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La Terapia del Paziente con Sincope La Terapia della Sincope Cardiogena. Gianluca Botto, MD, FESC, FACC Division of Cardiology Sant’ Anna Hospital, Como, Italy. SD_GENOVA_2010. Causes of Syncope in Patients Referred to Syncope Clinics. Neurally- Mediated. Orthostatic. Cardiac

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la terapia del paziente con sincope la terapia della sincope cardiogena

La Terapia del Paziente con SincopeLa Terapia della Sincope Cardiogena

Gianluca Botto, MD,

FESC, FACC

Division of Cardiology

Sant’ Anna Hospital, Como, Italy

SD_GENOVA_2010

causes of syncope in patients referred to syncope clinics
Causes of Syncope in Patients Referred to Syncope Clinics

Neurally-

Mediated

Orthostatic

Cardiac

Arrhythmia

Structural

Cardio-

Pulmonary

Cerebro-vascular

  • 1
  • Vasovagal
  • Carotid Sinus
  • Situational
    • Cough
    • Post-

micturition

  • 2
  • Drug Induced
  • ANS Failure
    • Primary
    • Secondary
  • 3
  • Brady
    • Sick sinus
    • AV block
  • Tachy
    • VT
    • SVT
  • Long QT Syndrome

*

  • 4
  • Aortic Stenosis
  • HOCM
  • Pulmonary
  • Hypertension

5

  • Steal Syndrome
  • TIA
  • Epilepsy

56%

2%

20%

3%

<1%

Unknown Cause = 18%

Alboni P. JACC 2001; 37: 1921

cardiogenic syncope
Cardiogenic Syncope

Cardiac Diseases and ArrhythmiasMost serious due to high mortality rates

  • Structural HD
  • Obstruction to flow
  • Pump Failure
  • Cardiac Tamponade
  • Pulmonary Htx
  • Aortic Dissection
  • Arrhythmias
  • Brady
  • IPG/ICD malfunction
  • Tachy
  • Channellopaties
  • Drug-Induced arrhythmias
causes of syncope pts with or w out suspected hd
Causes of SyncopePts with or w/out suspected HD

Alboni P. J Am Coll Cardiol 2001; 37: 1921

slide5

1.0

No syncope

Vasovagal and other causes

Unknown cause

0.8

Neurologic cause

Cardiac cause

0.6

Probability of Survival

0.4

0.2

Patients with cardiac causes for syncope have a significantly increased mortality risk.

0.0

0

5

10

15

20

25

Follow-up (yr)

Prognosis of Syncope

Soteriades ES. NEJM. 2002; 347: 878-85.

syncope 1 year sudden death regarding cause
Syncope1-year Sudden Death Regarding Cause

Sudden Death Rate (%)

Kapoor W. Medicine 69:160; 1990

syncope risk factors for poor outcome
SyncopeRisk Factors for Poor Outcome
  • Mortality = in pts with Cardiac Syncope and in pts with matched structural heart disease w/out Syncope
  • Structural heart disease (not Cardiac Syncope) is the best predictor of death

Kapoor W. Am J Med 1996; 100: 646

syncope 1 year sudden death in chf
Syncope1-year Sudden Death in CHF

Advanced Cardiac Heart Failure, LVEF ≈ 20%

The risk of SD is high regardless of causes of syncope

Sudden Death Rate (%)

Middlekauff H J Am Coll Cardiol 1993; 21: 110

clinical and ecg features suggesting cardiac syncope
Clinical and ECG Features Suggesting Cardiac Syncope

Presence of severe structural HD

Syncope during exertion or while supine

Palpitations at time of syncope

Heart failure / LV Dysfunction

ECG / Monitor findings of:

Baseline Wide QRS Complex

Mobitz 1 second degree AVB

Sinus bradycardia <50 bpm

Documented Non Sustained or Sustained VT

Preexcitation, Long QT, ARVD or Brugada Pattern

Adapted from ESC Syncope Guidelines– Update 2006

sincope treatment goals
SincopeTreatment Goals
  • Prevention of symptoms recurrences
  • Improvement of quality of life
  • Prolongation of survival

Task force for the diagnosis and management of syncope of the European Society of Cardiology (version 2009) available at escardio.org

slide11

Symptomatic ArrhythmiasRole of ILR Recordings

83 year old woman with syncope due to bradycardia: Pacemaker implanted

28 year old man presents to ER multiple times after falls resulting in trauma. VT Ablated

slide12

Task force for the diagnosis and management of syncope of the European Society of Cardiology (version 2009) available at escardio.org

slide13

Task force for the diagnosis and management of syncope of the European Society of Cardiology (version 2009) available at escardio.org

class i indications for icd therapy
Class I Indications for ICD Therapy
  • Cardiac arrest due to VF or VT not due to a transient or reversible cause(Level of Evidence: A)
  • Spontaneous sustained VT in association with structural heart disease (Level of Evidence: B)
  • Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at EP study when drug therapy is ineffective, not tolerated, or not preferred (Level of Evidence: B)

AVID

CASH

CIDS

CIDS

AVID

Registry

AVID

Substudy

Gregoratos G. ACC/AHA/NASPE Circulation 2002; 106: 2145

avid vs cids patients inclusion criteria
Survivors of VF

S-VT with syncope(> +8% in AVID)

S-VT + LVEF <40% + Symptoms(near_syncope; CHF; Angina)

Documented VF

CA requiring defib.

S-VT with syncope

S-VT + LVEF <35% * symptoms(near syncope; angina)

Syncope + VT induced (14% in CIDS)

AVID vs CIDSPatients Inclusion Criteria

AVID

CIDS

survival by arrhythmia type data from avid reg
Survival by Arrhythmia TypeData From AVID Reg.

Unexplained syncope

Non-syncopal VT w/symptoms

VF

Transient correctable VT/VF

Asymptomatic VT

VT w/syncope

1.00

.90

Cumulative Survival

.80

.70

p=0.007

.65

0

1

2

3

Years

Anderson JL. Circulation 1999; 99:1692-1699 (modif.).

unexplained syncope and inducible vt role of icd therapy
Unexplained Syncope And Inducible VTRole of ICD Therapy

p=0.9

VT/VF

Freedom from Appropriate

ICD Therapy

More CHF in Syncope Group

Months

Andrews NP.JACC 1999; 33: 1964-1970

icd as secondary prevention i
ICD as Secondary Prevention (I)
  • Patients with- resuscitated cardiac arrest- syncopal S-VT + structural heart disease- symptomatic S-VT + LVEF < 35 - 40%
  • Should receive an ICD as initial therapy
comparison of guidelines for icd implantation syncope with inducible sustained vt vf
Comparison of Guidelines for ICD ImplantationSyncope with Inducible Sustained VT/ VF

* with Severe Hemodynamic Compromise

^ w/out Severe Hemodynamic Compromise

icd as secondary prevention ii
ICD as Secondary Prevention (II)
  • Patients with- syncope with uncertain origin + inducible VT
  • Decision must be individualized !!!
slide21

Pts.

EF%

Ther.

F-U

Cardiac

Arrest

CAD

Mortality % (2 ys)

AVID

1.016

32

ICD

Amio >

18

45%

82%

19

26

CASH

346

46

ICD

Amio/Met

Propaf.

57

100%

73%

12

20

29 (1 a)

CIDS

659

34

ICD

Amio

35

48%

83%

15

21

Secondary Prevention of SCD

Role of ICD Therapy

Ezekowitz JA et al. Ann Intern Med 2003; 138:445-452

slide22

Task force for the diagnosis and management of syncope of the European Society of Cardiology (version 2009) available at escardio.org

syncope secondary to structural cardiac or cardiovascular disease
Syncope Secondary to Structural Cardiac or Cardiovascular Disease
  • The goal of treatment is ALSO- to treat the underlying disease - to reduce the risk of SCD
  • The mere presence of HD does not imply that syncope is related to the underlying cardiac disorder- pts with typical reflex syncope - the underlying disease may play a role in triggering reflex mechanism
unexplained syncope in pts with high risk of sca
Unexplained Syncope in Pts With High-Risk of SCA

Sudden Cardiac Death

SCD-HeFT

Heart Failure Trial

  • ICD prevents death in HF pts
  • Sincope predict death
  • ICD didn’t protect against syncope

Olshansky B. J Am Coll Cardiol 2008; 51: 1277-1281

slide25
Major Risk Factors for SD in HCMP
  • Cardiac arrest
  • Spontaneous s-VT
  • Family histoy of premature SD
  • Unexplained syncope
  • LV thickness ≥ 30 mm
  • Abnormal exercise blood pressure
  • Spontaneous ns-VT

Maron BJ. J Am Coll Cardiol 2003; 42: 1687-1713

hypertrophic cardiomyopathy syncope and risk of sudden death

Unexplained sincope <6 m

before initial evaluation

W/out unexplained sincope

Unexplained sincope >6 m

Hypertrophic CardiomyopathySyncope and Risk of Sudden Death
  • 1511 Pts with HCMP
  • F-U 5.6 years
  • Syncope in 205 (14%)
  • Unexplained in 153 – SD RR 1.78
  • Neurally mediated in 52 – RR SD 0.91

Spirito P. Circulation 2009; 119: 1703-1710

slide27
Hypertrophic CardiomyopathyImplantable Defibrillators for Prevention of SDTherapeutic ICD Interventions Regarding Presentation

No Sync. or CA

Cardiac Arrest

Sync.or CA

Syncope

Begley DA. PACE 2003; 26: 1887-1896

slide28

Brugada Syndrome

Risk Stratification

No Syncope no ECG

ECG

Syncope

ECG + Syncope

Priori SG et al.

Circulation 105: 1342; 2002

brugada syndrome appropriate icd shock
Brugada SyndromeAppropriate ICD Shock

Antzelevich C. Circulation 2005; 111: 659-670

Sacher F Circulation 2006; 114: 2317-24

arrhythmogenic right ventricular cardiomyopathy dysplasia
Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia

Corrado D. Circulation 2003; 108: 3084-3091

arvd clinical characteristics associated with appropriate icd intervention triggered by vf
ARVDClinical Characteristics Associated with Appropriate ICD Intervention Triggered by VF

Corrado D. Circulation 2003; 108: 3084-3091

treatment of cardiogenic syncope very difficult conclusions
Treatment of Cardiogenic SyncopeVery DifficultConclusions
  • Structural heart disease (not Cardiac Syncope) is the best predictor of death
  • Syncope in this context is often multifactorial, and could be influenced by V rate, LV function, and vascular compensation
  • Different treatment goals (reducing symptoms VS preventing SCA)
  • A disease-specific treatment is warrented
  • ICD Rx is probably the best choice for most patients
  • Some pts have a rationale for more precise diagnosis (ILR) of the diagnosis of syncope before embarking on ICD Rx
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