La Terapia del Paziente con Sincope La Terapia della Sincope Cardiogena

1. 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

2. 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

3. 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

4. Causes of SyncopePts with or w/out suspected HD Alboni P. J Am Coll Cardiol 2001; 37: 1921

5. 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.

6. Syncope1-year Sudden Death Regarding Cause Sudden Death Rate (%) Kapoor W. Medicine 69:160; 1990

7. 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

8. 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

9. 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

10. 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

11. 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

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

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

14. 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

15. 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

16. 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.).

17. 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

18. 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

19. Comparison of Guidelines for ICD ImplantationSyncope with Inducible Sustained VT/ VF * with Severe Hemodynamic Compromise ^ w/out Severe Hemodynamic Compromise

20. ICD as Secondary Prevention (II) • Patients with- syncope with uncertain origin + inducible VT • Decision must be individualized !!!

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Brugada Syndrome Risk Stratification No Syncope no ECG ECG Syncope ECG + Syncope Priori SG et al. Circulation 105: 1342; 2002

29. Brugada SyndromeAppropriate ICD Shock Antzelevich C. Circulation 2005; 111: 659-670 Sacher F Circulation 2006; 114: 2317-24

30. Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia Corrado D. Circulation 2003; 108: 3084-3091

31. ARVDClinical Characteristics Associated with Appropriate ICD Intervention Triggered by VF Corrado D. Circulation 2003; 108: 3084-3091

32. 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