How to evaluate falls from a cardiology standpoint?

Cardiology Evaluation of Falls in Older Adults

A comprehensive cardiology evaluation is essential for older adults with falls, as up to 30% of falls may be due to syncope and cardiovascular disorders are significant risk factors for falls. 1

Initial Assessment

• Obtain detailed history of fall circumstances, including whether loss of consciousness occurred, as amnesia is common with syncope and may be reported simply as a fall 1
• Assess for cardiac symptoms that preceded the fall (palpitations, chest pain, shortness of breath) 1
• Review medication list with special attention to vasodilators, diuretics, antipsychotics, and sedative/hypnotics that may contribute to falls 1
• Perform orthostatic vital sign measurements (blood pressure and heart rate while supine and after standing) 1

Cardiovascular Examination

• Complete cardiovascular examination focusing on heart rate and rhythm, murmurs, and signs of heart failure 1
• Perform carotid sinus massage in appropriate patients (without carotid bruits or history of stroke/TIA) to evaluate for carotid sinus hypersensitivity 1
• Consider tilt table testing for patients with suspected vasovagal syncope, especially when history suggests reflex-mediated syncope 1

Diagnostic Testing

• Obtain 12-lead ECG to identify arrhythmias, conduction abnormalities, or structural heart disease 1
• Consider troponin measurement with a threshold of >50 ng/L as clinically significant for further cardiac evaluation 2
• Perform echocardiography, as several valvular abnormalities are associated with increased fall risk:
  • Mitral regurgitation (HR 1.66,95% CI 1.01-2.89) 3
  • Tricuspid regurgitation (HR 2.41,95% CI 1.32-4.37) 3
  • Pulmonary regurgitation (HR 1.76,95% CI 1.03-3.01) 3
  • Pulmonary hypertension (HR 1.35,95% CI 1.08-1.71) 3

Specific Cardiovascular Conditions to Evaluate

• Orthostatic hypotension: Measure blood pressure supine and after 1-3 minutes of standing; a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic is diagnostic 1, 4
• Carotid sinus hypersensitivity: Consider in older adults with unexplained falls, as approximately 30% of older adults with non-accidental falls may have had syncope 1
• Arrhythmias: Consider ambulatory ECG monitoring (Holter or event recorder) for patients with suspected arrhythmic syncope 1
• Heart failure: Assess for signs and symptoms of heart failure, which shows consistent association with falls (4/5 studies showing positive association) 4
• Low blood pressure: Evaluate for hypotension, which shows consistent association with falls (4/5 studies showing positive association) 4

Management Considerations

• For patients with carotid sinus hypersensitivity and recurrent falls, cardiac pacing may reduce syncope recurrence (10% vs 40% at 12 months, p=0.008) 1
• For patients with falls related to cardioinhibitory carotid sinus syndrome, dual-chamber pacing may reduce fall events (216 vs 699 events at 12 months) 1
• Modify cardiovascular medications that may contribute to falls, especially those causing orthostatic hypotension 1
• Consider referral to a multidisciplinary team including geriatric and cardiac specialists for complex cases 1

Special Considerations

• Syncope in older adults often presents atypically as a fall without clear loss of consciousness 1
• Cognitive impairment is frequently present in older adults and can reduce the accuracy of symptom recall 1
• Multiple etiologies for falls often coexist in older adults, requiring comprehensive assessment 1
• Falls in older adults with cardiovascular disease are likely underestimated in clinical practice and occur in 40-60% of these patients 5

Follow-up Recommendations

• Consider cardiology referral for patients with abnormal cardiac findings or elevated troponin >50 ng/L 2
• Implement fall prevention strategies including gait training, medication review, and treatment of cardiovascular disorders 1
• Evaluate for driving restrictions in patients with syncope-related falls based on recurrence risk and type of cardiac condition 1