It is important to understand the difference between cardiac and non-cardiac causes of syncope. The cause of syncope can be identified in about 50 percent of patients by history and physical alone. Both past medical history and the history of the event are vital.
Cardiogenic Syncope can be life threatening. It generally requires specialized evaluation (echocardiogram, exercise stress test) and treatment and often requires activity restriction.
Listen in as Brian Birnbaum, MD explains that Vasovagal/Orthostatic Syncope is usually not life threatening and can often be diagnosed with history and a physical exam.
Evaluation of Pediatric Syncope for the Primary Care Practitioner
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Learn more about Brian Birnbaum, MD
Brian Birnbaum, MD
Brian Birnbaum, MD, is a pediatric cardiologist at Children’s Mercy Kansas City and a Clinical Assistant Professor of Pediatrics at the University of Missouri – Kansas City. Dr. Birnbaum received his medical degree from the University of Colorado at Denver and Health Sciences Center, in Denver, Colorado. He completed residency in internal medicine/pediatrics at Nationwide Children’s Hospital. He completed a fellowship in pediatric cardiology at Washington University/St. Louis Children’s Hospital. Dr. Birnbaum is board certified in Internal Medicine, Pediatric Cardiology and Pediatrics.Learn more about Brian Birnbaum, MD
Transcription:
Evaluation of Pediatric Syncope for the Primary Care Practitioner
Dr. Michael Smith (Host): Our topic today is “Evaluation of Pediatric Syncope for the Primary Care Practitioner”. My guest is Dr. Brian Birnbaum. He is a pediatric cardiologist at Children’s Mercy Kansas City, and a clinical Assistant Professor of Pediatrics at the University of Missouri Kansas City. Dr. Birnbaum, welcome to the show.
Dr. Brian Birnbaum (Guest): Thank you for having me.
Dr. Mike: Thanks for coming on. Let’s go ahead, Dr. Birnbaum, and start with just a nice review of the different types of syncope, and how common is it?
Dr. Birnbaum: So, syncope is something that’s very common. Probably 10% -20% of kids at some point will have a syncopal episode, and there are many, many more who will have, what we call “pre-syncope” or the feeling of lightheadedness or dizziness but without actually losing consciousness. So, it’s very, very common. When I think about syncope, I try to really break it down into heart-related causes or cardiogenic syncope, and then non-heart related causes--things like orthostatic, hypertension or vasovagal syncope.
Dr. Mike: And, that’s the important distinction, right? So, when it comes to distinguishing between a cardiac cause and non-cardiac cause, what are some of the most important questions that the doctor needs to be asking the patient or the parents?
Dr. Birnbaum: Well, I think, what is really vital is--the most vital thing is--getting a history of exactly what happened during their syncopal event, what happened when they passed out, and going into as much detail as possible about that event or the events that they’ve been having. That includes discussing with the patient, are these events that happened when they’re exerting themselves, when they’re playing sports, when they’ve been standing for a long time? Are there other things that have caused them to pass out such as pain or fear? Or, are they having any sort of prodrome or any other symptoms with their syncope. In particular, I always ask about palpitations or feelings of skip beats in their chest just to make sure there’s not any sort of arrhythmia process going on.
Dr. Mike: Yes. Of course, the scary part for the parents and the family is, if you have a young athlete, and they pass out, everybody worries about the sudden cardiac deaths--we see those in the news. How common is that actually for a young athlete to have a major cardiovascular event like that?
Dr. Birnbaum: Fortunately, it’s pretty uncommon that syncope is related to a heart condition. Certainly, when we hear about athletes who are having syncopal episodes, it does raise our attention as cardiologists that it may be cardiac in origin. However, there’s a lot of times when athletes put themselves in a disadvantage in terms of having syncopal episodes. So, many athletes are exercising or working hard throughout the day, don’t get a chance to really eat as much as they should or have an afternoon snack before their practices, and so they start their practices a little bit dehydrated, and then that puts them at risk for having syncopal episodes that are not necessarily related to their heart. With that being said, anytime I hear about an athlete who has a syncopal event on the field, whether it’s practice or a game, we certainly want to take that event seriously.
Dr. Mike: Yes. So, from the primary care physician point of view, if a cardiac cause of a syncopal episode is suspected, do we automatically just refer that to the cardiologist or are there things we can do first in the office, in the short-term to make sure that this patient is safe and stable, and then get them to you?
Dr. Birnbaum: I think, the most important thing you can do in addition to getting their history in the office, of course, is making sure that the patient themselves is stable, making sure they’re not having arrhythmia type of concerns in the office setting there. Many primary care providers have got an EKG machine, and they can perform an EKG, and at least evaluate a little bit for possible structural heart disease or potential arrhythmogenic heart disease--so things like Wolff-Parkinson-White for example. It at least gives you little bit of an idea what you might be dealing with. Unfortunately, a lot of times, we need to have additional testing to be performed before we can really safely rule out a cardiac cause, and that would include things such as echocardiograms or exercise stress tests. Obviously, many primary care providers aren’t able to do that in their office.
Dr. Mike: So, walk us through when a suspected cardiac cause of syncope is in your office from the specialist point of view, tell us a little bit of what you do, what your workup is just for a better understanding of how that patient is being cared for.
Dr. Birnbaum: So, probably the most important thing that I do is get a very thorough history and really talk with the patient, talk with the family about the event that happened or the events that are happening, and then also specifically the family history. Many of the worrisome causes of cardiac syncope are inherited in autosomal dominant fashion. Some of them are autosomal recessive but many are autosomal dominant. And so, it’s not uncommon that people get a history of many family members having pacemakers placed or defibrillators placed or having sudden death that maybe wasn’t exactly know why they had died. And so, going through their very thorough history is probably one of the most important things I do with the family and with the patient. After that, obviously, I get an EKG being a cardiologist, and usually if there is enough of a clinical concern after talking to the family about the history of the event, I’ll perform an echocardiogram as well. The EKG and the echocardiogram are useful for really screening for the three most common causes of cardiogenic syncope that can be life threatening in athletes, and that would be arrhythmia syndromes as well as hypertrophic cardiomyopathy, and then coronary abnormalities. Especially with the family history and the patient history along with the EKG and echocardiogram, usually we’re able to get a pretty good idea of how at risk an athlete would be.
Dr. Mike: So, again, focusing on the young athlete, when you’re doing your workup especially if you’re suspecting some of the more lethal causes of a cardiogenic syncope, what about physical restrictive activity? How do you deal with that? Does a young athlete absolutely have to stop what they enjoy doing--the sport, or is it just really based on each individual case.
Dr. Birnbaum: So, it’s really based on each individual case. There are, unfortunately, a lot of athletes that fall into a grey area in terms of whether they may have a significant cardiac disease or whether they have what’s called “athlete’s heart” which is a normal physiologic adaptation of their heart to strenuous activity. And it’s, obviously, very difficult to restrict athletes who are very competitive and have been excelling in their sports but, at times, we have to do that, and particularly if, for example, there’s enough do a family history or if the patient’s episodes are concerning enough, and this is truly a cardiogenic cause of their syncope, then we typically will restrict them. What I generally like to do is perform an exercise test as well. I’ll get an idea if there’s any sort of symptoms with their exercise test, and they may not have syncope with the exercise test, but they may have other symptoms such as chest pain or lightheadedness or dizziness or we may see arrhythmias on their exercise test that would clue us into this being a more severe or more likely to be a cardiogenic cause of their syncope.
Dr. Mike: So, when you refer to the athlete heart, that physiological response to exercise, usually its just an enlargement, correct? So, that’s not in and of itself necessarily really a disease or a pathology, correct?
Dr. Birnbaum: No, it is definitely not a disease or a pathology. It’s a very normal healthy adaptation for adolescents in particular who are healthy and competitive athletes. But, unfortunately, the studies that we’ve performed to screen for these lethal cardiac conditions, some of their results overlap with what an athlete’s heart looks like. So, an athlete’s heart will typically have some enlargement of the heart but there’s some thickening of the heart muscles as well just because the heart’s being asked to work more in the competitive athlete than in somebody that’s sedentary. We see that type of change also in somebody who has hypertrophic cardiomyopathy where the heart muscle gets really thick on its own. And, so it becomes a type of grey area.
Dr. Mike: Right. So, interestingly, most of our conversation so far with syncope has been focusing on the athlete. However, is that the most common type of patient that presents with syncope or are there other patients that we need to be aware of, not necessarily the athlete.
Dr. Birnbaum: Well, there are certainly many other patients to be aware of. Most children do have some form of structured physical activity during their day, and so, although not every child is necessary a competitive athlete, most children will have physical activity at times whether it be a gym class or recreational sports, and knowing whether or not they’re having symptoms during that, whether they have syncope or pre-syncope during those physical activities could be quite useful in trying to delineate whether this is a severe cardiac problem or whether this is a non-cardiac cause of their syncope.
Dr. Mike: Right. Well, Dr. Birnbaum, I want to thank you for all the work that you’re doing at Children’s Mercy, and also thank you for coming on this show today. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to www.childrensmercy.org. That’s www.childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.
Evaluation of Pediatric Syncope for the Primary Care Practitioner
Dr. Michael Smith (Host): Our topic today is “Evaluation of Pediatric Syncope for the Primary Care Practitioner”. My guest is Dr. Brian Birnbaum. He is a pediatric cardiologist at Children’s Mercy Kansas City, and a clinical Assistant Professor of Pediatrics at the University of Missouri Kansas City. Dr. Birnbaum, welcome to the show.
Dr. Brian Birnbaum (Guest): Thank you for having me.
Dr. Mike: Thanks for coming on. Let’s go ahead, Dr. Birnbaum, and start with just a nice review of the different types of syncope, and how common is it?
Dr. Birnbaum: So, syncope is something that’s very common. Probably 10% -20% of kids at some point will have a syncopal episode, and there are many, many more who will have, what we call “pre-syncope” or the feeling of lightheadedness or dizziness but without actually losing consciousness. So, it’s very, very common. When I think about syncope, I try to really break it down into heart-related causes or cardiogenic syncope, and then non-heart related causes--things like orthostatic, hypertension or vasovagal syncope.
Dr. Mike: And, that’s the important distinction, right? So, when it comes to distinguishing between a cardiac cause and non-cardiac cause, what are some of the most important questions that the doctor needs to be asking the patient or the parents?
Dr. Birnbaum: Well, I think, what is really vital is--the most vital thing is--getting a history of exactly what happened during their syncopal event, what happened when they passed out, and going into as much detail as possible about that event or the events that they’ve been having. That includes discussing with the patient, are these events that happened when they’re exerting themselves, when they’re playing sports, when they’ve been standing for a long time? Are there other things that have caused them to pass out such as pain or fear? Or, are they having any sort of prodrome or any other symptoms with their syncope. In particular, I always ask about palpitations or feelings of skip beats in their chest just to make sure there’s not any sort of arrhythmia process going on.
Dr. Mike: Yes. Of course, the scary part for the parents and the family is, if you have a young athlete, and they pass out, everybody worries about the sudden cardiac deaths--we see those in the news. How common is that actually for a young athlete to have a major cardiovascular event like that?
Dr. Birnbaum: Fortunately, it’s pretty uncommon that syncope is related to a heart condition. Certainly, when we hear about athletes who are having syncopal episodes, it does raise our attention as cardiologists that it may be cardiac in origin. However, there’s a lot of times when athletes put themselves in a disadvantage in terms of having syncopal episodes. So, many athletes are exercising or working hard throughout the day, don’t get a chance to really eat as much as they should or have an afternoon snack before their practices, and so they start their practices a little bit dehydrated, and then that puts them at risk for having syncopal episodes that are not necessarily related to their heart. With that being said, anytime I hear about an athlete who has a syncopal event on the field, whether it’s practice or a game, we certainly want to take that event seriously.
Dr. Mike: Yes. So, from the primary care physician point of view, if a cardiac cause of a syncopal episode is suspected, do we automatically just refer that to the cardiologist or are there things we can do first in the office, in the short-term to make sure that this patient is safe and stable, and then get them to you?
Dr. Birnbaum: I think, the most important thing you can do in addition to getting their history in the office, of course, is making sure that the patient themselves is stable, making sure they’re not having arrhythmia type of concerns in the office setting there. Many primary care providers have got an EKG machine, and they can perform an EKG, and at least evaluate a little bit for possible structural heart disease or potential arrhythmogenic heart disease--so things like Wolff-Parkinson-White for example. It at least gives you little bit of an idea what you might be dealing with. Unfortunately, a lot of times, we need to have additional testing to be performed before we can really safely rule out a cardiac cause, and that would include things such as echocardiograms or exercise stress tests. Obviously, many primary care providers aren’t able to do that in their office.
Dr. Mike: So, walk us through when a suspected cardiac cause of syncope is in your office from the specialist point of view, tell us a little bit of what you do, what your workup is just for a better understanding of how that patient is being cared for.
Dr. Birnbaum: So, probably the most important thing that I do is get a very thorough history and really talk with the patient, talk with the family about the event that happened or the events that are happening, and then also specifically the family history. Many of the worrisome causes of cardiac syncope are inherited in autosomal dominant fashion. Some of them are autosomal recessive but many are autosomal dominant. And so, it’s not uncommon that people get a history of many family members having pacemakers placed or defibrillators placed or having sudden death that maybe wasn’t exactly know why they had died. And so, going through their very thorough history is probably one of the most important things I do with the family and with the patient. After that, obviously, I get an EKG being a cardiologist, and usually if there is enough of a clinical concern after talking to the family about the history of the event, I’ll perform an echocardiogram as well. The EKG and the echocardiogram are useful for really screening for the three most common causes of cardiogenic syncope that can be life threatening in athletes, and that would be arrhythmia syndromes as well as hypertrophic cardiomyopathy, and then coronary abnormalities. Especially with the family history and the patient history along with the EKG and echocardiogram, usually we’re able to get a pretty good idea of how at risk an athlete would be.
Dr. Mike: So, again, focusing on the young athlete, when you’re doing your workup especially if you’re suspecting some of the more lethal causes of a cardiogenic syncope, what about physical restrictive activity? How do you deal with that? Does a young athlete absolutely have to stop what they enjoy doing--the sport, or is it just really based on each individual case.
Dr. Birnbaum: So, it’s really based on each individual case. There are, unfortunately, a lot of athletes that fall into a grey area in terms of whether they may have a significant cardiac disease or whether they have what’s called “athlete’s heart” which is a normal physiologic adaptation of their heart to strenuous activity. And it’s, obviously, very difficult to restrict athletes who are very competitive and have been excelling in their sports but, at times, we have to do that, and particularly if, for example, there’s enough do a family history or if the patient’s episodes are concerning enough, and this is truly a cardiogenic cause of their syncope, then we typically will restrict them. What I generally like to do is perform an exercise test as well. I’ll get an idea if there’s any sort of symptoms with their exercise test, and they may not have syncope with the exercise test, but they may have other symptoms such as chest pain or lightheadedness or dizziness or we may see arrhythmias on their exercise test that would clue us into this being a more severe or more likely to be a cardiogenic cause of their syncope.
Dr. Mike: So, when you refer to the athlete heart, that physiological response to exercise, usually its just an enlargement, correct? So, that’s not in and of itself necessarily really a disease or a pathology, correct?
Dr. Birnbaum: No, it is definitely not a disease or a pathology. It’s a very normal healthy adaptation for adolescents in particular who are healthy and competitive athletes. But, unfortunately, the studies that we’ve performed to screen for these lethal cardiac conditions, some of their results overlap with what an athlete’s heart looks like. So, an athlete’s heart will typically have some enlargement of the heart but there’s some thickening of the heart muscles as well just because the heart’s being asked to work more in the competitive athlete than in somebody that’s sedentary. We see that type of change also in somebody who has hypertrophic cardiomyopathy where the heart muscle gets really thick on its own. And, so it becomes a type of grey area.
Dr. Mike: Right. So, interestingly, most of our conversation so far with syncope has been focusing on the athlete. However, is that the most common type of patient that presents with syncope or are there other patients that we need to be aware of, not necessarily the athlete.
Dr. Birnbaum: Well, there are certainly many other patients to be aware of. Most children do have some form of structured physical activity during their day, and so, although not every child is necessary a competitive athlete, most children will have physical activity at times whether it be a gym class or recreational sports, and knowing whether or not they’re having symptoms during that, whether they have syncope or pre-syncope during those physical activities could be quite useful in trying to delineate whether this is a severe cardiac problem or whether this is a non-cardiac cause of their syncope.
Dr. Mike: Right. Well, Dr. Birnbaum, I want to thank you for all the work that you’re doing at Children’s Mercy, and also thank you for coming on this show today. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to www.childrensmercy.org. That’s www.childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.