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Current Trends in the Evaluation of Syncope

Current Trends in the Evaluation of Syncope. John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State University. Definition. a syndrome in which loss of consciousness is: relatively sudden temporary self-terminating

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Current Trends in the Evaluation of Syncope

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  1. Current Trends in the Evaluation of Syncope • John D. Hummel, M.D • Professor of Clinical Internal Medicine • Director of Electrophysiology Research • Ohio State University

  2. Definition a syndrome in which loss of consciousness is: relatively sudden temporary self-terminating usually rapid recovery due to inadequate cerebral perfusion most often triggered by a fall in systemic arterial pressure

  3. Syncope: High Incidence and Likely to Increase • 7814 participants followed for an average of17 years, 822 reported syncope • Estimated 10-year cumulative incidence of syncope was 6% • The incidence rates increased with age, with a sharp rise at 70 years • 22% of the study participants with syncope had a recurrence Soteriades et al. NEJM 2002; 347: 878

  4. Syncope Annual U.S. Emergency Dept. Visits • ~40% of the population will have at least one syncopal event in their lifetime1 • 10% of falls by elderly are believed due to syncope2 • Major morbidity reported in 6%1(e.g., fractures, motor vehicle accident) • Minor injury reported in 29%1(e.g., lacerations, bruises) 1Kenny RA, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27. 2Kapoor W. Medicine. 1990;69:160-175.

  5. SyncopeQOL Impact 73%1 71%2 60%2 Percent of Patients 37%2 Anxiety/Depression Alter DailyActivities RestrictedDriving ChangeEmployment 1Linzer M. J Clin Epidemiol, 1991;44:1037-1043. 2Linzer M. J Gen Int Med, 1994;9:181-186.

  6. Syncope • In one-third of participants, a cause for syncope could not be assigned • Risk of death was increased by 31% among all participants with syncope • Risk of death was doubled among participants with cardiac syncope • Neurologic syncope (CVA, TIA, seizure) also associated with three-fold risk of stroke Soteriades et al. NEJM 2002; 347: 878

  7. Causes of True Syncope Neurally- Mediated Reflex Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary • 3 • Bradycardia • Sinus pause/arrest • AV block • • Tachycardia • VT • SVT • LongQT Synd • 4 • Aortic Stenosis • HCM • Pulmonary Hypertension • Aortic Dissection • 1 • VVS • CSS • • Situational • Cough • Post- micturition • 2 • Drug-Induced • • ANS Failure • Primary • Secondary 10% 5% 15% 60% Unexplained Causes = Approximately 10%

  8. Goals • Determine whether the patient is at increased risk for death. • - patients with underlying heart disease • - myocardial ischemia • - Wolff-Parkinson-White syndrome • - life-threatening genetic diseases (LQTS, Brugada) • Once excluded, the goal becomes identification of the cause of syncope in an attempt to: • - improve the quality of the patient’s life • - to prevent injury to the patient or others. AHA/ACCF Scientific Statement on the Evaluation of Syncope Circulation, February 2006

  9. The Initial Evaluation:4 Key Questions Did the patient suffer ‘true’ Transient Loss of Consciousness (TLOC)? Was TLOC due to syncope or some other cause? Is heart disease present? Does the medical history (including observations by witnesses) suggest a specific diagnosis?

  10. Syncope vs. Non-Syncopal Events Task Force members, et al. Eur Heart J 2004 25:2054-2072

  11. Flow chart for the diagnostic approach to the patient with syncope Strickberger, S. A. et al. Circulation 2006;113:316-327

  12. History and Physical: The Most Valuable Part of the Initial Evaluation H&P yields a diagnosis prior to confirmatory studies in 45% of patients in 7 population based studies (n=1607) History: Prodome/Residua Activity/Posture Palpitations Seizure Activity Medications Prior Episodes Family History: Syncope, Sudden Death, Cardiac Disease Physical Exam Orthostatic BP Murmurs, Bruits, Pulses, Differential BP’s

  13. ECG • Abnormal in 50% of patients. Identifies potential cause in 2-11% • Pre-excitation • Conduction Delays • MI • LVH/RVH (Hypertrophic CM, Aortic Stenosis, Pulmonary HTN) • QT Interval (QTc=460) should raise suspicion • Brugada Abnormalities • Epsilon Waves (ARVD)

  14. ECG changes in the Brugada syndrome Strickberger, S. A. et al. Circulation 2006;113:316-327

  15. Long QT syndrome-Triggers LQT1 • Swimming- LQT1 • Auditory/emotional trigger- LQT2 • Inactivity- LQT3 LQT2 LQT2 LQT3

  16. Different patterns of QT prolongation in LQTS Strickberger, S. A. et al. Circulation 2006;113:316-327

  17. Twelve-lead ECG in normal sinus rhythm with epsilon wave Kenigsberg, D. N. et al. Circulation 2007;115:e538-e539

  18. High-resolution delayed enhanced magnetic resonance image Kenigsberg, D. N. et al. Circulation 2007;115:e538-e539

  19. Neurally Mediated Syncopal SyndromesThe Most Common Cause of Syncope • Vasodepressor Syndrome (Common Faint) • Micturition/Cough/Sneeze Syncope • Carotid Hypersensitivity

  20. Reflex Arcs in Neurally Mediated SyncopeUpright Posture: 15-20% Decrease in Plasma Volume With Decrease in C.O. Baroreceptors Mechanoreceptors Higher Centers (Cortex) Cranial Nerves V, VII, VIII GI/GU Mechanoreceptors Vagus Medullary Vasodepressor Region Skeletal Muscle & Resp. Pump Reflex Activation Central Sympathetic Outflow

  21. Vasodepressor Syncope • Clinical Syndrome Characterized By: • Settings: • young patients, no SHD • Frightening/stressful situation • hunger, fatigue, dehydration, hot room • standing position, sitting occasional • 2. Premonitory Signs: • - nausea, blurred vision • - warmth, diaphoresis • - pallor, yawning • Syncopal Event: • white, pale • no injury • may be aborted by becoming supine • 4. Recovery: • - nausea, diaphoresis • - fatigue

  22. Tilt Test • Supine 5 min, 20 min with I.V. pretest • Tilt 60-70 degrees • Passive 20-45 minutes • Isuprel or SL NTG 400 ug spray in neg for 15-20 minutes • Endpoint: Syncope or Full Duration Complete • Rapid Protocols: • 10 min baseline, Return to supine and infuse isuprel with HUTT for 20min after 20-25% increase in HR • Clomipramine I.V. 5mg (1mg/min) during the first 5 min of 20 min. TTT (spec.93%, sens. 64-83%

  23. Carotid Sinus Massage • Classification: Cardioihibitory, VDP, Mixed • Abnormal: • Ventricular pause > 3 seconds or fall in SBP > 50mmHg with symptoms • Technique: • Recommend continuous ECG and BP monitoring • Assess VDS response with repeat massage after 1 mg of atropine • Perform CSM with TTT if negative CSM supine: Only positive in HUTT in 49% • Complications: Neuro in 0.17-0.45% • Contraindicated: Sig. carotid disease • Treatment: PPM for CI, PPM±VDS meds mixed

  24. Right CSM 68 y/o man with a history of CAD, s/p, IMI, EF = 45% Presented with 2 recent syncopal episodes which occurred while sitting without prodrome. Holter = NSVT EPS=Normal

  25. Echo, Stress Testing • History and Physical • Presence of definite structural heart disease • Syncope during exertion or when supine • Syncope preceded by palpitations • Family history of SCA • Malignant Syncope • Hx of CADz • EKG • Bifasicular block or QRS>120 msec • Mobitz I, second degree AV block (off meds) • Asymptomatic Sinus Brady, pause > 3 sec • Long QT, WPW, Brugada, Neg precordial T’s/epsilon • Q waves EVM, Loop EPS

  26. Echocardiogram • Excellent for detecting associated cardiac disease • - Left atrial myxoma • - HOCM • - Early cardiomyopathy • - Valvular disease • - Amyloid • - Ischemic heart disease • - RV abnormalities (+/-) • Provides key data affecting prognosis and further evaluation

  27. Exercise Testing • Should be performed in the patient with unexplained syncope, especially if the episode was exercise related. • Exercise testing • in patients less than 40 years of age, a drop in blood pressure or failure of blood pressure to rise with exercise raises the question of hypertrophic obstructive cardiomyopathy or left main coronary artery disease. • In the elderly patient, it may be a manifestation of autonomic failure. • Exercise testing also screens for catecholaminergic polymorphic ventricular tachycardia and chronotropic incompetence (failure to achieve 100 bpm or 75% MPHR) • Exercise testing with a functional study can exclude ischemia as a potential cause of syncope

  28. EPS: Indications for Syncope Evaluation Syncope: Class I: Structural Heart Dz, Unexplained after initial eval. Palpitations preceding syncope Palps, Rapid pulse by medical personnel Class II: Recurrent Unexplained syncope, nl heart and neg TTT Palps, Inability to obtain recording Class III: Known cause of syncope, EPS will not guide Rx

  29. EPS: Catheter Insertion and Targets

  30. After IV Procainamide

  31. Induction of SMVT – Rate = 250bpm, SBP < 60

  32. WPW: Atrial Fibrillation, Ventricular Fibrillation

  33. Combined Use of EP and Tilt Table Testing for Syncope Unexplained Syncope (86pts.) +EPS, 29 (34%) pts. -EPS, 57 (66%) pts. +HUT 34 (60%) pts. -HUT 23 (40%) pts. Tachyarrhythmia Bradyarrhythmia VT, 21 (73%) pts. SVT, 5 (18%) pts. SND, 1 (3%) pts. AV Block, 2 (6%) pts. 70% of patients were diagnosed with the combined use of EP and Tilt Testing Sra et al, 1993

  34. Outcome in pts with Unexplained Syncope and Nondiagnostic EPS • the incidence of sudden death is low (<2%) • the remission rate of syncope is high (80%) • the EPS falsely negative in greater than or equal to 20% of patients who continue to have syncope (AV block, SN dysfunction)

  35. Flow chart for the diagnostic approach to the patient with syncope Strickberger, S. A. et al. Circulation 2006;113:316-327

  36. Types of External Arrhythmia Monitors • Electrocardiogram: snapshot in time • Holter monitor : 24 to 48 hours of continuous outpatient electrocardiographic (ECG) recording • Shortcoming: repeated monitoring if an arrhythmia not occur 24-48 hours • Processing can delay action on malignant arrhythmias • Event recorder: stores 1 to 2 minutes of ECG as soon as the patient activates • Enables much longer period of monitoring • Misses asymptomatic arrhythmias and some symptomatic arrhythmias when pt fails to activate • Automatic-trigger loop monitors: Records in continuous loop and automatically captures certain arrhythmias or can be manually activated during symptoms • Devices can capture detect several types of arrhythmias. • Typically worn for up to 30 days. • Real-time cardiac surveillance: continuous outpatient ECG monitoring for periods ranging up to several weeks, if necessary. • Cardiac activity detected by 3 electrodes attached to a ~2 ounce pager-sized sensor or telephone transmitter • Continuously analyzes the heart rhythm data. If an arrhythmia detected, the monitor automatically transmits data to a central monitoring station for analysis/action • Any symptoms recorded by the patient are also transmitted.

  37. Cumulative number of patients who sent an electrocardiogram from an event recorder by the number of days needed to record an electrocardiogram during palpitations Prospective, randomized crossover comparison 48 hour holter to 30 day EVM Twice as many symptomatic recordings from EVM as holter 19% of events recorded on EVM required intervention, none from the holter Kinlay, S. et. al. Ann Intern Med 1996;124:16-20

  38. MCOT Study • Multicenter randomized controlled trial • 266 pts with palpitations, presyncope, syncope and nondiagnostic Holter • Randomized to 30 days of MCOT (Cardionet) or external loop (Loop Group). • Results • Clinically significant arrhythmias • 55 (41%) pts in the MCOT Group • 19 (14%) patients in the Loop Group (p< 0.001). Rothman SA, Laughlin JC, Seltzer J, et al. J Cardiovasc Electrophysiol. 2007;18(3):241-247

  39. RAST studyRandomized Assessment of Syncope Trial Results: Primary strategy: diagnostic yield is 47% vs. 20% Diagnosis overall: 19 vs. 55% (p=0.0014) 39 A. Krahn. Circulation 2001; 104: 46-51

  40. ISSUE Study Implications • HUT outcome was not predictive of vasodepressor vs. cardioinhibitory response • Bradycardia is common in spontaneous VVS - independent of HUT outcome • Bradycardia is more prevalent in spontaneous events vs. HUT induced VVS • Clinical Implication: Consider a strategy of ILR guided evaluation in positive TTT patients unresponsive to medication Moya A. Circulation. 2001; 104:1261-1267

  41. ISSUE 2 Syncopal Episodes per Patient per Year Methods: • 392 patients with suspected neurally-mediated syncope were enrolled • 103 pts. had an ECG documented syncope, leading to therapy and a follow-up observational period 0.83 Results: • A 92% relative reduction in syncope burden and 80% relative reduction in one-year recurrence rate with pacing and antiarrhythmic therapies guided by ILR findings 0.07 0.05 Brignole M. Eur Heart J. 2006;27:1085-1092 (ISSUE 2). Non-Specific Therapy ILR-Based (all patients receiving antiarrhythmic therapy or pacemaker therapy) Pacemaker Therapy Only

  42. Diagnostic Methods & Yield 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med, 1991. 3 Linzer, et al. Ann Int. Med, 1997. 4 Kapoor, Medicine, 1990. 5 Kapoor, JAMA, 1992 6 Krahn, Circulation, 1995 7 Krahn, Cardiology Clinics, 1997. 8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8. 9 Day S, et al. Am J Med. 1982; 73: 15-23. 10 Stetson P, et al. PACE. 1999; 22 (part II): 782. * Structural Heart Disease † MRI not studied

  43. Symptom-Rhythm Correlation Auto Activation Point Patient Activation Point

  44. Syncope Diagnosis: Role of an ILR AHA/ACC Scientific Statement on the Evaluation of Syncope: “This approach (ILRs) is more likely to identify the mechanism of syncope than is a conventional approach that uses Holter or event monitors and EP testing and is cost-effective.” A. Strickberger et al. Circulation 2006; 113: 316-327

  45. Ideal System for Long Term Cardiac Monitoring • Subcutaneous placement, simple and fast to implant, excellent safety profile. • Reliably provides information that can aid selection and titration of therapies • High sensitivity detector in ILR • Signal processing software to remove false positives and extract information at monitoring center • Human over-read at service center to assure information delivered to physician is clinically relevant • Simple for the patient – requires little or no compliance • Long-range telemetry for automated data transfer • Simple for the physician – maximizes practice efficiency, follow up requires minimal work load • Data download tailored to institution/practice

  46. Sub-Q ILR’s: Evolution Reveal 1998 Reveal is developed to help diagnose unexplained syncope Reveal Plus 2000 Automatic detection added Transoma Sleuth Transoma: the first wireless and automated monitoring system Longevity and ECG memory increased (to 3 yrs., 49.5 minutes), with episode logs, ICD sensing technology, MRI labeling, and remote monitoring added Reveal DX 2007 Reveal XT, Sleuth AT Confirm 2009 AF detection and long-term trended diagnostics (the Cardiac Compass and AF Summary Reports)added

  47. Competing ILR’s

  48. RUP Study: Importance of Wireless Download Automatic detection mode in the REVEAL was activated, but no significant arrhythmias were recorded: because ILR memory “was always saturated by inappropriate activations.” 1.Franco Giada et al.. J Am Coll Cardiol 2007;49:1951–6

  49. Importance of an Antenna Loss of tissue contact from shape/form factor Krahn et al, PACE 2004; 27: 657

  50. Medicomp Arrhythmia Access Patient Activated Report Page

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