PracticeUpdate Cardiology June 2019

My Approach to Syncope in the Adult Interview with Paul D. Thompson MD by Aman Shah MD EXPERT OPINION 16

Dr. Shah: I’d like to talk to you about your approach to syncope in adults as a cardiolo- gist. Could you give us an overview and then we can get into the specifics of it? Dr. Thompson: I’ll start with that movie, Jerry McGuire, when he tells her that he loves her and he gives this big speech and she says, you had me at hello. Well, with syn- cope, actually, you should have it primarily at the history. So the most important part of evaluating syncope is the history, so let’s give some examples. Did the person pass out during exercise? If a person passed during exercise, that’s a concern. Did the person pass out after exercise? If they passed out after exercise, like they’re run- ning and then they stopped, that’s often just due to vasodilatation. Did they have a prodrome? Did they think they were going to pass out, did they get sweaty, did they get short of breath, did they feel the room spinning or something like that? That’s very suggestive of vasovagal episode. But if they passed out without anything before- hand, right, that’s a concern. Palpitations are important. Did the person feel palpitations, a change in their heart rhythm? If they didn’t and they had a pro- drome, that pushes, again, towards the vasovagal thing and then very important is how did they wake up? With an athlete, for example, if they woke up and they want to go right back into the game, that’s a prob- lem because most people with vasovagal Dr. Thompson is Physician Co-Director of the Hartford Healthcare Cardiovascular Institute and Professor of Medicine at the University of Connecticut in Storrs, Connecticut.

know, pulmonary embolus is often missed. It is oftenmissed in young people becausewe don’t think about it, we don’t think that it can happen. Seizures can fool you. So, those are the sort of things that I try to do. History is the most important, keep a wide differential when you’re going in, think of things that aren’t…the problem with us as cardiologists is we think everything’s the heart. Well, there’s lots of other things that we need to worry about and then work on down, but the key thing, the key thing in my evaluation of syncope is not to do too much, but to do a lot taking the history; a lot taking the history, and get the details. You can’t just ask the person about it, you’ve got to get all the details. One last thing I will say, and that is that when somebody has had recurring epi- sodes of syncope, I always try to go back to the first episode they have. That’s the one to be purest, without it being kind of influ- enced by the questions the doctor asks them over time. You see, the story changes as patients see more and more doctors, and by the time they get to a specialist, they’ve often kind of adopted, so that’s my approach – history, history, history. Dr. Shah: That’s fascinating. So, you go back to the first, the sort of the primary syncope or the first case… Dr. Thompson: It’s often the purest, it’s before the doctor has said things that you know,

will wake up a little confused and not exactly sure what’s going on. So, I think the most important thing in the whole story is the history. Now, you don’t want to get hooked on anything early on, but the history. And then obviously you go on and you do your testing, you do an EKG, do you look for long QT, do you look for Brugada-like pattern? So, elec- trocardiogram and then if you need an echocardiography and on. I like to tell people to avoid what I call diagnostic creep. Someone turned in with syncope and then you see the echo and you see something else that makes you concerned and so you switch from one diagnosis to another. If it sounds like vas- ovagal and it has all the characteristics of vasovagal, do enough of a work-up to make you satisfied and the patient comfort- able, but don’t do too much. Now, let’s go the other way, if it really doesn’t sound like vasovagal and it sounds like important cardiac syncope, then you’ve got to make sure that you rule out the dan- gerous stuff. So, for example, if it’s a young child or a young individual, adolescent, they can have things like anomalous coro- nary arteries. Now, I don’t want to go after zebras, but if the story is worrisome, that dictates how aggressive you are. Now, one last thing, don’t forget that there are a lot of things that mimic cardiac syncope, but are not cardiac syncope. For example, you

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