Transcript Syncope
My Chest Hurts and I Passed Out! Ryan Johnson, M.D. Arizona Pediatric Cardiology Consultants Chest Pain in Adolescents • Very common • More that 650,000 physician visits per year in patients 10-21 y/o • Second only to heart murmur among referrals to pediatric cardiology • 98% of the time it has nothing to do with the heart Non-Cardiac Chest Pain • • • • • Musculoskeletal Pulmonary Gastrointestinal Psychosocial Other Musculoskeletal • Chest wall pain (costocondritis) – most common cause (15-31%) – sharp/stabbing pain, upper-mid sternum, lasts for few seconds to minutes and often worse with deep breaths – frequently reproducible with palpation over costosternal joint(s) – always self limited, can have intermittent exacerbations Muskuloskeletal • Tietze syndrome – Localized inflammation of costochondral, costosternal or costoclavicular joint – Positive history of recent URI (? Coughing related) – Swelling, warmth and tenderness of single joint Muskuloskeletal • Trauma/exercise – Gymnastics, weightlifting, football, wrestling – Up to 2% of cases – Ask the question Muskuloskeletal • Precordial Catch “Texidor Twinge” – Intense, sudden onset, sharp pain over left lower sternal border to apex – Occurs at rest or during mild activity – Exacerbated by inspiration – Thought to be associated with poor posture and pinched nerve Muskuloskeletal • Treatment – Reassurance, Reassurance, Reassurance – “you are not having a heart attack” – Self limited – Can reoccur – Warm compress – NSAID Tid for 1 week Pulmonary • Asthma – 2 to 11% of cases – Weins et.al Pediatrics 1992 – PFTs during treadmill testing of children with chest pain revealed 75% with evidence of asthma • Pulmonary embolism – Intense chest pain with hypoxemia • Sickle Cell – Acute chest syndrome Gastrointestinal • GERD (gastroesophageal reflux) – 8% of cases – Burning type pain in epigastric to sub-sternal area – ? Bitter taste in mouth – H2 blockers or PPI • Cholecystitis • Esophageal stricture, foreign body Psychosocial • Anxiety – Anxiety attack, panic attack – Generalized pressure to sharp pain often accompanied by shortness of breath – history of recent social stressors or life changes • Hyperventilation – Often associated with anxiety – SOB, dizziness and paresthesias Other • Breast related – 1-5% of cases – Mastitis, fibrocystic disease, pregnancy • Hepes Zoster/Shingles – Burning type pain in a dermatomal pattern Cardiac Chest Pain • • • • Inflammatory Structural heart disease Coronary artery abnormalities Other Inflammatory • Pericarditis/myocarditis – Most common type of cardiac chest pain, but accounts for <5% of cases – Post infectious (cocksakie virus) – Sharp retrosternal pain, radiates to left shoulder, aggravated by supine position – Tachycardia/hypotension with myocarditis – Treatment = ibuprofen, steroids in rare cases, +/pericardiocentesis Structural Heart Disease • Cardiomyopathy (dilated and hypertrophic) • LVOT obstruction (aortic stenosis, subaortic stenosis and supravalvar aortic stenosis • Pain commonly associated with exercise • Harsh ejection murmur usually found on exam Coronary Artery Abnormalities • Congenital anomalies: ALCAPA, ALCA • Acquired: Kawasaki disease, post surgical (arterial switch, Ross procedure) • Heart transplant • Familial Hypercholesterolemia? • Squeezing, tightness, pressure associated with exertion Other Cardiac • Aortic dissection (Marfan, Ehlers-Danlos) • Pulmonary Hypertension (Primary or Secondary) • Drugs (cocaine, methamphetamine, marijuana) Syncope • Greek synkoptein “to cut short” or “cessation • William Harvey first describes vasovagal response during phlebotomy (1628) • Definition: Transient loss of conciousness and muscle tone with sponaneous recovery resulting from inadequate cerebral perfusion Syncope An Alternative Mechanism For Death by Crucifixion, Clinical Medicine, Ethics and Philosophy of MedicineIssueVolume 73, Number 3 / August 2006CategoryArticlePages282289Online DateTuesday, January 29, 2008 Prevalence • At least 15% of children between ages 8 – 18 years • Unusual before age of 6 years except in seizure disorders, breath holding spells History • Position (supine, sitting or standing) • Activity (Δ position, after urination, exercise) • Predisposing factors (warm place, prolonged standing, fear, pain, neck movements) • Onset of attack: palpitations, SOB, n/v, blurred vision, dizzy • Attack: fall (slump or kneel over), skin color, duration of LOC, movements • End of attack: N/V, confusion, skin color, injury, chest pain, palpitations, incontinence • Medications • Diet • Bathroom patterns • First attack, last attack and how many total Orthostatic Intolerance Syncope • Cardioinhibitory (vasovagal, neurocardiogenic, simple, neurally mediated) • Cardiodepressor (vasodepressor, dysautonomia) • Postural Orthostatic Tachycardia Syndrome (POTS) Cardioinhibitory Syncope • Uncommon before age 10 years • Prodrome of dizziness, nausea, pallor, flushing/diaphoresis, palpitations, blurry/dark vision, headache • Less than 1 min of LOC • Common in am, hot shower, prolonged standing, fright, pain, blood, crowded places, after prolonged exercise (stopped) Cardioinhibitory syncope • Upright posture causes pooling of blood in LE • Decrease in venous return causes transient hyperdynamic ventricle • Cardiac C fibers (mechanoreceptors) activate causing parasympathetic response resulting in bradycardia, peripheral vasodilation and hypotension • Abrupt decrease in BP and HR ± asystole Vasodepressor Syncope • • • • Wide age range Prodrome of dizziness only Less than 1 min LOC Common in dehydration, prolonged standing, prolonged bed rest • Guillain-Barre’ Syndrome, Complex regional pain syndrome Vasodepressor Syncope • Upright posture with venous pooling • Inappropriate or inadequate vasomotor response causing hypotension with little heart rate response • Decrease in blood pressure with blunted HR response POTS • Common in adolescent females • Venous pooling with sympathetic discharge • Dizziness, palpitations, nausea, exercise intolerance, chronic fatigue (syndrome) • Defined as increase in HR ≥ 30 bpm or HR ≥ 120 bpm in first 10 min after standing/upright POTS • Upright posture with venous pooling • Large sympathetic discharge resulting in significant tachycardia ± hypotension Work Up • Family History: epilepsy, sudden death/SIDS, cardiomyopathies, early adult heart disease • Social History: substance abuse, family stressors, psychiatric disorders • Physical Exam: usually normal (neuro, orthostatic vitals, murmur) • Labs: BMP, CBC, UA, thyroid • EKG: heart block, LQTS, WPW, ARVC, Brugada Tilt Table Test • • • • • • • • Used for: unexplained, recurrent, treatment failures Reproduces neurally mediated reflex Patient supine for 10-45 minutes prior to test Patient is tilted head-up at 60-70 degree for 20-45 minutes Can drug challenge (isoproterenol, nitroglycerin, edrophium) if passive phase negative False-positive: 10% NO sensitivity known d/t no “gold standard” for diagnosis of neurally mediated syncope Early studies showed angle < 60 = loss of sensitivity, >80= loss of specificity Treatment • Increase in fluid and salt intake • Support hose • Recognition of prodrome and aborting episode by lying down • Medications: fludrocortisone, midodrine, beta blockers, SSRI • reassurance When to refer • • • • • • Multiple episodes Atypical story Abnormal EKG Murmur Family history of sudden death Provider comfort level