Syncope: from admission to risk stratification
Giorgio Costantino, MDNicola Montano, MD, PhD
Cardiovascular Neuroscience Lab,Department of Biomedical and Clinical SciencesUniversity of MilanDepartment of Medicine Fondazione Policlinico, Milan
European School of Internal Medicine 2015Muravera, Sardinia, June 7-13
Non indicato nei pazienti con episodisincopali isolati e con chiare caratteristicheneuromediate desumibili dallanamnesi
Intro Less than 5% of syncopes may be
considered related to emergencyconditions
Impossible to consider all syncopalevents as emergency conditions
However, unrecognize those that hideemergent conditions may lead to dramatic consequences
What is the main problem with syncope?
Mrs. Silvana Admitted to the ER
after after a syncopalepisodes triggered by a relevant emotionalstress.
AP 100/60 mmHg; HR 110 b/m r
Miss Giulia Admitted to the ER
after after a syncopalepisodes triggered by a relevant emotionalstress.
AP 100/60 mmHg; HR 110 b/m r
Mrs. Silvana 78 years old, known
hypertensive under therapy
Syncope occurredwithout any prodromesafter being informedthat the mammographyshe underwent for a mammary nodule waspositive for breastcancer.
Miss Giulia 19 years old, silent
medical hystory Syncope occurred,
without any prodromes, after being informedthat she did not pass the test for the admission to the School of Medicine.
Mrs. Silvana Admitted to the clinical
ward for pulmorayembolism
Miss Giulia Discharged, in good
health
A 66 years-old woman
is admitted to the ER for a syncopal episodeoccurred during walking, without prodromes, followed by a head trauma.- Hypertensive, under ACEi tretment- She referred an episode of unclear bradycardia(no documentation provided) 5 years before.- In ER: negative CSM, negative telemetric ECG monitoring, few asymptomatic episodes of sinustachycardia.
.she underwent:
. Doppler Echocardiogram (normal),
. telemetric continuous monitoring (negative), .
. Holter ECG (negative).
- Discharged with diagnosis of UnexplainedSyncope.
admitted to the ward
Questions
What was her risk? Was admittance to the clinic
useful?
ER approach to Syncope
Recognize high-risk vs low-risk patients;
Do not discharge a patients at risk of a major
event;
Do not admit a patient who doesnt need.
Definition
Syncope is a transient loss of consciousness (T-LOC) due to a transient global cerebral hypoperfuzion characterized by:
rapid onset short duration spontaneous complete recovery
ESC Guidelines 2009
Syncope - Pathophysiology
ESC Guidelines 2009
Epidemiology
ESC Guidelines 2009
Soteriades, ES et al. NEJM 2002
Syncope - Survival
N=7814 patients mean follow-up 17 yrs
Initial evaluation
1. Is it Syncope?
2. Is syncope immediately evolving
3. What is the cause?
4. Is it a high-risk syncope?
Main clinical tools
Medical history Physical examination Lying and standing BP measurement ECG Other exams
MEDICAL HISTORY, PHYSICAL EXAMINATION AND ECG LEAD TO
DIAGNOSIS IN ABOUT 70% OF SYNCOPAL EPISODES.
VIM (Very Important Message)
Mrs Marta..
83 years-old, living alone Found at home lying down on the floor,
doesnt remember how did it happen She said she slipped down without being
able to get up for a very painful leg She doesn t remember how long she
stayed down on the floor
Is this Syncope?
Without witnesses, consider it as a
syncopal event (especially in the elderly).
Anamnestic Grid
Number of episodes Prodromes Associated symptoms Occurring circumstances Medical history of CAD Relevant comorbidities in medical history Episodes consequences Therapy
Mrs Hilary.
67 years old, is admitted to the ER for a syncopal episodes occured while she wasstanding still in the church
She refers a 20 years of history of recurrentsyncopale episodes, of short duration, both in orthostatism and sitting positions.
Nothing relevant in the medical history
NUMBER OF EPISODES
Recurrency over a short-term have usuallya negative prognostic meaning.
Recurrency over a long-term have usually a positive prognostic meaning.
First episode: variable, usually benign
Initial evaluation
1. Is it Syncope?
2. Is syncope immediately evolving
3. What is the cause?
4. Is it a high-risk syncope?
Mr Giancarlo..
64 years old, admitted to the ER for a syncopalepisodes without prodromes.
No overt cardiovascular diseases
During the triage, slightly confused.
Normal vital parameters.
.
Green code (medium severity) assigned The patient was waiting to undergo an
operation for cerebral aneurysm in the nextdays.
He waited 4 hour before being visited and during the medical visit fainted afterreferring a sudden acute headache.
Syncope associated with Emergent conditions
Pulmonary Embolism Hypertensive Pneumothorax
Aortic Dissection Major Cardiac Arrhythmias
Internal Hemorrhage Ectopic Pregnancy
Abdominal Aorta Aneurysm Subarachnoid Hemorrage
Myocardial Infarction Carotid Dissection
Cardiac Tamponade Fat Embolism
Alerting symptoms
PainDyspneaDisability (neurological signs and symptoms) tachycardia (unexplained)
VIM
The presence of at least one of thesesigns/symptoms allows to hypothesize the presenceof a life-threatening disease as the cause of the syncopal episode.
Thus, medical history, physical examination and diagnostic approch must be performed to exclude it.
Main clinical tools
Medical history Physical examination Lying and standing BP measurement ECG Other exams
12-leads ECG signs Sinus bradycardia; AV node blocks (II o III degree); AV block Mobitz 2 type tipo; Bundle branch block; Long or short QT; Specific ischemic repolarization signs; Signs of right heart overload; Arrhythmogenic dysplasia of the right ventricle /Brugada
syndrome; Signs of pericarditis or electrical alternans; Left or right ventricular hypertrophy.
VIM
MEDICAL HISTORY AND AN ECG NEGATIVE FOR CARDIAC DISEASES RULE OUT UP TO
97% A CARDIAC CAUSE FOR SYNCOPE
Main clinical tools
Medical history Physical examination Lying and standing BP measurement ECG Other exams
Other exams CSM in patients > 40 yrs Echocardiogram: if a cardiomyopathy is known or
suspected Continuous ECG monitoring: if an arrhythmis
syncope is supected Head-up Tilt Test: if syncope occurred while standing
or there is suspicion of a neuromediated Neurologic examination and blood exams: only if
there is suspicion of a non-syncopal T-LOC.
Initial evaluation
1. Is it Syncope?
2. (Is syncope immediately evolving)
3. What is the cause?
4. Is it a high-risk syncope?
Why stratify the risk in syncope?
Mortality: 1%
Major adverse events or major procedures: 5-
10%
Signs/Symptoms related to high risk Dyspnea Pain Dysability (neurological signs) Clinostatic syncope During exercise Without prodromes or with palpitations With severe trauma With structural cardiomyopathy or ECG anomalies Low EF, previous MI
Prognostic scoresOESIL RISK SCORE
(Colivicchi F et al. Eur Heart J 2003;24:811-819)
age > 65 anni = 1 pointcardiovascular disease history = 1 pointsyncope without prodromes = 1 pointECG alterations = 1 point
score 0-1: mortality risk at 1 year 0-0.8%score 2-4: mortality risk at 1 year 19.6-57.1%admission suggested for a score 2
SAN FRANCISCO SYNCOPE RULE(Quinn JV et al. Ann Emerg Med 2006;47:448-454)
ECG alterationsdyspneaheart failure historyhematocrit < 30%systolic arterial pressure < 90 mm Hg
Sn 98%, Sp 56% ( 1 factor) for mortality or morbidity within 1 month from the eventadmission when present at least 1 factor
Open question
Majority of prognostic scores assess the mortality associated with syncope within 6-12 months after the events.
Prognostic factors of long-term mortalityare the same of the short-term one?
676 patients admitted to the ER for syncope 4 major metropolitan hospitals 6-months enrollment 1-year follow Mortality and major adverse events (procedures and
readmittance for syncope) within 10 days and 1 year
JACC, 2008
JACC, 2008
Are scores for syncope RS useful?
Adverse events at 10 days
SERIOUS OUTCOME 10 days Sensitivity [95%CI] Specificity [95%CI]
CJ (n=6) 0.95 [0.91 - 0.97]
0.55 [0.44 - 0.65]
OESIL (n=5)
0.78 [0.69 - 0.85]
0.56 [0.49 - 0.63]
SFSR (n=4)
0.76 [0.64 - 0.85]
0.53 [0.34 - 0.70]
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
VIMs
Risk factors vs risk scores Further studies needed Need to define the acceptable risk Importance of using risk scores to reduce
errors, mostly in stressful conditions(overcrowding) or by syncope non-expertphysicians
Summary what to do
1. Recognize the patient with syncope
2. Exclude rapidly evolving diseases as cause of syncope (DPD) and confirm other diagnosis
3. Monitoring
4. Stratify risk (risk factors or score)
Low Risk
Young patient (< 40), without comorbidities, with a likely vasovagal syncope
Perform ECG (mandatory!) No other exams Discharge or eventually short observation in
ER (3-6 hours)
High Risk
Patients with syncope but suspicion of cardiogenic syncope or relevant comorbidities+ likely cardiogenic syncope (ischemiccardiomyopathy, low EF, COPD, ECG alterations, clinostatic syncope)
ECG, blood exams, chest X-ray, ECG monitoring , echocardiogram
Admit to the ward
Intermediate Risk
Not high, not low (ie. Relevant comorbiditiesbut likely vasovagal syncope)
ECG, ECG monitoring, exams and chest-X-ray, eventually
Monitoring in the ER for 24 hours ??
Exams to perform
All patients: ECG
In selected cases: ECG monitoring for 3/6 hours Carotid Sinus Message Blood exams BGA Echocardiogram
Do not perform
Head TC scan (unless suspect of epilepsy or patients with head trauma)
SAT Echodoppler (unuseful)
Neurologic visit (unles with a specific question epilepsy?)
Thanks!
Syncope: from admission to risk stratificationDiapositiva numero 2IntroWhat is the main problem with syncope?Diapositiva numero 5Diapositiva numero 6A 66 years-old womanadmitted to the wardQuestionsER approach to SyncopeDefinitionSyncope - PathophysiologyEpidemiologyDiapositiva numero 14Initial evaluationMain clinical toolsMEDICAL HISTORY, PHYSICAL EXAMINATION AND ECG LEAD TO DIAGNOSIS IN ABOUT 70% OF SYNCOPAL EPISODES. Mrs Marta..Is this Syncope? Anamnestic GridMrs Hilary.NUMBER OF EPISODESInitial evaluationMr Giancarlo...Diapositiva numero 26Diapositiva numero 27Diapositiva numero 28Diapositiva numero 29Diapositiva numero 30Main clinical tools12-leads ECG signsVIMMain clinical toolsOther examsInitial evaluationWhy stratify the risk in syncope?Signs/Symptoms related to high riskDiapositiva numero 39Open questionDiapositiva numero 41Diapositiva numero 42Are scores for syncope RS useful?Adverse events at 10 daysVIMsSummary what to doLow RiskHigh RiskIntermediate RiskExams to performDo not performDiapositiva numero 52