so Moy have you heard about the band where everyone in the audience has Syncopy oh no I feel like I know where this is going and I'm not sure you don't want to guess in sync oh no the Fallout boys I can respect that yeah I can respect that um do they have any songs with the word fall in it I don't think they do not that I know of about the top of my head Sugar We're Going Down is kind of like falling yeah okay all right enough of that the Cur Siders podcast is for entertainment education and information purposes only and the topics discussed should not be used Solly diagnos treat cure or prevent any diseases or conditions for the more Theus statements expressed on this podcast are SOL those of host and should not be interpreted to official policy or position of any entity aside from possibly cash moreos and affiliate Outreach programs if indeed there are any in fact there are none pretty much we are responsible if you screw up you should always be your own homework and let's [Music] know and welcome back to curbsiders uh I'm Dr monine and joined by my effervescent co-host Dr m trit how are you this afternoon afternoon evening what is time when you've gone from the east coast to the West Coast yeah that's right people we have flown to San Diego we are recording this actually the day before the conference starts but you'll be hearing this after our recap not that you really needed to know that but here we are um anyway Meredith will you please remind the good people in the audience what it is we do on the show sure Mo we are the internal medicine podcast we use expert interviews to bring you clinical Pearl and practice changing knowledge and today we have a fantastic conversation with our guest Dr Daniel Dressler he's a professor of medicine Master clinician director of internal medicine teaching services at Emer University Hospital he's an associate program director for the J Willis Hurst Internal Medicine Residency program he's also a medical student Society adviser and chair of the medical student society's Leadership Council at Emer University School of Medicine in Atlanta he's a textbook editor and Deputy editor of any New England Journal medicine Journal watch general medicine he loves talking about Syncopy but is never actually passed out himself so without further Ado we can get to it hey Dan thanks for coming on the show we've been we've been working on this one for a while so we're excited that we finally get to record it uh we're going to start with a few rapid fire questions first can you start by telling us a hobby or interest that you like outside of Medicine sure thanks for having me join you're saying took us a while because I'm a slow learner um Hobbies outside of medicine I enjoy going to the gym I enjoy running hanging out with my partner Heather and our puppy Willa and playing basketball a little bit poorly what's a little bit poorly mean um meaning I cannot shoot but I like defense okay and you play with othera [Laughter] I play with Heather Heather oh basketball no okay but so you're telling I'll just stop there so you're telling us you're more of a Ben Wallace not a Steph Curry yeah I'm so far from Steph um but I will eat Curry okay no lack of puns guys uh you've like clearly accomplished a lot in your career so what's some like helpful advice either you've gotten or that you like to give to people that are seeking advice cuz I imagine people come you a fair amount for that kind of thing yeah I I had to think about this a little bit although I think the best advice I got from one of my mentors early on uh which I think comes probably from a former president or something like that which is you can really accomplish anything that you want as long as you don't care who gets the credit and you know I try to keep that at the back of my mind for both things that I want to do and things that I think others uh can accomplish um because many of us are always trying to get like oh how do I get in the Limelight and it's okay to be outside the Limelight and you'll be noticed that's good one I don't know that we've had that one when we've recorded no I think that's definitely the first and I think if you've ever worked on anything with anybody you know that that's 100% true yeah I guess we can do one more question and then we'll go to Pi of the week sounds good cool why don't we end on like a fun kind of note what's your like a book movie show album any kind of art that you've been enjoying recently or not so recently I do spend a lot of time in medicine so but that's the question was outside of medicine so um I guess I was thinking of movies did love super bad and saw that at least somewhat recently on TV version um but what I what I watched recently with my kids was uh you are so not invited to my bot Mitzvah and that was great that's the new Adam Sandler one I haven't seen it yet yeah uhuh did you watch it no cuz I was waiting to watch it with like around the same time you did cuz I was going to have lots of questions yeah that's right that's what I'm here for hey you did never have I ever mhm yeah so you didn't have any questions anyway we're getting sidetracked already pic of the week yeah what yet oh man so many cuz it's been a while it has been but a lot of mine are going to be a little bit kid- themed I have no idea why so mine requires a backstory so I recently bought my son Max a book it's called The Paper Bag Princess and it's really a tale of why women are great um but the funny part of this whole story is that I think I bought like a miniature version of the book um it's about 1 in by 1 in but I didn't realize that so so when I got home I had a whole like long set of like Zoolander references from my husband about how I was buying books for my child that won't read good did Phil get the references he was the one giving them oh okay I thought you said the other way around okay so uh that was bringing me a lot of Joy recently and so that's going to be my first pick of the week while we're here in San Diego yeah and the size of it actually makes it seem a little longer I did get to read it recently guys if you're wondering so mine there's a couple I guess we have several episodes so maybe I can space it out but I'll start with Dune 2 uh which I'm sure Paul Williams is judging me heavily for such a popular movie but I have seen that movie three times in the theaters each with a different screen uh first time was a Dolby Cinema Edition second time was in the 70mm IMAX version highly recommend although it's probably not available in that anymore and then um two days ago when I didn't feel like packing I watched it at the theater by my house so Dune 2 highly recommend if you haven't already it'll probably be on a streamer by the time this comes out and I think that means we're ready to get hop over to casac to get her to our first case so I will take us there so we have Tamara she's a 42-year old woman with well-controlled hypertension she comes in for Urgent Care visit with an episode of lost of Consciousness she was hosting an outdoor piget fundraiser for her church and felt very stressed since the sound system was not working and the ice cream was melting before she could eat it she had taken her linal 40 Mig per usual and hadn't hydrated much all day she noted feeling nauseated had some blurry vision and then fainted while standing on the grass on luers noted about 5 to 10 seconds of leg jerking before she came to and was reoriented in Urgent Care her blood pressure was 110 over 65 heart rate was 88 and her other vitals were unremarkable no signs of trauma noted on exam so before we get too far into what this might be Dan can we start with a few definitions for starters what is syncopy cool case um yeah so so Syncopy and I always uh start Syncopy talks with well how do how do we Define this sometimes we in the medical record people list Syncopy but they don't know actually what they're uh what we mean by that and so Syncopy is both loss of consciousness and postural tone it happens suddenly so it's not something that happens over hours or days uh it is transient so if you are passed out for like hours days or weeks we call that you know in essence we we call that coma and the basic pathophysiology behind all types of Syncopy is that it is decreased blood flow to the brain essentially decreased blood flow to the reticular activating system of the brain and so things that are not doing that we should not be listing as Syncopy we might call it some other type of transient loss of consciousness so if you lose Consciousness because of low blood sugar uh that is not Syncopy if you lose Consciousness because of a seizure uh that is an electrical phenomenon in the brain that is not Syncopy and there are other ideologies what that we don't call Syncopy psychogenic things like that so I think that's sort of where I like to get everyone at the Baseline what about the definition for pre Syncopy like is that a thing it's a great question so pre Syncopy is referred to as this uh it's kind of interrelated with like phase of agal Syncopy or reflex Syncopy where you've feel like you're about to pass out you may get this kind of prod Drome and but you don't actually fully pass out because you either sit down or lay down or um but pre Syncopy when there there are at least two or three decent studies on pre Syncopy that suggest that the the risks related to PR Syncopy can be similar to that of Syncopy so um and so while some people think oh those are completely different phenomenon I consider them in the same genre okay um so I guess that's a good segue into thinking about about like the different causes of Syncopy and so I think you sort of alluded to it a little bit but like can we kind of put it into the different categories that we think about for Syncopy sure uh yeah so three major categories so we just talked about uh reflex Syncopy and reflex Syncopy of the primary ideology is Vasa vagal episodes uh and and then within that you also have like situational Syncopy or things that predis Expos us to a Vasa vagal episode or cored sinus Syncopy people who get recurrent episodes of essentially vasovagal Syncopy due to hyper stimulation of the CED sinus uh then we also our our second major category is orthostatic Syncopy which is predominantly volume depletion but that can also be caused by medications blood pressure medications or other medications that reduce heart rate or blood pressure uh and autonomic dysfunction or autonomic failure uh and that can also be medication induced but in situations where that's not the case we all know that there are predisposing factors to autonomic dysfunction things like diabetes things like primary neurologic disorders uh uh as well as other things that are less commonly thought of like HIV or rheumatologic diseases that can uh lead to autonomic dysfunction and and then finally we're where we're all worried about Syncopy is with the cardiac causes and so uh cardiac causes I try to break down into two major categories which are uh you either have a rhythm problem uh which I do on the dance floor as well um um or uh you have a structural problem of the heart uh and then with rhythm problems there are really only two Rhythm problems that can cause Syncopy uh and when I ask the health staff about about this they look at me quizzically and then start throwing out names and I just say yeah you're either fast or you're slow those are the two Rhythm problems that can cause Syncopy any abnormal Rhythm that can cause you to be heart rate to be fast or heart rate to be slow uh can lead to Syncopy um and but we obviously think about things that are more dangerous like ventricular teoc cardia or torsades uh we also think about dangerous slow rhythms like a third degree AV block and stuff like that then if we move to the structural cause es of uh or structural cardiac causes of Syncopy uh then those are really four major categories which are valvular which could be like aortic stenosis or mitro stenosis you can have obstructive uh which is generally like hypertrophic obstructive cardiomyopathy or Hokum you can also think of atomas in that category uh pump failure is the third uh major kind of obstructive problem or sorry structural problem and so pump failure can be either es schic if you have large esea to your left ventricle or could be a pressure overload phenomenon like cardiac tamponade uh and then you have vascular problems that you can think about that could include like pulmonary embolism but could include other less common vascular problems yeah that's a I think it's a good breakdown of all the different causes because I think if you just keep that framework in mind it's a lot easier just to think through them because it feels a little bit less overwhelming so you know with the case that we have with Tamara she comes in and I think the thing that especially when we're talking with Learners like it's really important to sus out certain things in the history so what are the sort of history and exam things you're looking for when you're hearing a presentation from a resident or whatever you're thinking through to yeah great um yeah so the way I'm thinking about this is is uh because lowrisk things are really common well okay I'm going to see way more low-risk things than I am high-risk things but I'm always going to worry about the high-risk things so but but most of the lowrisk ideologies of Syncopy are diagnosed simply based on history uh and so if I can get that really good history then I can say oh I've made myself really comfortable that the patient has a lowrisk cause either volume depletion or more commonly Vasa vagal episode and so then we talk about well what actually causes a the prod Drome in a Vasa Veo episode what causes those symptoms and it's really a sympathetic surge followed by a parasympathetic Surge and and so if you think about how all of us when we stand up you stand up you your blood pressure drops just slightly and and that activates the crudded sinus and when it does that it then leads to the cruded sinus sending a signal to the brain and that signal then sends back and says oh I need to increase the blood pressure a little bit or I need to increase the heart rate a little bit so what happens in individuals who develop a Vasa vagal episode is that they uh they get kind of a hypers stimulation of that so when they are standing up the blood pressure drops it sends a signal to the brain and says I need a sympathetic Surge and so it gives that sympathetic Surge and that is and that's what creates the first part of the prodrome which is oh I feel anxious I feel my heart racing palpitations and maybe I start sweating maybe I get goosebumps and that's the sympathetic Surge and what's happening is then the blood pressure is jumping up a little too high the heart rate's going up a little bit too much and so then that activation of the cored sinus then sends signal back to the brain saying the blood pressure is too high the heart rate's too high and and then it sends a parasympathetic Surge and that parasympathetic surge is oh I feel warm I feel nauseous maybe I vomit and then and then pass out and so those are the symptoms I'm trying to look for uh in the setting of a Vasa vagal episode or reflex Syncopy is does someone exhibit a number of those symptoms uh of the prod Drome such that I can say oh I'm pretty comfortable that that was the prodrome that I'm looking for and this is this was a Vasa vagel episode that's on the history side um you know other other historical things and other physical exam things so I would say some things can get a little confusing because we we tend to think about how people talk about like incontinence and and they say oh well incontinence is more indicative of seizure but that's not necessarily the the case because there's about an equal frequency of urinary Inc continents in patients who have seizure or patients who have Syncopy and so it's really not a great distinguishing factor and then other things especially for early level Learners uh or or early level Physicians or even early level attendings uh if you haven't seen hundreds or even getting to close to thousands of of cases of Syncopy then it's sometimes helpful to have a risk scoring system that can help us uh decide well is this patient high-risk or not and there are a number of these scoring systems that have been out over the last uh few decades but the the one uh in and they each have like we we'll say uh junky data behind them it's not that they were they were studied poorly it's just they're they're not as helpful but we did get a new Syncopy rule that came out in around 2016 and that's a Canadian Syncopy risk score uh and that it was studied initially in four about 4,000 patients was uh was validated in another 4,000 patients and then was revalidated uh around the world and another 2500 patients and so we now have over 10,000 patients that would have been prospectively studied uh and so this is the largest cohort of prospectively studied uh to that can help individuals especially if you haven't seen a lot of Syncopy to to say is this patient high risk or are they moderate risk or they uh or they low risk and and can I potentially discharge them or or do I need to do more evaluation but I'm speaking too much you're not I'm just laughing because I feel like with Syncopy that's always the question to discharge or not to discharge is really where it like comes down to and so I think that uh sums it up actually pretty nicely there were two things that I wanted to make sure we touched on um especially in this case she was jerking is that something like what do you think about jerking and Andor tongue biting yeah great um and so touching on the the jerking so uh there there was pretty well done study uh and then these European or English uh what's called the nice guidelines that came out related to things that make us think about seizure in unwitnessed transient loss of consciousness what would make you think about seizure rather than Syncopy and so some of the things that make you think of seizure would be La tongue biting and especially lateral tongue biting and so that probably has if you're into evidence-based medicine in in diagnoses has a likelihood ratio of close to 10 which is really good for as a positive likelihood ratio to make you more suspicious of seizure rather than Syncopy as a negative predictive value it's not very good so if someone doesn't have tongue biting I don't like to say that rules out uh seizure per se and again these are unwitnessed episodes um the other things that can help you uh sort of increase your likelihood that seizure was happening rather than Syncopy uh or things like a postal state if if it took you you know 10 minutes or 20 minutes to to come back to normal mental status uh that's helpful patients who have benign episodes of Syncopy or even cardiac Syncopy when they wake up they're usually back to their normal mentation within uh a minute or so and so those things are definitely helpful and then so the the the J issue is really important so um in and sometimes you're observers of the of the passing out uh can't give you a great history but there are some people who observe it you can ask them oh well show me what it looked like and a lot of us know what tonic clonic activity looks like uh but the other key thing with jerking movements is how long did it last so it is pretty unusual for tonic clonic activity to last less than about 30 seconds and so if you are described jerking movements in the order of a few seconds to even five or 10 seconds well that's not uh that is almost never going to be uh tonic clonic activity which lasts 30 seconds to a few minutes obviously if you get Beyond a few minutes that gets into status and so patients with Syncopy there's probably about a 10% incidence of uh myoclonic jerking that happens with Syncopy uh just immediately post Syncopy and so a lot of times that is what observers have uh seen is is my clonic jerks and then there's actually even a 1% incidence of what's called whole body stiffening uh which is probably a transient hyper profusion of the brain lasts a split second the patient comes back they're totally normal neurologically when they wake up and so it also means nothing um and so those things are can be really helpful I think the last thing would say back to the Canadian syncopy score just on a really quick note is that those are available on apps it's available on Med maath or it's available on qxmd uh for and so it's none of us need to memorize these things you just pull up the app and and plug it in awesome and we can link that in the show notes yep um so I I guess now that we have like a better idea of what we're thinking about for Miss Tamara what types of testing might you think about for her kind of given her story great question so uh yeah I mean her her history is pretty classic for a vas of vagel episode uh or a combination of vas of vagel plus volume depletion meaning she was outside it was hot she probably wasn't drinking enough and got a little bit volume depleted and then was also uh kind of self uh you know not intentionally but self- instigating sympathetic surges by anxiety and trying to get rid ready for this event and so um and so a lot of what she described sounds like a combination of uh vas of agal plus or minus volume depletion with that and so then what kind of testing do I want to do in that situation well the key is like oh I want to do a good history and physical exam as part of my physical exam I'm always thinking of three main things to do one is get Vital Signs and then definitively get orthostatics and get them as early as you can can uh but there's no time point at which I say I'm never going to get orthostatics there's no time point where I'd say oh we've gotten two or three liters of fluid I might as well not get orthostatics uh and that's because well someone could still be volume depleted even after that amount of time and the other thing is you can with orthostatics you can sometimes diagnose autonomic dysfunction uh by seeing a drop in blood pressure where the heart rate stays you know Stone Cold the same and so when you see that that is highly suspicious for autonomic dysfunction and so I'm always wanting to see orthostatics done and when you look at studies that have been done on this we still only see less than half of of people who are admitted to the hospital with a syncable episode that's uh documented that that get orthostatics done and so we're we're kind of trying to pound that in then the other exam findings that you you're looking for is you want to do a good card exam and a good neurologic examination um and we're we're talking to practicing clinicians who I think everyone knows and understands what what is meant by good complete and documented in a complete fashion the other piece with studies is well I think every guideline is recommending that every patient with a syncable episode gets an EKG even if you're so highly suspicious that uh this is a Vasa vagal episode an EK is relatively inexpensive and you don't want to miss uh congenital reasons to have uh a syncable episode especially in a young person uh but like hypertrophic obstructive cardiopathy uh and that incidence can actually increase uh as you age uh but there's also congenital prolonged QT syndrome there are other uh Rhythm problems or even you know RV dysplasia that could lead to syn episodes or aymas and so you you just don't want to miss that and and it's relatively inexpensive short of that there are no other definitive oh we have to get this or that test um there are no blood tests that you necessarily have to get uh and some of that should be based on your level of Suspicion so if you are a person seeing this patient in your office you might say oh I clearly based on history diagnosed a Vasa vagal episode your exam is normal your EKG is normal and so that may be the extent that you need to do I don't need to put you through a battery of tests necessarily okay so with that in mind how confident in your baso Bagel history are you because I feel like often what I get from the like maybe the emergency room is calling him the story sounds very vasovagal but this person might have an extensive cardiac history that then plays into it so yeah I think you bring up great points is is that so as internists and definitely as hospitalists uh we uh rarely are seeing a patient that has zero one or two problems and so you we definitively want to look at those you know their prior history and see well how is that playing in uh to our decision making and so what is going to make me concerned what is going to make me think about my patient more or decide oh I may want to do more testing is you know do they have other cardiac diseases and this plays into partly the the Canadian Syncopy risk or you know fered some of that out where any patient that has any type of cardiac disease whether it's coronary disease or a prior history of a rhythm problem including a fib or a prior history of uh cardiac dysfunction like heart failure or coronary disease all those patients get extra points for having that history and that contributes to why you might think someone might be a higher risk that history in and of itself if that's the only thing may not contribute enough to say oh I'm worried about a patient but I'm like you like if the patient is called to me uh about like oh I want to admit this patient then I might consider that and say oh well I I may go through the Canadian syn risk order and say oh well I calculated everything out and this patient is low risk and so I feel comfortable doing an outpatient workup or I might say oh well they're hitting moderate risk uh or if my Ed dock is still really concerned despite you know having this discussion it's easy enough for me to admit the patient that you usually already have some Labs it's easy to have them on Telemetry for 24 hours and and and see a set of cardiac enzymes and even though I wouldn't don't always necessarily do that for all of my patients there may be situations where that you know is is reasonable yeah so we've covered the cardiac history and now I want to talk about the elephant in the room pees um so ders and then sort of going through the peasant trial in terms of how we think through that yeah so the Peet trial which also was published back in 2016 really interesting stud study uh in that uh that it was kind of the first trial that looked at a cohort of all individuals who are coming into emergency rooms Syncopy now caveat to that is they they did exclude patients who this was not their first episode of Syncopy why is that important we well actually first episode of Syncopy portends a little bit higher risk for patients and why is that well in part because you have a number of patients who when they have multiple episodes of Syncopy they are just have recurrent vas of vagal episodes which are relatively benign but they come in a lot they're also patients who have psychogenic ideologies of Syncopy also tend to have multiple episodes and so the pest of trial looked at first episode of Syncopy and then what did they do well they did a very structured workup of these patient in the emergency department meaning a really good history a structured history and physical exam they all got EKGs and they got some really basic lab studies and and then they decided who could be discharged because they had a low risk of of a lowrisk ideology of their Syncopy like they had Vasa Vel or that was drug induced or it was volume depletion and that was actually about 75% of the patients and so then they only admitt aded about 25% of the patients I don't know about you guys but my hospital at least anecdotally seems to admit more patients than 25% of Syncopy now I say that a little tongue and cheek because I'm not down there in the emergency department seeing all the patients that they may be discharging however there is actually some data uh related to patients who come into hospitals with Syncopy coming into the US is uh coming into Canada for example where the patients coming to the US emergency departments with Syncopy uh close to 80% of them were being admitted uh versus patients coming into hospitals in Canada somewhere between 15 and 25% of them were being admitted and so uh I I mostly bring that up because the PES at trial has been criticized based on some of the the findings that we'll get into about about what it's saying the percentage of patients who might have a PE when they come in with Syncopy but part of that is because they uh did exclude and and essentially discharged home a lot of their patients who were low risk and so then the only patients that they were admitting were reasonably higher risk uh and they were first episode of Syncopy Syncopy that made also them a little bit even higher risk so with the PESA trial those patients came in and the final result were about 4% of all the patients that came into the Ed had a PE and the big result of the trial was that oh 177% of admitted patients uh uh with Syncopy have a PE well many of us say well we don't really see that but it's in part because we're admitting a lot more low-risk patients in in our hospitals circling back though so what did peset do so those patients that got admit uh what did they do with those patients well they said these are all high-risk patients and we don't have a lowrisk ideology and we didn't also clearly diagnose some high-risk ideology like you had a malignant arhythmia or something like that and so then all of those patients they said well they're high enough risk where we're admitting them and we don't know what the ideology is and so we are going to get a well a simplified well score and a d dier on each of those patients and so then they did that and if your D dier was negative which was about 2third of those admitted patients they did nothing further to work up for PE if your D dier was positive or your simplified well score was positive then they uh then they said well you're high enough risk and so we're going to do imaging for PE and then they found a relatively large percentage of patients who were admitted who were highrisk admitted for Syncopy who had a had a PE how I am us using this myself and how I'm asking my trainees to to use this is is understanding that we are we are seeing more low-risk patients admitted to us and so what I want uh my residents to do what I want my hospitals to do what I want to do is then redo my own work up of the patient if I work up the patient I say oh there's clearly your volume depleted or clearly you have autonomic dysfunction or you definitely had a Vasa vagal episode and and and my ER docs who are crazy busy and and seeing way too many patients they may just not have had time to do all of the things that uh that I may have more time to do and so if I made a lowrisk diagnosis when I saw the patient then what am I going to do I'm just going to discharge the patient it's only when I've uh admitted the patient uh I don't think that they have a lowrisk diagnosis or not one that I can say is clearly evident and I didn't also did not diagnose some other high-risk diagnosis and I just don't know what's going on well then I am calculating a simplified well score which takes a few seconds and then I am ordering a d dier and if the D dier is positive then I will get a Imaging study I find that this does not you know has only maybe increased my number of Imaging studies in a year by like five or 10 percent um but I I now do think about it a little bit more because uh because the risk is a little bit higher there are a handful of studies that were not as high quality as the peset trial a number of retrospective studies followed the pesit trial because people said oh they didn't believe that those results and and there were three or four retrospective uh cohort studies or combinations of multiple retrospective cohorts that said oh this is not true but those studies don't well Define Syncopy those studies uh include a lot of uh patients that may not even have Syncopy some of those studies actually include Al patients rather than Ed patients and then there was one follow-up study to the pesant trial that came out in 2019 uh that essentially uh did a similar algorithm where uh where the patients did get the same kind of algorithm of the dier uh and the well score uh if the patients were high-risk admitted and and they found somewhat similar results they found that about 2 and a half% of patients coming in the Ed uh did have a p which is again higher than some of these other studies were showing which uh in in close around 10 or 11% were uh of the admitted patients who got imaged did have a PE so it was uh somewhat similar results to uh to PES it and so that's why I'm still following this algorithm to still get the D dier on occasion uh when I admit patients and and even if I look at experts in VTE and what are they doing and what do they recommend if patients come in with Syncopy and they don't have a clear low-risk diagnosis and especially if it's their first episode of Syncopy and they're getting admitted hey probably would get D dimer and make sure that they're not having a PE in those that they do find a PE in like if I'm thinking about Syncopy and PE I think of like massive pees um or like some massive um but I often feel like when I do a synop workup and get like diers like elevated get the CT I get these like segmental pees and I'm just curious if that really can explain that patient Syncopy from like a pathophys yeah yeah no it's another great point and question I get all the time so interestingly in PID and and some of these other trials when they studied patients meaning they imaged them if they had a positive D dier or positive Wells score about two-thirds of them actually had large pees uh meaning it was either a saddle emis or a low bar PE but one/ third had had a segmental or sub segmental pees like the question you ask is well how how could that cause someone to pass out there are individuals who uh at least on a theoretical side have thought about this and and I don't think I I at least haven't seen someone studied it well but there there is a thought that uh PE and the potential inflammation related to that can activate receptors uh within the lung that then could lead to vas of legal episodes and so that is thought that why we might be seeing some of these smaller PES and someone passing out where where it's not necessarily a complete vascular obstruction that's doing it uh but it was like the symptom that that led us to like lead to even consider that or look for it okay um we've done a lot so I'm going to maybe summarize a little bit about what we've done so far and then we can advance the case so for Miss Tamara at least it sounds like she comes in has a very classic like Vaso vagel story but would probably still like do a Canadian Syncopy risk assessment to really evaluate low risis high risk based on like the other history you're getting based on her uh EKG and then because kind of her other history and everything really pointed to vzo Bagel kind of limiting the further testing that is like necessary for her I think the only other question that just we can kind of quickly go over which I think you may have alluded to was so in the patients that come in you know with their jerking movements or I guess even like the lateral tongue biting CTE EEG still or if they give you a good like you know other history for their Syncopy can you kind of bypass that yeah I've been reading about and I got very interested in Syncopy in residency because I felt like every time I was going working on a a different team and a different attending the workup seemed to be different and made no sense to me and that's why I started like reading about it and like trying to figure out the evidence and the data behind it and this comes to like one of my one of the Early times when I was running a conference um and I spoke about Syncopy I had this uh this guy came up to me at the end and said you say all that but that's a bunch of BS because I'm going to get sued if I don't do the cat skan or the EEG and then and so I tried to look into this more and tried to help and we had a a rather uh Avid discussion about this um and he he was just like giving it to me and he was like easily 10 or 15 years my senior or what have you but I feel like I I was able to like at least get some things across and and I do this Based on data now and and so for our particular patient and I'll get into the D but for our particular patient Tamara um because her jerking was uh short in duration only a handful of seconds did not get to like 30 seconds it was not described as tonic clonic by The Observers or when we asked them as clinicians and about that and she came too pretty quickly so she did not have a postictal state and she didn't have any tongue biting so we didn't get any other things that to suggest seizure and so the uh jerking movements alone are not going to prompt me to get the brain Imaging or the EEG and and that is now both supported Again by mostly retrospective cohort data but it is supported by that data and but it's also supported by uh organizations so like the believe shm uh has something on this as well but American College of Physicians does the American Academy of Neurology as well as the American Academy of Emergency Physicians all of these organizations recommend do not do imaging in patients with simple Syncopy unless you have neurologic findings by based on history or physical exam so in and a few jerks uh does not meet that criteria and so I think we can feel comfortable and and I will say that that gentleman who came up to me that that first conference which was probably a couple decad decades ago then uh uh is one of the few people that has come back to my conference every year for the last like 15 years eager to learn something new does he come up to you every year and conversation we he comes up to me every year and we have a conversation I probably remember this conversation well well better than he does but we we don't talk about Syncopy anymore um all right so for Tamara um just like we were kind of talking about her physical exam Labs unremarkable we did orthostatics but after um she had been hydrated um so they were normal and ultimately at this point she's ready to go home she's anxious about what happened how might you count counsel her on you know what transpired and what to be on the lookout for in the future yeah that's great so definitively one of the most important things is helping patients feel comfortable going home and what what happened here and and so I I generally describe what happened for this patient as a simple faint and that is sort of like the the the lay person or colloquial terminology as you had a simple faint um and I also tell them that this portends no increased risk for uh for you as compared to anyone who's never fainted uh and so that uh usually helps people feel more comfortable and and then we we just go over basic count counseling like oh if you're going to be outside in the heat for a long periods of time hydrate yourself well um there actually have been studies on especially on people who know that they're at risk of having Vasa vagal episodes if they know what those prompting uh factors can be like giving blood or things like that then if you do something very simple like drink a four glass of water right before you do it it uh that's been shown in in some reasonable studies to reduce the risk of of developing Vasa vagal episodes but it's very basic counseling that you had nothing that was highrisk imagine since it's lowrisk and a simple faint you probably don't maybe recommend urgent followup for someone like her no as long as I think almost anyone who comes to an emergency department I say yeah you should get to see your primary care physician within the next few weeks uh let them know what happened I send them information about what what happened and what we think happened but this does not require any urgent followup we already did the good history of physical exam got an EKG and we feel comfortable and so we can help the patient feel comfortable I'm realizing as we're ending this that tomorrow could have been me with her audio anxiety yeah I'm also thinking of all the times I passed out in the O as a medical student and I just want to say if I had known I just had to drink a big glass of water before that that would have been helpful did you lock your knees I did I lots of things probably wrong okay I think we probably need to get to the next case sounds good all right so the next one is we have Travis he's a 62-year-old accountant with a past medical history of hypertension hyper lipidemia with uh mediocre control on his linil htz and atorvastin he's been stressed at work due to upcoming deadlines to the season um and he noted a few seconds of fluttering in his chest a sudden loss of consciousness he came to and found co-workers standing over him paramedics on their way um and then when he got to the ER he felt a little tired no chest pain shortness of breath palpitations or any other symptoms vitals were unremarkable and exam and basic Labs were also unremarkable including a tronin and a Diemer that they did in the ER his EKG showed signs of right Axis deviation with a QRS access at 110 in duration of 140 milliseconds in overlapping QRS complexes from Deep precordial s waves he's eager to leave though and get back to work to get to all those deadlines so this seems a little bit different than the last case we just talked about um so are there other tools you're using or you still using your Canadian Syncopy risk assessment yeah no the clearly this gentleman is a little bit more concerning um for a couple of reasons but I I still would encourage someone to use the Canadian Syncopy risk score for this patient and it would likely be helpful and we can get to that in a in a second but um what I would say what what makes this patient concerning well he had what I would call palpitations and meaning he had this flutter he felt this fluttering in his chest palpitations is a challenging symptom because it can happen simply with uh vas of vagal or reflex Syncopy but it also can happen with aymas and so you you want to take it seriously the other concerning thing for him was aside from the palpitations he kind of lacked a prodrome so there was nothing else to suggest a sympathetic Surge and a parasympathetic surge he just felt this fluttering and then he passed out and so that makes me worried that could could there have been some sort of malignant arhythmia but let's say we didn't know some of that or uh as an early level learner I wasn't sure I could still plug uh his information into the Canadian Syncopy risk score and doing that even though he doesn't have uh a lot of past medical history that would contribute to it what does contribute is some of his EKG findings um and so the the fact that he has a abnormal axis either a left word or a right word access and that he's got a prolonged QRS duration those are two concerning findings and those both would contribute to higher risk based on the Canadian Syncopy risk score and so when I say higher risk well what if we put those in if we put those into Canadian Syncopy risk we'll pretend like we're doing it now and we end up with a risk uh somewhere between 5 and 133% why why is that why is it that VAR at the end of the Canadian Syncopy risk or there's a j judgement call and the Judgment call is do you think that the patient had a Vasa vagal episode do you think that the patient had a cardiac cause of their Syncopy those are the two options or do you think you're not sure or neither um and so clearly looking at this patient I would not say that oh I can clearly diagnose a Vasa vagal episode um and so I'm not going to make that judgment call there you can make a decision of well do I think I'm just not sure or do I think it's definitively cardiac you could say one way or another if I'm not sure and I say well I'm not going to call it cardiac then it would be about a 5% risk uh which puts a patient at moderate level risk moderate being anywhere above about two uh two to 3% put you at moderate risk uh and then if you said oh I do think this was cardiac because there was no prod Drome and he just had this palpitations and then pastel then that would put you at about 133% uh risk which is definitely too high to just discharge a patient and so the Canadian Syncopy risk or will help uh anyone in that situation if that got enough to what you were trying to get me to talk about I think so so based on Travis's history and what you just said it seems like you want to keep him and so I guess the next next sort of big hurdle to cross is the one about further cardiac testing echo or anything else that you'd be thinking about um because I know Echo are in the controversial range sometimes yeah other great points um Echo sort of think of well when when would I get an echo in a patient with Syncopy uh these used to be kind of done ubiquitously uh based on some earlier guidelines back in the you know back in the mid 2000s that suggested well anyone who has a snle episode and you don't know what's going on you should get an echo and so we got way more Echo that guideline obviously or I don't know if it's obvious or not but was a coming from a cardiac Society so was maybe a little bit self- serving although not necessarily intentionally so um but Echo are pretty dang expensive I mean it costs you know in my system probably cost ,500 to $2,000 for for an Echo and so I don't want to just get those kind of willy-nilly on everyone and so who do I get Echoes on well the the newer guidelines recommend getting Echo and this is based on data there was actually a things we do for no reason which is getting Echo cardiograms uh for all patients who come in with Syncopy and so uh that publication kind of documented there's about six studies uh all retrospective cohorts but showing that if we get Echoes on everyone with Syncopy the yield is only going to be 1% or less and so then who do we get Echoes on well Echo should be based on if you have either history findings which there's not a lot of history findings that say I should get an echo but one of the big history findings would be if you have exertional Syncopy if you pass out while you're exerting yourself uh that's a high risk for an obstructive phenomenon and so you you'd want to get an echo related to that Mo but mostly physical exam and EKG so physical exam if you hear a new murmur and a patient who had Syncopy well hey that's reason enough to get an echocardiogram uh or abnormal EKG uh so when EKG is abnormal and there was actually a good recent study in 2019 that s kind of defined these abnormalities on EKG and then defin Echo abnormalities and and could these be predictive and so it was somewhere on the order of if you had no EKG abnormalities your risk was about one or two% of having an abnormal Echo versus if you had any abnormality on EKG and those abnormalities defined as like abnormal Axis or abnormal QRS and a few other things then you had about a 25% chance of having an abnormality on your Echo that should explain the Syncopy and so Echo is something that is a useful tool but just not something that needs to be done in everyone and so do we want to talk about other tests or or should I if you have other tests go for it yeah I mean so definitively in this patient uh who has a a widen QRS not unreasonable to get an echo to me I'm not sure it's going to really even matter what the echo findings show with with the wiing QRS I am probably going to get uh my cardiologist involved because I'm I'm concerned that the patient may need an EP study or electrophysiologic study um and why is that there was uh another good study and sorry I don't remember authors and names of the study but I can give you any of these references if you want any of them um but there was a study done maybe 10 is years ago that looked at patients who were coming in with Syncopy who had a widen QRS a Qs I think over 130 and so what did they do well they said well do we have a diagnosis based on the EKG or Telemetry when they in the ER in the hospital and that was only about a third of patients got a diagnosis and so what did they do well they did they actually did EP studies on everyone and so once they did an EP study everyone they were actually another third of the patients just based on the EP study were able to get a diagnosis that was a rhythm problem diagnosis most of them were actually uh slow rhythms like inducing uh like thir degree AV block or things like that and then a smaller proportion did have like inducible malignum arrhythmias like a VT or something like that um so then we then had 2/3 of them diagnosed based on that the rest of the PTI patients if they didn't have a diagnosis based on that then they they got an implantable loop monitor uh and another sixth so about 177% of patients additionally got diagnosed so if they followed that algorithm in patients with a widen QRS then they were able to get diagnoses in close to 90% of the patients and these are not like uh benign diagnosis and so you know if I see a wi in QRS I'm going to going have a very low threshold to get a cardiologist involved or maybe an electrophysiologist involved to uh help make some of this decisions and or say we need to go to an additional testing that only they can really do so I have this memory from training of one patient I had who came in a Syncopy it sounded like cardiac Syncopy like she had injuries from her events and everything um but the initial workup was negative long story short when we were about to discharge her cuz we hadn't found anything she syncopized again and it was like a VT um run she had on her monitor yeah and then one thing led to another and it turned out she had like a big lad lesion so one of my questions I often have is like are there anything that would indicate going down like an ACS pathway for their rhythmus or you're getting like your cardiologist involved anyway so it's kind of relevant for well no it's a great point because I mean esea can lead to Syncopy and so uh while the overall yield of our patients admitted to the hospital who we stick on Telemetry and we get we might get cardiac enzymes I say might but like I'm seeing like every patient getting at least one or two sets of ciic enzymes uh that yield is relatively low but some patients do have that as the ideology so anyone who who says they had any sort of chest pain either before during or after their Syncopy I I'm going to consider them for or have a much lower threshold to do cardiac workup in even in addition to even if my troponin are negative uh I might do a stress test on them and and that is because you can have you know we definitely see unstable angena and left main lesion or an lad lesion those are the lesions that could be large enough that in a even in a transient esic episode could hit enough of the left ventricle to cause it to even if transient to stop for a few seconds could cause you to pass out and so I think it's definitely important to to think about and and potentially pursue in while you've got the patient kind of quote unquote captured in the inpatient uh setting which which also brings to mind like well you know some we got to use our Gestalt and and do we have a level of comfort that this was something low risk and again that goes back to the history that we talked about before and what makes all of us uncomfortable is when we don't clearly have something low risk we don't clearly have something high risk risk and we're in this intermediate and and then and then do I keep you in the hospital and do a bunch of things or do I let you go home and try to schedule some things in the outpatient or or do I let you go home and do nothing and it always makes us all feel a little bit uh angst provoking yeah uh so hearing that story Meredith uh I think everyone should go home on a halter or a loop recorder the longest one I can ever keep them straight so that's probably a good place for you to kind of walk through the different monitors and like what we should be like when to order what cuz otherwise I'm just going to send everyone on like the 2-year monitor so yeah and and I will say Syncopy I find very challenging to you know and it gives us all a little bit of angst and so but I I do see some practitioners I've even had family members say oh I passed out and my my doctor uh gave me this monitor to and I was like oh have you ever passed out like how what's and so what do I do with Loop monitors so there they're the I kind of separate them into three or four different types of monitoring so you've got a halter monitor which is actually recording your entire Rhythm for 24 or 48 Hours however long you order it for and then there's a clinician who is then looking at that entire thing and saying did they find any rhythm issues um then you've got got uh the different types of loop recorders an external loop recorder that's kind of sticks on your skin and can stay there for uh up to a month maybe two months a lot of people don't tolerate it hanging out there or just they get sweaty and it comes off or uh or they have body hair and it it won't stay on and so but theoretically you could have those for a month or so and then you've got implantable Loop monitors which used to be more invasive than they are now these days it's a little device that can get implanted like right under the skin and and can also be easily taken out and those can stay in for months to years uh and those are not continuously recording a rhythm but uh but they can they're like recording and erasing uh and they can identify abnormal rhythms so who who should get these monitors usually it is not the person who's coming in with a first episode of Syncopy and less I have some something to suggest that there's a high risk of an arhythmia meaning they complain you know they they have palpitations is their main symptom and then they had palpitations and they passed out but the challenge with any of these Rhythm monitoring things is like well uh if you come in with the first episode of Syncopy you didn't clearly have uh something that was was suggesting a rhythm problem or that you had palpitations and then so when when's the next one going to happen maybe never you actually the vast majority of people it'll be never and so usually when I'm considering ordering these things is either they have palpitations as a predominant symptom and maybe they've had them even though they haven't always passed out with them or they've come in multiple times now so now if they've come in two or three times and I know well they came in a month ago and then they came in now well okay I know I can guesstimate that the next one may happen around that same time frame so I can say oh I could I could consider a loop monitor because can put that on for a month or so meaning an external loop monitor versus like oh someone who says oh yeah I've passed out uh four times in my life and and they don't give you really clear that these are vas of vagel um and the four times in their life was once 12 years ago once uh 8 years ago once a year and a half ago and then once now so now these episodes are occurring relatively infrequently and I know a halter won't catch it I'm pretty sure a external loot monitor won't catch it and so that's a opportunity to say I can put it I can request an internal loop monitor so that's how I'm thinking about those different types of monitoring systems and whether or not I'm going to use it but I'm generally not for the vast majority of patients recommending that they get it on a first episode of Syncopy um because it's uh if if I did that with everyone it's those are reasonably uh expensive and and the yield is going to be relatively low we have covered an impressed amount of stuff would you agree Meredith yes um so uh maybe a couple take-home points a two or three take home points for my main take-home points is always do a a good history that is looking for uh those pral symptoms that we talked about doing a really good physical exam always doing orthostatics uh always doing a good and complete cardiac exam uh that realize we we all don't always do don't always check the jvp don't always check the apical impulse on every patient but in my patients with Syncopy I'm going to be intentional about doing those uh those things and then doing a really good neurologic exam as part of that physical exam again uh something that Feels Like H well do I really need the patient seems kind of normal in front of me do I but I don't want to miss things can say that there's been once or twice where a cerebella schic episode was not can be missed because I didn't do my I didn't do a good cerebella exam as part of my neurologic physical exams so good history good physical exam and then the other key take-homes if there's no clear Lo low risk uh or clear high-risk ideology on initial evaluation then uh I would do a simplified well score plus a d dier if either of those are positive I do image my patients for uh to rule them out for PE and then only do neurologic testing for patients with history or physical exam findings that suggest a neurologic ideology either seizure or stroke and then Echo for suspected structural heart disease and we talked about that sweet do you have anything to plug for yourself probably my nose with all of my allergies but I guess I would say if you're looking for a guideline on Syncopy the ACC guidelines are a little bit challenging to read and follow uh the European uh Cardiology Society has a very easy to follow and very easy to read and and everything they write makes a lot of sense and so tend to go to that they are very long guidelines and so but if you're looking for something oh what what do I do about tilt table testing and then I can go there and they explain it very uh simply great this has been another episode of the curbsiders bringing you a little knowledge food for your brain hole yummy get your show notes at the curbsiders dcom and sign up for our mailing list to get our weekly show notes in your inbox plus twice each month you'll get our curbsiders Digest recapping the latest practice changing articles guidelines and news and internal medicine and we're committed to high value practice changing knowledge and to do that we need your feedback so please subscribe rate and review the show on Apple podcast or Spotify or email us at ask curbsiders gmail.com a very special thanks to our writer and producer of this episode Dr Emmy OKO motto and to our whole team the curbsiders is produced and edited by the team at podcast Elizabeth Proto runs our social media and Stuart Brin composed our theme music until next time I've been monia mean and as always I'm Meredith troit thank you and good night [Applause]