3 dizziness and syncope. karen hauer, md

Dizziness and Syncope Karen E. Hauer, MD University of California, San Francisco

Dizziness and Syncope: Outline ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dizziness ,[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Etiology of dizziness

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Vertigo: acute vestibular asymmetry ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Vertigo: history and exam ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Anatomy American Academy of Otolaryngology/HNS

Dix-Hallpike maneuver: to induce positional vertigo and nystagmus ,[object Object],[object Object],[object Object]

Dix-Hallpike maneuver: diagnostic and therapeutic ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Vertigo: when to image?

Case: unsteadiness ,[object Object],[object Object],[object Object]

Disequilibrium: often multifactorial ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dizziness: a geriatric syndrome ,[object Object],Tinetti, Ann Intern Med 2000 1.31 Prior MI 1.31 Postural hypotension 1.30 > 4 meds 1.34 Impaired balance 1.27 Decreased hearing 1.36 Depression 1.69 Anxiety Relative risk Risk factor

Case: “I feel like I’m going to faint” ,[object Object]

Dizziness: psychiatric etiology ,[object Object],[object Object],[object Object],[object Object]

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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Diagnostic Challenges ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Syncope: management questions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Case Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Etiology of Syncope ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

The Key to Diagnostic Evaluation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Diagnostic Algorithm Syncope Cardiac Noncardiac Idiopathic Arrhythmia Mechanical Neurocardiogenic Orthostatic Neurologic Psychiatric

Cardiac syncope: inadequate cardiac output, arrhythmia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Arrhythmia evaluation - telemetry ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Estrada, Am J Cardiol, 1995

Arrhythmia evaluation: 24 hr ambulatory (Holter) monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Arrhythmia evaluation: improving the yield ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Neurocardiogenic Syncope Vasovagal Micturition Vasodepressor Neurally - mediated Reflexive Orthostatic intolerance Carotid sinus syncope Cardioneurogenic

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Neurocardiogenic Syncope Clinical Presentation Syncope Trigger

Neurocardiogenic Syncope: Pathophysiology

Diagnosing neurocardiogenic syncope by history and exam ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Is Laughter Really the Best Medicine? ,[object Object],[object Object],[object Object]

Tilt table testing 60-80˚ ,[object Object],[object Object],[object Object],[object Object]

Tilt table testing: why the controversy? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Neurocardiogenic syncope: treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Vasovagal syncope: pacemakers ineffective ,[object Object],[object Object],Connolly, JAMA 2003 p = NS %

“ Idiopathic” syncope: improving diagnostic yield ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Prognosis: Framingham 25 year follow up *p<0.01 NEJM 2002;347:878 1.08 Vasovagal 1.32* Idiopathic 1.54* Neurologic 2.01* Cardiac Adjusted risk of death Etiology of syncope

Prognosis: ED risk stratification ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Prognosis: Guideline for admission - the San Francisco Syncope Rule ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Prognosis: Guideline for admission - the San Francisco Syncope Rule

ACP Guidelines for Hospital Admission ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Guidelines for Hospital Admission: implications for practice ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Syncope in the elderly: the geriatric challenge ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Syncope in the elderly: a poor prognostic sign Kapoor, Am J Med, 1986

Recommendations for Driving: following the law ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

American Heart Association Guidelines for Driving ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

The Potentially Costly Workup ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Trust the Careful History: Excess Cost of Vasodepressor Syncope ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Case Presentation: Is typical practice cost effective? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Cost-effective workup: Internists vs. cardiologists ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dizziness: key points ,[object Object],[object Object],[object Object],[object Object],[object Object]

Syncope: key points ,[object Object],[object Object],[object Object],[object Object],[object Object]

3 dizziness and syncope. karen hauer, md

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