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Syncope A Diagnostic and Treatment Strategy. David G. Benditt, M.D. University of Minnesota Medical School Minneapolis, MN USA. Richard Sutton, DScMed Royal Brompton Hospital London, UK. Transient Loss of Consciousness (TLOC). Syncope Neurally-mediated reflex syndromes

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syncope a diagnostic and treatment strategy

SyncopeA Diagnostic and Treatment Strategy

David G. Benditt, M.D.University of Minnesota Medical SchoolMinneapolis, MN USA

Richard Sutton, DScMed

Royal Brompton Hospital London, UK

classification of transient loss of consciousness tloc
Syncope

Neurally-mediated reflex syndromes

Orthostatic hypotension

Cardiac arrhythmias

Structural cardiovascular disease

Disorders Mimicking Syncope

With loss of consciousness, i.e., seizure disorders, concussion

Without loss of consciousness, i.e., psychogenic “pseudo-syncope”

Classification of Transient Loss of Consciousness (TLOC)

Real or Apparent TLOC

Brignole M, et al. Europace, 2004;6:467-537.

syncope a symptom not a diagnosis
Syncope – A Symptom, Not a Diagnosis
  • Self-limited loss of consciousness and postural tone
  • Relatively rapid onset
  • Variable warning symptoms
  • Spontaneous, complete, and usually prompt recovery without medical or surgical intervention

Underlying mechanism is transient global cerebral hypoperfusion.

Brignole M, et al. Europace, 2004;6:467-537.

presentation overview
Presentation Overview

I. Etiology, Prevalence, Impact

II. Diagnosis

III. Specific Conditions and Treatment

IV. Special Issues

causes of true syncope
Causes of True Syncope

Neurally-

Mediated

Orthostatic

Cardiac

Arrhythmia

Structural

Cardio-

Pulmonary

  • 3
  • Brady
    • SN Dysfunction
    • AV Block
  • • Tachy
    • VT
    • SVT
  • Long QT Syndrome
  • 1
  • VVS
  • CSS
  • • Situational
    • Cough
    • Post-

Micturition

  • 2
  • Drug-Induced
  • • ANS Failure
    • Primary
    • Secondary
  • 4
  • Acute Myocardial Ischemia
  • Aortic Stenosis
  • HCM
  • Pulmonary Hypertension
  • Aortic Dissection

Unexplained Causes = Approximately 1/3

DG Benditt, MD. U of M Cardiac Arrhythmia Center

syncope mimics
Syncope Mimics
  • Acute intoxication (e.g., alcohol)
  • Seizures
  • Sleep disorders
  • Somatization disorder (psychogenic pseudo-syncope)
  • Trauma/concussion
  • Hypoglycemia
  • Hyperventilation

Brignole M, et al. Europace, 2004;6:467-537.

impact of syncope
Impact of Syncope
  • 40% will experience syncope at least once in a lifetime1
  • 1-6% of hospital admissions2
  • 1% of emergency room visits per year3,4
  • 10% of falls by elderly are due to syncope5
  • Major morbidity reported in 6%1eg, fractures, motor vehicle accidents
  • Minor injury in 29%1eg, lacerations, bruises

1Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27.

2Kapoor W. Medicine. 1990;69:160-175.

3Brignole M, et al. Europace. 2003;5:293-298.

4 Blanc J-J, et al. Eur Heart J. 2002;23:815-820.

5Campbell A, et al. Age and Ageing. 1981;10:264-270.

impact of syncope us trends
Impact of Syncope: US Trends

Inpatient Trend*

Physician Office Visits**

(000s)

(000s)

*All patients discharged with syncope and collapse (ICD-9 Code:780.2) listed among diagnoses.

**Syncope and collapse (ICD-9 Code: 780.2) listed as primary reason for visit.

NHDS 2003.

NAMCS 2002.

impact of syncope us trends1
Impact of Syncope: US Trends

HospitalOutpatient Visits*

EmergencyDepartment Visits*

(000s)

(000s)

+

+ Not available

*Syncope and collapse (ICD-9 Code:780.2) listed as primary reason for visit.

NHAMCS 2002.

impact of syncope nhs hospitals england 2002 2003
Impact of Syncope: NHS Hospitals, England, 2002-2003*
  • 74,813 hospital consults for syncope and collapse
  • 80% required hospital admission
  • Average length of stay: 6.1 days
  • 327,201 hospital bed days, second only to senility

*Hospital Episode Statistics, Dept. of Health, Eng. 2002-2003.

impact of syncope costs
Impact of Syncope: Costs
  • Estimated hospital costs exceeded $10 billion US1
  • Estimated physician office expenses exceeded $470 million2
  • £104,285 spent on 1,334 patients with syncopal codes (UK) (EaSyAS)3
    • Hospital admission: 67% of investigational costs
  • Over $7 billion is spent annually in the US to treat falls in older adults4

1Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27.

2OutPatientView v. 6.0. Solucient LLC, Evanston IL.

3Farwell D, et al. J Cardiovasc Electrophysiol. 2002;13(Supp):S9-S13.

4Olshansky B. In: Grubb B and Olshansky B. eds. Syncope: Mechanisms and Management. Futura. 1998:15-71.

impact of syncope quality of life
Impact of Syncope: Quality of Life

73%1

71%2

60%2

Percent of Patients

37%2

Anxiety/Depression

Alter DailyActivities

RestrictedDriving

ChangeEmployment

1Linzer M. J Clin Epidemiol. 1991;44:1037.

2Linzer M. J Gen Int Med. 1994;9:181.

quality of life uk population norms vs syncope patients
Quality of Life: UK Population Norms vs. Syncope Patients

49%

43%

37%

36%

26%

% Prevalence

19%

9%

4%

3%

1%

Mobility

Usual Activities

Self-Care

Pain/Discomfort

Anxiety/Depression

Rose M, et al. J Clin Epidemiol. 2000;53:1209-1216.

syncope mortality
Syncope Mortality
  • Low mortality vs. high mortality
  • Neurally-mediated syncope vs. syncope with a cardiac cause

Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347(12):878-885. [Framingham Study Population]

implications of syncope for driving a vehicle
Those who drive and have recurrent syncope risk their lives and the lives of others

Places considerable burden on the physician

Essential to know local laws and physician responsibilities

Some states – Invasion of privacy to notify motor vehicle department*

Other states – Reporting is mandatory*

If the patient has sufficient warning of impending syncope – Driving may be permitted

Implications of Syncope for Driving a Vehicle

Olshansky B, Grubb B. In: Syncope: Mechanisms and Management. Futura. Armonk, NY. 1998.

*Medtronic, Inc. Follow-up Forum. 1995/96;1(3):8-10.

challenges of syncope
Challenges of Syncope
  • Diagnosis
    • Complex
  • Quality of life implications
    • Work
    • Mobility (automobiles)
    • Psychological
  • Cost
    • Cost/year
    • Cost/diagnosis
diagnostic objectives
Diagnostic Objectives
  • Distinguish true syncope from syncope mimics
  • Determine presence of heart disease
  • Establish the cause of syncope with sufficient certainty to:
    • Assess prognosis confidently
    • Initiate effective preventive treatment
a diagnostic plan is essential
A Diagnostic Plan is Essential
  • Initial Examination
    • Detailed patient history
    • Physical exam
    • ECG
    • Supine and upright blood pressure
  • Monitoring
    • Holter
    • Event
    • Insertable Loop Recorder (ILR)
  • Cardiac Imaging
  • Special Investigations
    • Head-up tilt test
    • Hemodynamics
    • Electrophysiology study

Brignole M, et al. Europace, 2004;6:467-537.

diagnostic flow diagram for tloc
Diagnostic Flow Diagram for TLOC

Initial Evaluation

Syncope

Not Syncope

Certain Diagnosis

Suspected Diagnosis

Unexplained Syncope

Confirm with Specific Test or Specialist Consultation

Cardiac Likely

Neurally-Mediated or Orthostatic Likely

Frequent or Severe Episodes

Single/Rare Episodes

Cardiac Tests

No Further Evaluation

Tests for Neurally-Mediated Syncope

Tests for Neurally-Mediated Syncope

+

-

+

-

+

-

Re-Appraisal

Re-Appraisal

Treatment

Treatment

Treatment

Treatment

Brignole M, et al. Europace, 2004;6:467-537.

initial exam detailed patient history
Initial Exam: Detailed Patient History
  • Circumstances of recent event
    • Eyewitness account of event
    • Symptoms at onset of event
    • Sequelae
    • Medications
  • Circumstances of more remote events
  • Concomitant disease, especially cardiac
  • Pertinent family history
    • Cardiac disease
    • Sudden death
    • Metabolic disorders
  • Past medical history
    • Neurological history
    • Syncope

Brignole M, et al. Europace, 2004;6:467-537.

initial exam thorough physical
Initial Exam: Thorough Physical
  • Vital signs
    • Heart rate
    • Orthostatic blood pressure change
  • Cardiovascular exam: Is heart disease present?
    • ECG: Long QT, pre-excitation, conduction system disease
    • Echo: LV function, valve status, HCM
  • Neurological exam
  • Carotid sinus massage
    • Perform under clinically appropriate conditions preferably during head-up tilt test
    • Monitor both ECG and BP

Brignole M, et al. Europace, 2004;6:467-537.

carotid sinus massage csm
Method1

Massage, 5-10 seconds

Don’t occlude

Supine and upright posture (on tilt table)

Outcome

3 second asystole and/or 50 mmHg fall in systolic BP with reproduction of symptoms = Carotid Sinus Syndrome

Absolute contraindications2

Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months

Complications

Primarily neurological

Less than 0.2%3

Usually transient

Carotid Sinus Massage (CSM)

1Kenny RA. Heart. 2000;83:564.2Linzer M. Ann Intern Med. 1997;126:989.

3Munro N, et al. J Am Geriatr Soc. 1994;42:1248-1251.

other diagnostic tests
Other Diagnostic Tests
  • Ambulatory ECG
    • Holter monitoring
    • Event recorder
      • Intermittent vs. Loop
      • Insertable Loop Recorder (ILR)
  • Head-Up Tilt (HUT)
    • Includes drug provocation (NTG, isoproterenol)
    • Carotid Sinus Massage (CSM)
  • Adenosine Triphosphate Test (ATP)
  • Electrophysiology Study (EPS)

Brignole M, et al. Europace, 2004;6:467-537.

heart monitoring options
Heart Monitoring Options

OPTION

10 Seconds

12-Lead

2 Days

Holter Monitor

Event Recorders(non-lead and loop)

7-30 Days

Up to 14 Months

ILR

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

TIME (Months)

Brignole M, et al. Europace, 2004;6:467-537.

neurological tests rarely diagnostic for syncope
Neurological Tests: Rarely Diagnostic for Syncope
  • EEG, Head CT, Head MRI
  • May help diagnose seizure

Brignole M, et al. Europace. 2004;6:467-537.

head up tilt test hut
Head-Up Tilt Test (HUT)

60° - 80°

  • Protocols vary
  • Useful as diagnostic adjunct in atypical syncope cases
  • Useful in teaching patients to recognize prodromal symptoms
  • Not useful in assessing treatment

Brignole M, et al. Europace. 2004;6:467-537.

head up tilt test
Head-up Tilt Test

Click once on image to play video.

Carlos Morillo, MD, FRCPC

Professor, Faculty of Health Sciences

McMaster University, Hamilton Ontario

head up tilt test ecg leads and intra arterial pressure tracing
Head-Up Tilt Test:ECG Leads and Intra-Arterial Pressure Tracing

2

1

DG Benditt, MD. U of M Cardiac Arrhythmia Center

adenosine triphosphate atp test
Ongoing investigation in the US

Provokes a short and potent cardioinhibitory vasovagal response

Advantages

Simple

Inexpensive

Correlation with pacing benefit

Seems to identify a unique mechanism of syncope found in patients with:

Advanced age

More hypertension

More ECG abnormalities

Adenosine Triphosphate (ATP) Test

Brignole M. Heart. 2000;83:24-28. Donateo P. J Am Coll Cardiol. 2003;41:93-98.

Flammang D. Circ. 1999;99:2427-2433.

insertable loop recorder ilr
Insertable Loop Recorder (ILR)

The ILR is an implantable patient – and automatically – activated monitoring system that records subcutaneous ECG and is indicated for:

  • Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias
  • Patients who experience transient symptoms that may suggest a cardiac arrhythmia
symptom rhythm correlation with the ilr
Symptom-Rhythm Correlation with the ILR

CASE: 56 year-old woman with refractory syncope accompanied with seizures.

CASE: 65 year-old man with syncope accompanied by brief retrograde amnesia.

Medtronic data on file.

r andomized a ssessment of s yncope t rial rast
Randomized Assessment of Syncope Trial (RAST)

60 Patients

Unexplained Syncope

EF > 35%

30 Patients

30 Patients

Conventional Testing(AECG, Tilt, EPS)

PrimaryStrategy

ILR

14

6

+

+

Diagnosis

1

8

+

+

Crossover

ILR

AECG, Tilt,EP Study

Results:

  • Combining primary strategy with crossover, the diagnostic yield is 43% ILR only vs. 20% conventional only1
  • Cost/diagnosis is 26% less than conventional testing2

1Krahn AD, et al. Circ. 2001;104:46-51. 2Krahn AD, et al. JACC. 2003;42:495-501.

conventional ep testing in syncope
Conventional EP Testing in Syncope
  • Greater diagnostic value in older patients or those with SHD
  • Less diagnostic value in healthy patients without SHD
  • Useful diagnostic observations:
    • Inducible monomorphic VT
    • SNRT > 3000 ms or CSNRT > 600 ms
    • Inducible SVT with hypotension
    • HV interval ≥ 100 ms (especially in absence of inducible VT)
    • Pacing induced infra-nodal block

Benditt D. In: Topol E, ed. Textbook of Cardiovascular Medicine. Lippencott;2002:1529-1542.

Lu F, et al. In: Benditt D, et al. The Evaluation and Treatment of Syncope. Futura. 2003;80-95.

Brignole M, et al. Europace. 2004;6:467-537.

diagnostic limitations of eps
Diagnostic Limitations of EPS
  • Difficult to correlate spontaneous events and laboratory findings
  • Positive findings1
    • Without SHD: 6-17%
    • With SHD: 25-71%
  • Less effective in assessing bradyarrhythmias than tachyarrhythmias2
  • EPS findings must be consistent with clinical history
    • Beware of false positive

1Linzer M, et al. Ann Int Med. 1997;127:76-86.

2Lu F, et al. In: Benditt D, et al. The Evaluation and Treatment of Syncope. Futura. 2003;80-95.

issue i nternational s tudy of s yncope of u ncertain e tiology
ISSUEInternational Study of Syncope of Uncertain Etiology
  • Multicenter, international, prospective study
  • Analyzed the diagnostic contribution of an ILR in three predefined groups of patients with syncope of uncertain origin:
    • Isolated syncope: No SHD, Normal ECG1
      • Negative tilt
      • Positive tilt
    • Patients with heart disease and negative EP test2
    • Patients with bundle branch block and negative EP test3

1Moya A. Circulation. 2001; 104:1261-1267.

2Menozzi C, et al. Circulation. 2002;105:2741-2745.

3Brignole M, et al. Circulation. 2001;104:2045-2050.

issue patients with isolated syncope and tilt positive syncope
ISSUEPatients with Isolated Syncope and Tilt-Positive Syncope

111 Patients with Syncope

No SHD, Normal ECG

Tilt Test Followed by

Insertable Loop Recorder

82: Tilt-Negative “Isolated Syncope”

29: Tilt-Positive

Follow-Up to Recurrent Spontaneous Episode

Moya A. Circulation.

2001;104:1261-1267.

issue isolated syncope vs tilt positive syncope
ISSUEIsolated Syncope vs. Tilt-Positive Syncope

Conclusions

  • Results similar in the two arms, including syncope recurrence and ECG correlation
  • Tilt-negative patients had as many bradycardias (18%) astilt-positive patients (21%)
  • Most frequent finding was asystole secondary to progressive sinus bradycardia, suggesting a neuro-mediated origin
  • Homogeneous findings from tilt-negative and tilt-positive infer low sensitivity of tilt-testing

Moya A. Circulation. 2001;104:1261-1267.

issue patients with heart disease and a negative ep test
ISSUE Patients with Heart Disease and a Negative EP Test

35 Pts with Heart Diseaseand Insertable Loop Recorder

Pre-Syncope: 13 Pts (37%)

Syncope: 6 Pts (17%)

ECG-Documented: 6 Pts (17%)

ECG-Documented: 8 Pts (23%)

AV block + asystole: 1

A.Fib + asystole: 1

Sinus arrest: 1

Sinus tachycardia: 1

Rapid A.Fib: 2

Sustained VT: 1

Parox. A.Fib/AT: 1

Post tachycardia pause: 1

No rhythm variations: 4

Sinus tachycardia: 1

Menozzi C, et al. Circulation. 2002;105:2741-2745.

issue patients with heart disease and a negative ep test1
ISSUEPatients with Heart Disease and a Negative EP Test

Conclusions

  • Patients with unexplained syncope, overt heart disease, and negative EP study had a favorable medium-term outcome
  • Mechanism of syncope was heterogeneous
  • Ventricular tachyarrhythmia was unlikely
  • “ILR-guided strategy seems reasonable, with specific therapy safely delayed until a definite diagnosis is made.”

Menozzi C, et al. Circulation. 2002;105:2741-2745.

issue patients with bundle branch block and negative ep test
ISSUEPatients with Bundle Branch Block and Negative EP Test

52 Pts with BBBand Insertable Loop Recorder

Syncope: 22 Pts (42%)*

Stable AVB: 3 Pts (6%)

Death: 1 Pt (2%)

ILR-DetectedPre-Syncope:2 Pts (4%)**

ILR-Detected: 19

Not Detected: 3

AVB: 2 (4%)

AVB: 12 (63%)

SA: 4 (21%)

Asystole-undefined: 1 (5%)

NSR: 1 (5%)

Sinus tachy: 1 (5%)

* 5 of these also had ≥1 presyncope

** Drop-out before primary-end point

Brignole M., ET AL.,Circulation. 2001;104:2045-2050.

issue patients with bundle branch block and negative ep test1
ISSUEPatients with Bundle Branch Block and Negative EP Test

Conclusion:

  • In patients with BBB and negative EP study, most syncopal recurrences have a homogeneous mechanism that is characterized by prolonged asystolic pauses mainly attributable to sudden-onset paroxysmal AV block

Brignole M. Circulation. 2001;104:2045-2050.

specific conditions
Specific Conditions
  • Cardiac arrhythmia
    • Brady/Tachy
    • Long QT syndrome
    • Torsade de pointes
    • Brugada
    • Drug-induced
  • Structural cardio-pulmonary
  • Neurally-mediated
    • Vasovagal Syncope (VVS)
    • Carotid Sinus Syndrome (CSS)
  • Orthostatic
cardiac syncope
Cardiac Syncope
  • Includes cardiac arrhythmias and SHD
  • Often life-threatening
  • May be warning of critical CV disease
    • Tachy and brady arrhythmias
    • Myocardial ischemia, aortic stenosis, pulmonary hypertension, aortic dissection
  • Assess culprit arrhythmia or structural abnormality aggressively
  • Initiate treatment promptly

Brignole M, et al. Europace. 2004;6:467-537.

cardiac syncope can be a harbinger of sudden death
“…cardiac syncope can be a harbinger of sudden death.”

1.0

0.8

0.6

0.4

0.2

0.0

Probability of Survival

No Syncope

Vasovagal andOther Causes

Cardiac Cause

0 5 10 15

Follow-Up (yr)

  • Survival with and without syncope
  • 6-month mortality rate of greater than 10%
  • Cardiac syncope doubled the risk of death
  • Includes cardiac arrhythmias and SHD

Soteriades ES, et al. N Engl J Med. 2002;347:878.

syncope due to structural cardiovascular disease principle mechanisms
Acute MI/Ischemia

2° neural reflex bradycardia – Vasodilatation, arrhythmias, low output (rare)

Hypertrophic cardiomyopathy

Limited output during exertion (increased obstruction, greater demand), arrhythmias, neural reflex

Acute aortic dissection

Neural reflex mechanism, pericardial tamponade

Pulmonary embolus/pulmonary hypertension

Neural reflex, inadequate flow with exertion

Valvular abnormalities

Aortic stenosis – Limited output, neural reflex dilation in periphery

Mitral stenosis, atrial myxoma – Obstruction to adequate flow

Syncope Due to Structural Cardiovascular Disease: Principle Mechanisms

Brignole M, et al. Europace. 2004;6:467-537.

syncope due to cardiac arrhythmias
Syncope Due to Cardiac Arrhythmias
  • Bradyarrhythmias
    • Sinus arrest, exit block
    • High grade or acute complete AV block
    • Can be accompanied by vasodilatation (VVS, CSS)
  • Tachyarrhythmias
    • Atrial fibrillation/flutter with rapid ventricular rate (eg, pre-excitation syndrome)
    • Paroxysmal SVT or VT
    • Torsade de pointes

Brignole M, et al. Europace. 2004;6:467-537.

ilr recordings
ILR Recordings

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

CASE: 28 year-old man presents to ER multiple times after falls resulting in trauma. VT: Ablated and medicated.

Reveal ® ILR recordings; Medtronic data on file.

cardiac rhythms during unexplained syncope
Cardiac Rhythms During Unexplained Syncope

Composite: N=133 to 7109

Bradycardia 16%(11-21%)

No Recurrence 36%(31-48%)

Arrhythmia 22%(13-32%)

Tachycardia 6%(2-11%)

Other 11%

Normal Sinus Rhythm 31%(17-44%)

Seidl K. Europace. 2000;2(3):256-262.

Krahn AD. PACE. 2002;25:37-41.

Medtronic ILR Replacement Data. FY03, 04. On file.

long qt syndromes
Long QT Syndromes
  • Mechanism
    • Abnormalities of sodium and/or potassium channels
    • Susceptibility to polymorphic VT (Torsade de pointes)
  • Prevalence
    • Drug-induced forms – Common
    • Genetic forms – Relatively rare, but increasingly being recognized
    • “Concealed” forms:
      • May be common
      • Provide basis for drug-induced torsade

Schwartz P, Priori S. In: Zipes D and Jalife J, eds. Cardiac Electrophysiology. Saunders;2004:651-659.

syncope torsade de pointes
Syncope: Torsade de Pointes

From the files of DG Benditt, MD. U of M Cardiac Arrhythmia Center

long qt syndromes 12 lead ecg
Long QT Syndromes: 12-Lead ECG

From the files of DG Benditt, MD. U of M Cardiac Arrhythmia Center

drug induced qt prolongation list is continuously being updated
Antiarrhythmics

Class IA ...Quinidine, Procainamide, Disopyramide

Class III…Sotalol, Ibutilide, Dofetilide, Amiodarone, NAPA*

Antianginal Agents

Bepridil*

Psychoactive Agents

Phenothiazines, Amitriptyline, Imipramine, Ziprasidone

Antibiotics

Erythromycin, Pentamidine, Fluconazole, Ciprofloxacin and its relatives

Nonsedating antihistamines

Terfenadine*, Astemizole

Others

Cisapride*, Droperidol, Haloperidol

Drug-Induced QT Prolongation(List is continuously being updated)

*Removed from U.S. Market

Brignole M, et al. Europace, 2004;6:467-537.

treatment of long qt
Treatment of Long QT
  • Suspicion and recognition are critical
  • Emergency treatment
    • Intravenous magnesium
    • Pacing to overcome bradycardia or pauses
    • Isoproterenol to increase heart rate and shorten repolarization
    • ICD if prior SCA or strong family history
    • If drug induced:
      • Reverse bradycardia
      • Withdraw drug
      • Avoid ALL long-QT provoking agents
    • If genetic:
      • Avoid ALL long-QT provoking agents
  • For more information visit www.longqt.org

Schwartz P, Priori S. In: Zipes D and Jalife J, eds. Cardiac Electrophysiology. Saunders;2004:651-659.

treatment of syncope due to bradyarrhythmia
Treatment of Syncope Due to Bradyarrhythmia

0.4

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0.2

08:23:21

0.0

-0.2

-0.4

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0.4

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8:23:29

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-0.2

-0.4

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  • Class I indication for pacing using dual chamber system wherever possible
  • Ventricular pacing in atrial fibrillation with slow ventricular response

ACC/AHA/NASPE 2002 Guideline Update. Circ. 2002;106:2145-2161.

treatment of syncope due to tachyarrhythmia
Treatment of Syncope Due to Tachyarrhythmia
  • Atrial tachyarrhythmias
    • AVRT due to accessory pathway – Ablate pathway
    • AVNRT – Ablate AV nodal slow pathway
    • Atrial fib – Pacing, linear/focal ablation for paroxysmal AF
    • Atrial flutter – Ablate the IVC-TV isthmus of the re-entrant circuit for ‘typical’ flutter
  • Ventricular tachyarrhythmias
    • Ventricular tachycardia – ICD or ablation where appropriate
    • Torsade de pointes – Withdraw offending drug or implant ICD (long QT/Brugada/short QT)
  • Drug therapy may be an alternative in many cases

Brignole M, et al. Europace. 2004;6:467-537.

neurally mediated reflex syncope
Neurally-Mediated Reflex Syncope
  • Vasovagal Syncope (VVS)
  • Carotid Sinus Syndrome (CSS)
  • Situational syncope
    • Post-micturition
    • Cough
    • Swallow
    • Defecation
    • Blood drawing, etc.

Brignole M, et al. Europace, 2004;6:467-537.

pathophysiology
Pathophysiology

Autonomic Nervous System

Benditt D, et al. Neurally mediated syncope: Pathophysiology, investigations and treatment. Blanc JJ, et al. eds. Futura. 1996.

vvs clinical pathophysiology
VVSClinical Pathophysiology
  • Neurally-mediated physiologic reflex mechanism with two components:

1. Cardioinhibitory (↓ HR)

2. Vasodepressor (↓ BP) despite heart beats, no significant BP generated

  • Both components are usually present

1

2

Wieling W, et al. In: Benditt D, et al. The Evaluation and Treatment of Syncope. Futura. 2003;11-22.

vvs incidence
VVSIncidence
  • Most common form of syncope
    • 8% to 37% (mean 18%) of syncope cases
  • Depends on population sampled
    • Young without SHD, ↑ incidence
    • Older with SHD, ↓ incidence

Linzer M, et al. Ann Intern Med. 1997;126:989.

vvs vs css
VVS vs. CSS
  • In general:
    • VVS patients younger than CSS patients
    • Ages range from adolescence to older adults (median 43 years)

Linzer M, et al. Ann Intern Med. 1997;126:989.

vvs recurrences
VVS Recurrences

1000

> 75%

800

Two Year Risk

100

50

Total Number of Syncopal Episodes

25

50-75%

8

4

25-50%

2

< 25%

1

1

2

3

6

24

84

480

Months Since Symptoms Began

  • 35% of patients report syncope recurrence during follow-up ≤3 years1
  • Positive HUT with >6 lifetime syncope episodes: recurrence risk >50% over 2 years2

1Savage D, et al. STROKE. 1985;16:626-29.

2Sheldon R, et al. Circulation. 1996;93:973-81.

vvs spontaneous
VVS Spontaneous

16.3

sec

Continuous Tracing

1 sec

16 year-old male, healthy, athletic, monitored for fainting.

From the files of DG Benditt, MD. U of M Cardiac Arrhythmia Center

vvs diagnosis
VVSDiagnosis
  • History and physical exam, ECG and BP
  • Head-Up Tilt (HUT) – Protocol:
    • Fast > 2 hours
    • ECG and continuous blood pressure, supine, and upright
    • Tilt to 70°, 20 minutes
    • Isoproterenol/Nitroglycerin if necessary
    • End point – Loss of consciousness

60° - 80°

Benditt D, et al. JACC. 1996;28:263-275.

Brignole M, et al. Europace, 2004;6:467-537.

vvs general treatment measures
Optimal treatment strategies for VVS are a source of debate

Treatment goals

Acute intervention

Physical maneuvers, eg, crossing legs or tugging arms

Lowering head

Lying down

Long-term prevention

Tilt training

Education

Diet, fluids, salt

Support hose

Drug therapy

Pacing

VVS General Treatment Measures

Brignole M, et al. Europace, 2004;6:467-537.

vvs tilt training protocol
VVS Tilt Training Protocol
  • Objectives
    • Enhance orthostatic tolerance
    • Diminish excessive autonomic reflex activity
    • Reduce syncope susceptibility/recurrences
  • Technique
    • Prescribed periods of upright posture against a wall
    • Start with 3-5 min BID
    • Increase by 5 min each week until a duration of 30 min is achieved

Reybrouck T, et al. PACE. 2000;23(4 Pt. 1):493-498.

vvs tilt training clinical outcomes
VVS Tilt Training: Clinical Outcomes
  • Treatment of recurrent VVS
  • Reybrouck, et al.*: Long-term study
    • 38 patients performed home tilt training
    • After a period of regular tilt training, 82% remained free of syncope during the follow-up period
    • However, at the 43-month follow-up, 29 patients had abandoned the therapy
    • Conclusion: The abnormal autonomic reflex activity of VVS can be remedied. Compliance may be an issue.

*Reybrouck T, et al. PACE. 2000;23:493-498.

vvs tilt training clinical outcomes1
VVS Tilt Training: Clinical Outcomes
  • Foglia-Manzillo, et al.*: Short-term study
    • 68 patients
      • 35 tilt training
      • 33 no treatment (control)
    • Tilt table test conducted after 3 weeks
    • 19 (59%) of tilt trained and 18 (60%) of controls had a positive test
    • Tilt training was not effective in reducing tilt testing positivity rate
    • Poor compliance in the majority of patients with recurrent VVS

*Foglio-Manzillo G, et al. Europace. 2004;6:199-204.

vvs pharmacologic treatment
VVS Pharmacologic Treatment
  • Fludrocortisone
  • Beta-adrenergic blockers
    • Preponderance of clinical evidence suggests minimal benefit1
  • SSRI (Selective Serotonin Re-Uptake Inhibitor)
    • 1 small controlled trial2
  • Vasoconstrictors
    • 1 negative controlled trial (etilefrine)3
    • 2 positive controlled trials (midodrine)4,5

1Brignole M, et al. Europace, 2004;6:467-537.

2Di Girolamo E, et al. JACC. 1999;33:1227-1230.

3Raviele A, et al. Circ. 1999;99:1452-1457.

4Ward C, et al. Heart. 1998;79:45-49.

5Perez-Lugones A, et al. J Cardiovasc Electrophysiol. 2001;12(8):935-938.

midodrine for vvs
Midodrine for VVS

100

80

60

40

20

0

20

40

60

80

100

120

140

160

180

Midodrine

Symptom-Free Interval

Fluid

p < 0.001

0

Months

Perez-Lugones A, Schweikert R, Pavia S, et al. J Cardiovasc Electrophysiol. 2001;12(8):935-938.

the role of pacing as therapy for syncope
The Role of Pacing as Therapy for Syncope
  • VVS with +HUT and cardioinhibitory response:Class IIb indication for pacing
  • Three randomized, prospective trials reported benefits of pacing in select VVS patients:
    • VPS I1
    • VASIS2
    • SYDIT3
  • Subsequent study results less clear
    • VPS II4
    • Synpace5
    • INVASY6

4Connolly S. JAMA. 2003;289:2224-2229.

5Giada F. PACE . 2003;26:1016 (abstract).

6Occhetta E, et al. Europace. 2004;6:538-547.

1Connolly SJ. J Am Coll Cardiol. 1999;33:16-20.

2Sutton R. Circulation. 2000;102:294-299.

3Ammirati F. Circ. 2001;104:52-57.

role of pacing as therapy for syncope summary
Role of Pacing as Therapy for Syncope: Summary
  • Three earlier studies single blind – Bias?
  • Pacemaker implantation may modulate reflex syncope and autonomic responses1
  • Study results may differ based on pre-implant selection criteria and tilt-testing techniques
  • Pacing therapy is effective in some but not all (cardioinhibition vs. vasodepression)
  • In five pacing studies, syncope recurred in 33/156 (21%) of paced patients, 72/162 (44%) in non-paced patients (p<0.000)2

1Kapoor W. JAMA. 2003;289:2272-2275.2Brignole M, et al.. Europace. 2004;6:467-537.

css carotid sinus syndrome
CSSCarotid Sinus Syndrome
  • Syncope clearly associated with carotid sinus stimulation is rare (≤1% of syncope)
  • CSS may be an important cause of unexplained syncope/falls in older individuals
  • Prevalence higher than previously believed
  • Carotid Sinus Hypersensitivity (CSH)
    • No symptoms
    • No treatment

Kenny RA, et al. J Am Coll Cardiol. 2001;38:1491-1496.

Brignole M, et al. Europace. 2004;6:467-537.

Sutton R. In: Neurally Mediated Syncope: Pathophysiology, Investigation and Treatment. Blanc JJ, et al. eds. Armonk, NY: Futura;1996:138.

css etiology
CSSEtiology
  • Sensory nerve endings in the carotid sinus walls respond to deformation
  • “Deafferentation” of neck muscles may contribute
  • Increased afferent signals tobrain stem
  • Reflex increase in efferent vagal activity and diminution of sympathetic tone results in bradycardia and vasodilatation

Carotid Sinus

falls incidence recurrence csh
Falls:Incidence, Recurrence, CSH*

50% 1

30% 1

% of Population

23% 2

Incidence> Age 65

Recurrence

CSH* Presentin Fallers > Age 50Presenting at ER

*Carotid Sinus Hypersensitivity

1 J Am Geriatr Soc.1995.

2 Richardson D, et al. PACE. 1997;20:820.

css role of pacing syncope recurrence rate
Class I indication for pacing (AHA and BPEG)

Limit pacing to CSS that is:

Cardioinhibitory

Mixed

DDD/DDI superior to VVI

Mean follow-up = 6 months

CSS Role of Pacing – Syncope Recurrence Rate

57%

% Recurrence

%6

Brignole M, et al. Eur JCPE. 1992;4:247-254.

safe pace s yncope a nd f alls in the e lderly p acing a nd c arotid sinus e valuation
Objective

Determine whether cardiac pacing reduces falls in older adults with carotid sinus hypersensitivity

Randomized controlled trial (N=175)

Adults > 50 years, non-accidental fall, positive CSM

Pacing (n=87) vs. No Pacing (n=88)

Results

More than 1/3 of adults over 50 years presented to the Emergency Department because of a fall

With pacing, falls  70%

Syncopal events  53%

Injurious events  70%

SAFE PACESyncope And Falls in the Elderly –Pacing And Carotid Sinus Evaluation

Kenny RA. J Am Coll Cardiol. 2001;38:1491-1496.

safe pace
SAFE PACE
  • Conclusions
    • Strong association between non-accidental falls and cardioinhibitory CSH
    • These patients usually not referred for cardiac assessment
    • Cardiac pacing significantly reduced subsequent falls
    • CSH should be considered in all older adults who have non-accidental falls

Kenny RA, J Am Coll Cardiol. 2001; 38:1491-1496.

orthostatic hypotension
Etiology

Drug-induced (very common)

Diuretics

Vasodilators

Primary autonomic failure

Multiple system atrophy

Parkinson’s Disease

Postural Orthostatic Tachycardia Syndrome (POTS)

Secondary autonomic failure

Diabetes

Alcohol

Amyloid

Orthostatic Hypotension

Brignole M, et al. Europace, 2004;6:467-537.

treatment strategies for orthostatic intolerance
Treatment Strategies for Orthostatic Intolerance
  • Patient education, injury avoidance
  • Hydration
    • Fluids, salt, diet
    • Minimize caffeine/alcohol
  • Sleeping with head of bed elevated
  • Tilt training, leg crossing, arm pull
  • Support hose
  • Drug therapies
    • Fludrocortisone, midodrine, erythropoietin
  • Tachy-Pacing (probably not useful)

Brignole M, et al. Europace, 2004;6:467-537.

section iv

Section IV:

Special Issues

syncope diagnostic testing in hospital strongly recommended
Syncope: Diagnostic Testing in Hospital Strongly Recommended
  • Suspected/known ‘significant’ heart disease
  • ECG abnormalities suggesting potential life-threatening arrhythmic cause
  • Syncope during exercise
  • Severe injury or accident
  • Family history of premature sudden death

Brignole M, et al. Europace. 2004;6:467-537.

seeds s yncope e valuation in the e mergency d epartment s tudy
SEEDS: Syncope Evaluation in the Emergency Department Study

Long-Term Clinical Outcomes

Survival Free from Death

Survival Free from Recurrence

100%

100%

90%

90%

Syncope Unit Group

Syncope Unit Group

80%

80%

Standard Care Group

Standard Care Group

P=0.30

P=0.72

70%

70%

0

1

2

0

1

2

Years

Years

Results:

  • Syncope unit improved diagnostic yield in the ED and reducedhospital admission and length of stay

Shen W, et al. Circ. 2004;110(24):3636-3645.

the integrated syncope unit
The Integrated Syncope Unit
  • To optimize the effectiveness of the evaluation and treatment of syncope patients at a given center
  • Best accomplished by:
    • Cohesive, structured care pathway
    • Multidisciplinary approach
    • Core equipment available
    • Preferential access to other tests or therapy
  • Majority of syncope evaluations – Out-patient or day cases

1Kenny RA, Brignole M. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:55-60.

2Brignole M, et al. Europace, 2004;6:467-537.

conclusion
Conclusion
  • Syncope is a common symptom with many causes
  • Deserves thorough investigation and appropriate treatment
  • A disciplined approach is essential
  • ESC guidelines offer current best practices

Brignole M, et al. Europace, 2004;6:467-537.

challenges of syncope1
Challenges of Syncope
  • Cost
  • Quality of life implications
  • Diagnosis and treatment
    • Diagnostic yield and repeatability of tests
    • Frequency and clustering of events
    • Difficulty in managing/treating/controlling future events
    • Appropriate risk stratification
    • Complex etiology

Olshansky B. In: Grubb B and Olshansky B. eds. Syncope: Mechanisms and Management. Futura. 1998:15-71.

Brignole M, et al. Europace, 2004;6:467-537.

brief statement
Brief Statement

Indications

9526 Reveal® Plus Insertable Loop Recorder

The Reveal Plus ILR is an implantable patient- and automatically activated monitoring system that records subcutaneous ECG and is indicated for

Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias

Patients who experience transient symptoms that may suggest a cardiac arrhythmia

6191 Activator

The Model 6191 Activator is intended for use in combination with a Medtronic Model 9526 Reveal Plus Insertable Loop Recorder.

Contraindications

There are no known contraindications for the implantation of the Reveal Plus ILR. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated.

Warnings/Precautions

9526 Reveal Plus Insertable Loop Recorder

Patients with the Reveal Plus ILR should avoid sources of magnetic resonance imaging, diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, and radiofrequency ablation to avoid electrical reset of the device, and/or inappropriate sensing.

6191 Activator

Operation of the Model 6191 Activator near sources of electromagnetic interference, such as cellular phones, computer monitors, etc., may adversely affect the performance of this device.

Potential Complications

Potential complications include, but are not limited to, body tissue rejection phenomena, including local tissue reaction, infection, device migration and erosion of the device through the skin.

2090 Programmer

The Medtronic/Vitatron CareLink programmer system is comprised of prescription devices indicated for use in the interrogation and programming of implantable medical devices. Prior to use, refer to the Programmer Reference Guide as well as the appropriate programmer software and implantable device technical manuals for more information related to specific implantable device models. Programming should be attempted only by appropriately trained personnel after careful study of the technical manual for the implantable device and after careful determination of appropriate parameter values based on the patient's condition and pacing system used. The Medtronic/Vitatron CareLink programmer must be used only for programming implantable devices manufactured by Medtronic or Vitatron.

See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1-800-328-2518 and/or consult Medtronic’s website at www.medtronic.com. To learn more about syncope, visit www.fainting.com.

Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.