Transcript Syncope
Syncope Priya Victor M.D Introduction ► Syncope is defined as transient loss of consciousness and postural tone ► Accounts for 3% of all ER visits and 6% of all hospital admissions ► Could be the manifestation of benign neurocardiogenic or the first manifestation of an occult lifethreatening condition Objective ► To determine the utility of various diagnostic tests in the evaluation syncope CT scans Echo EKG Holter monitor EEG Tilt table test Methods ► Retrospective study ► 100 patients from the RCRMC ER admissions with a diagnosis of syncope were identified ► Chart review was performed with attention to the cause of syncope, investigations and results of further testing. Results of CT scans 1% 39% 60% Negative CT scan Old changes Acute changes Echo cardiogram 11% 1% 88% Negative Echo Insignificant changes Significant changes(AS) EKG 15% 1% 84% Normal Significant changes Insignificant Other tests ► 24 hr holter monitor two were done, both normal. ► One adenosine cardiolyte – normal. ► One ETT – normal. ► Two tilt table test , both were positive for hypotension. ► One dobutamine stress test – normal. Causes of syncope ► ► ► ► ► ► ► ► ► ► ► ► ► vasovagal Orthostatic hypotension Hypoglycemia Secondary to medications Sick sinus syndrome Symptomatic bradycardia PSVT BPV Iron defi anemia Seizures Afib with RVR Neck mass Unknown etiology 23 9 6 3 2 2 2 1 1 1 1 1 48 Discussion ► Of patients visiting ER with syncope: (Alboni et al JACC 2001;37:1921) Cardiac (often arrhythmia) 23% Neurally mediated 58% Neuro-psychiatric 1% Unexplained 18% ► Of patients with cardiac syncope, 24% subsequently develop Sudden Death (Kapoor, Medicine (Baltimore) 1990;69:160) Approach ► Accurate diagnosis of etiology is possible from history, examination, basic lab & ECG in 2/3 of patients. ► Of those who require detailed work-up: Clinically targeted: Dx. Reached by work-up in 73% Not targeted: Dx. Reached by work-up in 25% (Sarasin et al Am J Med 2001;111:177) ► Work-up depends on duration of symptoms,frequency of attacks, known preexisting disease, and age of the patient. Neurologic testing ► EEG (Hyperventilation, Sleep-deprived, Nasopharyngeal) ► Brain CT / MRI ► Carotid Duplex Some test is done in over half pts with syncope Rarely useful, except in very well-selected cases Pires et al. Arch Int Med 2001;161:1889 CONCLUSION ► Of all the tests performed, EKG was of greatest yield. ► The most common etiology was vasovagal. ► Even though vasovagal syncope was a common diagnosis , the tilt table test was only ordered for a minority of patients. CONCLUSION ► Of currently available diagnostic tests, the initial clinical history provides the greatest yield. ► A broad range of specialized tests can be performed for patients with syncope whose initial history and physical examination do not provide a diagnosis.