Syncope: common in the elderly and had multiple causes.

Clinical bottom line (level 3b)

  1. 15% of institutionalized elderly patients had a syncopal episode over three years, often due to multiple causes.
  2. Patients were at increased risk if they had any of:
    • aortic stenosis (NNH = 23 at unknown)
    • coronary artery disease (NNH = 30 at unknown)
    • insulin therapy (NNH = 30 at unknown)
    • postural hypotension (of 20 mmHg or more) (NNH = 42 at unknown)
    • functional impairment (NNH = 66 at unknown)
  3. Carotid sinus massage and Holter monitoring were not good at predicting which patients had syncope.
Lipsitz et al: Journal of Chronic Diseases 1986; 39 (8): 619-630
Expires July 2004

The study

Case-control study with objective outcomes, adjusted for confounding factors, validated in an independent set of patients.

Setting: long-term care facility, USA

828 patients (aged mean 87 years, 77% female) elderly patients

Excluded if
  • known seizures
  • moribund, semi-comatosed or bed-bound
  • unwitnessed syncopal episode


    • Cases: 711 patients (% female, mean age ): elderly patients with syncope
    Controls: 118 patients (% female, mean age ): controls matched for date of entry. Many control patients had similar investigations to syncopal patients

    Factors studied:
  • demographics, functional status, medications (including insulin use, hypnotics and cardiac drugs), medical conditions


    • Factors summarised:
  • coronary artery disease
  • functional impairment (three classes, no validated scale used)
  • postural hypotension 20 mmHg or more
  • aortic stenosis
  • insulin therapy
  • >50% slowing of respiratory rate
  • 2-4 sec pause
  • >4 sec pause
  • >20 mg fall in blood pressure
  • dizzy
  • paroxysmal atrial fibrillation
  • frequent, multiform, paired premature ventricular contractions
  • ventricular tachycardia
  • Mobitz II
  • >2 second pause
  • heart rate <40


    • Multivariate regression analysis was performed on risk factors.

    Outcomes studied:
  • syncope
  • carotid sinus massage
  • Holter monitoring

    • Patients were followed for three years or until dead.
    • All patients who had syncope had blood count, U&E, creatinine, glucose, calcium, CK and appropriate drug levels. Also had cardiac enzyme series. Also had immediate ECG and 24 hour Holter monitoring. If seizure or anatomical cardiac deficit or focal neurological deficit had EEG, echocardiogram, CT head.

    The evidence

    Patient expected event rate for syncope: 13.6%
    risk factor for
    syncope     		adjusted OR
    (95% CI)    		 NNH
    (95% CI)
    coronary artery disease 1.29
    (1.13 to 1.49)     		30
    (18 to 66)
    functional impairment 1.13
    (1.04 to 1.22)     		66
    (40 to 213)
    postural hypotension 20 mmHg or more 1.21
    (1.07 to 1.37)     		42
    (24 to 122)
    aortic stenosis 1.38
    (1.09 to 1.74)     		23
    (13 to 95)
    insulin therapy 1.29
    (1.03 to 1.62)     		30
    (15 to 284)

    Patient expected event rate for carotid sinus massage: -%
    risk factor for
    carotid sinus massage     		adjusted RR
    (95% CI)
    >50% slowing of respiratory rate 0.8
    (0.46 to 1.3)
    2-4 sec pause 1.4
    (0.30 to 7.0)
    >4 sec pause 1.1
    (0.11 to 12.2)
    >20 mg fall in blood pressure 0.8
    (0.18 to 3.2)
    dizzy 1.1
    (0.11 to 12.2)

    Patient expected event rate for Holter monitoring: -%
    risk factor for
    Holter monitoring     		adjusted RR
    (95% CI)
    paroxysmal atrial fibrillation 1.1
    (0.63 to 1.7)
    frequent, multiform, paired premature ventricular contractions 0.8
    (0.43 to 1.5)
    ventricular tachycardia 0.5
    (0.03 to 8.5)
    Mobitz II inf
    (0.187 to inf)
    >2 second pause 1.4
    (0.27 to 6,7)
    heart rate <40 3.3
    (0.41 to 26.2)

    • Causes of syncope:
      • unknown: 26%
      • MI: 6%
      • aortic stenosis: 5%
      • volume depletion: 4%
      • seizure: 3%
      • arrhythmia: 7%
      • situational: drug: 11%
      • post-prandial: 8%
      • defecation: 7%
      • postural: 6%
    • 77% of patients with syncope had two or more risk factors, compared with 36% of control patients).

    Citation

    1. Lipsitz LA, Pluchino FC, Wei JY, et al: Syncope in institutionalised elderly: the impact of mulitpe pathological conditions and situational stress. Journal of Chronic Diseases 1986; 39 (8): 619-630
    Contributor: Chris Ball and Musab Hayatli, July 2000
    Reviewer: Malcolm Man-Son-Hing

    Clinical Question.
    Patient elderly patients with syncope
    Intervention or Exposure clinical and ECG factors
    Outcome recurrent syncope