CC Sept 2017 Syncope in adults

echoecho's version from 2017-10-15 22:16


Question Answer
In March 2017, the American College of Cardiology and American Heart Association released their long-awaited guidelines for evaluation and management of patients with syncope. What was the focus of the guidelines? on providing an evidence-based risk stratrification and maangement tool on syncope (especially cardiac syncope)
Prior to this release, most of the recommendations for evaluation and management came from what guideline?2009 European Society of Cardiology guideline on syncope
What was the recurrent theme of both documents?1) assessing the short- and long-term risk of death and related life-threatening conditions 2) assessing the risk of recurrent syncope leading to potential physical injury and / or diminished quality of life
The above risks were also emphasized in a 2002 study of > 7800 patients enrolled in the Framinham Heart Study (1971-1981), what were the results?a statistically significant increaes in all-cause mortality (HR 1.31, 95%, CI 1.14-1.51) for all patients with syncope and a larger increase due to cardiac-related syncope (all-cause HR 2.01, 95%, CI 1.48-2.73; acute MI / coronary artery-related death HR 2.66, 95%, CI 1.69-4.19; fatal/nonfatal stroke, HR 2.01, 95%, CI 1.06-3.8)
Define syncope?the abrupt, transient, complete LOC associated with an inability to maintain postural tone, with rapid and spontaneous recovery
The above syncope definition separates syncope (thought to be due to cerebral hypoperfusion) from other causes of transient LOC such as what?seizures, antecedent head trauma, apparent LOC
Syncope is subdivided into what 3 categories?1) cardiac syncope 2) neurally-mediated (reflex) syncope 3) orthostatic hypotension
Which of the 3 categories is the most common?neurally-mediated (followed by cardiac syncope and orthostatic hypotension)
Syncope accounts for about ____ million emergency department visits as well as 250,000 hospital admission and > 2.4 billion dollars in cost per year in the US, mostly due to high rates of ambulance and hospitalization, usually > 2 days per admission?6.7 million
*** The 2017 ACC/AHA guidelines recommends what for evaluation of all patients presenting with syncope?1) thorough history 2) physical exam (including measurements of orthostatic blood pressures) 3) EKG
A detailed hx can determine the cause in ____% of the cases?50
List the factors associated with likely cardiac vs. noncardiac etiology of syncope?1) likely cardiac = male; > 60 y.o; known heart disease / arrhythmias; palpitations, brief prodrome or no prodrome; syncope during exertion; syncope in supine position; 1-2 syncopal episodes; abnormal cardiac exam; fm hx sudden cardiac death < 50 y.o.; known congenital heart disease 2) likely non-cardiac = younger age; no known heart disease / arrhythmias; syncope only in standing position; associated with positional change, supine to sitting to standing; prodrome (nausea, vomiting, feeling of warmth); specific triggers (dehydration, pain, medical environment, stressful situations); situational triggers (micturition, laugh, cough, defecation); frequent occurrence
If the cause is evident, what is done?treatment and risk stratification
If the cause is not evident, what is done?additional workup and risk stratification are both undertaken, based on the severity of the presenting symptoms, medical comorbidities and overall clinical picture
These results drive testing and include consideration of ______ ?hospitalization
Special attention should be given to the evaluation of what conditions?cardiac arrhythmias, cardiac or vascular nonarrhythmic dconditions (ischemia, valvular stenosis, pulmonary embolism), significant noncardiac conditions (GI bleeding or hx of significant trauma)
*** Prodromal symptoms preceding LOC are more often associated with a _______ cause of syncope and are not considered a short or long-term risk factor?non-cardiac
List the short-risk factors associated with increased risk of morbidity and mortality with syncope?1) male gender 2) age > 60 y.o. 3) no prodrome 4) palpitations, LOC 5) exertional syncope 6) structural heart disease 7) heart failure or CVD 8) fm hx of sudden cardiac death 9) trauma 10) evidence of bleeding 11) persistent vital sign abnormalities 12) abnormal EKG 13) positive troponin
List the long-term risk factors associated with increased risk of morbidity and mortality with syncope?1) male gender 2) age > 60 y.o. 3) absence of nausea, vomiting during event 4) ventricular arrhythmias 5) cancer 6) structural heart disease 7) heart failure or CVD 8) M 9) high CHADS-2 score 10) abnormal EKG 11) low GFR
Determination of the best syncope scoring system arises when considering the syncope workup and stratifying the patient's short and long-term risk of death or other serious outcomes, true or false?true
How many scoring systems exist?6
What does the San Francisco Syncope Rule look at?serious events (acute MI, pulmonary embolism and CVA) focusing on a 7-day interval, the shortest interval of all of the scoring systems
What do the Boston (2007), Canadian (2016) and Risk Stratification of Syncope in the ED (ROSE) target?outcomes at 30 days or more
What does the Osservatorio Epidermiologico sulla Sincope nel Lazio (OESIL) and Evaluation of Guidelines in Syncope Study (EGSYS-1/2) scoring systems look at?outcomes at 1 and 2 years respectively
*** The 2017 ACC/AHA guidelines states that " use of risk stratification may be reasonable" but point out what 5 limitations of the tools?1) inconsistent definitions of syncope, outcomes, outcome timeframes and predictors 2) inclusion of patients with serious outcomes already identified in the ER (a major source of potential bias), 3) use of composite outcomes that combine events with different pathophysiologies 4) small sample sizes 5) limited external validication
Generally, the 2017 ACC/AHA guideline points out that the risk stratification scoring systems, do what?"have not performed better than unstructured clinical judgement"
Orthostatic hypotension and neurally-mediated syncope round out the other 2 causes of syncope. These are not life-threatening, however repeated episodes can cause what?physical injury and diminished quality of life
What is the most common cause of neurally-mediated syncope?vasovagal syncope
What is vasovagal syncope triggered by and what symptoms occur?1) emotional or orthostatic stressors (pain / protracted standing, sight of blood, venipuncture) 2) episode of prodromal symptoms (sudden sweating, pallor, lightheadedness, nausea)
*** The 2017 guideline recommends patient on the dx and prognosis of vasovagal syncope and what else?1) teaching injury avoidance techniques (assuming a supine position upon sensation of prodromal symptoms) 2) increased consumption of fluids and salt (2-3 liters of fluid and 6-9 grams of salt per ay) 3) for patients with sufficiently long prodromal symptoms, counterpressure maneuvers (crossing legs, squatting, limb / abdominal contraction)
What options are reserved for patients with repeated episodes of vasovagal syncope not responsive to the above interventions?1) medications (midodrine, fludrocortisone) 2) beta-blockers (in patients > 42 y.o.) 3) SSRI 4) orthostatic training 5) dual-chamber pacemaker therapy
***SUMMARY = Syncope accounts for about ____ million emergency department visits per year, resulting in significant hospital admission and high medical cause?6.7
***SUMMARY = What is the initial evaluation for all patients with syncope?1) hx 2) physical exam 3) EKG
***SUMMARY = Up to ____% of patients will not need further testing?50
***SUMMARY = Common diagnoses for hospital admission include?1) EKG abnormalities 2) hx or physical exam indicating cardiac disease or suspected cardiac arrhythmia and serious comorbidities