SYNCOPE Module 2 Ed Vandenberg MD CMD Geriatric

SYNCOPE Module #2 Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198 -1320 evandenb@unmc. edu Web: geriatrics. unmc. edu 402 -559 -7512

PROCESS Series of 3 modules and questions on Etiologies, Evaluation, & Management Step #1 Power point module with voice overlay Step #2 Case-based question and answer Step #3 Proceed to additional modules or take a break

Etiologies P-A-S-S O-U-T (mnemonic) n n n n P A S S ressure (hypotensive causes) rrhythmias eizures ugar (hypo/hyperglycemia) O U T utput (cardiac)/O 2 (hypoxia) nusual causes ransient Ischemic Attacks & Strokes

B) A rrhythmias TYPES: n n Bradyarrhythmias Tachyarrhythmia’s SVT, NSVT, A. F. , pacemaker malfunctions DIAGNOSIS n 1 st step: n HISTORY: n n n sudden onset associated with known heart disease, quick post event recovery of consciousness EKG Continuous cardiac monitor (Inpatient vs. Holter) or n —>Event Monitor or Stress Testing (Exercise vs DSE) or n Electro-physiologic study ( EPS)

C) Seizures 1 HISTORY----is the key to diagnosis Compared to young patients; § § § Many more occur with out warning Many more have atypical prodrome POST-ICTAL sx’s: -longer than any other cause of syncope (second only to death: JOKE!) DIAGNOSIS: “The Gold Standard”: n EEG positive and appropriate symptoms witnessed n n The “Fall-Back Position” EEG negative and appropriate symptoms witnessed Gave dx in: < 2 %

Question: 2 Can decreased CNS perfusion causes seizures ? n n n Decrease CNS perfusion by 35% SYNCOPE Decrease in CNS perfusion for: >10 secs------>SYNCOPE >15 secs. ----->Seizure (possible) PEARL: EEG —>of no use in ABSENCE OF SEIZURE ACTIVITY by history

D) Sugar (hypo/hyperglycemia) hypoglycemia from D. M. with hypoglcemic therapy ONLY n hyperglycemia from DM and not enough therapy Tips: n Don’t look for hypoglycemia in the NONDiabetic n GTT doesn’t add diagnostic information n

E) Output (cardiac)/O 2 (hypoxia) History: n usually sudden onset (exception in CHF), n Associated cardiac sx’s: -dyspnea -chest pain -tachypnea Causes: n CARDIAC n PULMONARY (O 2)

E) Output (cardiac)/O 2 Causes: Name some causes of impaired cardiac output:

E) Output (cardiac)/O 2 Causes: CARDIAC : n n n n Aortic or Mitral or Pulmonic Stenosis Hypertrophic Cardiomyopathy Cardiomyopathies: (Restrictive or Dilated) Atrial Myxoma Cardiac Tamponade Aortic Dissection MYOCARDIAL INFARCT CHF PULMONARY (O 2 Related) n n Pulmonary embolii Pulmonary Hypertension Carbon monoxide COPD exacerbation ( add PCO 2)

E) Output (cardiac)/O 2 The DIAGNOSIS: Tests: n n n Sa. O 2 +/- ABG’s EKG CXR Echo? CT chest? NOTE: n ECHO: helpful in 5 % of all syncopes Therefore: use Echo in: n structural heart dz, n heart murmurs n hx of : impaired cardiac output symptoms

F) U nusual causes Causes: n Anxiety n Panic disorder n Somatizations disorder n Major Depressive disorder n Hyperventilation syndrome History n Psychiatric history n Symptoms don’t fit n Diagnosis -sometimes by exclusion “The Good News” n infrequent in the elderly

G) Transient Ischemic Attacks & Strokes (and other CNS causes) Causes: n CVAs n TIAs (vertebro-basilar) n Subarachnoid hemorrhage n Subdural hematoma n n n Basilar artery migraine Subclavian steal CNS mass effect: tumor, edema, AVM Diagnosis; Neuroimaging n (“Aren’t you glad you live in the New Millennium? ”)

The End of Module two on 3 Evaluation of Syncope

Post Test 4 n A 72 -year-old man is hospitalized following a syncopal episode that occurred while he was walking to the library. Cardiac monitoring reveals sick sinus syndrome with short periods of paroxysmal atrial fibrillation and prolonged episodes of sinus bradycardia with occasional sinus pauses of up to 3. 2 seconds. The patient takes no medications and has been well except for an episode of dizziness that occurred while he was walking down the hall at home. Cardiac telemetry at that time revealed a 3. 0 -second sinus pause. The patient tells you that he is not concerned about dying but does want to remain alert, functional, and able to walk to the library. Which of the following should you recommend?

Which of the following should you recommend? A. Exercise stress test B. Electrophysiologic study (EPS) C. Dual-chamber pacemaker D. Ventricular pacemaker E. Ventricular pacemaker and amiodarone therapy

Answer: C. Dual-chamber pacemaker n This patient clearly meets the criteria for sick sinus syndrome; further diagnostic testing is not needed. The symptomatic sinus pause is an indication for pacemaker therapy. Although coronary artery disease can cause sick sinus syndrome in elderly patients, it most often is caused by degeneration and fibrosis of the sinus node. Several large, randomized, controlled trials have investigated the best pacing mode for elderly patients with symptomatic bradycardias. This patient is less concerned about mortality than quality of life; therefore, a pacing mode that will eliminate his symptoms, permit continued social function, and prevent stroke and recurrent atrial fibrillation is most desirable. In the Pacemaker Selection in the Elderly (PASE) study, both ventricular and dual-chamber pacing were found to improve overall quality of life in patients with sinus bradycardia, but nearly one quarter of those assigned to ventricular pacing developed pacemaker syndrome and eventually required dual-chamber pacing.

n During the 18 -month follow-up period, dual-chamber pacing was found to result in moderately better quality of life and cardiovascular function. Studies have shown no effect of pacing mode on overall survival. In another study, 1474 elderly patients (average 73 ± 10 years) with symptomatic bradycardia were randomly assigned to either ventricular or dual-chamber pacing. No overall effect of pacing mode on stroke or death from cardiovascular causes was reported. However, in a subgroup of patients aged 74 and under, a significant reduction in both outcomes was seen with dual-chamber pacing. The study also showed an 18% reduction in the risk of atrial fibrillation. Treatment with amiodarone is not indicated at this time. End

REFERENCES 1. Ramsay ER, Rowan JA, Pryor FM. Special considerations in treating the elderly patient with epilepsy. Neurology 2004; 62: S 24 -S 29 2. Davis TL, Freemon FR. Electroencephalography should not be routine in the evaluation of syncope in adults. Arch Int Med 1990; 73: 593598 3. Bush D. Syncope. In: Geriatric Review Syllabus: A Core Curriculum in Geriatric Medicine, 5 th Edition (Cobbs EL, Duthie EH, Murphy JB, eds. ), Blackwell Publishing for the American Geriatrics Society, Malden, MA, Chapter 24, pp 165 -169, 2002 4. Used with permission from Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus, AGS 2002, New York, NY