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A A R H U S U N I V E R S I T E T
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 Y
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
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
ESC syncope guidelines 2009
Transient Loss of Consciousness – T-LOC
Emergency Department Doctors Geriatricians
Cardiologists Neurologists Geriatricians
- 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
Syncope – definition:
Work-Up in Syncope
greek ”syn”+”koptein”- to cut or to interrupt
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
A A R H U S U N I V E R S I T Y
Syncope hos ældre-‐ særlige udfordringer
• 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?
• Common clinical problem 3-5% of emergency room visits 1-3% of hospital admissions In the community, 15-23% during 10 year period
• Unravelling of underlying cause difficult • Variable frequency of attacs – weeks/months/years
• Ideal diagnostic test not avaliable in most cases:
Reproduction of syncope and patognomonic patophysiology in the laboratory
• 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
Recurrent syncope and diagnostic work-up: Background
Gold Standard for Diagnostic Test: ECG – Symptom Correlation Recording of:
ECG
Blood Pressure EEG Cardiac Output
During Clinical Syncope
Focused history for syncope General history – Heart, CNS
Clinical examination, BP supine / standing, ECG
Syncope / Loss of Consciousness, +/- Convulsions
Frequency: 10-30% Benign prognosis
Frequency: 15-40% Adverse prognosis -
mortality 20-30%/year
Frequency: 5-15% SUDEP-
increased mortality
Neurocardiogenic cause - Vasovagal syncope
- Carotid Sinus Syndrom
Diagnostic Hypothesis
Cardiac cause -Arrhytmia; -Obstructive;
- Ischemia
Neurological cause - Epilepsy, TCI, psychiatric
Recurrent syncope and diagnostic work-up: prognosis
A A R H U S U N I V E R S I T Y
Hyppigste årsager Nl synkope hos ældre
• OrtostaNsk hypotension(OH)
• 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
Background – Reccurent syncope
Key for a relevant work-up:
Anamnesis
Structural Heart Disease – Yes / No
Have a work-up algorithm
A A R H U S U N I V E R S I T Y
Kliniske karakterisNka ved iniNale vurdering som taler for OrtostaNsk Hypotension
• EZer at have rejst sig • Tidsmæssig relaNon Nl start eller ændringer i medicin
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)
• 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 E T
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
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
OrtostaNsk BT måling
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
Diagnosis of Neurocardiogenic Syndromes Syndromes causing recurrent syncope through sudden HR and BP drop
Carotid Sinus Syndrome (CSS)
Carotid sinus massage
Documented hypersensitive carotid sinus: Cardioinihibotory / Vasodepressor respons
Asystole > 3 s / BP drop > 50 mm Hg
+ reproduction of clinical symptoms
Malignant Vasovagal Syncope (VVS)
Tilt-table test
Positive tilt-table test:
Cardioinhibitory / Vasodepressor respons
+ reproduction of clinical symptoms
Recurrent syncope – Neurocardiogenic syndromes
A A R H U S U N I V E R S I T E T
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
Refleks besvimelse
Neurokardiogen synkope
Vasovagal Synkope
Godartet besvimelse
Dåne
Passing out
Ligfald
Kært barn mange navne
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?
Principal Mechanisms of Vasovagal Syncope
”Central Type” Benign VVS
Fear, ”white mouse”
”Peripheral Type” Malignant VVS
No precipitating factors
CNS
Vasodilatation Bradycardia Hypotension Asystole
Syncope
Sympathetic Parasymp
Vasodepres. Cardioinhib.
Mechanoreceptor Activation
Decreased Ventricular Filling
Venous Pooling of Blood
Bezold-Jarisch Reflex (affer. Vagal C-fibers)
Hypovolemic vigoursly contracting left ventricle; dP/dt increased
Defect ?
*
*
A A R H U S U N I V E R S I T E T
Hvordan sNlles diagnosen vasovagal synkope?
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)
Tilt-table Testing - Westminster Protocol
• Methodology: • Motorized Tilt-table with footboard • 2 ECG leads • Beat by beat non-invasive BP Finapres – photoplesthysmography • Principally off drugs • Recording of ECG,BP, event markers • 2 technicians present
• Procedure: • 10 min supine – baseline • 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
Reproducibility: Concordance – pos-test: 80% ; neg.test: 85%
Low false positive rate: 7% ( healthy subjects without symptoms)
Recurrent syncope – Tilt-table test
Diagnosis of Malignant Vasovagal Syncope Positive Tilt-table test:
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
Loss of consciousness + significant hypotension or bradycardia
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.
Treatment of Vasovagal Syncope
• Information, importance of prodromes to avoid syncope
• Pharmacological - Midodrine ( alfa agonist ) • Pacemaker – dual chamber - rate drop response
- closed loop stimulation(CLS)
Recurrent syncope – vasovagal syncope
Information mundtlig og skriftlig om Vasovagal Synkope
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
Recurrent syncope – carotid sinus syndrome
A A R H U S U N I V E R S I T Y
Hyppigste årsager Nl synkope hos ældre
• OrtostaNsk hypotension(OH)
• 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
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
A A R H U S U N I V E R S I T Y
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%
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%
Implantable ECG Recorder – Reveal plus
RevealLINQ – Implanterbar EKG optager
A A R H U S U N I V E R S I T Y
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
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!
