3 dizziness and syncope. karen hauer, md

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 acute vestibular asymmetryasymmetry

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

1.31Prior MI

1.31Postural hypotension

1.30> 4 meds

1.34Impaired balance

1.27Decreased hearing

1.36Depression

1.69Anxiety

Relative riskRisk factor

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 Syncope: management questionsquestions

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 The Key to Diagnostic EvaluationEvaluation

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, inadequate cardiac output, arrhythmiaarrhythmia

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 - Arrhythmia evaluation - telemetrytelemetry

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) 24 hr ambulatory (Holter) monitoringmonitoring

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

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Arrhythmia evaluation: improving the Arrhythmia evaluation: improving the

yieldyield

– 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

NeurocardiogenNeurocardiogenic Syncopeic Syncope

Vasovagal

Mictur i tionVasodepressor

Ne u r a l l y - me d ia t e d

R e f le x iv e

Orthostatic intolerance

Carotid sinus syncope

C a r d io n e u r o g e n ic

May be predominantly Cardioinhibitory

(bradycardia) Vasodepressor

(hypotension) or Both

Neurocardiogenic SyncopeNeurocardiogenic SyncopeClinical PresentationClinical Presentation

0

20

40

60

80

100

120

140

2468time (minutes)

BloodpressurePulse

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: Neurocardiogenic syncope: treatmenttreatment

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 Vasovagal syncope: pacemakers ineffectiveineffective

Randomized double-blind trial

DDD pacer vs. sensing-only pacer

010203040

5060708090

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 Framingham 25 year follow upup

1.08 Vasovagal

1.32*Idiopathic

1.54*Neurologic

2.01*Cardiac

Adjusted risk of death

Etiology of syncope

*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 Recommendations for Driving: following the lawDriving: following 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, CT

Calkins, 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 Is typical practice cost effective?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