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Dizziness and SyncopeDizziness and Syncope
Karen E. Hauer, MDKaren E. Hauer, MDUniversity of California, University of California,
San FranciscoSan Francisco
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.
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
Rule out tumor 1/9307 - dizziness, normal hearing 1/638 - dizziness, asymmetric hearing loss
Rule out vascular compromise
IndicationsNew neuro symptoms/signs
Sudden vertigo & stroke risk factors Vertigo & new severe headache
Test of choice: MRI/ MRAGizzi, Arch Neurol 1996
Vertigo: when to image?Vertigo: when to image?
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%
Linzer, Ann Intern Med, 1997
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
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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
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
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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
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
Vasovagal syncope: pacemakers ineffectiveVasovagal syncope: pacemakers ineffective
Randomized double-blind trial
DDD pacer vs. sensing-only pacer
0
10
20
30
40
50
60
70
80
90
100
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
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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
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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
Linzer, Ann Intern Med, 1997
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
Syncope in the elderly:Syncope in the elderly:a poor prognostic signa poor prognostic sign
Cumulative Mortality after Syncope
05
10152025303540
0 3 6 9 12 15 18 21 24
Months
%
elderly-cardiac syncope
elderly-noncardiacsyncope
young-cardiac syncope
young-noncardiacsyncope
Kapoor, Am J Med, 1986
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
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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?)
The Potentially Costly WorkupThe Potentially Costly Workup
TestTest Charge*Charge*
H & P $160EKG $9024-hour Holter $468Loop recorder - 30 day $284Electrophysiology study $4678Psychiatric evaluation $150CT brain $888Echo $580Stress test $433Tilt table test $683
*Average at 4 academic centers, Linzer, 1997
Trust the Careful History:Trust the Careful History:Excess Cost of Vasodepressor SyncopeExcess Cost of Vasodepressor Syncope
30 patients referred for “undiagnosed” syncope All characteristic vasodepressor
history
Mean cost of prior testing $3763 - 1991
Majority had Holter, echo, CTCalkins, Am J Med, 1993
Calkins, Am J Med, 1991.
Number of Major Diagnostic Tests Per
Patient
0
2
4
6
8
10
# tests
# p
ts
0 9
Case Presentation: Case Presentation: Is typical practice cost effective?Is typical practice cost effective?
Hypothetical scenario presented to 916 MDs 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
Cost-effective workup:Cost-effective workup:Internists vs. cardiologistsInternists vs. cardiologists
Diagnosis: vasovagal syncopeIntended plan: observation +/- overnight teleSurvey results: aggressive approach
Cardiologists Internists YOUAdmit? 79% 72% ?
Mean # additional tests 2.7 2.3 ?
Glassman, Arch Intern Med, 1997
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