Syncope: Difference between revisions
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*Exertion preceding the event | *Exertion preceding the event | ||
**Note that syncope during exertion much more concerning than syncope after exertion | **Note that syncope during exertion much more concerning than syncope after exertion | ||
*No preceding symptoms | |||
**Concerning for cardiac dysrhythmia | |||
*History of cardiac disease in the patient | *History of cardiac disease in the patient | ||
*Family history of sudden death, deafness, or cardiac disease | *Family history of sudden death, deafness, or cardiac disease | ||
Line 17: | Line 19: | ||
*Recumbent episode | *Recumbent episode | ||
*Prolonged loss of consciousness | *Prolonged loss of consciousness | ||
*Associated [[chest pain]] or [[palpitations]] | *Associated [[chest pain]], [[shortness of breath]] or [[palpitations]] | ||
*Use of medications that can alter cardiac conduction | *Use of medications that can alter cardiac conduction | ||
==Clinical Features== | ==Clinical Features== | ||
Line 60: | Line 55: | ||
==Evaluation== | ==Evaluation== | ||
===Work-Up=== | ===Work-Up=== | ||
''ACEP only recommends ECG and H&P as must haves'' | ''ACEP only recommends [[ECG]] and H&P as must haves'' | ||
*[[ECG]] | *[[ECG]] | ||
**Perform on every patient, unless trigger clearly identified (i.e. following blood draw) and no risk factors | **Perform on every patient, unless trigger clearly identified (i.e. following blood draw) and no risk factors | ||
*Urine pregnancy | *Urine pregnancy | ||
;Consider based on history/symptoms: | ;Consider based on history/symptoms: | ||
* | *CBC (or POC hemoglobin) & chemistry (or POC glucose) | ||
*[[Troponin]] | *[[Troponin]] | ||
**Not recommended to rule out A[[MI]] in patients with isolated syncope<ref>Reed MJ, Newby DE, Coull AJ, et al. Diagnostic and prognostic utility of troponin estimation in patients presenting with syncope: a prospective cohort study. Emerg Med J. 2010; 27(4):272-276</ref> | **Not recommended to rule out A[[MI]] in patients with isolated syncope<ref>Reed MJ, Newby DE, Coull AJ, et al. Diagnostic and prognostic utility of troponin estimation in patients presenting with syncope: a prospective cohort study. Emerg Med J. 2010; 27(4):272-276</ref> | ||
**Elevated troponin predicts adverse cardiac outcome in syncope<ref>Reed MJ, Mills NL, Weir CJ. Sensitive troponin assay predicts outcome in syncope. Emerg Med J. 2012;29(12):1001- 1003</ref> | **Elevated troponin predicts adverse cardiac outcome in syncope<ref>Reed MJ, Mills NL, Weir CJ. Sensitive troponin assay predicts outcome in syncope. Emerg Med J. 2012;29(12):1001- 1003</ref> | ||
**May be useful for risk stratification | **May be useful for risk stratification | ||
*[[CXR]] | |||
*Orthostatics (symptomatic) | |||
*Guaiac | *Guaiac | ||
*CT scan of head is not recommended in asymptomatic, insignificant trauma with normal neurologic examination | *CT scan of head is not recommended in asymptomatic, insignificant trauma with normal neurologic examination | ||
**Part of [[Choosing wisely ACEP]] | **Part of [[Choosing wisely ACEP]] | ||
*Does [[Pulmonary Embolism (PE)|PE]] need to be worked up? | *Does [[Pulmonary Embolism (PE)|PE]] need to be worked up? | ||
**NEJM paper by Prandoni<ref>Prandoni P, Lensing AW, Prins MH, Ciammaichella M, Perlati M, Mumoli N, Bucherini E, Visonà A, Bova C, Imberti D, Campostrini S, Barbar S; PESIT Investigators. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016 Oct 20;375(16):1524-1531. PubMed PMID: 27797317.</ref> showed | **NEJM paper by Prandoni<ref>Prandoni P, Lensing AW, Prins MH, Ciammaichella M, Perlati M, Mumoli N, Bucherini E, Visonà A, Bova C, Imberti D, Campostrini S, Barbar S; PESIT Investigators. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016 Oct 20;375(16):1524-1531. PubMed PMID: 27797317.</ref> showed that 7.14% of patients admitted for syncope had a pulmonary embolism and of the cohort that were not low risk with a negative d-dimer, the risk was as high as 17.3% | ||
**2018 systematic reviewed <ref>Prevalence Of Pulmonary Embolism In Patients Presenting With Syncope: A Systematic Review And Meta-Analysis Oqab, Z., et al, Am J Emerg Med 36(4):551, April 2018</ref> showed 0.8% of admitted ED pts with syncope had PE | **2018 systematic reviewed <ref>Prevalence Of Pulmonary Embolism In Patients Presenting With Syncope: A Systematic Review And Meta-Analysis Oqab, Z., et al, Am J Emerg Med 36(4):551, April 2018</ref> showed 0.8% of admitted ED pts with syncope had PE | ||
**Also supported by 2019 study showing prevalence of 2.3% in undifferentiated patients admitted with syncope<ref>Prevalence of pulmonary embolism in patients with syncope Badertscher P, du Fay de Lavallaz J, Hammerer-Lercher A, et al. J Am Coll Cardiol. 2019;74(6):744-754.</ref>. | |||
**Both of these two studies refute the findings of the PESIT study listed first | |||
*Bedside [[Ultrasound (main)|US]] | |||
**PSL view may show thickened ventricular septum | |||
**High sensitivity to rule out [[AAA]] | |||
===Diagnosis=== | ===Diagnosis=== | ||
*Overall yield of testing is low | |||
*Cardiovascular findings and evidence of bleeding strongest predictors of adverse outcomes after syncope<ref> D’Ascenzo F, Biondi-Zoccai G, Reed M, et al. Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the emergency department with syncope: an international meta-analysis. Int J Cardiol. 2013;167(1)57-62</ref> | |||
*[[ECG]] findings associated with adverse cardiac outcome in 30 days: <ref>Quinn J, McDermott D. Electrocardiogram findings in emergency department patients with syncope. Acad Emerg Med. 2011;18(7):714-718</ref><ref>Thiruganasambandamoorthy V, Hess EP, Turko E, et al. Defining abnormal electrocardiography in adult emergency department syncope patients: the Ottawa Electrocardiographic Criteria. CJEM. 2012;14(4):248-258</ref> | |||
**Normal ECG has high NPV<ref>Sud S, Klein GJ, Skanes AC, et al. Predicting the cause of syncope from clinical history in patients undergoing prolonged monitoring. Heart Rhythm. 2009;6(2):238-243</ref> | |||
**May show: | |||
***[[Myocardial ischemia|ischemia]] | |||
***[[Heart block]] | |||
***[[WPW]]- short PR, Delta waves, wide QRS | |||
***[[Long QT]] (QTc >0.450 sec), [[short QT]] | |||
***[[Brugada]]- incomplete [[RBBB]] with ST elevations in V1-3 | |||
***[[HOCM]]- [[LVH]], ST changes, T wave inversions, lateral leads needle like Q waves and absent R waves | |||
***[[Arrhythmogenic right ventricular dysplasia]]– incomplete [[RBBB]] with T waves inversion in V1-3, epsilon wave is pathognomonic (up-notching of a terminal Q wave) | |||
***[[Early repolarization]] | |||
***[[Low voltage ECG|low voltage]]/[[pericardial effusion]] | |||
***RV strain pattern | |||
***LBBB, 2nd degree Mobitz II, 3rd degree AV block, RBBB w/LAFP or LPFB | |||
==Management== | ==Management== | ||
Line 126: | Line 119: | ||
===Discharge=== | ===Discharge=== | ||
*None of the above findings (esp if age <45) | *None of the above findings (esp if age <45) | ||
*No events on telemetry after period of observation (2-4 hours in the ED) | |||
*Consider referral for holter or til-table test | *Consider referral for holter or til-table test | ||
==Additional Risk Stratification Tools for Selecting Low-Risk patients for Discharge== | |||
===Canadian Syncope Risk Score<ref>Thiruganasambandamoorthy, V et al. Development of the | |||
Canadian Syncope Risk Score to predict serious adverse | |||
events after emergency department assessment of syncope. | |||
CMAJ. 2016 Sep 6;188(12):E289-E298.</ref> [https://www.mdcalc.com/canadian-syncope-risk-score MDCalc]=== | |||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Category''' | |||
| align="center" style="background:#f0f0f0;"|'''No''' | |||
| align="center" style="background:#f0f0f0;"|'''Yes''' | |||
|- | |||
| Predisposition to vasovagal symptoms (triggered by being in a warm crowded place, prolonged standing, fear, emotion, or pain)||0||-1 | |||
|- | |||
| Heart disease history (CAD, afib, flutter, CHF, valvular disease)||0||1 | |||
|- | |||
| SBP < 90 or > 180mmHg||0||2 | |||
|- | |||
| Elevated troponin||0||2 | |||
|- | |||
| Abnormal QRS axis ||0||1 | |||
|- | |||
| QRS > 130ms||0||1 | |||
|- | |||
| Corrected QT interval >480ms||0||2 | |||
|- | |||
| Vasovagal syncope (based on clinical impression||0||-2 | |||
|- | |||
| Cardiac Syncope (based on clinical impression)||0||2 | |||
|} | |||
*Score < 0 associated with < 2% risk of serious adverse event at 30 days. | |||
*Externally validated per data presented at SAEM 2018 and only 0.3% 30 day adverse events for very low risk patients in 2020 Jama study <ref>Multicenter Emergency Department Validation of the Canadian Syncope Risk Score. JAMA Intern Med. 2020 Mar 23. https://doi.org/10.1001/jamainternmed.2020.0288 </ref> | |||
===[[EBQ: San Francisco Syncope Rule | San Francisco Syncope Rule]]=== | |||
*1.4% of patients who are rule-negative will have a 7-day serious outcome | |||
*10% of patients meeting the below criteria will have a 7-day serious outcome | |||
{{San_Francisco_Syncope_Rule}} | |||
====Limitations==== | |||
*Performed poorly on external validation<ref name="Birnbaum">Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008;52(2):151-9.</ref> | |||
*External validation of San Francisco Syncope Rule showed sensitivity 90% but only specificity of 33% <ref> Thiruganasambandamoorthy et al, External validation of the San Francisco Syncope Rule in the Canadian setting. Ann Emerg Med. 2010 May;55(5):464-72. doi: 10.1016 </ref> | |||
==External Links== | ==External Links== |
Revision as of 11:53, 21 May 2020
For pediatric patients patients see syncope (peds)
Background
- Transient loss of postural tone and consciousness due to cerebral hypoperfusion
- Syncope and pre-syncope assessed similarly
- Important considerations:
- Is this true syncope or something else (eg, stroke, seizure, head injury)?
- If this is true syncope, is there a clear life-threatening cause?
- If this is true syncope and the cause is not clear, is the patient at high risk for serious outcome?
Risk Factors for Serious Cause
- Exertion preceding the event
- Note that syncope during exertion much more concerning than syncope after exertion
- No preceding symptoms
- Concerning for cardiac dysrhythmia
- History of cardiac disease in the patient
- Family history of sudden death, deafness, or cardiac disease
- Consider unexplained deaths and deaths due to single vehicle accidents
- Recurrent episodes
- Recumbent episode
- Prolonged loss of consciousness
- Associated chest pain, shortness of breath or palpitations
- Use of medications that can alter cardiac conduction
Clinical Features
Physical Exam
- Evaluate volume status
- Evaluate for head and neck trauma (related to fall from syncopal event)
- Focus cardiac exam on detecting murmurs (aortic stenosis, mitral regurgitation, tricuspid stenosis)
- Evaluate for signs of heart failure
- Palpate abdomen for pulsating mass (AAA)
- Rectal exam to eval for GI bleed
- Thorough neurologic exam
- Examine for possible sources of infection
Clinical Features by Cause
- Cardiovascular-mediated syncope
- Usually occurs without warning (absence of prodrome)
- History of structural heart disease
- Family history of sudden cardiac death
- Syncope during exertion
- Chest pain or palpitations associated with syncope
- Abnormal ECG
- Neurally mediated syncope
- Trigger event (fear/pain, prolonged standing, warm environment)
- Prodrome of nausea/vomiting, tunnel vision, lightheadedness, diaphoresis, warmth [1]
- Associated with head movement or pressure on neck
- Orthostatic hypotension-mediated syncope
- After standing up
- Change in medications
Differential Diagnosis
Syncope Causes
- Cardiovascular-mediated syncope
- Dysrhythmias:
- Cardiovascular disease
- Neurally mediated syncope
- Vasovagal:
- Fear, pain, emotion, valsalva, breath-holding spell
- Situational (associated with):
- Vasovagal:
- Orthostatic hypotension-mediated syncope:
- Volume depletion:
- Autonomic Dysreflexia
- Autonomic failure due to meds
- Other serious causes
- Stroke
- SAH
- TIA
- Vertebrobasilar Insufficiency
- Subclavian steal
- Heat syncope
- Hypoglycemia
- Hyperventilation
- Asphyxiation
- Seizure
- Narcolepsy
- Psychogenic (anxiety, conversion disorder, somatic symptom disorder)
- Toxic (drugs, carbon monoxide, etc.)
Evaluation
Work-Up
ACEP only recommends ECG and H&P as must haves
- ECG
- Perform on every patient, unless trigger clearly identified (i.e. following blood draw) and no risk factors
- Urine pregnancy
- Consider based on history/symptoms
- CBC (or POC hemoglobin) & chemistry (or POC glucose)
- Troponin
- CXR
- Orthostatics (symptomatic)
- Guaiac
- CT scan of head is not recommended in asymptomatic, insignificant trauma with normal neurologic examination
- Part of Choosing wisely ACEP
- Does PE need to be worked up?
- NEJM paper by Prandoni[4] showed that 7.14% of patients admitted for syncope had a pulmonary embolism and of the cohort that were not low risk with a negative d-dimer, the risk was as high as 17.3%
- 2018 systematic reviewed [5] showed 0.8% of admitted ED pts with syncope had PE
- Also supported by 2019 study showing prevalence of 2.3% in undifferentiated patients admitted with syncope[6].
- Both of these two studies refute the findings of the PESIT study listed first
- Bedside US
- PSL view may show thickened ventricular septum
- High sensitivity to rule out AAA
Diagnosis
- Overall yield of testing is low
- Cardiovascular findings and evidence of bleeding strongest predictors of adverse outcomes after syncope[7]
- ECG findings associated with adverse cardiac outcome in 30 days: [8][9]
- Normal ECG has high NPV[10]
- May show:
- ischemia
- Heart block
- WPW- short PR, Delta waves, wide QRS
- Long QT (QTc >0.450 sec), short QT
- Brugada- incomplete RBBB with ST elevations in V1-3
- HOCM- LVH, ST changes, T wave inversions, lateral leads needle like Q waves and absent R waves
- Arrhythmogenic right ventricular dysplasia– incomplete RBBB with T waves inversion in V1-3, epsilon wave is pathognomonic (up-notching of a terminal Q wave)
- Early repolarization
- low voltage/pericardial effusion
- RV strain pattern
- LBBB, 2nd degree Mobitz II, 3rd degree AV block, RBBB w/LAFP or LPFB
Management
- Treat underlying cause, if known (~50% of patients do not have a firm diagnosis)
Disposition
Admit[11]
- Abnormal ECG
- CHF
- Suspicion of structural heart disease
- Ischemic, dysrhythmic, obstructive, valvular
- HCT <30
- Shortness of Breath
- Hypotension(SBP <90)
- Family history of sudden cardiac death
- Advanced age
- Evidence of hemorrhage (occult blood)
- Syncope without prodrome
Discharge
- None of the above findings (esp if age <45)
- No events on telemetry after period of observation (2-4 hours in the ED)
- Consider referral for holter or til-table test
Additional Risk Stratification Tools for Selecting Low-Risk patients for Discharge
Canadian Syncope Risk Score[12] MDCalc
Category | No | Yes |
Predisposition to vasovagal symptoms (triggered by being in a warm crowded place, prolonged standing, fear, emotion, or pain) | 0 | -1 |
Heart disease history (CAD, afib, flutter, CHF, valvular disease) | 0 | 1 |
SBP < 90 or > 180mmHg | 0 | 2 |
Elevated troponin | 0 | 2 |
Abnormal QRS axis | 0 | 1 |
QRS > 130ms | 0 | 1 |
Corrected QT interval >480ms | 0 | 2 |
Vasovagal syncope (based on clinical impression | 0 | -2 |
Cardiac Syncope (based on clinical impression) | 0 | 2 |
- Score < 0 associated with < 2% risk of serious adverse event at 30 days.
- Externally validated per data presented at SAEM 2018 and only 0.3% 30 day adverse events for very low risk patients in 2020 Jama study [13]
San Francisco Syncope Rule
- 1.4% of patients who are rule-negative will have a 7-day serious outcome
- 10% of patients meeting the below criteria will have a 7-day serious outcome
- Criteria (CHESS Pneumonic)[14]
- CHF History
- Hct < 30%
- ECG Abnormality
- SOB history
- SBP < 90mmHg at triage
Limitations
- Performed poorly on external validation[15]
- External validation of San Francisco Syncope Rule showed sensitivity 90% but only specificity of 33% [16]
External Links
See Also
References
- ↑ Romme JJCM, van Dijk N, Boer KR, et al. Influence of age and gender on the occurrence and presentation of reflex syncope. Clin Auton Res. 2008;18(3):127-133
- ↑ Reed MJ, Newby DE, Coull AJ, et al. Diagnostic and prognostic utility of troponin estimation in patients presenting with syncope: a prospective cohort study. Emerg Med J. 2010; 27(4):272-276
- ↑ Reed MJ, Mills NL, Weir CJ. Sensitive troponin assay predicts outcome in syncope. Emerg Med J. 2012;29(12):1001- 1003
- ↑ Prandoni P, Lensing AW, Prins MH, Ciammaichella M, Perlati M, Mumoli N, Bucherini E, Visonà A, Bova C, Imberti D, Campostrini S, Barbar S; PESIT Investigators. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016 Oct 20;375(16):1524-1531. PubMed PMID: 27797317.
- ↑ Prevalence Of Pulmonary Embolism In Patients Presenting With Syncope: A Systematic Review And Meta-Analysis Oqab, Z., et al, Am J Emerg Med 36(4):551, April 2018
- ↑ Prevalence of pulmonary embolism in patients with syncope Badertscher P, du Fay de Lavallaz J, Hammerer-Lercher A, et al. J Am Coll Cardiol. 2019;74(6):744-754.
- ↑ D’Ascenzo F, Biondi-Zoccai G, Reed M, et al. Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the emergency department with syncope: an international meta-analysis. Int J Cardiol. 2013;167(1)57-62
- ↑ Quinn J, McDermott D. Electrocardiogram findings in emergency department patients with syncope. Acad Emerg Med. 2011;18(7):714-718
- ↑ Thiruganasambandamoorthy V, Hess EP, Turko E, et al. Defining abnormal electrocardiography in adult emergency department syncope patients: the Ottawa Electrocardiographic Criteria. CJEM. 2012;14(4):248-258
- ↑ Sud S, Klein GJ, Skanes AC, et al. Predicting the cause of syncope from clinical history in patients undergoing prolonged monitoring. Heart Rhythm. 2009;6(2):238-243
- ↑ Huff JS, Decker WW, Quinn JV et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49(4):431-444
- ↑ Thiruganasambandamoorthy, V et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016 Sep 6;188(12):E289-E298.
- ↑ Multicenter Emergency Department Validation of the Canadian Syncope Risk Score. JAMA Intern Med. 2020 Mar 23. https://doi.org/10.1001/jamainternmed.2020.0288
- ↑ Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006 May;47(5):448-54. PubMed PMID: 16631985.
- ↑ Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008;52(2):151-9.
- ↑ Thiruganasambandamoorthy et al, External validation of the San Francisco Syncope Rule in the Canadian setting. Ann Emerg Med. 2010 May;55(5):464-72. doi: 10.1016