Can triage correctly stratify cardiogenic syncope in patients admitted to the emergency department for a transitory loss of consciousness?

Background The Manchester Triage System (MTS) is the most popular validated triage system in Europe. It allows the stratification of the large volume of patients admitted to the emergency department (ED) into five increasing risk categories, assigning higher priority to the most serious patients [1]. Purpose To evaluate the effectiveness of the MTS in stratifying patients admitted to the ED for syncopal transitory loss of consciousness (TLOC) and correctly identifying cardiogenic syncope. Methods All patients consecutively evaluated in the ED between 1 January 2017 and 1 July 2019 for a TLOC episode were retrospectively considered. TLOCs were retrospectively classified according to the guidelines of the European Society of Cardiology (ESC) [2]. Syncopal TLOCs were separated from non-syncopal TLOCs. Demographic and baseline characteristics of all patients were recorded. Patients were divided into two groups for comparison according to the MTS code assigned at triage: blue/green/yellow (low priority) versus orange/red (high priority). Considering only syncopal TLOCs, the primary study outcome was the presence of cardiogenic syncope as defined in the ESC guidelines. The performance of the MTS was evaluated using a 2x2 table, deriving sensitivity, specificity and accuracy, and through analysing receiver operating characteristic curves. Sensitivity analyses were also performed on patient subgroups. Results A total of 2,291 patients with TLOC were considered (83% low priority versus 17% high priority). Of these, 90.2% (2,066/2,291) presented syncopal TLOC. Among the patients with syncopal TLOC, 85.7% (1,770/2,066) were assigned a low priority code, while 14.3% (296/2,066) were given high priority. Patients with a high priority code were older (median age 66 versus 77 years; p<0.001), presented more altered vital signs (p<0.001), presented more associated symptoms (p<0.001) and presented more cardiac comorbidities (p<0.001). Overall, cardiogenic syncope was present in 7.5% (154/2,066) of patients with syncopal TLOC. Of these, 55.2% (85/154) were stratified with a low priority code, while 44.8% (69/154) were stratified with a high priority code (p<0.001). The MTS presented a sensitivity of 44.8%, a specificity of 88.1% and an accuracy of 84.9%. The area under the receiver operating characteristic curve for the prioritisation of cardiogenic syncope through MTS codes was 0.683. Sensitivity analyses on specific subgroups of patients, such as those with or without other associated symptoms in triage or major cardiac comorbidities, revealed comparable performance. Conclusions Syncopal TLOC is an insidious clinical condition. Currently, limited information is available about triage systems and the correct prioritisation of syncope. Although the MTS has demonstrated good performance for other cardiac symptoms, its performance is not acceptable for syncopal TLOC [3]. Improvements are needed to optimise triage systems for syncopal TLOC. FUNDunding Acknowledgement Type of funding sources: None.

A Case Report of Cardiogenic Syncope Due to Loperamide Abuse: Acute Presentation and Novel Use of Buprenorphine

Introduction: Loperamide is a non-prescription anti-diarrheal agent targeting µ-opioid receptors in the intestinal tract. At high doses it crosses the blood-brain barrier, where µ-opioid agonism can cause euphoric effects. Misuse has been increasing for both the euphoric effects and as an alternative treatment for opioid dependence and withdrawal. Case Report: Here we report the case of a 30-year-old woman presenting with syncope, who was found to have severe myocardial conduction delays in the setting of chronic loperamide abuse. Conclusion: Treatment with sodium bicarbonate and hypertonic sodium resulted in improvement of her conduction abnormalities. Prior to discharge she was initiated on buprenorphine for her opioid use disorder.

The features of autonomic nervous system homeostasis and adaptive potential in children with syncope

The investigation of the nature of syncope shows that it is caused by failure of compensatory reflex mechanisms of the autonomic nervous system. Therefore, the determination of specific parameters of autonomic nervous system homeostasis and adaptive potential improves the approach to determining the clinical predictors of the syncope and facilitate its early diagnosis. Purpose — to determine the nature and compare of autonomic dysregulation and functional changes of in children with syncope of different genesis, to identify the circumstances for the formation of insufficient autonomic regulation. Materials and methods. The enrolled subjects were 125 children with syncope, aged 8–17 years, and 41 controls. Children were divided into three groups for analysis: 81 — with vasovagal syncope, 25 — with syncope due to orthostatic hypotension, 19 — with cardiogenic syncope. All children underwent a clinical and functional examination of the cardiovascular system to identify features of autonomic homeostasis. Results. Autonomic imbalance with a predominance of sympathetic autonomic regulation was detected in children of all study groups. The results of functional tests and quantitative integrative indicators showed significantly increased autonomic reactivity with depletion of adaptive potential in all study groups (p<0.05). Children with vasovagal syncope had excessive levels more often (p<0.05), and children with syncope due to orthostatic hypotension had insufficient levels of autonomic support (p<0.05). Violations of cardiorespiratory inter systemic connections were found in children with vasovagal and cardiogenic syncope significantly more often, compared to the control group (p <0.05). Correlations were found between the parameters of the initial autonomic balance, autonomic support of the circulatory system, and the manifestations of syncope in children. Conclusions. The correlation between pathological types of autonomic response and the frequency and duration of syncopal episode indicates a pathogenetic relationship between the state of autonomic support and the ability of the circulatory system to respond to triggers. Therefore, indicators of the autonomic homeostasis and adaptive potential can be applied for predicting the occurrence of syncopal episodes and monitoring of effective management of syncope in children. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: children, syncope, autonomic nervous system homeostasis, adaptive potential.

Heart of the Matter: Syncope as a Rare Presentation of Lung Cancer Invading the Heart

Syncope is common, affecting approximately 1 million Americans every year. Although multiple pathophysiological mechanisms regarding its etiology have been documented, neurocardiogenic or vasovagal syncope is the most common cause of these episodes. Other less appreciated etiologies include various cardiac abnormalities in which a structural, electrical, or obstructive disturbance leads to a temporary reduction in blood flow to the brain, resulting in transient loss of consciousness. Cardiac malignancies, while rare, can present with syncope by either disrupting the cardiac conduction apparatus or simply obstructing blood flow through the cardiac chambers. Electrocardiograms and echocardiography are often very helpful in identifying these abnormalities. Here, we report a rare case of late-stage invasive squamous cell carcinoma of the lung presenting with recurrent syncopal events. The cancer invaded the cardiac right atrium causing various dysrhythmias, leading to a very rare cause of cardiogenic syncope. We also discuss how lung cancer can present in a subclinical manner and at times without obvious respiratory symptoms, dramatic physical examination abnormalities, and/or thoracic imaging abnormalities on chest radiograph.

Head Up Tilt Table Test. Short versus Long Protocol

ABSTRACT Background: Vasovagal syncope is the most common cause of cardiac related syncope. Meticulous history taking and stepladder multi- investigatory tools are necessary to detect the underlying causes. However, in view of cardiologist’s busy day, a short protocol of Head up tilt table test could save effort and money. Objective: To evaluate the effectiveness of short timed protocol of Head Up Tilt (HUT) table test versus the traditional long protocol in assessment of neuro-cardiogenic syncope. Methods: The current study was conducted among 138 patients with history of syncope or pre-syncope, referred for HUT test during the study period from February 2019 to January 2020. A complete general and local examination and 12 leads baseline ECG was carried out. Patients were randomly divided into two groups- Conventional HUT test with 15 minutes long protocol group with 75 patients and modified short HUT test (10 minutes’ protocol) group with 63 patients. Results: No significant differences were observed in the test outcomes between both groups. However, a significant difference was observed in the mean patient recovery time in short protocol (2.64±1.35 minutes) as compared to the long protocol (4.05±1.19l minutes) (P <0.001). Conclusion: Applying the short timed protocol in tilt table testing is considered as effective as doing the traditional long protocol and would not affect the test results. The short protocol improved the patient wellbeing and helped in saving time and effort.

Abstract 367: Are We Over-utilizing Echocardiogram for the Evaluation of Syncope Patients?

Background: Syncope is one of the most common reasons for emergency department visits. The most common causes of syncope include vasovagal, orthostatic, neurogenic and cardiogenic. In some cases, history and physical examination can point towards a specific cause. While in most cases, history and physical alone are insufficient to indicate an obvious etiology. Patients with cardiogenic syncope have an increased rate of all-cause mortality as well as mortality associated with cardiovascular events. The risk of missing these serious conditions often results in low-risk patients being admitted for further workup and undergoing extensive investigation including a transthoracic echocardiogram (TTE). However, the utility of such testing including TTE in patients with a negative initial evaluation with history, physical exam and ECG is uncertain. The aim of this study was to assess the utility of TTE in the evaluation of patients admitted with syncope with an initial negative evaluation Methods: It is a retrospective study. Data was collected from all the patients admitted to the hospital for the workup of syncope from January to October 2019. Baseline characteristics including age, sex and ethnicity were collected for each patient. Data was also collected in regard to their significant cardiac past medical and family history. History of present illness and physical examination at the time of admission was noted. Patients were divided into two groups based on if the medical evaluation indicated a cardiogenic etiology. Cardiac testing data including EKG and TTE were included in the analysis. Abnormal EKG was defined by the presence of bradycardia, arrhythmia, QT prolongation, bundle branch blocks, heart blocks and left ventricular hypertrophy. Positive TTE findings were defined as low ejection fraction, significant left ventricular outflow tract obstruction, significant valvular abnormalities, wall motion abnormality and presence of pericardial effusion. Collected data were analyzed using Chi-square test and multiple linear regression. Results: The mean age of the study group was 72 years with 45% of males. Out of the total of 93 patients included in the study, 57(61%) patients had a TTE done. Out of this only 10(17%) patients had positive TTE. Only 2 patients with positive TTE had a negative EKG. In these two patients, the history was, however suspicious for cardiogenic syncope. A significant association of positive TTE findings with abnormal EKG (p-value: 0.003) was found. The odds of having a positive TTE finding when the EKG was negative was only 6%. These results remained significant with multiple linear regression analyses. Conclusions: TTE is being overutilized in the evaluation of patients presenting with syncope to rule out cardiac etiology. A thorough history and complete physical examination along with the basic cardiac testing including EKG can help reduce the overutilization

Syncope in children clinicoetiological correlation

Background: Syncope is the abrupt cessation of cerebral blood flow leading to temporary loss of consciousness. Identification of etiology is utmost important as any syncopal event may be life threatening. Aim was to correlate the clinical and etiological causes of syncope in children and to note their investigational profile.Methods: Among 40 patients presenting with syncope and presyncope were studied. History of the event, precipitating factors were noted. They were investigated with the help of blood pressure, Electrocardiogram (ECG), 2D Echocardiogram and Electroencephalogram (EEG).Results: Out of the 40 patients of syncope 65% were above the age of 10 years with male preponderance (60%). Vasovagal syncope (57%) was the most common cause of syncope followed by orthostatic hypotension (15%), neurological (15%), and cardiac etiology (6%). In the neurological etiology the EEG showed diffuse slow background with occasional sharp bursts in right frontal area in 2 patients while in 4 patients sharp bursts were present in the centero-temporal region. 17% were classified as presyncope, 60% as mild and 22% as having severe syncope. There was a significant correlation of etiology of syncope with duration of hospitalization of more than 4 days and with recurrence of syncope. There was significant correlation of Evaluation of Guidelines in Syncope (EGSYS) score >3 with cardiogenic syncope. On follow up, neurological syncope patients had significant decrease in the number of syncopal episodes as they were immediately started on antiepileptics.Conclusions: Electrocardiogram, 2D Echocardiogram and Electroencephalogram are important tools for the early management and treatment of cardiac and neurological etiology of syncope.