Characteristics of Cardiac Vs Vasovagal Syncope in Kids (Printer-Friendly)

Characteristics of Cardiac vs Vasovagal Syncope in Kids (printer-friendly)
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CME/CE Information
CME/CE Released: 10/02/2013; Valid for credit through 10/02/2014
Target Audience
This article is intended for primary care clinicians, cardiologists, and other specialists who treat children with syncope.
Goal
The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to
enhance patient care.
Learning Objectives
Upon completion of this activity, participants will be able to:
1. Evaluate the epidemiology of syncope among children.
2. Distinguish variables that separate vasovagal from cardiac syncope among children and adolescents.
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Author(s)
Megan Brooks
Megan Brooks is a freelance writer for Reuters Health.

Disclosure: Megan Brooks has disclosed no relevant financial relationships.
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Laurie E. Scudder, DNP, NP
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CME Author(s)
Charles P. Vega, MD, FAAFP
Associate Professor and Residency Director, Department of Family Medicine, University of California-Irvine, Irvine
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Program Manager, Medscape, LLC

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From Reuters Health Information CME
Characteristics of Cardiac vs Vasovagal Syncope in Kids CME/CE

News Author: Megan Brooks
CME Author: Charles P. Vega, MD, FAAFP
CME/CE Released: 10/02/2013; Valid for credit through 10/02/2014
Clinical Context
Syncope is a common event among children and adolescents. The authors of the current study note that 15% of children
experience at least 1 episode of syncope. Although these episodes are distressing, only 1.5% to 5% of all cases of syncope
are the result of underlying cardiac disease. Aberrant coronary artery anomalies are one of the most feared causes of
syncope, as children with these anomalies may present with normal physical examination and electrocardiographic (ECG)
findings. Coronary anomalies may account for 17% to 23% of cases of sudden cardiac death among children.
Increased scrutiny for cardiac abnormalities among young athletes has led to increased recognition of syncopal episodes,
and many of these patients are then referred to cardiology practices for further evaluation. Are there clinical characteristics that
might help differentiate vasovagal from cardiac syncope and thereby reduce the rate of cardiology referrals? The current
study by Tretter and Kavey evaluates this issue.
Study Synopsis and Perspective

A new screening rule can help distinguish cardiac syncope from vasovagal syncope in young people, its developers say.
In a review of children and adolescents diagnosed with cardiac syncope, they found that characteristics in the history, physical
exam, and ECG will accurately identify those with a cardiac etiology.
In their series, all patients with a cardiac etiology for syncope had at least one of the following: (1) history of syncope
associated with exertion; (2) a concerning cardiac family history; (3) an abnormal physical examination; or (4) an ECG
interpreted as abnormal by a pediatric cardiologist.
Syncope is a common problem in children and adolescents and is rarely cardiogenic in origin, creating a diagnostic challenge
for primary care physicians, say Dr. Justin Tretter and Dr. Rae-Ellen Kavey from Golisano Children's Hospital at the University
of Rochester Medical Center in Rochester, New York.
In The Journal of Pediatrics, online August 29, they point out that as many as 15% of children experience a syncopal event,
but only 1.5% to 5% of these are caused by underlying cardiac disease.
Increased attention from the media to sudden death in young athletes has led to more visits to physicians for syncope during
the past two decades. Yet, research on syncope has largely focused on adults, "with no uniform diagnostic approach to
pediatric syncope, leading to high costs with low diagnostic yield."
Drs. Tretter and Kavey compared the characteristics of 89 individuals with confirmed vasovagal syncope and 17 with
confirmed cardiac syncope, all age 18 or younger.
Characteristics seen more often with cardiac than vasovagal syncope included syncope surrounding activity (65% vs. 18%,
p<0.001); family history of cardiac disease or sudden cardiac death (41% vs. 25%, p=0.2); abnormal findings on the physical
examination supporting cardiac diagnosis (29% vs. 0%, p<0.001); and abnormal findings on ECG (76% vs. 0%, p<0.001).
"This analysis points to dramatic differences in presentation between those with cardiac etiology and those with benign
vasovagal syncope," write Drs. Tretter and Kavey.
They say screening for cardiac disease using any one of these four characteristics had a sensitivity of 100% and specificity of
60%. "Using this screening rule, we found that 60% of patients with vasovagal syncope would not have been referred to
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cardiology."
Dr. Samuel Asirvatham, a pediatric cardiologist at Mayo Clinic Children's Center in Rochester, Minnesota, commented that
"fainting is a very common problem both in children and adults. With adults, the issue is more that they have other cardiac
causes, like slow heart rate, previous heart attack and so on. With children, sometimes the mistake is made in that we think just
because it's a young person it's going to be vasovagal. What this study shows is, just like in adults, if the history doesn't fit with
vasovagal, just because they are children you shouldn't assume it's vasovagal."
On the other hand, "the more the history favors vasovagal syncope, the less you need a workup for cardiogenic syncope," Dr.
Asirvatham, who wasn't involved in the study, told Reuters Health.
Overall, he said, this study is "a good contribution to the literature, but it's a very small study for such a common problem. To
really test out an algorithm I would guess we would need something close to 10 times the number of patients."
Drs. Tretter and Kavey acknowledge this limitation and others in their paper, including the study's retrospective design, which
depended on the validity of documented patient details. "Historic details may not have been asked or recorded by the
physician," they point out.
The authors did not respond to request for comment.
J Pediatr. Published online August 29, 2013.
Study Highlights
Study data were drawn retrospectively from a single tertiary pediatric cardiology practice in the United States. Children
and adolescents up to 18 years old with vasovagal and cardiac syncope were compared for demographic and clinical
factors.
Children with vasovagal syncope were identified during a 1-year period. As cases of cardiac syncope are far less
common, these children were identified during a 10-year period by a record review of 14 diagnosis codes commonly
associated with syncope.
89 children between 4 and 18 years old with vasovagal syncope were compared vs 17 children between 4 months and
17 years old with cardiac syncope. The mean ages of children in the cardiac syncope and vasovagal cohorts were 10.5
and 12.7 years, respectively. The overall study cohort was fairly balanced between male and female patients.
The most common underlying diagnosis among children with cardiac syncope was long-QT syndrome (8/17 cases).
Rates of a previous syncopal event were 71% in the cardiac syncope group and 36% in the vasovagal syncope group.
Conversely, the respective rates of presyncopal symptoms were 12% and 69%.
There was no difference between groups in the rates of chest pain or palpitations before syncope or exercise
tolerance.
However, cardiac syncope occurred around exercise in 65% of children vs only 18% of children with vasovagal
syncope.
Rates of a positive family history of heart disease in the cardiac and vasovagal syncope groups were 41% and 25%,
respectively.
29% of children with cardiac syncope had abnormal physical examination findings vs none of the children with
vasovagal syncope.
76% of children with cardiac syncope had an abnormal ECG result vs none of the children with vasovagal syncope.
Researchers concluded that 4 variables were most helpful in discriminating cardiac vs vasovagal syncope: exertional
syncope (especially around peak exercise), a family history of cardiac problems, abnormal physical examination
findings, and abnormal ECG results. The average number of these characteristics present among children with cardiac
syncope and children with vasovagal syncope was 2.1 and 0.4, respectively.
With use of the presence of any of these 4 variables as a guide, all cardiac syncope patients would receive a specialist
evaluation. However, 60% of cardiology referrals for what turned out to be vasovagal syncope could have been
avoided.
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Clinical Implications
An estimated 15% of children experience at least 1 episode of syncope, and only 1.5% to 5% of all pediatric cases of
syncope are the result of underlying cardiac disease. Children with syncope from aberrant coronary artery anomalies
may present with normal physical examination and ECG findings. Coronary anomalies may account for 17% to 23% of
cases of sudden cardiac death among children.
In the current study by Tretter and Kavey, the 4 variables with the greatest power to discriminate between cardiac and
vasovagal syncope were exertional syncope (especially around peak exercise), a family history of cardiac problems,
abnormal physical examination results, and abnormal ECG findings.
CME Test
To receive AMA PRA Category 1 Credit, you must receive a minimum score of 75% on the post-test.
You are seeing a previously healthy 11-year-old boy with an episode of syncope 2 days ago. What should
you consider regarding the epidemiology of syncope among children?
Less than 1% of children experience syncope
Half of cases of syncope among children are from cardiac causes
Children with aberrant coronary artery anomalies can have completely normal cardiac examination
results
Coronary anomalies rarely result in sudden cardiac death
According to the findings of the current study by Tretter and Kavey, which of the following variables in this
patient's case would be most suggestive of cardiac vs vasovagal syncope?
A family history of cardiac problems
Chest pain before syncope
A history of poor exercise tolerance
Nonexertional syncope
Disclaimer
The educational activity presented above may involve simulated case-based scenarios. The patients depicted in these
scenarios are fictitious and no association with any actual patient is intended or should be inferred.
The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that support educational
programming on medscape.org. These materials may discuss therapeutic products that have not been approved by the US
Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be
consulted before using any therapeutic product discussed. Readers should verify all information and data before treating
patients or employing any therapies described in this educational activity.
Reuters Health Information CME 2013 Reuters, Ltd.
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