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This article is a CME/CE certified activity. To earn credit for this activity visit:
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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.
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)
Family Physicians - maximum of 0.25 AAFP Prescribed credit(s)
Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)
All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of
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Note: Total credit is subject to change based on topic selection and article length.
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Author(s)
Megan Brooks
Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of
Nursing and Allied Health, George Washington University, Washington, DC
Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.
CME Author(s)
Charles P. Vega, MD, FAAFP
Associate Professor and Residency Director, Department of Family Medicine, University of California-Irvine, Irvine
Disclosure: Charles P. Vega, MD, FAAFP, has disclosed no relevant financial relationships.
CME Reviewer(s)
Yullee C. Chui
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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.
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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
This article is a CME/CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/810720
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.
This article is a CME/CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/810720
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