Fainting may cause physical injury, lead to hospitalization and be a sign of an underlying cardiac disorder. Our cardiac electrophysiologist will review the causes of fainting, tell who's at risk, and discuss methods to minimize the chances of fainting. Presentation by Summit Medical Group Cardiologist Roy Sauberman, MD FACC

1. FAINTING Causes and Ways to Minimize Risk Roy Sauberman, MD FACC Summit Medical Group

5. 1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997 2 Gendelman HE, et al. NY State J Med 1983 3 Day SC, et al, AM J of Med 1982 4 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175

6. EXPLAINED 60% UNEXPLAINED 60% 40%

7. Cardiac? Non-Cardiac?

10. A Diagnostic Plan is Essential Modified after ESC Syncope Task Force, 2004

13. Cardiovascular Causes Common Denominator Transient Global Cerebral Hypoperfusion

18. History and Physical Exam Surface ECG Neurological Testing • Head CT Scan • Carotid Doppler • MRI • Skull Films • Brain Scan • EEG CV Syncope Workup • Holter • ELR • Tilt Table • Echo • EP Testing Other CV Testing • Angiogram • Exercise Test • SAECG Psychological Evaluation ENT Evaluation Endocrine Evaluation

27. Echocardiography

28. A AORTIC STENOSIS HYPERTROPHIC CARDIOMYOPATHY

30. No Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration

31. Tilt Table Testing

32. Tilt Table Testing

36. +/- Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1% * 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration

38. Diagnostic Gold Standard for Arrhythmias ECG strip recorded during clinical symptoms ECG Monitoring

41. Hospital Telemetry

43. ECG Monitoring Options ILR MCOT External Loop Recorder Event Recorder Holter Monitor 12-Lead 2 Days 7 Days 30+ Days 36 Months 10 Seconds ILR = insertable loop recorder MCOT= mobile cardiac outpatient telemetry

44. Mobile Cardiac Outpatient Telemetry (MCOT) Patient Indicates symptoms on PDA. Abnormal ECG transmitted automatically PDA or cell phone stores ECG data and symptom status. Wireless transmission capability provided. Monitor center receives, reviews and transmits data to physician. Pre-determined ‘urgency’ criteria determine timing of physician alerts Physician receives and acts upon data as medically appropriate

47. Implantable Loop Recorder • Battery longevity up to 36 months • Gold standard (symptom – rhythm correlation) • High diagnostic yield for patients with infrequent events • High patient compliance

51. Krahn, Circ. 1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and clinical assessment) Rhythm strip useful in diagnosis of 132 patients (64%) 206 Patients with Syncope Diagnostic Yield

52. 64% Diagnostic Yield Krahn, Circ. 1999; 100:I-20. Arrhythmic Vasovagal NSR Non-Compliant No Event 6 Month Minimum Follow-up 47 (23%) 21 (10%) 64 (31%) 9 (4%) 65 (32%) (Based on rhythm and clinical assessment) Rhythm strip useful in diagnosis of 132 patients (64%) 206 Patients with Syncope Diagnostic Yield

53. ILR Advantages • The less frequent the symptoms are . . . – The less likely conventional testing will yield a diagnosis – The more testing will be required – The more costly the attempts to diagnose will be – The longer the diagnostic process – The more frustrated the patient and clinician become – The more likely the patient may be in harm’s way • Breaks the costly & time consuming diagnostic cycle

55. “ Those who suffer from frequent and severe fainting often die suddenly.” Hippocrates, 1000 BC

56. MicroVolt T Wave Alternans (MTWA) Even Beats Odd Beats Mean V alt V alt

57. Mechanism Linking MTWA to Ventricular Arrhythmias Long APD Short APD Long APD Short APD Action Potential Alternans Leads to T-Wave Alternans Long APD Region Short APD Region Spatially Discordant Alternans Leads to Dispersion of Recovery, Wave Front Fractionation, and Reentry

58. MicroVolt T Wave Alternans Testing

60. Reduction of noise through adaptive cancellation of artifact LL (Segment) LL Impedance Respiration LL (Center) LL Enhanced Noise Reduction

62. Ikeda, et al.: Am J Cardiol 2002; 89:79-82 Post-MI CHF Klingenheben, et al.: Lancet 2000;356:651-52 Syncope Bloomfield, et al.: Circulation 1999;100:1-508

63. Gold, et al.: J Am Coll Cardiol 2000;36:2247-53

67. Structural Heart Disease * Yield based on mean time to diagnosis of 5.1 months 7 ** Structural Heart Disease *** Provocative test 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med , 1991. 3 Linzer, et al. Ann Int. Med , 1997. 4 Kapoor, Medicine , 1990. 5 Kapoor, JAMA , 1992 6 Krahn, Circulation , 1995 7 Krahn, Cardiology Clinics , 1997. History & Physical 49-85% 1,2 NA 12 lead ECG 2-11% 2 15 minutes Holter Monitor 1%* 1-3 days Electrophysiology Study 11% 3 NA*** without SHD** External Loop Recorder 20% * 2-3 weeks Tilt Table Test 11- 87% 4,5 NA*** Electrophysiology Study 49% 3 NA*** with SHD** Implantable Loop Recorder 65 - 88% 6,7 Up to 14 months Test/Procedure Yield Monitoring Duration

70. Intracardiac Recordings PA = Intra-atrial Conduction Interval A = Atrial Electrical Activity AH = Atria-His Bundle Conduction Interval H = His Bundle Electrical Activity HV = His Bundle-Ventricle Conduction Interval V = Ventricular Electrical Activity Surface ECG High Right Atrium IEGM His Bundle IEGM CS IEGM RV Apex IEGM PR Basic Sinus Cycle Length QRS A V V

74. Sudden Death Risk High Coronary Risk Post M I Heart Failure/ EF < 35%) Previous VF / VT Syncope / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)

75. Sudden Death Risk High Coronary Risk Post M I Heart Failure/ EF < 35%) Previous VF / VT Syncope / Heart Disease 0 100 200 300 50 (thousands) (millions) Population Size 0 10 20 50 1 2 5 SCD Percent / Year Total SCD / Year 0 10 1 2 5 20 (percent)

77. Leading Causes of Death in the US 1 National Vital Statistics Report , Vol 49 (11), Oct. 12, 2001 2 MMWR . State-specific mortality from sudden cardiac death – US 1999.Feb 15, 2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers

78. Leading Causes of Death in the US 1 National Vital Statistics Report , Vol 49 (11), Oct. 12, 2001 2 MMWR . State-specific mortality from sudden cardiac death – US 1999.Feb 15, 2002;51:123-126 Sudden cardiac arrest (SCA) Septicemia Nephritis Alzheimer’s Disease Influenza/pneumonia Diabetes Accidents/injuries Chronic lower respiratory diseases Cerebrovascular disease Other cardiac causes All cancers Only ALL cancers combined cause more deaths each year than sudden cardiac arrest!!

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