kuliah sinkop

Dizziness and SyncopeDizziness and Syncope

Abdul Gofir

Blok 18

Dizziness and Syncope: Dizziness and Syncope: OutlineOutline

Dizziness: common etiologies Case examples

Syncope Diagnosis

Efficient workup

Management

DizzinessDizziness

“There can be few physicians so

dedicated to their art that they do not

experience a slight decline in spirits

on learning that their patient’s

complaint is of giddiness [dizziness]”WB Matthews, 1975

Vertigo 50% Disequilibrium 2%

Psychiatric 2-16%

Presyncope 4-14%

Single etiology 52%Kroenke, Ann Intern Med 1992

UpToDate 2005

Etiology of dizzinessEtiology of dizziness

CaseCase

A 72 year old woman with hypertension and

migraine has 2 episodes of sudden onset

dizziness. She reports “side to side

movement” lasting several hours, with left

sided hearing loss, tinnitus, ear fullness,

unsteadiness. Oscillopsia since.

Central (15%) Brainstem infarct/ischemia Tumor

Cerebellopontine angle Brainstem

Migraine

Vertigo: Vertigo: acute vestibular asymmetryacute vestibular asymmetry

Peripheral (85%) Benign positional Labyrinthitis Meniere’s Otitis media

Central Gradual onset (except

stroke) Persistent Neuro findings common Nystagmus any direction -

changes with gaze Nystagmus not suppressable Unable to stand

Vertigo: history and examVertigo: history and examPeripheral Sudden, severe Episodic Ear symptoms common Nystagmus

horizontal/torsional, no change with gaze

Nystagmus suppressed with fixation

Able to stand, lean to lesion

AnatomyAnatomy

American Academy of Otolaryngology/HNS

Dix-Hallpike maneuver: to induce Dix-Hallpike maneuver: to induce positional vertigo and nystagmuspositional vertigo and nystagmus

Benign positional vertigo: #1 cause of peripheral vertigo Episodic symptoms Free floating debris

in semicircular canals

Dix-Hallpike maneuver: Dix-Hallpike maneuver: diagnostic and therapeuticdiagnostic and therapeutic

• Positional vertigo:•Vertigo/nystagmus reproduced

•Latency 5-15 seconds•Decreases w/in 30 seconds•Fatigues on repeat

Case: unsteadinessCase: unsteadiness

A 78 year old woman with coronary artery disease,

type 2 diabetes, cataracts, anxiety and depression

has chronic dizziness - “unsteady while walking”

Meds: insulin, lovastatin, atenolol, fludrocortisone,

prozac

Neuro exam: slightly wide based gait. DTRs absent in

ankles. Reduced vibration sense to ankle bilaterally.

Short of breath with neuro exam maneuvers.

Disequilibrium: often multifactorialDisequilibrium: often multifactorial

Sense of imbalance -worse with walking

Contributing factors

Vision, hearing impairment

Peripheral neuropathy

Musculoskeletal disease/gait disturbance

Medications

Dizziness: a geriatric syndromeDizziness: a geriatric syndrome

24% of community-living elders had dizziness > 1 month

Risk factor Relative riskAnxiety 1.69

Depression 1.36

Decreased hearing 1.27

Impaired balance 1.34

> 4 meds 1.30

Postural hypotension 1.31

Prior MI 1.31

Tinetti, Ann Intern Med 2000Tinetti, Ann Intern Med 2000

Case: “I feel like I’m going to faint”Case: “I feel like I’m going to faint”

A 30 year old woman reports episodes

of feeling as if she will faint, with

palpitations and lightheadedness, worse

when anxious. Three episodes of

syncope over past 10 years; none

recently - able to avoid by lying down.

Dizziness: psychiatric etiologyDizziness: psychiatric etiology

Young healthy patient

Symptoms reproduced with

hyperventilation Nystagmus suggests vestibular lesion

Treat underlying anxiety/depression

Establishing Diagnosis of SyncopeEstablishing Diagnosis of Syncope

Presyncope & syncope: similar etiologies & workup

Syncope: sudden transient loss of consciousness with loss of postural tone and spontaneous recovery

Mechanism: transient hypoperfusion of brainstem or both cerebral hemispheres

Differential diagnosis:comanarcolepsyseizure

Syncope: scope of the problemSyncope: scope of the problem

Common 3% Emergency Department visits 1-6% hospital admissions

Costly Multiple diagnostic tests often performed

Average charge for each diagnostic test ranges from $284 to $4678

Linzer, Ann Intern Med, 1997

Diagnostic ChallengesDiagnostic Challenges

History often unclear Prognosis varies widely

Common etiologies are benign Potentially high mortality

Need to identify high-risk patient early Many available tests 40% of patients may elude diagnosis

Syncope: management questionsSyncope: management questions

Diagnostic challenges What is the best diagnostic test? How and when to rule out arrhythmia? How to diagnose neurocardiogenic syncope? How to decrease the # “idiopathic”?

Management dilemmas When to admit? How are the elderly different? When to resume driving?

Case PresentationCase Presentation

50 yo healthy woman, standing at church Becomes weak, lightheaded, & nauseated Collapses, awakens after 1 minute Feels well in ED - “I want to go home” Normal exam, EKG, labs, CXR

Diagnosis? Plan - Admit? Further testing?

Glassman, Arch Intern Med, 1997

Etiology of SyncopeEtiology of Syncope

Idiopathic 34%

Neurally-mediated

Vasovagal 18%

Other (situational, carotid sinus) 6%

Cardiac

Arrhythmia 14%

Mechanical 4%

Neurologic 10%

Orthostatic 8%

Medications 3%

Psychiatric 2%


The Key to Diagnostic EvaluationThe Key to Diagnostic Evaluation

History and Exam establish diagnosis in 45% History: setting, symptoms, medical hx, meds Exam: HR, BP, cardiovascular, neurologic

EKG adds 5% diagnostic yield Cheap, non-invasive, readily available Can indicate important cardiac disease

Prior MI, ventricular hypertrophy, long QT Bradycardia, conduction block

Abnormalities guide further testing

Diagnostic AlgorithmDiagnostic Algorithm

Syncope

Cardiac Noncardiac Idiopathic

ArrhythmiaMechanical

NeurocardiogenicOrthostaticNeurologicPsychiatric

Cardiac syncope: Cardiac syncope: inadequate cardiac output, arrhythmiainadequate cardiac output, arrhythmia

Cardiac enzymes - Cardiac enzymes - only if history or EKG suggestive of MI– 1-10% MI’s present with syncope– EKG up to 100% sensitive for MI

EchoEcho -- rule out structural heart disease– before stress test if obstruction suspected– yield: 5-10%

Exercise stress test - Exercise stress test - exertional syncope– identifies exertional arrhythmia– yield: low (1%)

Georgeson, J Gen Intern Med, 1992Linzer, Ann Intern Med, 1997

Arrhythmia evaluation - telemetryArrhythmia evaluation - telemetry Indication: suspected arrhythmia

palpitations, no prodrome Idiopathic syncope or underlying heart disease

Routine telemetry low yield 2240 non-ICU telemetry patients 10% syncope/dizzy

all syncopeICU transfer-arrhythmia 0.8% 0.4%

Telemetry “Helpful” 12.6% 16% Mortality 0.9% 0

Linzer, Ann Intern Med, 1997 Estrada, Am J Cardiol, 1995

Glassman, Arch Intern Med, 1997.

Estrada, Am J Cardiol, 1995

Arrhythmia evaluation: Arrhythmia evaluation: 24 hr ambulatory (Holter) monitoring24 hr ambulatory (Holter) monitoring

2612 syncope/dizzy patients• Symptomatic arrhythmia = positive result

• Diagnostic arrhythmia in 4%• Symptoms without arrhythmia

• Arrhythmia ruled out in 15%Bottom line

• Benefit: monitors during usual activity• Limitation: brief duration limits yield unless daily

symptomsLinzer, Ann Intern Med, 1997

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this p icture.

Arrhythmia evaluation: improving the yieldArrhythmia evaluation: improving the yield

– Loop recorder Loop recorder – Indication: recurrent syncope with normal heart

– frequent syncope -> continuous loop recorder (weeks)– infrequent syncope -> implantable loop recorder (years)

– Electrophysiologic studyElectrophysiologic study – Indication: syncope with organic heart disease

– Signal average EKGSignal average EKG– Detects late potential in QRS - substrate for VT/VF– indication: normal heart, idiopathic syncope?

Linzer, Ann Intern Med, 1997Zimetbaum , Ann Intern Med, 1999

Neurocardiogenic Neurocardiogenic SyncopeSyncope

Vasovagal

MicturitionVasodepressor

Neurally - mediated

Reflexive

Orthostatic intolerance

Carotid sinus syncope

Cardioneurogenic

May be predominantly Cardioinhibitory

(bradycardia) Vasodepressor

(hypotension) or Both

Neurocardiogenic SyncopeNeurocardiogenic SyncopeClinical PresentationClinical Presentation

0

20

40

60

80

100

120

140

2 4 6 8time (minutes)

Bloodpressure

Pulse

Syncope

Trigger

Neurocardiogenic Syncope: Neurocardiogenic Syncope: PathophysiologyPathophysiology

SYNCOPE

Hypotension

Vasodilation

InhibitsSympathetic tone

SYNCOPE

Bradycardia/Asystole

IncreasesVagal tone

MechanoreceptorStimulation

Increased LV contractility

Decreased venous return

Diagnosing neurocardiogenic Diagnosing neurocardiogenic syncope by history and examsyncope by history and exam

Precipitant Vasovagal: pain, emotion, standing Situational: vagal stimulus

Autonomic symptoms Rapid recovery of mental status

Bradycardia, pallor may persist Carotid sinus massage

>3 sec asystole or hypotension=hypersensitivity

Neurocardiogenic syncope: treatmentNeurocardiogenic syncope: treatment

Indicated for frequent syncope Lifestyle modification

Add salt, avoid triggers Handgrip, tense arms and legs

Medications B blocker, SSRI, midodrine, fludrocortisone Repeat tilt test on therapy?

Pacemaker

Is Laughter Really the Is Laughter Really the Best Medicine?Best Medicine?

“A 63-year-old man was referred with a 20-year history of syncope preceded by intense laughter. We were able to diagnose a gelastic syncope (from the Greek ‘gelos’, laughter). Laughter-related syncope may be induced by the Valsalva manoeuvre.

We advised him not to laugh so hard in the future, and when we saw him again, he had been able to follow this advice, and had suffered no further syncope.”

Braga. Lancet 2005


are needed to see this picture.

Tilt table testingTilt table testing

60-80˚

• Goal: provoke neurocardiogenic syncope

• Indication: recurrent unexplained syncope without cardiac disease

• Protocol: passive tilt 45-60 min•positive response reproduces symptom

Tilt table testing: Tilt table testing: why the controversy?why the controversy? Accuracy difficult to define

Gold standard? Protocol? Reproducibility 71-87%

Positive tilt test with idiopathic syncope: 49% with passive tilt 66% with tilt plus isoproterenol

Tradeoff: decreased specificity Kapoor, Am J Med, 1994

Vasovagal syncope: pacemakers ineffectiveVasovagal syncope: pacemakers ineffective

Randomized double-blind trial

DDD pacer vs. sensing-only pacer

0

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syncope presyncope

DDD pacerplacebo

Connolly, JAMA 2003

p = NS%

““Idiopathic” syncope: Idiopathic” syncope: improving diagnostic yieldimproving diagnostic yield

Up to 40% patients Prognosis good Potential morbidity, lifestyle implications

Consider:DiagnosisDiagnosis TestingTesting

Neurocardiogenic Tilt table

Anxiety/depression Psychiatric evaluation

Arrhythmia EPS, implanted event monitor Empiric pacemaker?

Prognosis:Prognosis:Framingham 25 year follow upFramingham 25 year follow up

Etiology of syncope Adjusted risk of death

Cardiac 2.01*

Neurologic 1.54*

Idiopathic 1.32*

Vasovagal 1.08

*p<0.01NEJM 2002;347:878

Prognosis: Prognosis: ED risk stratificationED risk stratification

ED predictors of arrhythmia or mortality Abnormal EKG Prior VT/VF History of CHF Age > 45

Martin, Ann Emerg Med, 1997

Arrhythmia or death at one year

0%10%20%30%40%50%60%70%80%

0 1 2 3 or 4Number of risk factors

Prognosis: Prognosis: Guideline for admission - the San Guideline for admission - the San

Francisco Syncope RuleFrancisco Syncope Rule Prediction rule to identify patients at risk of bad

outcomes (need admit) over 30 days Death, MI, arrhythmia, PE, stroke, transfusion Syncope or related event requiring procedure, ED

visit or admit First assess the patient for cause of syncope If cause unknown, apply the rule

98% sensitive 56% specific

Quinn, Ann Emerg Med, 2006



CHF - history of

Hematocrit <30%

ECG abnormal

Shortness of breath

Systolic blood pressure <90 mm Hg at triage

Quinn, Ann Emerg Med, 2006

Prognosis: Prognosis: Guideline for admission - the San Guideline for admission - the San

Francisco Syncope RuleFrancisco Syncope Rule



ACP Guidelines for Hospital ACP Guidelines for Hospital AdmissionAdmission

Definitely admit HPI: chest pain PMH: CAD, CHF,

ventricular arrhythmia Exam: CHF, valve dz,

focal neurologic deficit EKG: ischemia/MI,

arrhythmia, bundle branch block

Often admit HPI: age >70,

exertional syncope, frequent syncope

Exam: tachycardia, orthostatic hypotension, injury

Cardiac dz suspected


Guidelines for Hospital Admission:Guidelines for Hospital Admission: implications for practiceimplications for practice

Myth: Every syncope patient should be admitted Recommendation: Establish clear goals for admission,

usually diagnostic

Myth: Every syncope patient requires “rule out MI” Recommendation: Admission not necessary with careful

history ruling out symptoms of ischemia and normal EKG

Myth: Telemetry improves outcomes Recommendation: One-year mortality rarely affected by 24

hours of monitoring

Syncope in the elderly:Syncope in the elderly:the geriatric challengethe geriatric challenge

History often obscure Syncope vs. dizziness vs. fall?

Often multifactorial - elderly at high risk for Situational syncope Polypharmacy, adverse drug events Cardiac, neurovascular disease Decreased physiologic reserve Atypical presentation of disease

Abnormalities do not prove causation

Recommendations for Driving: Recommendations for Driving: following the lawfollowing the law Laws vary by state - available from DMV

California law requires reporting of any loss of consciousness

County health officer receives report DMV determines fitness to drive

Physician can provide influential prognostic information to DMV

Physicians’ recommendations variable Awareness of law often poor



American Heart Association American Heart Association Guidelines for DrivingGuidelines for Driving

VT/VF (treated with medical or ICD therapy) Risk greatest 1st 6 mo, up to 10% at 1 year Resume driving: 6 months arrhythmia free

Bradycardia with syncope Resume driving: 1 week after pacemaker

Neurocardiogenic syncope -> risk stratify Mild: presyncope, clear warning & precipitant

Resume driving: immediately Severe: syncope, no warning or precipitant, frequent

Resume driving: after therapy, waiting period (duration?)

Dizziness: key pointsDizziness: key points

Vertigo is most common etiology Positional triggers, nystagmus help confirm

peripheral etiology Neuro findings, stroke risk prompt imaging

Disequilibrium - commonly due to multifactorial deficits in elderly

Presyncope - manage like syncope

Syncope: key pointsSyncope: key points History, exam, EKG guide further testing

Identify possible cardiac syncope early Admit if high risk of cardiac disease

Neurocardiogenic syncope - diagnosed

clinically or by tilt table

Idiopathic syncope has multiple etiologies

and good prognosis

Thank for attentionReference from Lecture

Karen E. Hauer, MDKaren E. Hauer, MD

University of California, University of California,

San FranciscoSan Francisco

kuliah sinkop

Documents

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