Forbigående tab af bevidsthed og fald Kardielle årsager udredning Synkope

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1 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

2 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

3 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

4 Transient Loss of Consciousness T-LOC Emergency Department Doctors Geriatricians Cardiologists Neurologists Geriatricians

5 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: , 2009

6 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

7 Incidence Rate of Syncope in General Population In Relation to Sex and Age N Engl J Med 2002;347: ) 10 years cumulative incidence of syncope 6%

8 Opgørelse fra Danmark Kilde: Ruwald MH et al. Europace 2012;14:

9 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? A A R H U S U N I V E R S I T Y

10 Recurrent syncope and diagnostic work-up: Background 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

11 Gold Standard for Diagnostic Test: ECG Symptom Correlation Recording of: ECG Blood Pressure EEG Cardiac Output During Clinical Syncope

12 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

13 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 A A R H U S U N I V E R S I T Y

14 Background Reccurent syncope Key for a relevant work-up: Anamnesis Structural Heart Disease Yes / No Have a work-up algorithm

15 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

16 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

17 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

18 Undersøgelser ved mistanke om kardiel synkope A A R H U S U N I V E R S I T E T 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

19 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

20 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

21 Recurrent syncope Neurocardiogenic syndromes 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

22 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

23 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

24 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

25 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

26 Principal Mechanisms of Vasovagal Syncope Central Type Benign VVS Fear, white mouse Defect? Peripheral Type Malignant VVS No precipitating factors Sympathetic CNS Vasodilatation Bradycardia Hypotension Asystole Vasodepres. Syncope Parasymp Cardioinhib. * Bezold-Jarisch Reflex (affer. Vagal C-fibers) Mechanoreceptor Activation * Decreased Ventricular Filling Venous Pooling of Blood Hypovolemic vigoursly contracting left ventricle; dp/dt increased

27 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

28 Recurrent syncope Tilt-table 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)

29 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 min. Sutton R et al. Proposed classification of tilt induced vasovagal syncope. Eur J C P E 1993;2:

30 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.

31 Recurrent syncope vasovagal syncope 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)

32 Information mundtlig og skriftlig om Vasovagal Synkope

33 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

34 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 A A R H U S U N I V E R S I T Y

35 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 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

36 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

37 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

38 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%

39 RevealLINQ Implanterbar EKG optager

40 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

41 Epilepsy versus Syncope Epilepsy Syncope InconRnence yes yes Presence of jerks yes yes Eyes open yes yes Nature of jerks Large 1 min synchroneus Muscle tone rigid flaccid Small 10 seconds asynchroneus Tonque bi^en Yes, side Rare, Np Sleepiness a_erwards yes Yes(children) Confusion a_erwards Yes No!