We reviewed an NEJM clinical case of a 63 year old man evaluated for syncope. We used Dr. Harmon’s framework (see below) and practiced using clinical prediction tools (JAMA Rational Clinical Exam: Did this patient have cardiac syncope) and EGSYS (Clinical Predictors of Cardiac Syncope in Initial Evaluation of patients referred urgently to a general hospital) to help generate a differential and create a targeted approach to work-up.
Dr. Bryn McGhee referenced The Cost Effective Evaluation of Syncope, summarized below.
Cost-effective Work-up for Syncope/Take-Home Points:
1) A meticulous history and physical examination
Routine blood tests, neuro-imaging with computed tomography scans, MRIs, carotid Doppler, echocardiography, and inpatient telemetry monitoring rarely contribute to the diagnosis but add substantial cost.
There are multiple risk stratification tools that help identify high-risk patients and guide management. Applying these tools can reduce syncope-related costs substantially without increasing risks to patients.
Diagnosis (Spoiler Alert)
The patient was found to have 2 masses compressing the tricuspid annulus at the juncture of the atrium and the right ventrilce, which were determined to be saphenous vein aneurysms. The syncopal episode was ultimately felt to be due to decreased preload (either due to reflex sympathy or orthostatic hypotension) compounded by impaired filling on the right side of the heart by saphenous-vein-graft aneurysm.
A systematic review of saphenous-vein–graft aneurysm showed that it arises a mean of 13 years after CABG, usually occurs during the sixth decade of life, and is found predominantly in men.
External compression of the right atrium or right ventricle occurs in nearly 20% of cases.
Chest pain or shortness of breath develops in more than half the cases of saphenous-vein– graft aneurysm, but in nearly one third of cases, the aneurysm is discovered incidentally.
Myocardial infarction is the presenting symptom in approximately 8% of cases, and heart failure and syncope each occur in approximately 2%.
Angiography of the coronary artery and graft may be of limited use if there is an intra-luminal thrombus or the aneurysm is thrombosed, because the aneurysm can be missed or its size underestimated.
Cardiac CT is the preferred test, with cardiac magnetic resonance imaging (MRI) as an alternative, to confirm the diagnosis and determine the effect on adjacent heart structures.
Albassam et al. Did This Patient Have Cardiac Syncope? The Rational Clinical Examination Systematic Review. JAMA, June 25 2019, Volume 321, Number 24 pages: 2448-2457: https://jamanetwork.com/journals/jama/fullarticle/2736568
Steven Angus, MD, The Cost-Effective Evaluation of Syncope. Medical Clinics of North America. volume 100, Issue 5, September 2016, Pages 1019-1032: https://www-sciencedirect-com.liboff.ohsu.edu/science/article/pii/S0025712516372741?via%3Dihub
Weiner et al. Case 25-2018: A 63-Year-Old Man with Syncope. New England Journal of Medicine. August 16 2018. 379:670-680: https://www-nejm-org.liboff.ohsu.edu/doi/pdf/10.1056/NEJMcpc1800340?articleTools=true