PracticeUpdate Cardiology June 2019

EXPERT OPINION 17

" … if the story’s good, the work-up has to be good. If the story’s good for vasovagal, which is going to be by far the common causes, you know, don’t spend a million bucks finding that the person is afraid of needles. "

room 2 weeks later with syncope. So why 2 weeks later? Because she probably hit her heart and got a little blood in the pericar- dium. But a little blood doesn’t cause much in terms of tamponade, but when those red blood cells break down, they pull in fluid. So, that the characteristic story is some- body that’s a football player that got hit and then 2–3 weeks later, they come in with a syncopal episode, I would consider those zebras. Now, two other zebras that we need to think about. One is the anomalous coro- nary artery. So, this is characteristically a young person, almost always before the age of 20, but not always, and for some reason in that sort of age group between 10 and like 20, 10 and 25, they’ll present with symptoms of anomalous coronary artery, which can be syncope, can be the cause, but we don’t know exactly why it presents at that time. I’ve often speculated it’s because the heart grows at that time, so the anomalous coronary artery cannot supply the myocardium. But if somebody has a really worrisome symptom and is in the teen years, thinking about anomalous coronary arteries is also possible. And then really rare, really in the hens tooth is some- one who has a myocardial bridge, in other words, part of the coronary artery is bridged by the myocardium. Now, both the anom- alous coronary artery and the bridging is often an issue during exercise, something I’m interested in, but those would be sort of the rarities that we’d think about. Now, there’s the obvious and that’s why we got an echo early on, there’s aortic stenosis you know, post-exercise aortic stenosis syn- cope, there’s hypertrophic cardiomyopathy, there are other things, the electrocardio- gram, looking for things like Brugada that we mentioned, but those would be the rare ones that I would think of. What’s my key point? My key point is that if the story’s good, the work-up has to be good. If the story’s good for vasovagal, which is going to be by far the common causes, you know, don’t spend a million bucks finding that the per- son is afraid of needles. Go to www.practiceupdate.com/c/81057 to watch this interview with Dr. Thompson.

prevent syncope. So, I always say the taller you are, the more often you fall, which is potentially true. So, all those little things go into the decision process. Dr. Shah: Now, let’s talk about what you called the zebras, you know, the specific one-off cases, could be underlying heart disease or a previous heart procedure or maybe specific kinds of athletes. Is there anything in these zebras that you feel the community cardiolo- gists should be aware of? Dr. Thompson: First of all, there’s a big dif- ference from somebody who has prior heart disease and somebody who has not had prior heart disease. I used to work in an emergency room and there was this very funny guy that worked there as well and when anybody would come in, he’d say, did you ever have anything like this before. And the person would say, yes, and he said, well, you got it again. Because if you’ve got heart disease, it’s more likely that your syncopal episode is related to that heart disease. So, before we go look- ing for zebras, remember, I call it the law of parsimony, you want to make as few diag- noses as possible. So, if the person has heart disease, worry that it’s a residual scar or something like that, that could cause the syncope. Now, one other thing we didn’t talk about, but I should put in, and that is that there’s a lot of…there’s a very big role for moni- toring the patients, electrocardiographic monitoring of the patients if it’s a worrisome sort of story, not consistent with vasova- gal. And so people always ask, should I put in a loop recorder, should I do a regular loop recorder, should I do an implantable device, can I do a 24-hour holter? What you do depends on how frequent the epi- sodes are. If they’re frequent, well then you can do it with a 24-hour holter with some luck, or a 30-day monitor, or you may have to implant a loop recorder if they’re rare. Now, let’s talk about zebras. One of the zebras, but it’s not really a zebra is pulmo- nary embolus, always need to think about that possibility. The other thing that we for- get about, we forget about tamponade. So, here’s a classic story, a woman I saw who fell down the stairs, hit her chest on the banister, and she came into the emergency

that lead them down a different way. And we do that even without knowing it, you know, if you say something to me and I say, really? Well, you’re more likely to bring that up the next doctor you see, right? So, I think we can change people’s stories. Dr. Shah: And so, if you now suspect a patient has cardiac syncope, you’re working up the heart, like you said, an EKG or an echo, but then you said there could be other things as well. So, what would a typical work-up look like? Where would you start with and what are the kinds of things you would be looking for? Dr. Thompson: That’s a good question. So, the history, as I mentioned, and then an electrocardiogram, obviously looking at that carefully. An echocardiogram, you know, if it’s a great story of syncope in a sort of a youngish sort of person, I may look for an anomalous coronary artery with car- diac MR angiogram, such as that. I do not rely on the echo in that instance. So, the history dictates where you go with the work-up and how aggressive you are with that work-up. You know, most syncope, … I can’t remember the percentage of peo- ple, but its 20% to 25% of people by the time they reach age 18, they’ve had a syn- copal episode. And you know that rule, the bigger they are the harder they fall? Well, it’s true with syncope, for example, in tall people, because there’s a long distance from the heart to the top of your head and that’s what you got to perfuse your head to

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