Cardiac syncope . . . Never heard of it? Perhaps you should
Since launching Prois Hunting Apparel in 2008, I have had the amazingly good fortune of finding wonderful people throughout this crazy journey. While they are too numerous to list, I feel very compelled to mention Kim Zimmerman from Sand Springs, Montana.
We were introduced through a mutual love of hunting, but what struck a chord is that Kim is also a registered nurse. We began to speak about our medical careers and the paths we took leading us away from a lifelong choice of being caregivers. Kim, a former cardiovascular nurse, packed her bags and left California for the rural reaches of Montana. She introduced me to her new “calling,” www.carolsvoice.org.
Kim recently lost her mother, Carol, to cardiac syncope–a common, albeit underdiagnosed heart disorder. She has taken the pain from the untimely loss of her mom and channeled her energy into education and outreach about this disorder.
“My goal is to educate as many patients, caregivers and hospitals about this disease in hopes of changing hospital protocols in efforts to better detect cardiac syncope,” states Kim. Apparently a girl who doesn’t shy away from a challenge, Kim established Carol’s Voice as a nonprofit organization as a means to educate the masses.
That said, I felt it important to share some information about cardiac syncope on First Aid Afield. Realizing that this particular article is not fraught with the gruesome trauma details that I so love, it is the perfect forum to discuss a disease process that is often undetected and remains a silent killer.
Equally important is the fact that Kim is a lover of the outdoors and exemplifies what it means to take a chance and chase what is truly important in life. With that, here are the facts:
SYNCOPE (pronounced SIN-ko-pea) is a brief loss of consciousness and posture caused by a temporary decrease in blood flow to the brain, usually accompanied by falling. It typically has a spontaneous recovery. It is a common clinical condition that affects approximately one million Americans annually.
It is classified into four categories: reflex mediated, orthostatic (due to position change, such as standing up), cerbrovascular (disruption of blood flow in the brain) and cardiac (due to irregular heartbeats).
In most cases, people who have syncope recover quickly and are not at risk of further episodes once the current episode subsides. Unfortunately, some causes of syncope are quite dangerous and may indicate that sudden death is imminent.
Carol’s Voice was created to bring public awareness to the fourth type of syncope, CARDIAC SYNCOPE. The most serious of all syncope, cardiac syncope accounts for 10-30% of all syncopal episodes and is caused by a reduction in blood flow and oxygen to the brain brought on by episodes of abnormal heart rhythm or blood pressure, and has the highest rates of morbidity and mortality.
The first-year mortality for cardiac syncope is 20-30%, against 5% for noncardiac causes and 10% for syncope of unknown origin. Sudden death occurred in 17% of cardiac syncope cases.
Cardiac syncope can be due to a heart or blood vessel condition that interferes with blood flow to the brain. These conditions may include an abnormal heart rhythm (arrhythmia), obstructed blood flow in the heart or blood vessels (coronary artery disease), valve disease, aortic stenosis, blood clot, or heart failure.
Patients with underlying cardiac disease are at greater risk for recurrent syncopal events than are any other patients with syncope. Compared with all other patients with syncope, patients with cardiac syncope have almost double the risk of all-cause mortality, and an increased risk of fatal and nonfatal cardiovascular events. A cardiac cause is found in only 3% of patients who have no previous diagnosis of heart disease.
The physical examination should focus on vital signs, cardiac, vascular and neurological systems. The cardiac exam should assess volume status, valvular heart disease, and arrhythmias (irregular heart rhythms).
An electrocardiogram (EKG) should be ordered for all patients with syncope. Abnormal EKG findings are common in patients with syncope. However, a normal EKG in a patient with syncope is also important.
Twenty-four-hour Holter monitoring is indicated when there is an increased likelihood of arrhythmic syncope. This includes syncope with EKG abnormalities, known or suspected heart disease, patients with syncope that was preceded by palpitations, syncope when lying down or with exertion, and patients with a family history of sudden cardiac death.
If the 24-hour Holter monitor is negative, then prolonged electrocardiographic monitoring (an event monitor or loop recorder) is indicated.
Echocardiography (echo) is unlikely to be helpful in the absence of known cardiac disease, a history suggestive of cardiac disease or an abnormal EKG. However, in patients with syncope who have a history of heart disease or an abnormal EKG, echocardiography is useful.
Exercise testing (stress test) can diagnose ischemia, tachyarrhythmias (fast, irregular heartbeats), and exertional syncope.
Intracardiac electrophysiologic studies (EP studies) can be used to discover heartbeat conduction abnormalities that predispose patients to irregular heart rhythms.
Tilt table testing is used widely for the evaluation of patients with unexplained syncope and is particularly important in those with structurally normal hearts. Tilt table testing uses changes in position to reproduce the symptoms of the syncopal event by inducing a slow heartbeat or low blood pressure.
For patients with more than two episodes of syncope and no diagnosis on “routine” testing, an implantable loop recorder is the tool of choice. It is simple to insert, relatively painless for the patient and lasts 14 to 18 months.
Smaller than a pack of gum, the loop recorder is inserted just beneath the skin in the upper chest area. The procedure typically takes 15 to 20 minutes. Once inserted, the device continuously monitors the rate and rhythm of the heart. Upon waking from a “fainting” spell, the patient places a handheld, pager-size device, called an activator, over the implanted device and simply presses a button. This information is stored and retrieved by the physician.
EVALUATION OF SYNCOPE:
A serious problem in the evaluation of syncope is the lack of a gold standard against which the results of diagnostic testing can be assessed. How far do we go when the initial findings are negative? Should there be a protocol for patients with multiple unexplained episodes? Why are they released from hospitals without extensive testing? There are algorithms (methods of solving a problem by repeatedly using a simpler method) written by prominent physicians for the diagnosis of syncope. Why are they not followed by every physician?
There are institutions where any patients presenting with syncope have initial evaluations that include screening, tilt table testing, blood volume determination, hemodynamic testing and autonomic nervous system testing. How many lives could we save if we were to adopted a gold standard, if we were to change or add to the standard of care by our hospitals and physicians? Carol’s Story can tell you of one such life.