Dizziness and Syncope

Dizziness and Syncope:

Outline

 Dizziness: common etiologies

 Case examples
 Syncope
 Diagnosis
 Efficient workup
 Management
Definition of Syncope
 Sudden and brief loss of consciousness
associated with a loss of postural tone,
from which recovery is spontaneous
(NEJM 343:1856)
 Syncope – A Symptom, Not a
Diagnosis
 Self-limited loss of consciousness and
postural tone
 Relatively rapid onset
 Variable warning symptoms
 Spontaneous, complete, and usually
prompt recovery without medical or
surgical intervention

Brignole M, et al. Europace, 2004;6:467-537.

Dizziness

 “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
Etiology of dizziness
 Vertigo 50%
 Disequilibrium 2%
 Psychiatric 2-16%
 Presyncope 4-14%
 Single etiology 52%
Kroenke, Ann Intern Med 1992
UpToDate 2005
Case

 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.
Case

 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.
 Vertigo:
acute vestibular asymmetry
Central (15%) Peripheral (85%)
 Brainstem infarct/ischemia  Benign positional

 Tumor  Labyrinthitis

 Cerebellopontine angle  Meniere’s

 Brainstem
 Otitis media
 Migraine
 Vertigo: history and exam
Central
 Gradual onset (except
stroke)
 Persistent
 Neuro findings common
 Nystagmus any direction -
changes with gaze
 Nystagmus not suppressable
 Unable to stand
Peripheral
 Sudden, severe
 Episodic
 Ear symptoms common
 Nystagmus
horizontal/torsional, no
change with gaze
 Nystagmus suppressed
with fixation
 Able to stand, lean to
lesion
Anatomy

American Academy of Otolaryngology/HNS

Dix-Hallpike maneuver: to induce
positional vertigo and nystagmus

 Benign positional
vertigo: #1 cause of
peripheral vertigo
 Episodic symptoms
 Free floating debris
in semicircular
canals
Dix-Hallpike maneuver:
diagnostic and therapeutic

• Positional vertigo:
•Vertigo/nystagmus reproduced
•Latency 5-15 seconds
•Decreases w/in 30 seconds
•Fatigues on repeat
 Vertigo: when to image?
 Rule out tumor
 1/9307 - dizziness, normal hearing

 1/638 - dizziness, asymmetric hearing loss

 Rule out vascular compromise

Indications
New neuro symptoms/signs
 Sudden vertigo & stroke risk factors
 Vertigo & new severe headache
Test of choice: MRI/ MRA
Gizzi, Arch Neurol 1996
 Case: 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 multifactorial
 Sense of imbalance -worse with walking
 Contributing factors
 Vision, hearing impairment
 Peripheral neuropathy
 Musculoskeletal disease/gait disturbance
 Medications
 Dizziness: a geriatric syndrome
24% of community-living elders had dizziness > 1 month

Risk factor Relative risk

Anxiety 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 2000
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 etiology

 Young healthy patient

 Symptoms reproduced with
hyperventilation
 Nystagmus suggests vestibular lesion
 Treat underlying anxiety/depression
Establishing 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:
coma
narcolepsy
seizure
Syncope: 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 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
Case 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 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
Risk Factors
 Predictors of arrhythmic syncope or
cardiac death at one year
 CHF
 Ventricular tachyarrhythmias
 Abnormal ECG
 Age >45 years
 Presence of 2 or more of these is
associated with >10% incidence of
syncope or cardiac death
Cardiac Differential
Cardiac Syncope: LOC often w/o prodrome
 Indicates Outflow Obstruction
 AS, HOCM, PAH, Pulmonic Stenosis, PE
 MI, USA, Coronary Artery Spasm, Aortic
Dissection
 Arrhythmias
 Prolonged QT (either Congenital or Drug Induced)
 AV Block, Sinus Node Dysfunction
 Ventricular tachycardia
 Arrhythmogenic right ventricular dysplasia
 Supraventricular tachycardia (Wolff-Parkinson-White)
Neurally Mediated Syncope
 Most Common Causes
 Vasovagal, Situational, and Carotid
Sinus Syncope
 Results from sudden reflex mediated
hypotension/ and or bradycardia
 Triggered by various stretch/
mechanoreceptors (carotid sinus,
bladder, esophagus, respiratory tract
 Carotid Sinus Syncope and Autonomic Dysfunction

Freeman, M. Neurogenic Orthostatic Hypotension. NEJM 2008; 358: 616

Orthostatic Hypotension
 Decline of >20mm Hg in SBP/ 10mm
Hg in DBP from supine to standing
 Supine HTN common in these patients
 Elderly especially vulnerable
 ↓ Baroreceptor sensitivity, ↓ Cerebral Blood
Flow, ↑ renal sodium wasting, ↓thirst response
with aging
 Peripheral sympathetic tone impairment
 Diabetic neuropathy, antihypertensive
medication
General Mechanisms
 ↓ cardiac output
 ↓ vascular resistance
 ↓ in cerebral perfusion
 causes with normal cerebral blood flow
 hypoglycemia
 hypoxia
 Causes of True Syncope
Structural
Neurally- Cardiac Cardio-
Orthostatic
Mediated Arrhythmia Pulmonary

1 2 3 4
• VVS • Drug-Induced • Brady • Acute
• CSS • ANS Failure SN Myocardial
Dysfunction Ischemia
• Situational Primary
AV Block • Aortic
Cough Secondary
• Tachy Stenosis
Post-
VT • HCM
Micturition
SVT • Pulmonary
• Long QT Hypertension
Syndrome • Aortic
Dissection

Unexplained Causes = Approximately 1/3

DG Benditt, MD. U of M Cardiac Arrhythmia Center
Diagnostic Evaluation
 H and P! – 45% of time can identify cause
 CBC, BMP
 ECG- Low yield but can be important clues to
look for underlying heart disease
 CT Head, EEG: low yield
 Echocardiogram/ Stress Test: Helpful when
presence of underlying cardiac disease
cannot be determined clinically
The 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 Algorithm

Syncope

Noncardiac Idiopathic
Cardiac

Arrhythmia Neurocardiogenic
Mechanical Orthostatic
Neurologic
Psychiatric
 Cardiac syncope:
inadequate cardiac output, arrhythmia
Cardiac enzymes - only if history or EKG suggestive of MI
– 1-10% MI’s present with syncope
– EKG up to 100% sensitive for MI
Echo - rule out structural heart disease
– before stress test if obstruction suspected
– yield: 5-10%
Exercise stress test - exertional syncope
– identifies exertional arrhythmia
– yield: low (1%)
Georgeson, J Gen Intern Med, 1992
Linzer, Ann Intern Med, 1997
 Arrhythmia 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 syncope
ICU transfer-arrhythmia 0.8% 0.4%
Telemetry “Helpful” 12.6% 16%
Mortality 0.9% 0
Estrada, Am J Cardiol, 1995
Linzer, Ann Intern Med, 1997
Estrada, Am J Cardiol, 1995
 Arrhythmia evaluation:
24 hr ambulatory (Holter) monitoring

2612 syncope/dizzy patients

• Symptomatic arrhythmia = positive result

• Diagnostic arrhythmia in 4%

• Symptoms without arrhythmia Quick Time™a nd a

TIFF ( Unco mpre ssed ) dec ompr esso r
ar e nee ded to see this pictur e.

• Arrhythmia ruled out in 15%

Bottom line
• Benefit: monitors during usual activity

• Limitation: brief duration limits yield unless daily

symptoms
Linzer, Ann Intern Med, 1997
Arrhythmia evaluation: improving the yield

– Loop recorder
– Indication: recurrent syncope with normal heart

– frequent syncope -> continuous loop recorder (weeks)

– infrequent syncope -> implantable loop recorder (years)
– Electrophysiologic study
– Indication: syncope with organic heart disease

– Signal average EKG

– Detects late potential in QRS - substrate for VT/VF

– indication: normal heart, idiopathic syncope?

Linzer, Ann Intern Med, 1997

Zimetbaum , Ann Intern Med, 1999
 Reflexive
Vasodepressor
Micturition
Orthostatic
intolerance

Neurocardiogenic
Syncope
Vasovagal
Carotid sinus syncope
Neurally - mediated
Cardioneurogenic
 Neurocardiogenic Syncope
Clinical Presentation
140 Trigger
May be predominantly 120
 Cardioinhibitory
100
 (bradycardia)
80 Blood
 Vasodepressor pres sure
60 Pulse
 (hypotension) or
40
 Both Syncope
20
0
2 4 6 8
time (minutes)
Neurocardiogenic Syncope:
Pathophysiology
Decreased venous return

Increased LV contractility

Mechanoreceptor
Stimulation

Inhibits Increases
Sympathetic tone Vagal tone

Vasodilation Bradycardia/
Asystole

Hypotension SYNCOPE

SYNCOPE
 Diagnosing neurocardiogenic
syncope 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
 Syncope: 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
Neurocardiogenic 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 ineffective

Randomized double-blind trial

DDD pacer vs. sensing-only pacer
100
90
80
70
% 60
50 p = NS DDD pacer
placebo
40
30
20
10
0
syncope presyncope
Connolly, JAMA 2003
 “Idiopathic” syncope:
improving diagnostic yield
 Up to 40% patients
 Prognosis good
 Potential morbidity, lifestyle implications
 Consider:
Diagnosis Testing
Neurocardiogenic Tilt table
Anxiety/depression Psychiatric evaluation
Arrhythmia EPS, implanted event monitor
 Empiric pacemaker?
 Prognosis:
Framingham 25 year follow up

Etiology of syncope Adjusted risk of

death
Cardiac 2.01*
Neurologic 1.54*
Idiopathic 1.32*
Vasovagal 1.08

*p<0.01
NEJM 2002;347:878
 Prognosis:
ED risk stratification

 ED predictors of Arrhythmia or death

at one year
arrhythmia or
80%
mortality 70%
60%
 Abnormal EKG
50%
 Prior VT/VF 40%
30%
 History of CHF 20%
10%
 Age > 45 0%
0 1 2 3 or 4
Number of
Martin, Ann Emerg Med, 1997 risk factors
 Prognosis:
Guideline for admission - the San
Francisco 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
Quic k Ti me™ and a

 98% sensitive
T IFF (Unc om pres s ed) dec om pres s or
are needed to s ee t his pic t ure.

 56% specific

Quinn, Ann Emerg Med, 2006

Prognosis:
Guideline for admission - the San
Francisco Syncope Rule

 CHF - history of
QuickTime™ and a
TIFF ( Uncompressed) decompressor

 Hematocrit <30% are needed to see this pictur e.

 ECG abnormal
 Shortness of breath
 Systolic blood pressure <90 mm
Hg at triage
Quinn, Ann Emerg Med, 2006
ACP Guidelines for Hospital
Admission

Definitely admit Often admit

 HPI: chest pain  HPI: age >70,
exertional syncope,
 PMH: CAD, CHF,
frequent syncope
ventricular arrhythmia
 Exam: tachycardia,
 Exam: CHF, valve dz, orthostatic hypotension,
focal neurologic deficit injury
 EKG: ischemia/MI,  Cardiac dz suspected

arrhythmia, bundle
branch block Linzer, Ann Intern Med, 1997
 Guidelines for Hospital Admission:
implications 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:
the 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:
a poor prognostic sign
Cumulative Mortality after Syncope

40
35
elderly-cardiac syncope
30
25
elderly-noncardiac
20
%

syncope
15
young-cardiac syncope
10
5
young-noncardiac
0 syncope
0 3 6 9 12 15 18 21 24
Months
Kapoor, Am J Med, 1986
 Dizziness: 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 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