or older?

-3

Do you remember anything while unconscious?

-2

Lightheaded spells or fainting with prolonged sitting or standing?

+1

Diaphoresis or warm feeling prior to faint?

+2

Lightheaded

spells or fainting with

pain or in medical settings?

+3

Vasovagal syncope if the total point score

is

≥ -2

Excludes patients with known cardiomyopathy or myocardial infarction

Sheldon R,

Eur

Heart J 2006Slide27

Red Flags – San Fran Syncope Rule

C

ongestive heart failure history

H

ematocrit < 30%

E

KG changes

S

hortness of breath

S

ystolic Blood Pressure < 90 mm Hg at triage

No to all = Low risk for serious outcome at 7 days

Quinn J, Ann

Emerg

Med 2004Slide28

OESIL Risk Score

Abnormal ECG

History of cardiovascular disease

Lack of

prodrome

Age > 65

12 month all cause mortality:

0% - score 0

0.6% - score 1

14% - score 2

29% - score 3

53% - score 4

Colvicchi

F,

Eur

Heart J 2003Slide29

Recap of Risk Factors

Age

Known cardiac disease

Abnormal ECG

Lack of

prodrome

Associated chest pain or shortness of breathSlide30

Syncope Evaluations in the Elderly

Retrospective Review

from 2002-2006

at Yale

2106

syncope admits, aged ≥65

Admission or discharge diagnosis of syncope

Syncope Etiology:

Unknown 47%

Vasovagal 22%

Orthostasis

13%

Arrhythmia 12%

Dehydration 8%

Other cardiac causes 4%

Situational 3%

>1 Etiology 9%

Mendu

ML, Arch Intern Med 2009Slide31

Diagnostic Yield in Older Patients

Test

Obtained

Abnormal

Affected

Dx

Etiology

Management

ECG

2081

(99)

438 (21)

147 (7)

72

(3)

153 (7)

Telemetry

2001 (95)

314 (16)

212 (11)

95 (5)

245 (12)

Enzymes

1991 (95)

108 (5)

31 (2)

9 (0.5)

29 (1)

Head CT

1327 (63)

138 (10)

28 (2)

7 (0.5)

28 (2)

TTE

821 (39)

516 (63)

35 (4)

13 (2)

36 (4)

Postural BP

808 (38)

230 (28)

142 (18)

122

(15)

202 (25)

Carotid US

267 (13)

122 (46)

2 (1)

2 (0.8)

6 (2)

EEG

174 (8)

68 (39)

2 (1)

1

(0.6)

2 (1)

Head

MRI

154 (7)

46 (30)

20 (13)

3 (2)

19 (12)

Stress Test

129 (6)

53 (41)

13 (10)

2 (2)

12 (9)

Mendu

ML, Arch Intern Med 2009Slide32

Diagnostic Yield in Older Patients

Test

Obtained

Abnormal

Affected

Dx

Etiology

Management

ECG

2081

(99)

438 (21)

147 (7)

72

(3)

153 (7)

Telemetry

2001 (95)

314 (16)

212 (11)

95 (5)

245 (12)

Enzymes

1991 (95)

108 (5)

31 (2)

9 (0.5)

29 (1)

Head CT

1327 (63)

138 (10)

28 (2)

7 (0.5)

28 (2)

TTE

821 (39)

516 (63)

35 (4)

13 (2)

36 (4)

Postural BP

808 (38)

230 (28)

142 (18)

122

(15)

202 (25)

Carotid US

267 (13)

122 (46)

2 (1)

2 (0.8)

6 (2)

EEG

174 (8)

68 (39)

2 (1)

1

(0.6)

2 (1)

Head

MRI

154 (7)

46 (30)

20 (13)

3 (2)

19 (12)

Stress Test

129 (6)

53 (41)

13 (10)

2 (2)

12 (9)

Mendu

ML, Arch Intern Med 2009Slide33

Test

Cost

per test result affecting management

EEG

$32,973

Head CT

$24,881

Cardiac Enzymes

$22,397

*Troponin I alone

$4,818

Carotid Ultrasound

$19,580

Head MRI

$8,678

Stress Test

$8,415

Echo

$6,272

ECG

$1,020

Telemetry

$710

Postural

Blood Pressure

$17

Mendu

ML, Arch Intern Med 2009Slide34

What is NOT helpful?

EEG

Head CT

Cardiac Enzymes

Carotid USSlide35

EEG and Syncope

Myoclonic jerks associated with true syncope

Can be mistaken for seizure activity

Ictal

asystole

is a rare but severe complication of epileptic seizures

828 patients admitted for

presurgery

video EEG monitoring between 2003-2013.

9 (1.08%) had

ictal asystole

Lasting 13 +/- 7 seconds

Mostly asymptomatic

Nguyen-Michel VH,

Epilepsia

2014Slide36

Head CT and Syncope

Of 293 ED syncope patients, 113 underwent CT head

5% had abnormal head findings

2 with subarachnoid hemorrhage

2 with cerebral hemorrhage

1 with stroke

Abnormal CTs associated with:

Focal neurological findings, headache, or trauma

Only half of patients undergoing CT had any neurological findings, headache, trauma above the clavicles, or

coumadin

use.

Grossman SA, Intern

Emerg

Med 2007Slide37

Cardiac Enzymes and Syncope

Troponin unlikely to be beneficial unless other signs or symptoms point to MI.

Copeptin

– surrogate marker for Vasopressin

Studied in Acute Myocardial Infarction

Small studies have found increased levels in patients with positive head up tilt test.

1

1

Lagi

A,

Int

J

Clin

Pract

2013Slide38

Carotid US and Syncope

Choosing Wisely Recommendation #2:

Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

Langer-Gould AM,

Neuro

2013Slide39

What does work?

Thorough history with collateral information from witness

Physical examination

Postural blood pressure

ECG

Cost = $435

https://www.healthcarebluebook.com

/Slide40

Take a good history!

“5 Ps”

Precipitants

Prodrome

Palpitations

Position

Post-event phenomena

Appearance

Abnormal Movements

Eyes open or closed

Mental State

Incontinence/Tongue Biting

Chronic medical issues

Family history of SCD

Parry SW, BMJ 2010Slide41

ECG and Telemetry

ECGs are relatively cheap and informative

Structural Heart Disease

Q-waves (infarct)

ST segment changes (ischemia)

Conduction System Disease

Bundle

b

ranch block

Atrioventricular

(AV) block

Electrical DiseaseWolff-Parkinson-White (WPW) syndrome

Brugada

syndrome

Long QT syndrome

Marine JE, J

Electrocardiol

, 2013Slide42

Outpatient ECG Monitoring

Holter

Monitor – daily

syncopal

episodes

Event Recorder – weekly

syncopal

episodes

Implantable Loop Recorder – monthly

syncopal

episodesSlide43

Postural Blood Pressure

Have the patient lie supine for 10 minutes

Measure blood pressure and pulse

Have the patient stand

Inquire about symptoms

Repeat blood pressure after 1 and 3 minutes

Classical Orthostatic Hypotension is defined by:

Drop in SBP >20 mm Hg or DBP >10 mm Hg within 3 minutes of standingSlide44

Carotid Sinus Syncope

Carotid Sinus Massage

10 second sequential (right then left) with patient supine and erect

Hypersensitivity defined by:

Ventricular pause lasting >3 seconds

Fall in systolic BP >50 mm Hg

Carotid Sinus Syncope define by hypersensitivity in the presence of syncopeSlide45

Post - H&P, ECG, and Postural BP

You should be able to answer:

Syncope or not?

Etiology determined based on the above?

High risk of cardiovascular events or death?Slide46

Echocardiogram and Syncope

Echo is helpful to confirm or refute suspicion of cardiac disease after the basics

Not indicated for syncope without suspicion of cardiac disease

Must have 2

nd

diagnosisSlide47

Advanced Cardiac Testing

Stress

testing and Left Heart Catheterization

If concern for ischemia

EP study

If concern for tachyarrhythmia

Tilt

test

For diagnostic dilemma or if it will affect treatmentSlide48

Tilt Table Testing

An effective technique for providing direct diagnostic evidence indicating susceptibility to vasovagal syncope

Utilizes a drug-free tilt lasting 45 minutes and pharmacologic provocation (Isoproterenol)

Monitor heart rate and blood pressure

Positive test with provocation of

neurally

-mediated hypotension or bradycardia (or both)

Benditt

DG, JACC, 1996Slide49

General Concepts

Perform a comprehensive history and physical examination using evidence based tools

Routinely obtain an ECG

Utilize EEG, Head CT, or MRI only with clinical suspicion of focal neurological deficit or seizure

Consider

Holter

, event recorder, or implantable loop recorders if an

arrythmia

is suspected, depending on frequency of events

Utilize cardiac imaging only with clinical suspicion of structural or

valvular

heart disease

Perform invasive EP study only with clinical suspicion of a tachyarrhythmia

Obtain a Tilt test only for diagnostic dilemma and if it will affect treatment and/or outcomeSlide50

Do’s and Don’ts

Do every time:

H&P, ECG, Postural Blood Pressure

Try to avoid:

EEG, Cardiac Enzymes, Head CT, Carotid US

Other testing as indicated based on findings

Try to avoid the shot gun approach Slide51

Bibliography

Moya A, Sutton R,

Ammirati

F, Blanc JJ,

Brignole

M,

Dahm

JB, et al. Guidelines for the diagnosis and management of syncope (version 2009): the task force for the diagnosis and management of syncope of the European Society of Cardiology (ESC).

Eur

Heart J

2009;30:2631-71.

Soteriades

ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, et al. Incidence and prognosis of syncope.

N

Eng

J Med

2002;347:878-85.

Sun BC,

Emond

JA, Camargo CA Jr. Direct medical costs of syncope-related hospitalizations in the United States.

Am J

Cardiol

2005;95:668-71.

Linzer M,

Pontinen

M, Gold DT, Divine GW, Felder A, Brooks WB. Impairment of physical and psychosocial function in recurrent syncope.

J

Clin

Epidemiol

1991;44:1037-43.

Rosanio

S, Schwarz ER, Ware DL,

Vitarelli

A. Syncope in adults: systematic review and proposal of a diagnostic and therapeutic algorithm.

Int

J

Cardiol

2013;162(3):149-57.

Parry SW, Tan MP. An approach to the evaluation and management of syncope in adults.

BMJ

2010;340:c880.

https://www.healthcarebluebook.com/

Radack

KL. Syncope. Cost-effective patient workup.

Postgrad Med

1986;80(8):169-76.

Simpson CS,

Krahn

AD, Klein GJ, Yee R,

Skanes

AC,

Manda

V, Norris C. A cost effective approach to the investigation of syncope: relative merit of different diagnostic strategies. Can J

Cardiol

1999;15(5):579-84.

Strickberger

, SA, Benson DW,

Biaggioni

I,

Callans

DJ, Cohen MI,

Ellenbogen

KA, et al. AHA/ACCF scientific statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society.

Circulation

2006;113(2):316-27.

Brignole

M,

Hamdan

MH. New concepts in the assessment of syncope.

J Am

Coll

Cardiol

2012;59(18):1583-91.

Sheldon R, Rose S, Connolly S, Ritchie D,

Koshman

ML,

Frenneaux

M. Diagnostic criteria for vasovagal syncope based on a quantitative history.

Eur

Heart J

2006;27(3):344-50.

Quinn JV,

Stiell

IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes.

Ann

Emerg

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