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Forbigående tab af bevidsthed og fald Kardielle årsager – udredning Synkope Dansk Selskab for Geriatri 13 marts 2015 Svendborg Professor, overlæge, dr.med. Henning Mølgaard Kardiologisk afdeling B, Aarhus Universitets Hospital, Skejby A A R H U S U N I V E R S I T E T
DefiniNons -­‐ Naming spells, syncope, seizure, falls, adam-­‐stokes aSack, fits, fainNng, loss of consciousness, Before a diagnosis is made: Transient loss of consciousness, T-­‐LOC Advocated by European Society of Cardiology A A R H U S U N I V E R S I T Y
ESC syncope guidelines 2009
DCS annual meeting 6-8 may 2010:
Implementation of ESC syncope guidelines in Denmark
Henning Mølgaard MD DMSc; Department of Cardiology B, Århus University Hospital, Skejby, Denmark
Transient Loss of Consciousness – T-LOC
Emergency
Department
Doctors
Geriatricians
Cardiologists
Neurologists
Geriatricians
Work-Up in Syncope
Syncope – definition:
greek ”syn”+”koptein”- to cut or to interrupt
- Transient total loss of consciousness
- Usually accompanied by loss of tone
- Self-limited
- Spontaneous complete recovery
- Usually of brief duration, sec. to few min.
- Can be associated with convulsions
Cause: abrupt cerebral hypoperfusion
Guidelines on management(diagnosis and treatment) of syncope-update 2004
Task force on syncope. European Society of Cardiology. Europace, 2004;6:467-535, 2009
Transient Loss of
Consciousness /
Syncope
Common problem
Causes much anxiety
Potentially life
Threatening
Work-up difficult, often
delayed,30-50% undiag
nosed
Key:
-History
-Structural or electrical
Heart disease
-Evaluate risk
-Find mechanism treatment
-Work-up algorithms
needed
Incidence Rate of Syncope in General Population
In Relation to Sex and Age
N Engl J Med 2002;347:878-85.)
10 years cumulative incidence of syncope 6%
Opgørelse fra Danmark Kilde: Ruwald MH et al. Europace 2012;14:1506-­‐14 Syncope hos ældre-­‐ særlige udfordringer • 
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OZere mulNfaktorielt Ikke så gode oplysere Problemer med amnesi for omstændigheder Har oZere strukturel hjertesygdom (hypertension, afli, iskæmisk hjertesygdom) Kommer alvorligere Nl skade – frakturer Omfanget af udredning ved meget gamle? (KAG, EPS, Implanterbar EKG optagere) Udredningsprogram i relaNon Nl leveNd? A A R H U S U N I V E R S I T Y
Recurrent syncope and diagnostic work-up: Background
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Common clinical problem
3-5% of emergency room visits
1-3% of hospital admissions
In the community, 15-23% during 10 year period
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Unravelling of underlying cause difficult
Variable frequency of attacs – weeks/months/years
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Ideal diagnostic test not avaliable in most cases:
Reproduction of syncope and patognomonic
patophysiology in the laboratory
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Diagnosis often a probability evaluation
Precise data on sens. and spec. of diagnostic tests
therefore not avaliable( no true value)
Potentially large number tests – efficiency / price
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Gold Standard for Diagnostic Test:
ECG – Symptom Correlation
Recording of:
ECG
Blood Pressure
EEG
Cardiac Output
During Clinical Syncope
Recurrent syncope and diagnostic work-up: prognosis
Syncope / Loss of Consciousness, +/- Convulsions
Focused history for syncope
General history – Heart, CNS
Clinical examination,
BP supine / standing, ECG
Diagnostic Hypothesis
Neurocardiogenic cause
-  Vasovagal syncope
-  Carotid Sinus Syndrom
Frequency: 10-30%
Benign prognosis
Cardiac cause
-Arrhytmia; -Obstructive;
- Ischemia
Frequency: 15-40%
Adverse prognosis mortality 20-30%/year
Neurological cause
- Epilepsy, TCI, psychiatric
Frequency: 5-15%
SUDEPincreased mortality
Hyppigste årsager Nl synkope hos ældre •  OrtostaNsk hypotension(OH) • 
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Refleks synkope – oZe sinus caroNcus syndrom(CSS) men også vasovagal synkope(VVS) Kardielle arytmier. Syg sinus knude syndrom, AV blok; hurNg SVT og VT; Bradykardi < 40 spm i vågen Nlstand A A R H U S U N I V E R S I T Y
Background – Reccurent syncope
Key for a relevant work-up:
Anamnesis
Structural Heart Disease – Yes / No
Have a work-up algorithm
Kliniske karakterisNka ved iniNale vurdering som taler for OrtostaNsk Hypotension •  EZer at have rejst sig •  Tidsmæssig relaNon Nl start eller ændringer i medicin • 
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med vasodilataNon / vasodepressions effekter Længere Nds stående, varme tætpakkede rum Tilstedeværende neurologisk sygdom: autonom neuropathi, Parkinson, Shy Drager Stående eZer fysisk anstrengelse A A R H U S U N I V E R S I T Y
Kliniske karakterisNka ved iniNale vurdering som taler for Refleks synkope(VVS og CSS) • 
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Ingen tegn på hjertesygdom Længere historie med gentagne besvimelser EZer ubehageligt syn, lugt, lyd, smerter Lang Nds stand, tæt menneske mængde, varmt Associeret med kvalme, uNlpashed, opkastning Under eller lige eZer målNd Post execise, Ved hoveddrejning, stram krave, barbering hals A A R H U S U N I V E R S I T Y
Kliniske karakterisNka ved iniNale vurdering som taler for Kardiel Sygdom •  Tilstedeværelse af strukturel hjertesygdom •  Synkope i relaNon Nl fysisk anstrengelse •  Besvimet liggende •  Synkope forudgået af pludselig hjertebanken •  Patologisk EKG. LBBB, RBBB+LAH/LPH HF < 50 spm i vågen Nlstand(-­‐ betablokker) Pauser >= 3 sekunder( også i afli); AV blok II, type II Non-­‐sustained VT WPW mønster; Lang QTc(> 500 ms) NegaNve T-­‐takker i V2-­‐V4(ARVC) A A R H U S U N I V E R S I T Y
Undersøgelser ved mistanke om kardiel synkope EKG, BT og puls St.c et p., puls a.femoralis OrtostaNsk BT måling(5 min) Sinus caroNcus massage Ekkokardiografi Ambulant EKG monitorering(2-­‐7 døgn) Implanterbar EKG optager(mdr-­‐år) Tilt-­‐test; Cykel-­‐test A A R H U S U N I V E R S I T E T
OrtostaNsk BT måling BT+P liggende efter
passende hvileperiode
↓
BT+P hvert minut stående i
5 min
Positiv test hvis besvimelse /
nærbesvimelse og BT ↓
< 90 mm Hg systolisk
Gentag testen, gerne
morgen, ikke særlig
reproducerbar, eller i tæt
relation til nyligt anfald
Medicinsk behandling Juster / seponer BT sænkende medicin
Medicinsk behandling af ortostatisk
hypotension er ikke velundersøgt, men bør
forsøges ved svære symptomer
Midodrine 2,5 – 10 mg x 3 – perifert virkende α-­‐agonist. Effekt i små studier på stående blodtryk og på symptomer. Bivirkn: hypertension i liggende sRlling, paræstesier, hudkløe, vandladningstrang Recurrent syncope – Neurocardiogenic syndromes
Diagnosis of Neurocardiogenic Syndromes
Syndromes causing recurrent syncope through sudden HR and BP drop
Carotid Sinus Syndrome
(CSS)
Malignant Vasovagal Syncope
(VVS)
Carotid sinus massage
Tilt-table test
Documented hypersensitive carotid sinus:
Cardioinihibotory / Vasodepressor respons
Asystole > 3 s / BP drop > 50 mm Hg
Positive tilt-table test:
Cardioinhibitory / Vasodepressor respons
+ reproduction of clinical symptoms
+ reproduction of clinical symptoms
Vasovagal Synkope Meget almindelig Nlstand BenySer en refleks vi alle har Alle kan bringes Nl at besvime med denne refleks Stort klinisk spektrum – situaNons relateret – benign – malign Anamnesen afgørende for diagnosen Varslings symptomer VigNgste behandling er råd og vejledning A A R H U S U N I V E R S I T E T
Vasovagal Synkope Kært barn mange navne Vasovagal synkope Refleks besvimelse Neurokardiogen synkope Godartet besvimelse Dåne Ligfald Passing out A A R H U S U N I V E R S I T E T
Vasovagal Synkope SituaNons relateret: Blodprøvetagning Synet af blod / ubehagelig synsindtryk Lille rum, varme, mange mennesker Varme, sauna, varme bade Smerter, svære Vandladning – micNons syncope Hoste synkope Lang Nds stående Dehydrering, tømmermænd, træthed Gastroenterit, kvalme, opkastninger A A R H U S U N I V E R S I T E T
Vasovagal Synkope Hvad er formålet med refleksen? Responset bradykardi og vasodilataNon med BT fald er et paradokst respons der vil fører Nl cerebral hypoperfusion besvimelse og fald – modsat kamprefleksen Ligge død refleks – et andet forsvar imod farer? Forsvar imod blødning? Smerte? svært ubehag? A A R H U S U N I V E R S I T E T
Principal Mechanisms of Vasovagal Syncope
”Central Type”
Benign VVS
”Peripheral Type”
Malignant VVS
Fear, ”white mouse”
No precipitating factors
Defect ?
CNS
Sympathetic
Bezold-Jarisch Reflex
(affer. Vagal C-fibers)
Parasymp
Vasodilatation
Mechanoreceptor Activation
Bradycardia
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Hypotension
Asystole
Vasodepres.
Decreased Ventricular Filling
Venous Pooling of Blood
Cardioinhib.
Syncope
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Hypovolemic vigoursly contracting
left ventricle; dP/dt increased
Vasovagal Synkope Hvordan sNlles diagnosen vasovagal synkope? Historien, varslingssymptomer, optakt Nl besvimelse som kan brydes ved at sæSe sig eller lægge sig Hvis tvivl eller typiske anfald men med alvorlige synkoper med Nlskadekomst eller hyppige anfald eller vigNgt med diagnosNsk anlaring: Tilt-­‐test(vippeleje test) A A R H U S U N I V E R S I T E T
Recurrent syncope – Tilt-table test
Tilt-table Testing - Westminster Protocol
•  Methodology:
•  Motorized Tilt-table with footboard
•  Procedure:
•  10 min supine – baseline
•  2 ECG leads
•  Beat by beat non-invasive BP
Finapres – photoplesthysmography
•  Principally off drugs
•  Recording of ECG,BP, event markers
•  Tilt up to 60 degrees, for 30 min
quiet room, minimize talking
•  After 30 min NTG challenge further 15 min in tilt-up
•  Allow full expression of syncope
before tilt down
•  Symptoms marked
•  2 technicians present
Reproducibility: Concordance – pos-test: 80% ; neg.test: 85%
Low false positive rate: 7% ( healthy subjects without symptoms)
Diagnosis of Malignant Vasovagal Syncope
Positive Tilt-table test:
Loss of consciousness + significant hypotension or bradycardia
Vasodepressor type:
BP < 75 mm Hg and no bradycardia
(HR > 40 bpm and pauses < 3 seconds)
Cardioinhibitory type:
Significant asystole or bradycardia –
Pauses > 3 seconds and or HR < 40
bpm for > 10 seconds
Comments:
- allways a vasodepressor component
- pauses sinusarrest / AV block( pancardiac inhibition)
- average tilt-time to syncope 15-20 min.
Sutton R et al. Proposed classification of tilt induced vasovagal syncope. Eur J C P E 1993;2:180-183
Malignant Vasovagal Syncope – Cardioinhibitory Type
50 year old woman, recurrent syncopes, seizure like appareance, 1994 fractur of foot, work-up for epilepsy negative.
The last 2 years 4 severe syncopees, allways prodromes(15 s), clin.exam., ECG and Echocardiography normal.
Recurrent syncope – vasovagal syncope
Treatment of Vasovagal Syncope
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Information, importance of prodromes
to avoid syncope
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Pharmacological
- Midodrine ( alfa agonist )
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Pacemaker – dual chamber
- rate drop response
- closed loop stimulation(CLS)
Information mundtlig og skriftlig om Vasovagal Synkope
Recurrent syncope – carotid sinus syndrome
Diagnosis of Carotid Sinus Syndrome
Clinical history of syncope or falls
+
Reproduction of symptoms and
Syncope by carotid sinus massage and
associated asystole > 3 seconds
and / or BP drop > 50 mm Hg
+
Exclusion of other possible causes
of syncope
Hyppigste årsager Nl synkope hos ældre •  OrtostaNsk hypotension(OH) • 
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Refleks synkope – oZe sinus caroNcus syndrom(CSS) men også vasovagal synkope(VVS) Kardielle arytmier. Syg sinus knude syndrom, AV blok; hurNg SVT og VT; Bradykardi < 40 spm i vågen Nlstand A A R H U S U N I V E R S I T Y
Methods for ECG Symptom Correlation
12 lead ECG (10 sec) – on-­‐line Hospital telemetri( 24 hours-­‐ week) – on-­‐line Ambulatory telemetry ECG, conNnously-­‐ 24-­‐hours-­‐weeks Trans-­‐phone-­‐sample daily-­‐ 10-­‐30 sec ECG – on-­‐line Holter Monitorering – 24-­‐hours-­‐ 2 weeks (records and keeps everything) – off-­‐line External Event recorders-­‐ 24 hour-­‐ 2 weeks (records detected arrhythmia or acNvaNon) -­‐ off-­‐line Implantable ECG recorders (Reveal DX/XT)-­‐ up to 3½year (records detected arrhythmia or acNvaNon) – off-­‐line Metoder til EKG Symptom Korrelation
Recidiverende Synkoper: Anfaldshyppighed: dagligt – op Nl 1 gang per måned: Holter monitorering 2 – 7 døgn ( evt 2 uger) Anfaldshyppighed: 1 gang per 4 uger eller sjældnere: Implanterbar EKG optager -­‐ RevealLinq DiagnosNsk udbySe af Holter ved Synkope Hos hvor mange procent fanger man en synkope under 2 døgns Holter? 3% Hos hvor mange procent uden synkope fanger man en betydende arytmi( 2.grads AV blok type 2; pause 3-­‐5 sekunder, hurNg VT eller SVT(> 180 spm;> 30s), bradykardi < 35 spm i vågen Nlstand 12% A A R H U S U N I V E R S I T Y
Implantable ECG Recorder – Reveal plus
Bipolar recording, unit read
transcutaneosly
Activated manually or automatically,
Records 42 minuttes of loop
recording.
Battery for 36 months of recording.
Diagnostic succes rate 30-40%
RevealLINQ – Implanterbar EKG optager
Neurologists, Geriatricians and Cardiologists Common Problem: How to make af certain diagnosis in paRents with T-­‐LOC How do we reduce the number of undiagnosed paRents – improve outcome of our diagnosRc work-­‐up A A R H U S U N I V E R S I T Y
Epilepsy versus Syncope Epilepsy Syncope InconRnence yes yes Presence of jerks yes yes Eyes open yes yes Nature of jerks Large 1 min synchroneus Small 10 seconds asynchroneus Muscle tone rigid flaccid Tonque bi^en Yes, side Rare, Np Sleepiness a_erwards yes Yes(children) Confusion a_erwards Yes No!