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Managing Syncope - A Case Based Approach

Feb 14 | 2:30 PM

Transitory loss of awareness and postural tone caused by temporary global cerebral hypoperfusion are the most common presenting symptoms of Syncope. Intensive efforts have been made on many fronts in recent years to improve the evaluation process and explore therapy possibilities. Let's hear from Dr. Hygriv Rao on how to diagnose syncope, the importance of an ECG, and syncope management, which includes a broad range of acute care and quick assessments of airway, breathing, circulation, and neurologic status.

[Music] good evening everyone i am dr brushali behalf of netflix or this uh talk on vaso vehicle syncope it's a case-based approach we'll be hearing some interesting cases that doctor highgrave it's more of a practical approach rather the theoretical is a senior consultant cartoonist and director division of pacing and electro physiology kim's hospital hyderabad recently he was with us in cutting his on expert stake as well because he recently had written an article how yoga helps in decreasing the syncope effects and in general prevents cinco so we thought it's a very interesting topic which we should take forward rather than just begin cutting edge we also have with us dr anupag senior cardiologist in kim's hospital he will be the moderator for the session today thank you good evening all uh to be with us this evening for a very interesting discussion on synthetic this is something which is exceedingly common that no matter which field of medicine you are practicing you are bound to see patients like these and we as a cardiologist are at the center of managing these patients but many of the times the first baton is with the general physician and pretty much the first doctor who sees the patient so we have dr haigreev here who needs no introduction he is an authority in electrophysiology nationally he will be walking us through some of the cases that he has curated which in his opinion all of us at least should get a flavor of it so that not only we get an idea of what syncope is but also kind of get ourselves accustomed with how cardiologists approach towards the syncope is and how we can help in managing such patients so without any uh delay doctor high grief the floor is yours and we can't wait to see all the cases that you have thank you charlie can you put on my presentation yeah thank you very much uh at the answer to i thank very much profusely metflux for giving uh me and anub this opportunity to be with you and today we're going to talk about syncope and the way we are going to go about is uh i have some of the cases that i have dealt with in the last 20 years of my career and it's a big topic so given the constraints of time i selected those which are going to be most uh illustrative examples uh for a practicing a doctor not just a physician and the way uh we have dr anupag cardiologist at care hospitals hyderabad and is one of the very insightful cardiologists that i know of so that is why what we will do is that he will be giving us insights as a cardiologist apart from the presentation that i'm going to give and we are going to stop after each case and let annual give an important message and see how it goes on and we encourage you to ah be free and ask questions from the comments and after that uh look we'll take over those questions and we both will try to see how we can answer them so the very so let us start with the very basics sim copy syncope is a transient loss of consciousness due to cerebral hypoperfusion a very simple definition now those people who fall down unconscious and for half an hour one hour two hours this is not symcopy syncope is a transient loss of consciousness somebody who is just talking and loses a sensorium or consciousness for a brief minute one minute two minutes and spontaneously wakes up on his or her own using copy it is brief it is reversible it is full recovery of neurological baseline function so somebody who has loss of consciousness and paralysis that is not a syncope in the true sense it is full recovery of the neurological baseline function does not require specific resuscitative measures and a lifetime incidence of syncope is estimated to be at least 30 to 35 percent this sentence is very important that means an average there is a one-third chance of somebody having a syncope once in a lifetime at least you know you can see for yourselves and recall how many times you saw somebody who is losing consciousness not necessarily going to the hospital but very transient now the last sentence is also important although we talk syncope very lightly there is a mortality and two percent less than two percent and ten days after syncope uh die and eight percent at one year now this figures are important because a physician although we take syncope lightly and reassure and all that we have to identify those patients of syncope who can die and that is a very very important responsibility on a physician's head when he sees the patient with sympathy now as he is seen in medicine you make a common diagnosis you're usually right it's you close your eyes and make a common diagnosis you are right so that is why you know these days you have cough fever cold and you know you say kovat you are probably most of the time right right these days so like that now if you look at the epidemiology of syncope there are two important things that are striking in this slide only two important things number one the commonest cause of syncope is vasovagal syncope or reflux vasovagal syncope cost instituting 56 percent of the cases of syncope a very important point that means you close your eyes a person falls unconscious you know that it is incomplete the second point i would like to make is eighteen percent of the cases no matter what you do however much you investigate we will not know the cause of syncope the second important point the third point is there are about three percent of uh so uh which are important causes of cardiac sync now cardiac syncope is not very common but it is important to rule out so it's the patient doesn't come with a label saying that i don't have cardiac symptoms so it is a responsibility on the physician's head to make sure that although he's making a common diagnosis of neural immediate syncope he still does not rule out so the victim in medicine as my professor in cardiology taught me that make always a common diagnosis but never miss a dangerous diagnosis very very important both the points are it's not it's so true in syncopating now it is important to have a management protocol the reason is a patient with syncope can come to anybody it is not that he will come to a cardiologist although the majority fifty six percent of ace vehicle is not going to come to cardiologists he can come to a cardiologist no doubt he can come to electrophysiology and come to a neurologist a general physician more importantly the people who lose consciousness repeatedly they are thought that they are not stable they are taken to a psychiatrist also so anybody can see a syn copy and it is important to have a management protocol and to understand whoever it is they should not investigate only in their specialty and say that like okay fine come to a psychiatrist they say you are not depressive you are not maniac you go i don't know what you have that's not the approach you have to make a diagnosis no matter which speciality the patient comes now look at this patient's history let us start how it is the 55 year old lady this is a very illustrative case for me a common diagnosis but then the way she presented is very important a 50 year old lady lives in dubai recurrent seizure attacks that's exactly what was her complaint recurrent seizure attacks then she took a neurology and neurosurgery concerns repeatedly ct mri was done and every time a new generation mri came she underwent that mri never made a diagnosis so what happened is she came to an emergency room in our hospital again she was this many many years ago more than 10 years ago this patient this was again came to the emergency room again admitted under neurology but then fortunately the resident cardiology resident was asked to see the patient because there's something wrong with the ecg and this is what the easy is now please see this was the ecg taken to the patient when she came to the er and admitted under neurology but cardiology resident was called in because there's something wrong with the ecg and then when he asked the patient patient said i i exactly feel like this all these years in dubai and here too and this is exactly my problem uh then you can see what it is you can see as the arrows point out there are a lot of periods a positive qr qrs complex a few qrs complexes a lot of views so ultimately this is a heavy dissociation a complete heart block a very common diagnosis not so rare at all so that nobody would put an ecg like this in these days uh and people would say what's a big deal you're putting a complete hard block it's not a question of complete hard lock now please remember it is the question of thinking about it this was what was not thought about when the patient's presentation was seizures and she went on and on so at this point we put in a pacemaker as you can see this is a pacemaker the left side you can see the replica of a pacemaker what if for those of you who have never seen a pacemaker is a pacemaker and is implanted under the sub pectoral fascia and there are two leads one in the right atrium and one right so at this point i'd like to briefly halt and uh give anu to see what you would like to say on complete hard block and so sir before uh we discussed this this patient also has sternal wire she underwent some heart surgery before yes actually the i had just put an illustrative pacemaker for this this is not for this patient oh okay i see these patients just showing people what a pacemaker looks like right so few things that i have gathered from your discussion so far one very important is the diagnosis of syncope or the definition because as we all know that many of the times you can diagnose syncope becomes a clinical diagnosis you should be able to diagnose syncope the etiological diagnosis may take time but the clinical diagnosis of syncope is pretty easy to make and the one that you mentioned seizure as a presenting complaint of a rhythmic pathology in this case a brady arrhythmia or a complete heart block but sometimes we have seen patients with vt or vf presenting as seizures and they are mislabeled as seizure disorder and they are put on all these kind of medicines because remember at the end of the day if brain does not get enough blood it will cease it's almost like having ischemia of the brain so uh i think this point needs absolute attention and every single person who is attending today should at least simplify it and keep it to their memory that if we are talking about a cns event a generalized cns event or a global cns event then a cardiac rhythm disorder should be one of the top differential be it seizure disorder b transient loss of consciousness or whatnot cardiac rhythm disorder should be on the top of differential and in your case it's a clear complete heart block and i'm sure by you putting a pacemaker in her she wouldn't have this symptom at all ever in the future this is this is uh you pretty much put the nail in the coffin this patient will never have this symptom again so rightly this patient as i said this is the case very very long ago and this lady although uh i i don't no longer work in that hospital where i saw the patient this patient keeps coming to me every six months from dubai and she never never had a syncope again and clearly proving the point that her problem was complete hard block had a treatment of space maker a simple diagnosis simple treatment but sometimes we so often mischa that is the point we wanted to make right now now comes to the question now having given an introductory case to all of you what constitutes a syncope evaluation this is what everybody needs to know because whenever a patient comes now it is a reflex action on the part of the doctors to write about 15-20 investigations for the patient and ultimately coming to no conclusion so what i would say suggest is every person who comes to a hospital with a syn copy either to the emergency room or to the outpatient saying the recurrence in coming must always have these four things the first i would like to repeatedly emphasize history history history three times there is nothing nothing more important than history so whenever a patient has a syncope please make all the efforts to find out a witness for the syncope ask the person who witnessed this in copy and talk to the person even if the person is not there pick up the phone do a whatsapp chat video chat or whatever and try to get the details of history because once you get the history as i will illustrate in subsequent examples you will know the cause of syncope the second is an ecg an echocardiogram and basic biochemistry basic biochemistry i mean a blood sugar a creatinine in a complete blood picture because you have you sometimes you while going into big things you miss small things like a hemoglobin of four or five you music somebody having a hypoglycemia or uncontrolled diabetes or simple things like that should not be missed so basic biochemistry which includes apart from these electrolytes also and then a thyroid tsh at least if not p3d4 these are the basic things one must always do it is not that these are responsible for syncope but we must not miss them as a doctor a person who comes to diabetes or anemia must not be missed anyway in ecg and eco they will clearly rule out the cardiac syncope because i'm not showing any slides data and other things but i would like to state that patients who have a cardiac syncope if you look at they have a high mortality when compared to person who do not have any cardiac syncope that means if you have a normal ecg normal eco and no cardiac diagnosis the chances of even if you don't make a diagnosis the chance of that person dying are remote that is why you should have these basic things even if you're a neurologist you must do this even if you're a psychiatrist you must do this it's not just cardiologists now the second thing the right hand side you see a lot of investigation these things must be individualized you should not just write all these seven investigations just because the patient came to you and especially the neuro imaging patients undergo a lot of ct scan and mri eeg for a person who has syncope without doing the first four things and that puts a lot of economic burden on the patient and lot of waste of time and ultimately leading to nothing and psychological distress now the objectives what are the objectives in the management of syncope these investigations now every doctor must have these five objectives we have in the mind of a physicist and these are also objectives of the patient also these are the questions the patient also going to ask number one when a person has sympathy as i have shown in the first case sometimes they mimic seizures so ask yourself is it syncopated or is it not synchro that's the first question you have to ask the second thing is is it life-threatening this has to at the end of investigations we have to answer to the patient is the syn copy life-threatening in 18 of the cases i told you we cannot diagnose the cause but then you should be able to answer is it life threatening or not that much you must be able to tell third is it curable now curable cause of syncope must never never be ignored and never be missed because it is so dramatically makes a life different for the patient and his family and last can we avoid the perils perils means when a person has syncope he sometimes falls down hits his head has head injury sometimes fractures now even if we don't diagnose syncope even if we can't do anything for the patient can we avoid the perils of syncope which is very important and last a battery of tests are they needed or not ask yourself i am writing 20 investigation are they needed do i know why i am writing and are they going to contribute to the patient's problem or am i just buying time by writing this investigation this is very important in the objectives of sim copy now never ignore a patient these two things are extremely important we emphasize again and again both of us never ignore or under invest or investigate some company that caused injury suppose somebody said i fell down and i broke my arm or i had a head injury don't ever say that you you the patient did not eat food properly that day or he was little you know weak that is why he fell down no if syncope which caused injury is very important we have to investigate and if you can't investigate do not know please send it to someone take help of your colleagues or friends or your co specialists who are going to use it never send the patient back home and last if your syncope occurs in a patient with heart attack in the past or a patient who has a weak heart on eco these two things never ignore never say it is because of weakness or post fever or something like that these two things are extremely important now let's go to the next question next patient young man in our office your 32 year old mr c he had syncopal attacks since last two years four definite episodes were there and these episodes did occur history i told you history is very important and what did the history says the first episode had happened standing in the bus the second walking to the bathroom third while supervising workers now this patient had a normal physical examination and normally i told you i always take history then a physical examination then an ecg and eco is ecg normal all the biochemistry or normal then look at it what is the causal ecg normal echo normal everything normal and he still has this what investigation does he need this is very important what is the diagnosis and what investigation does he need now which investigation is appropriate should i do a halter should i do a ct brain mri should we do eeg tilt test or ep studies so look at it this patient has one episode every one or two months a holder is a test which is only for 24 hours it is of no use in a patient like this straight away a lot of us put holder thinking that something will come out nothing will come out in a person who has syncope once in two months or three months a ct brain mri i'm not sure we should do it eeg totally unnecessary now we did a tilt test now the tilt test is something like this this is a lesser uh used test the person who lies flat the tilt table goes to 60 degrees or so about 30 minutes and then is provocative then after 30 minutes nothing happens you put a sublinguals arbitrate and then throughout the period watch for blood pressure heart rate these are monitored by a physician and then you look if the person has sym copy you put it quickly the tilt is brought back now this is a very useful investigation in violation of sympathy and is useful in avoiding unnecessary investigations and those with normal needs now this patient had when we put this patient mr c on a tilt machine his blood pressure came down from 140 to 70 millimeter systolic and he had a typical syncopal attack what he was having all these times before he told us sir exactly i feel like this i feel a pro drum i feel a blurring and i lose consciousness that's exactly what happened and you now you just reproduce the same thing so this is a positive till test and it is not orthostatic the difference is somebody wants to know what is orthostatic hypotension what is still now i will tell you briefly what it is now this vasovegal syncope what it is or a loss of consciousness and upright position is the price that we pray for erect costume all the animals before us had a horizontal posture the heart and the brain were at the same level it's only the man who is an upright posture and has to pump blood against the gravity so this is a price the vasovagal syncope is what we pay because of the evolution but does it happen in every person does it happen all the time no it happens in some people some of the times even in those people it happens it happens only some of the times and this is because the these are the neuro vascular reflexes which become which don't uh help us in pumping blood against gravity some of the time most of the time they do help sometimes they give way and that is when we when people become con lose consciousness now orthostatic hypotension vasovagal syncope and what is called as a postural orthostatic tachycardia these are the spectrum of the same disease orthostatic hypotension occurs by definition within the first three minutes after a person becomes upright whereas vasovagal syncope occurs after three minutes that is the difference between orthostatic and vasovagal syn we're not going to talk about the last one parts out of the purview of the today's talk but these two things are important vasovagal syncope and orthostatic approach now the triggers for these are generally simple like a person standing upright for a long time particularly if the person has not taken enough fluids dehydrated or a person sees an obnoxious smell or pain pain is one of the important triggers many people after giving injection called on and they blame the doctor that he gave injection and i fell down it's not the injection that caused but the pain of the injection that causes this one now the management of this condition it is first important is reassurance because vasovagal is a benign condition the problems with vasovagal syncope occur only if they are associated with injuries of syncope not perceive esophageal so reassurance tell the patient it's a benign disorder doesn't cause heart attack doesn't cause death and a cinco try to explain to the patient how to avoid injuries from syncope the patient on standing taking baths falls down multiple times tell the patient to sit down and not uh take baths while standing tell the patient not to stand talk to his friends or her friends which is a common uh habit in some people and not to these people will never have syncope while running or walking will have only on standing that's one trigger so those people who have pain try to tell their families that whenever there is a pain is likely to happen so please make the person sit down anticipate that he is going to lose consciousness and the adequate hydration all these people must take adequate fluids and they require culprit medicines some of them are diuretics these must be removed and there are some exercises that we do what is called as filtering again the beyond the purview of this talk but then there are sort of physical exercises that we do and recently we came up with a yoga sana called tadasana where we published in one of the journals where the person just like you can see stands in the ball of the feet alternatively and toes and then lifts his hands up and takes a deep breath this exercise is done 15 minutes a day maximum and these episodes these asanas like many physical manners in our experience have shown to decrease the incidence of vasovegal syncope so at this point again i stopped for a brief minute for dr anup to give his insights on this condition yeah you know uh your story and your discussion about orthostatic hypotension and differentiating it with vesovegal syncope this is this is very very important for us to understand uh i recollect there was i believe there was a systematic study that suggested there is there is on an average a nine to ten minutes lag between the trigger and the actual uh loss of consciousness or syncope or on the other hand orthostatic hypotension that as you said happens uh immediately uh or within three minutes so definitely a vasovagal syncope is a totally distinct entity as compared to this orthostatic hypotension and the tin table here is very very impressive it can at times not only help us diagnose the problem that anyway history kind of helps us diagnosing but it helps us avoid all the other unnecessary investigation that at times we end up doing one of them what you said like a 24 hour halter in a person who is having one event a month that really does not make any sense you have to be really lucky that you put it on 24 hour and it gets event at that month but most of the time these tests are useless so many of the times you just hit it exactly where it's needed put them on a tilt table it gives you an idea you do some corrective measures and this is again one place where i might want to highlight that we just don't simply put pacemakers in all of them even when there is a cardiodepressive syndrome you try to see what all corrective measures you can do and pacemaker becomes one of the option when things don't work out so i think that point is well taken sir and it's easy for us to kind of grasp through it and work our way up great great and we question about how to stand on the heels you use the you use the wall to support yourself and then stand on the heels the idea is to strengthen your quadriceps and leg muscles so you can use a support to do that now let's go to the next question next case a 40 year old worker is again a case which i saw about 8 to 10 years back forty year old worker he's a construction worker suffered a henry head injury after losing consciousness at work brought to the er in unconscious state this person was working on a building and doing some construction and then he had some palpitations or something and he fell down from the top of the construction house and they brought him with a head injury he was not brought with the cardiac problem brought him with the head injury now the cardiologist because then somebody in the emergency room saw that the patient was having a very fast ventricular rates very fast heart rates then they thought something is happening which is cardiac then they called in the cardiology consultation and they called it the cardiology consultation and this is the ecg that was seen what does this ecg show now this ecg first shows a very fast heart rates no doubt about it so you can see the rr intervals are very short and is very fast heart rate no doubt more than 170 or 180 second point the three important point the first part is the fast heart rate the second point is the qrs complexes are irregular the pulse so logically the pulse also if somebody feels will be regular so you can see the distance between one qrs complex and another qrs complex is short sometimes long sometimes very short so this is an irregular complex and third important thing is the qrs is broad so the curious is broad so it is broad [Music] it is irregular it is fast three important points so when a person has a broad fast irregular qrs complexes this is considered as a wpw syndrome underlying or an atrial fibrillation so whenever you have irregular heart rate it is af until crude otherwise so it is an irregular heart rate so this patient the cardiology resident who saw him quickly shocked the patient and brought him to normal rhythm and when you brought this patient to normal rhythm you can see the normal rhythm what actually you can see is that the qrs complex is slightly broad at the base the p r interval is very short so those of you who can zoom it please zoom this to see that what i'm trying to show you the red arrow which i put it please see that carefully a p followed by short pr interval and a slight irregularity at the base of the qrs so this is a pre-excitation a manifest pre-excitation meaning that between the atrium and ventricle and the impulse is not going through the av node but is going to an accessory pathway and that is why it is called as a manifest pre-excitation or a www syndrome parkinson white syndrome so these patients the important thing is now this patient underwent a radio frequency ablation to cure it now if you remember the very first slide i said please don't miss curable forms of symcopy this is one such example now please see the first three beats of the qrs complex followed by the next first four beats followed by the next three beats now the red arrow and the light red light red arrow you can see the difference the broad qrs is suddenly gone the pr interval which was narrow has become slightly prolonged and the qrs is totally different from the first three weeks so as you are applying the radio frequency energy you it's a simple procedure that you do in the cath lab just like an angiogram and you burn or you melt the axillary pathway and you cause the loss of pre-excitation so this patient is completely cured of the pre-excitation he will never ever have the fast beats except in one personal dedication forever recurrence 99 percent of the times he will never have it again and is a curable form of simcoe and yeah before i go to the next slide yes again yes sir the ecg that you showed i think this is a very classic example of a ecg pattern that if you see once you can never forget it and all the audience who has seen this ecg once uh i suggest that you just just take a mental picture of what this ecg looks like it's amazing how every afib and wpw acg just looks like the same beat usb india beat probably in the on the moon as well they all look exactly the same you have got afa you have got wpw the ecg the heart rate is fast it is irregular its a wide complex there are multiple treatment algorithms defined for it but truly speaking all these patients you do a curative ablation and they all do absolutely fine these patients literally you take a life-threatening disease and just just get rid of it just like your first case this patient is most likely not going to have any such recurrence and the good thing is they don't need any medicines for it they literally they are free of medicine free of any future procedures and they do absolutely fine these are curable cases uh they very very frequently present with loss of consciousness of unknown etiology i remember a few months ago we were discussing one similar case with a young young person and this is this is beautifully done this is phenomenal uh and every person at least should identify or or acknowledge that something of this sort exists in the cardiology space and the treatment is curative yeah this is a great uh comment and message now you see another kind of a similar kind of uh curable form of arithmetic now this is a lady who came with to the outpatient with a sinus rhythm but with some kind of uh you know broad qrs complexes like this and which are negative in lead one sorry lead v1 and positive in uh 2 3 and avf so when you have a broad qrs which is negative in v1 or which is called as a left bundle branch morphology we know it's coming from the right ventricle and it is positive in two three we have the inferior leads it's coming from the top of the right ventricle so this patient had a v if a broad qrs tachycardia with a palpitations exactly similar you can see the v one is negative two three avf is positive and uh the transition anyway uh again positive in the v5 so this is a ventricular tachycardia this patient is having a broadcast ventricular tachycardia the patient has recurrent palpitations the echo is totally normal it is one of those structurally normal hearts with a uh is one and then when we found out this is a map of the right ventricle as you can see the entire thing is a map of the three-dimensional map of the right ventricle which we created in in our cath lab by using a a system a 3-d mapping system and then you can see the red area that is the area that the focus of the vt is coming from and we gave a burns by the brown dots and then this destroyed the focus which is causing vt and it destroyed the the patient's focus which is causing problems and it completely cured often so this is another patient where a syncope is curable like the previous one is curable the treatment is radioactive frequency ablation in the last two cases and the curative in a large percentage of the cases and that is very important point that we uh see now before uh uh yeah now i'll give another a similar situation of vt where it is not curable by radio frequency ablation and then anub can give a talk i give you comments on the ventricular tachycardia and syncope now this 61 year old male diabetes high potential artery disease old myocardial infarction and this patient underwent angioplasty and stent in the past now as i said such patients when who have angioplasty and stent and who have a heart attack in the past if they present with syncope never ignore it is going to be serious most of the times this patient present with syncope patient was not sure he had calculations or not but definitely there was a witness who said they were the same copy now we assess this patient and ecg showed that there was an old mi the echo showed the ejection fraction was low for those of you who may not know a normal ejection fraction is between 55 and 60. now this patient rejection fraction of 37 um uh yes uh cardiac mri it showed a corresponding scar in the area of infarct angiogram was done for this patient finished so the cardiac mri showed a corresponding scar in the area of the infarct and the coronary angiogram was done and the patent strength was seen but this patient please see the ecg on the left and the right i have pointed out some arrows which shows abnormal q errors in inferior leads showing that this patient has had a heart attack in the past and this patient's ecg is like this and when the patient came with the palpitations this is the kind of ecg that the patient had you can see that the patient has a broad qrs regular tachycardia so this is the last two cases i've shown you a broad qrs regular tachycardia which are fast unlike the first which is irregular so this is a ventricular tachycardia on a patient who has a heart attack or inferior wall mi in the past so these variations are very important so this patient also uh sometimes you do an ep study also they have an hypotensive vt in a patient with cad and syncope so this is a patient who has a high chance of sudden cardiac death so these patients who have a ventricular tachycardia after a heart attack they have a high chance of sudden cardiac death and they are very dangerous and the way to treat them is before that is you should realize that these are the patients where syncope is not light as it said in the textbook of cardiology death is in syncope is where patient doesn't wake up and this is such example and one must understand physicians must know that in some of these end copies it can be a manifestation of sudden cardiac death so syncope is not always benign like a vaso vehicle this is what one must rule out now the way to treat these patients is an icd now i showed you a pacemaker example this is a icd looks just like a pacemaker only thing is a more complicated computer it has a lead in the heart and what icd does is whenever there is a vt or a southern cardiac arrest the lead detects sends the information to the computer which is inside case in the metal what's called implantable the cardiovascular and gives a shock and saves the life of the patient and this is how the programmer which can talk with the icd and can tell us what uh now implantable cardiovascular deformatory icds are the present day prescription for the prevention of sudden cardiac death and patient did not have a simple vt like that can have a cardiac arrest with ventricular fibrillation like this you can see this is the ecg of a ventricular fibrillation the patient can have and the icd will shock the patient and save the patient from surrender dr anub your comments please yes sir yeah i think that you know i briefly touched upon in your first case where you mentioned about complete hard blog seizure syncope and loss of consciousness all of these could be the presenting symptom of vt or vf what we call it as in the cardiology world we call it that these are non-perfusing rhythm which means these are the kind of cardiac rhythm which don't generate enough of systolic pressure that your cerebral perfusion pressure goes down and these patients they either manifest in the form of loss of consciousness fall or in the form of a seizure which is just a hypoperfusion of the brain what is also important is that these are not vasovagal because by definition vasovagal cinco patients should wake up by themself and they should wake up without a neurological deficit in these kind of rhythm disorders if the rhythm does not autocorrect by itself they may not wake up and that is where the whole definition of sudden cardiac death comes patients with previous mi and who had got scarring they are at a higher risk of these rhythm disorders and that is why we send our patients to electrophysiologists for a preventative icd if their ejection fraction is less than 35 they don't necessarily need to have a vt before this is called a primary prevention where if there is a patient who had a previous mi whose ejection fraction is less than 35 percent and could not recover that means there is enough of scar burden that this patient is at higher risk of this kind of rhythm and as i said that many of the times sudden cardiac death could be the very first presentation of these kind of scars and not everybody gets lucky and reach the hospital where they can get a defibrillation so in many of these cases we as a interventionist send these patients to electrophysiologists like yourself who can put who can implant an icd and thereby giving them so called a lifeline so that in case if in the future they develop a vt or vf the icd can literally shock them it's a it's a beautiful it's a miracle device that the medical technology has come up with where the device kind of just ideally sits inside a person's chest and may not do anything for seven eight years and waits for that one bt or vf which if it occurs it gives an internal shock hereby saving the patient's life so bt and vf needs to be taken it very very seriously what the case that you showed is what we call it as a secondary prevention where somebody already had an event and you are doing an icd to make sure they don't they are saved with a second event but one can justify even putting an icd in those patients who have very weak heart even if they never had the vt or vf again because they are very very dangerous what you also showed is that whenever these rhythms are there remember icds don't reduce the incidence of event all they will do is if there is an event they will shock the person out of it they will save a life but how will you reduce the event to begin with and that is where the uh the radio frequency ablation that you showed actually comes on the way so you have a patient who has a lot of scar and they come to you with so-called syncope which as dr hydro said you should not take it lightly syncope in this patient 99 of the time is vt or vf and in those cases you send them to electrophysiologists who can map those scar the 3d mapping that you saw even to me it looks very complicated so i wouldn't go into the color scheme or whatnot but just to give an idea that there are mapping catheters which go inside the heart the map where is the normal tissue and where is the scar tissue and an electrophysiologist is able to exactly pinpoint where the vt or the vf is coming from and they are able to induce a radio frequency ablation or a burn in the myocardial circuit which literally abolishes these kind of events from happening you still put an icd because you know that if the event does occur in the future they at least will have a chance of survival so all these cases who had a heart attack before if they come up with syncope or syncope like symptom think of vtvf almost always you will be right these patients need an icd and if the events are frequent you should do an rf ablation like the one which was showed in a previous case yeah an important point many important points were made by anup i would like to add just one point to uh as a message now we have shown vt with the keyword with the radio conference ablation we have shown a vt where icd was put in now many physicians and cardiologists ask when do we put a v icd when do we do a vt application now uh there could be a lot of uh you know answers a long answer to that we can talk for 20 minutes on this but i would like to say only one important sentence as a take home message for everyone if you have a vt in a patient whose echo is abnormal the heart is weak or the patient has heart attack think of icd if a person has a vt in a patient whose echo is totally normal cardiac armor is totally normal ejection fraction is normal think of radio frequency ablation so there are exceptions to both but by and large please remember around the conversation if you have a person who is totally normal heart and your colleague or somebody has said icd please think two times ask another person to have a look because in a normal hearts we rarely put an icd we always put icds in an abnormal part now before we uh go on to the last two cases the two other cases quickly and uh i'd like to just summarize what all we have done till now now syncope on upper right posture please think of vasovagal syncope a person who gets syncope only on standing vasovagal syncope which is benign especially if the person's heart is normal if the person has a heart attack or elderly dysfunctional past think of sudden cardiac death if there are palpitations if the patient says i have palpitations preceding the syncope think of arrhythmia think of ablation and if the patient has seizure like activity it could be complete heart block or ventricular tachycardia or it could be even a neurological you cannot rule out a neurological but only after you have ruled out a complete heart block or a ventricular attack cardio think of a neurological cause so these are the important parts in history now the last simple two cases a 55-year-old lady with sympathy she is hypertensive diabetic coronary artery disease i specifically put in the trade names so that you're all aware what she's taking stem lobita and amy fruit are exactly what she was taking i took her from a discharge summary and her ecg shows this now what does this easy show straight away there are two important points in gcg one thing is it's a very slow ecg very slow heart rate the heart rate is about 30 35 and the second thing is there are only qrs complexes and t waves qrs and t there is no p wave so a slow heart rate no previous is what this patient's ecg shows and that's exactly what she had when she had a syn copy so we did as i said we do ecg eco history and routine biochemistry routine biochemistry it shows that the patient had a potassium of 6.5 corrected the potassium and the patient's peers became normal heart rate became normal nothing else so please remember these are the patients although they have a slow heart rate they don't need pacemaker because the heart rate the heart rates which are slow are reversible because of the hyperkalemia now the last case is a 35 year old gentleman with a recurrent syncope and had this kind of ecg now this ecg shows that this patient has a sinus rhythm pqrs but there is a very peculiar very rare i do not expect anybody to see it in the practice regularly because even in a cardio a cardiologist see very rarely so this you can see that there is an st elevation and right bundle branch kind of morphology and this is called as a brugada pattern or a braga type of ecg and this is associated why i'm showing you this is associated with sudden cardiac death and that importance of ecg when i said a patient with syncope you must always take ecg and eco sometimes 99 ecgs may be normal one pcg you may have this kind of ecg which will tell you the cause of syncope is sudden death it's not a very benign thing don't take it lightly and if this patient if you never if you didn't take ecg you will not make a diagnosis you can do 100 investigations on this patient including cardiac armor coronary angiogram ct energy whatever you want but you will not make it diagnosis unless you would have done an ecg on this patient and this was uh discovered by the three brothers joseph regatta pedro brugada and roman brugada and this is what is called as the brugada syndrome and associated surrender i just want people to know so now this patient if you look at the 35 year old man which i was talking his father had died at a young age the same patient who was took unknown reason we don't know why he died he just said father died and many people who die sorry people who die at a young age everybody says he had a heart attack and there's no proof all deaths are not heart attack some of them are sudden death and his brother also died suddenly at the age of 6 30. this is a very very important history so this patient who has a regard at ecg sim copy two people died in his family high risk of surrender and is a candidate for icd again so this patient as dr anub said some people who have to put an icd even before the vt comes there is one such case where icd was put and the patient was saved now i just want to complete my talk by giving a an overview of what the abnormalities on ecg are now please see ecg is a very important investigative tool simple investigative tool for all periods syncope and it gives a lot of information in many patients not all patients now it's a logical cure suppose you have pathological cures in inferior leads or anterior leads this indicates the old myocardial infarction and this means the patient with syncope with this ecg risk of surrender and may require an icd patient can have a brugada which i showed you there are other things which i did not show because of positive time the long qt or an arvd kind of pattern these are inherited genetic syndromes all these things are likely they run in families please take history of family history of surrender and they die some of them you will find again risk of certain death may need an icd specific morphology of ventricular ectopic i assured you there is a rvo tvt which can be curable by radio frequency ablation i showed you another case a short pure interval delta wave wpw syndrome where it is curable by radio frequency relation so ecg can show the curable form of syncope or a sudden contact in form of syncope and all these important things an echocardiogram again i said ecg and require very important apart from history normal echo with an associated normal ecg the std is rich is raw icd almost never i repeated this statement before i am repeating it again because of the importance if a person has a normal normal ecg the risk of sudden correct death is low and i would add to normal eco and normal ecg normal cardio cameras these days if everything is normal the risk of std is very low and the icd is almost never if an abnormal led dysfunction or hypertrophic cardiomyopathy or risk of certain cardiac may need icd if the echo is abnormal like dilated atr past surgical scars atrial ventricular arthritis these patients you must think of arrhythmias medication or radiofrequency ablation so in conclusions syncope evaluation has to be broad and multi-dimensional it cannot be focused by one speciality you have to think of all areas management aims are again to exclude sudden cardiac death causes must be most important aim of a person who is evaluating any patient who comes to syncope ask yourself have i excluded the cause of sudden death in this patient if you have done that you have done 50 of the job or more to pick out curable and treatable entities very important like wpw syndrome or a svt which is causing syncope don't miss them please pick them up and treat them and reassure the patients and relatives invasive vehicles and could be fifty six percent of the case so you can reassure them tell them you're not going to die of it reassure them you'll be fine and try to make a definite diagnosis now don't just say patient did not eat food today that is why never ever say that try to make a definite diagnosis in all of them and remember eighteen percent of the case you can't make a diagnosis it's okay and uh i request i know now to give an overview and also look at the you know questions and we will try to answer both of us any questions that are there thank you so much sir just a few things that i will add to your discussion and i'm just highlighting few of the things that you said in the last five minutes so uh brugada you mentioned about that ecg i think the point that needs to be highlighted again is in many of these situations there may be 99 ecgs that may be normal and then 100 ecg may actually come abnormal so every time when this event is there till the time you have made a conclusive diagnosis it's okay to repeat an ecg in fact the wpw patient that you showed you showed the baseline ecg which had the revealed accessory pathway so many times we see patients who do have accessory pathway but ecg is completely normal and there you would call it as a concealed accessory pathway and in those patients you do 10 ecg one of them will show the accessory pathway other 9 will not so show accessory pathway same thing is with regatta syndrome or whatnot so repeating ecg with every event till a diagnosis is made is not overkill it's actually the correct thing to do as far as syncope evaluation is concerned uh i would add one thing which was taught during my training it's kind of just a rhetoric way of saying but it gets the point across my one of my senior used to say that when you are evaluating a patient of syncope and this is internal medicine that whenever you are evaluating a patient with syncope the first speciality you call for help is cardiology and the last speciality you call for help is neurology and the idea there is that if you have a global cerebral hypo function then most of the time the etiology is either cardiac or something metabolic like the hyperkalemia that you presented or dehydration truly speaking and very rarely it so happens that you have got a cns event which leads to a proper syncope you can have seizures but there you see an obvious seizure for most part so while it's a rhetoric statement it kind of gets the point across the point of family history is very very important so if a patient comes to you with a syncope history and the only thing that you know is there are pages there are people in his family who had syncope and who had either a certain characteristic or had a icd you immediately know that you are not dealing with a benign syncope you have got something which is a major catastrophe which which for which you can make a definitive diagnosis and for which you potentially can provide a curative option one entity which i think which is worth mentioning in syncope discussion is hypertrophy cardiomyopathy that is one uh cardiac pathology it's a autosomal dominant genetic mutation where you have got a myocyte which kind of just hypertrophy and because of that it causes both hemodynamic compromise as well as rhythm compromise and these patients also sometimes present with syncope because their cardiac output decreases sometimes they have severe iot stenosis which presents as syncope and in all of these cases echo will not be normal so you deal with rhythm problems when you say echo is normal which dr highgrive has highlighted multiple times but in these cases your echo will not be normal they will either show a major valvular disease or they will show hypertrophic cardiomyopathy and there we have to figure out whether the syncope is happening because of chemodynamic disturbance or whether it is happening because of rhythm disturbance if it is and based upon that you provide effective treatment so all in all i think when we talk about syncope we start with the history first and as has been pointed out in the talk multiple times you try to figure out is it something which is life threatening is this something that is going to kill the patient and if you get enough of hints and those hints also has been discussed patients who do not wake up fast who has got injury patients who have family history who have abnormal echo all those things if you have these hints then you pick up those make sure you come to a definitive diagnosis you will be able to save a life and in those patients where you define that these are not life-threatening events there you can do investigations like till table or whatnot to diagnose or confirm vasovagal syncope and do corrective measures as has been pointed out so i think uh dr highgrip you covered most of the part and in a case-based scenario which i think was very easy and simple for people to follow and we can go through some of the comments which have been listed and i'll try to cover each one of them so i'm just going from the newest to the oldest one question that comes is [Music] okay this is going to let me see [Music] okay so dr parthasarthi asks how do you collect hyperkalemia with the drug history of diuretic in the previous case does patient has chronic renal failure so dr highgrip do you remember what happened why this patient had hyperkalemia of yours this patient actually was a heart failure patient and was on diuretics and other drugs so this is from a remote village actually so not the ideal drugs patient was getting amlodipine and the beta blocker not the ideal that cementite should not be given in such patients with heart failure but this patient was getting for hypertension heart failure and diuretics and that's why the patient so please remember the patient with heart failure or diabetics please monitor their creatinine and potassium frequency uh i think that point is well taken and in fact one of the common thing that happens is ace inhibitors or arb particularly tell me saturn is sometimes is one of the very commonly prescribed medication for hypertension it's a very good medicine but the problem is i see often patients who have been taking tell me saturn for years and have never checked their potassium level they get one uti they get acutenal failure and voila they present with hyperkalemia so in lot of these patients checking for potassium becomes very very important i am reading more questions sir this is an important question what to do if a patient got syncope on a dental chair how to manage uh yeah from uh very important and important question see whenever not only this if you have a person who is within consciousness and upright position whether it is a dental chair or standing make the person lie down immediately that is the first thing you must do a mistake that people do is they continue to hold the patient in upright position or to make the person sit don't do that immediately make the person lie if it is a vasovagal syncope on lying down it will reverse immediately and lift the legs a little bit put some pillows under the legs and within one or two minutes patient becomes all right and give the patient a glass of water or some fluids and the patient will be all right and cpr is not indicate see the cpr and syncope as i told in the first slide by definition if you have a person who needs resuscitation that is not a syn copy a person who loses consciousness one or two minutes later that's a syn copy so patient who have a syncope in a cardiac arrest is something like a what i should say is a self-revived or aborted sudden cardiac arrest that's called the aborted sudden cardiac arrest loses consciousness and comes and these are the people whom we can save them if the person loses consciousness loses the rhythm and then you do cpr it is strictly by definition not async i'm also trying to read through some of the questions sir so collapse in syncope are considered together well they are two different terms when we call as cardiovascular collapse if it is irreversible then you would call it a cardiac arrest and the algorithms are different syncope should correct by itself and if it corrects by itself then you wouldn't call it a cardiovascular collapse i would say it is more of semantic than anything else the idea here is if you have a loss of consciousness that does not get better within a minute or two you are dealing with something more sinister and one thing that i think dr hagery what you pointed out in the last question the purpose of syncope and this is this is a basic way of looking at it the purpose of syncope is to put you down on the ground so that your cerebral perfusion is uh re-established and that your brain injury kind of resolves so you know the dental chair or the dining chair or what not if you have syncope that whole purpose is not solved so the patients need to lie down on the floor so that they get the cerebral perfusion started and even after that if the cautiousness is not resumed within within a reasonable time you would say maybe 30 seconds or a minute you are dealing with something more sinister you can't call it syncope thereon you are probably dealing with a arrhythmic event or a cardiovascular collapse in that regard so there you may need cpr you may need resuscitation and whatnot a lot of the comments are explanations uh rather than questions sir one of the question is what is the role of anti-arrhythmic in these kind of scenarios [Music] can be both cause and effect of syncope please remember that patients who are anti-rhythmics like especially on please look for qt prolongation repeatedly because the patients on heroin can have prolonged qt and can have sympathy and a cardiac arrest so they can be caused second thing is those patients who have arrhythmias like in atrial fibrillation or atrial flutter or svt until you do a curative ablation you can always use anti-rhythmic drugs but these are strictly beta blockers and diltiazem and rarely you have a requirement for amadoran in these patients sir one question is i think this is a simple thing for cardiac causes ecg is required during episode and the answer is yes see you don't know whether it's a cardiac cause or not all you know is it's syncope and unless you do an ecg you probably wouldn't know but sir uh my question to you is in the same form you know these days we are dealing we are actually there is a significant awareness in the public about home monitoring there are days when homes typically used to have maximum of a thermometer now now we see a lot of families they own a digital blood pressure machine they own a pulse oximeter now you know there are a lot of these handy gadgets which also do rhythm analysis your apple watch does the same thing there are these devices called alive core or cardia which does the same thing there are many such devices samsung device does the same thing but what do you think you think that these devices can be of help in this kind of rhythm detection if syncope happens at home particularly in a well-aware patient you know who are educated who can do some recording what is your take on that yeah that's it i think the technology is uh there for us to use and it's a great uh opportunity for us to be useful because the one thing that anybody can do at home is a pulse oximeter when you put you can tell the person's heart rate is okay or not now if the person is very very useful not only for syncope so anybody who calls and says he has palpitations you're a cardiologist and you just say what is your heart rate now and he puts out a pulse oximeter and says it is 80 or 90. i'm reassured that you are not dealing with the negative on the contrary if it says it's 150 or 200 you know that you're dealing with so similarly consciousness and his pulse is okay bp is okay at least you know that you know you don't have to be afraid of sudden cardiac death or rushing to the hospital so that way these jackets are extremely useful to my knowledge yeah i think it's a time we can conclude it's a thank you very much for everybody's attention and a patient hearing

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dr. Hygriv Rao

Dr. Hygriv Rao

Senior Consultant Cardiologist and Director, Division of Pacing & Electrophysiology | KIMS Group of Hospitals, Hyderabad

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dr. Hygriv Rao

Dr. Hygriv Rao

Senior Consultant Cardiologist and Director, ...

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