![San Francisco Syncope Rules
To Guide Inpatient Admission
1. C – (History of Congestive heart failure)
2. H – (Hematocrit < 30%)
3. E – Abnormal ECG
4. S – Shortness of breath
5. S – SBP < 90
1st validation study: 96% sensitive, 62%
specific for predicting serious outcome at 7
days
2nd validation study: not as good
Main point: “further validation is needed
before can be widely applied…[but]syncope... 27](https://image.slidesharecdn.com/seminarsyncope-170630114309/85/Seminar-syncope-27-320.jpg)
Seminar syncope
- 1. Chandan kr SYNCOPE syncope... 1 Dr CHANDAN KUMAR VMMC&SAFDAJUNG,
- 2. Self-limited loss of consciousness and postural tone Relatively rapid onset Variable warning symptoms Spontaneous complete recovery Loss of consciousness occurs within 10 seconds of hypoperfusion of the reticular activating system in the mid brain syncope... 2
- 3. Causes of True Syncope Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary 1 • VVS • CSS • Situational Cough Post- Micturition 2 • Drug-Induced • ANS Failure Primary Secondary 3 • Brady SN Dysfunction AV Block • Tachy VT SVT • Long QT Syndrome 4 • Acute Myocardial Ischemia • Aortic Stenosis • HCM • Pulmonary Hypertension • Aortic Dissection Neurally- Mediated 66% 10% 11% 5% unexplained2% Manual of cardiovascular medicine 4thed..griffin et al syncope... 3
- 4. Neurally-Mediated Syncope Absence of cardiac disease Long history of syncope After sudden unexpected, unpleasant sensation Prolonged standing in crowded, hot places Nausea vomiting associated with syncope During or after a meal With head rotation or pressure on carotid sinus After exertion syncope... 4
- 5. Vasovagal Syncope (VVS) Carotid Sinus Syndrome (CSS) Situational syncope Post-micturition Cough Swallow Defecation Blood drawing, etc. syncope... 5
- 6. Neurally-mediated physiologic reflex mechanism with two components: 1. Cardioinhibitory (↓ HR) 2. Vasodepressor (↓ BP) despite decrease in heart beats, no significant BP generated Both components are usually present Wieling W, Gert van Dijk J, van Lieshout J, Benditt D. Pathophysiology and clinical presentation. In: Benditt D, Blanc J-J, et al. eds. The Evaluation and Treatment of Syncope. Elmsford, NY: Futura. 2003;11-22. syncope... 6
- 7. VVS General Treatment Measures • Optimal treatment strategies for VVS are a source of debate • Treatment goals – Acute intervention • Physical maneuvers, eg, crossing legs or tugging arms • Lowering head • Lying down • Long-term prevention – Tilt training – Education – Diet, fluids, salt – Support hose – Drug therapy – Pacing •Drug therapy should be used as a second line option. Midodrine and beta- adrenergic blockers are the agents most thoroughly studied to date syncope... 7
- 8. CSS Carotid Sinus Syndrome • Syncope clearly associated with carotid sinus stimulation is rare (≤1% of syncope) • CSS may be an important cause of unexplained syncope/falls in older individuals • Prevalence higher than previously believed • Carotid Sinus Hypersensitivity (CSH) syncope... 8
- 9. Sensory nerve endings in the carotid sinus walls respond to deformation Previous neck surgery may contribute Increased afferent signals to brain stem Reflex increase in efferent vagal activity and diminution of sympathetic tone results in bradycardia and vasodilatation syncope... 9
- 10. Carotid Sinus Massage (CSM) • Method – Massage, 5-10 seconds – Don’t occlude – Supine and upright posture (on tilt table) • Outcome – 3 second asystole and/or 50 mmHg fall in systolic BP with reproduction of symptoms = Carotid Sinus Syndrome • Absolute contraindications – Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months • Complications – Primarily neurological – Less than 0.2% syncope... 10
- 11. SAFE PACE Syncope And Falls in the Elderly – Pacing And Carotid Sinus Evaluation • Objective – Determine whether cardiac pacing reduces falls in older adults with carotid sinus hypersensitivity • Randomized controlled trial (N=175) – Adults > 50 years, non-accidental fall, positive CSM – Pacing (n=87) vs. No Pacing (n=88) • Results – More than 1/3 of adults over 50 years presented to the Emergency Department because of a falls have CS hypersensitivity – With pacing, falls 70% – Syncopal events Kenny RA. J Am Coll Cardiol. 2001;38:1491-1496. syncope... 11
- 12. Syncope due to orthostatic hypotension After standing up Temporal relationship to taking a medication that can cause hypotension Prolonged standing Presence of autonomic neuropathy After exertion syncope... 12
- 13. Orthostatic Hypotension • Etiology • Drug-induced (very common) – Nitrates,ACE inhibitors,CCB,diuretics. alpha blockers, • Primary autonomic failure Multiple system atrophy – Parkinson’s Disease – Dementia with lewy body – Postural Orthostatic Tachycardia Syndrome (POTS) • Familial dysautonomia (Riley day syndrome- • Hereditary sensory and autonomic neuropathy- AR inheritance- hperhidrosis,labileBP,pain insensitivity etc syncope... 13
- 14. Secondary autonomic failure Diabetes Alcohol Amyloid SPINAL TUMOURS syncope... 14
- 15. Upright posture results in translocation of 30% of central blood volume to dependent body parts within seconds and transcapillary fluid shifts over 30 minutes further reduce blood volume by 5%. Compensatory responses Muscle pump Nuerovascular compensation Humoral compensation Local vascular syncope... 15
- 16. autonomic disturbance characterised by the clinical symptoms of orthostatic intolerance, mainly light‐headedness, fatigue, sweating, tremor, anxiety, palpitation, exercise intolerance and near syncope on upright posture. Increase in heart rate to >120 beats/minute or an increase of 30 beats/min with standind that subsides on lying down. Male :female=5:1 Age-15 to 50 years Pathogenesis unclear.beta receptor insessitivity,impaired brain stem regulation syncope... 16
- 17. TREATMENT Expansion of fluid volume Postural training Midodrine,fludrocortisone –tried with some success. syncope... 17
- 18. syncope... 18
- 19. syncope... 19
- 20. syncope... 20
- 21. syncope... 21
- 22. Patient education, injury avoidance Hydration Fluids, salt, diet Minimize caffeine/alcohol. Sleeping with head of bed elevated Tilt training, leg crossing, arm pull Support hose Drug therapies Fludrocortisone, midodrine, erythropoietin. syncope... 22
- 23. syncope... 23
- 24. Cardiac Syncope Presence of structural heart disease With exertion or supine Preceded by palpitations Family history of sudden death syncope... 24
- 25. Bradycardia/asystole Sick sinus syndrome 2nd or 3rd degree AV blocks Pacemaker malfunction Have high suspicion in patients with bundle blocks… Tachycardia Ventricular tachycardia Ventricular fibrillation SVT Long QT syndrome syncope... 25
- 26. Valvular disease (especially aortic stenosis) HOCM Cardiac masses (myxoma) Pericardial disease (tamponade or restrictive processes) Prosthetic valve dysfunction Acute aortic dissection Pulmonary hypertension (exercise related) PE syncope... 26
- 27. San Francisco Syncope Rules To Guide Inpatient Admission 1. C – (History of Congestive heart failure) 2. H – (Hematocrit < 30%) 3. E – Abnormal ECG 4. S – Shortness of breath 5. S – SBP < 90 1st validation study: 96% sensitive, 62% specific for predicting serious outcome at 7 days 2nd validation study: not as good Main point: “further validation is needed before can be widely applied…[but]syncope... 27
- 28. Triad 1.RBBB pattern in right precordial leads 2.Transient/persistent ST elevation in v1-v3 3.Sudden cardiac death Structurally normal heart Pathogenesis-Na channel abnormality Association with young and healthy men from southeast asia who present with sudden cardiac death Brugada sign may be asymptomatic High risk of sudden cardiac death in those who have syncope or family history of sudden death (Indication for AICD based upon observational data) syncope... 28
- 29. syncope... 29
- 30. TREATMENT- Quinidine ICD syncope... 30
- 31. syncope... 31
- 33. 3 main factors contributing to syncope or SCD Exercise (LQT1), especially swimming Emotions or emotional stress (LQT2) Events occurring during sleep or at rest, with or without arousal (LQT2 or LQT3) syncope... 33
- 34. Long QT1-most common. Chromosome 11p15.5 (LQT1), Exercise precipitates Two LQ1 alleles-Jervell and Lange –Nielson syndrome ---- marked QT prolongation associated with deafness…..worse prognosis T wave is broad Long QT2- Chromosome 7q35-36 (LQT2),T wave notched and bifid-precipitated by emotional stress,sleep or auditory stimulation syncope... 34
- 35. Long QT3-sodium channel defect- chromosome 3p21-24 (LQT3). Twave –late onset biphasic T wave or asymmetric peaked T wave. Male predominance Most events occur during sleep worst prognosis of all QTs. Treatment- a.ICD implantation Beta blocker are also effective Avoidance of drugs that prolong QT interval syncope... 35
- 36. syncope... 36 Moss AJ, et al. Circulation 1995;92:2929-2934
- 37. In current practice ECG monitoring is usually undertaken with conventional 24–48 h, or even 7 day, Holter recorders Daily single or multiple episodes of LOC might increase the potential for symptom–ECG correlation. the true yield of Holter in syncope may be as low as 1–2% in an unselected population. syncope... 37
- 38. loop memory that continuously records and deletes ECG connected to the patient through cutaneous patch electrodes. When activated by the patient, typically after a symptom has occurred, 5–15 min of pre- activation ECG is stored and can be retrieved for analysis. syncope... 38
- 39. The ILR is an implantable patient – and automatically – activated monitoring system that records subcutaneous ECG. -battery life of up to 36 months. syncope... 39
- 40. Patient Activator Reveal® Plus ILR 9790 Programmer Reveal ® Plus Insertable Loop Recorder syncope... 40
- 41. syncope... 41
- 42. syncope... 42
- 43. syncope... 43
- 44. syncope... 44
- 45. an invasive procedure that evaluated abnormal heart rhythm disturbances. syncope... 45
- 46. syncope... 46
- 47. 1. rapid (,2 s) injection of a 20 mg bolus of ATP (or adenosine) during ECG monitoring. 2. The induction of AV block with ventricular asystole lasting .6 s, or the induction of AV block lasting .10 s, are considered abnormal. 3. ATP testing produced an abnormal response in some patients with syncope of unknown origin . 4.paroxysmal AV block could be the cause of unexplained syncope. syncope... 47
- 48. Seems to identify a unique mechanism of syncope found in patients with: Advanced age More hypertension More ECG abnormalities syncope... 48
- 49. syncope... 49
- 50. syncope... 50
- 51. syncope... 51
- 52. syncope... 52
- 53. syncope... 53
- 54. Migraine* Acute hypoxemia* Hyperventilation* Somatization disorder (psychogenic syncope) Acute Intoxication (e.g., alcohol) Seizures Hypoglycemia syncope... 54
- 55. Disorders without impairment of consciousness Cataplexy Psychogenic pseudo-syncope Disorders with loss of consciousness Metabolic disorders Epilepsy Intoxications Vertebrobasilar transient ischemic attacks syncope... 55
- 56. Proximal subclavian artery stenosis Decreased blood flow to distal subclavian artery worsened with exertion of arm Blood from vertebral artery on opposite side goes to basilar artery and then down ipsilateral vertebral artery, away from brainstem, to serve as collateral for arm Usually asymptomatic Atherosclerosis Symptoms of vertebrobasilar insufficiency (dizziness, vertigo, diplopia, nystagmus) Rare to have permanent neurological deficits Diagnosis with dopplers, MRA Treatment: surgical revascularization, stents syncope... 56
- 57. syncope... 57 Conventional Diagnostic Methods/Yield * Structural Heart Disease † 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med, 1991. 3 Linzer, et al. Ann Int. Med, 1997. 4 Kapoor, Medicine, 1990. 5 Kapoor, JAMA, 1992 6 Krahn, Circulation, 1995 7 Krahn, Cardiology Clinics, 1997. 8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8. 9 Day S, et al. Am J Med. 1982; 73: 15-23. 10 Stetson P, et al. PACE. 1999; 22 (part II): 782.
- 58. The only difference between syncope and sudden death is that in one you wake up………THANKU.
- 59. The efficacy of beta-blockers in these patients may be due to blunting of elevated catecholamine levels that precede vasovagal syncope Journal of the American College of Cardiology Vol. 51, No. 24, 2008 syncope... 59
- 60. syncope... 60