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Bradycardia and Syncope
P Boon Lim, MB BChir PhD
Imperial College Healthcare
London, UK
Disclosures
Medtronic: Research Grant
Boston Scientific: Consulting Fee, Research Grant
Biosense Webster: Consulting Fee
St Jude Medical: Consulting fee
Sanofi – Speaker fee for BJCA meeting
Bayer – Speaker fee for BJCA meeting
Bradycardia
Lead II
Q: A 75 yo man had a PPM implant on the ward for 2:1 HB, and has palpitations
the day after implant . What is the diagnosis?
1) Atrial flutter with PPM tracking
2) Atrial tachycardia with PPM tracking
3) Pacemaker mediated tachycardia
4) Ventricular tachycardia
Lead II
Q: Why does this initiate?
1) VA conduction
2) Atrial non-capture
3) PVARP too short
4) All of the above
UR Interval
Vpace
VACT
Asense
Retro P
Vpace
Pacemaker mediated tachycardia
Rate PMT < Upper rateVACT = VA conduction time, AVI = AV interval
AVI
UR Interval
Vpace
VACT
Retro P
AVI
Asense
DDD pacemaker atrial non capture induced
1 5 10 16
Q: Why does this terminate?
1) VA conduction block occurs spontaneously
2) VA conduction for one beat is rapid falling within PVARP
3) PVARP is extended
4) Pacemaker switches to non-atrial sensing mode (VVI)
DDD pacemaker atrial non capture induced
1 5 10 16
Extension PVARPFor 1 cycle
Tachycardia termination algorithm
UR IntervalUR Interval
Vpace
VACT
Asense
Retro P
Vpace
Tachycardia terminating algorithm
VACT = VA conduction time, AVI = AV intervalPVARP + AVI = Total atrial refractory period
AVI
Prolonged AVI
PVARP
VACT
Extended PVARP AVI
Vpace
ApaceP Ingnored
Retro P
Bradycardia
Anatomy of the conducting system - bradycardia
Sinus bradycardia
Sinus arrest
Sick sinus syndrome
Carotid sinus
hypersensitivity1st degree heart block
2nd degree heart block
- Wenkebach
- Mobitz II
3rd degree heart block
Trifascicular block
Sinus bradycardia
Sinus arrest
Sick sinus syndrome
Carotid sinus
hypersensitivity
1st degree heart block
2nd degree heart block
- Wenkebach
-Mobitz II
3rd degree heart block
Trifascicular block
Below AV node:
Fibrosis/disease
LOW THRESHOLD
FOR PACING
Above AV node: Vagal
tone
HIGH THRESHOLD
FOR PACING
Anatomy of the conducting system - bradycardia
Questions: What are these rhythms?
Reversible causes Do not pace
ESC pacing guideline 2013, EHJ
Reversible causes Do not pace
Reversible causes Do not pace
65 yo man received a VVI (single chamber) pacemaker last month but
remains very short of breath. What needs to be done now ?
1. Echocardiogram
2. Upgrade pacemaker to DDD
3. Urgent pacemaker check
4. Upgrade pacemaker to CRTP
65 yo man received a VVI (single chamber) pacemaker last month but
remains very short of breath. What was likely previous underlying rhythm?
1. AF with CHB
2. Atrial flutter with pauses
3. AF with offset pauses
4. Trifascicular block
Q: A 56 yo man with sinus arrest only, with 10 second pauses and
unheralded syncope, with PR interval of 140ms, and otherwise normal 12
lead ECG is recommended for PPM . What device should he receive?
1. AAI pacemaker
2. DDD pacemaker
3. DDD Pacemaker with AV delay management
4. DDDR pacemaker
5. DDDR pacemaker with AV delay management
ESC pacing guideline 2013, EHJ
Q: A 36 yo man with reflex syncope, with 12 second pauses on Holter, with PR interval
of 140ms, and otherwise normal 12 lead ECG is recommended for PPM. Normal and
echo ETT. He is recommended for pacing. What device should he receive?
1. DDD pacemaker
2. DDD pacemaker with AV delay management
3. DDDR pacemaker
4. DDDR pacemaker with AV delay management
5. Do not put in a pacemaker – refer to specialist syncope unit
Q: A 36 yo man with reflex syncope, with 12 second pauses on Holter, with PR
interval of 140ms, and otherwise normal 12 lead ECG is recommended for PPM.
Normal and echo ETT.
What other questions would you ask to determine pace or not?
Q: A 36 yo man with reflex syncope, with a 12 second pause on Holter, with PR
interval of 140ms, and otherwise normal 12 lead ECG is recommended for PPM.
Normal and echo ETT. He is recommended for pacing. What device should he
receive?
What other questions would you ask to determine pace or not?
1. Frequency of symptoms
2. Trigger
3. Warning / prodromal symptoms
4. What was he doing at the time of 12s pause
5. What is hydration / salt state
Shades of grey
Brignole et al, EHJ 2018 Syncope Guidelines
82 yo man presents to GP with unexplained syncope without prodrome with
negative Holter, normal echo and normal tilt. What is next management step?
1. ILR implant
2. PPM insertion
3. EP study
4. 7 day Holter
ESC pacing guideline 2013, EHJ
Old patients with BBB and unexplained syncope after a reasonable work-up might benefit from empirical PM, especially if syncope is unpredictable (with no- or short prodrome) or has occurred in supine positionor during effort.
ESC pacing guideline 2013, EHJ
EP MDT meetings can be useful in grey cases
65yo man with previous MI, EF 34%, with NYHA 3 on best medical
Rx with no syncope – what is next appropriate step ? 1. CRT
2. CRT-D
3. VT stim ? VT to guide therapy
4. Prolonged holter monitoring to look for NSVT
EF <35%
LBBB + QRS >120 CRT
NON-LBBB QRS >150 CRT
NON-LBBB QRS >120 ? CRT
EF <35%
QRS < 120 NO CRT
ESC task force guidance 2013 – CRTP vs CRTD
The evidence from RCTs is insufficient to show the superiority of combined CRT and ICD over CRT
alone. Owing to the potential incremental survival benefit of CRT-D over CRT-P, the prevailing opinion
among the members of this Task Force is in favour of a superiority of CRT-D in terms of total mortality
and sudden death. Nevertheless trial evidence is usually required before a new treatment is used
routinely. In the absence of proven superiority by trials and the small survival benefit, this Task Force is of
the opinion that no strict recommendations can be made, and prefers to merely offer guidance regarding
the selection of patients for CRT-D or CRT-P, based on overall clinical condition, device-related
complications and cost (Tables 17 and 18).
What about patients with EF<35% and permanent AF?
What about patients with EF<35% and permanent AF?
More “greyness” …
Q: A 64yo man has just undergone TAVI, and after d4, remains epicardially-pacing
dependent with an escape junctional rhythm of 37bpm, with good BP with this
escape rhythm with no dizziness. What is next appropriate management?
1. Depends on the day of week
2. Depends on the surgeon
3. DDD Pacemaker insertion
4. Wait until day 7, then reassess, so long as epicardial wires are
checked daily
5. All of the above are reasonable
A 46 yo man with HCM with LVOTO is paced following “unsuccessful septal
alcohol ablation” for post-operative AV block which is now recovering . How
should the pacemaker be set?
1. Minimise Ventricular pacing mode (ie AAI with MVP)
2. DDD-R
3. DDD with long AV delay
4. DDD with short AV delay
Syncope
Syncope and Transient Loss of Consciousness
Brignole et al, EHJ 2018 Syncope Guidelines
Syncope
Syncope = transient loss of consciousness due to global cerebral hypoperfusion
This is usually caused by a combination of:-
• reduced Cardiac output (i.e. Asystole > 6s pause, or BP<60mm Hg)
AND/OR
• reduced peripheral vascular resistance
Brignole et al, EHJ 2018 Syncope Guidelines
Tachycardia (VT)
Bradycardia (CHB)
Structural (AS/HCM)
Channelopathies
(Brugada, Long QT)
ECG
Echo
24h tape
“Other Ix” – cardiac
MRI, ILR, ajmaline
or adrenaline
challenge, EPS
Blood loss
Dehydration
Orthostatic
intolerance(OI) =
inability to
maintain BP on
standing
a) Early OI, initial
BP drop, then
recovery
b) Delayed OI,
common in
elderly due to
inability to
maintain
compensatory
reflexes
c) POTS
Primary and
secondary
autonomic failure
syndromes
Multiple syst atrophy
Parkinson’s
Diabetes, Amyloid
Alcohol, diuretics,
vasodilators
Situational (cough,
sneeze, micturition,
post-prandial /
exercise, laugh)
Carotid sinus syncope
Vasovagal (mediated
by emotional stress,
fear, pain, blood
phobia, orthostatic
stress)
How to diagnose syncope ?
1. History
2. History
3. History(unrushed, with an open trusting patient-physician relationship)
Key points:
Posture immediately before event
Provoking factors (dehydration, warm environment, stress)
Warning symptoms, appearance, colour
Abnormal movements / behaviour
Injury
Confusion after recovery
A 24 yo woman presents with syncope whilst on a flight back from USA. She has
history of childhood syncope. What is the next appropriate management step?
1. History, Echo, ECG, Holter and Tilt test
2. History, Holter, ECG
3. History, BP measurements, physical exam
4. History, active stand, ECG, physical exam
5. History, BP measurements, ECG, physical exam, tilt test
A positive active stand for orthostatic hypotension is:
1. sBP drops >30mm Hg, without symptoms
2. dBP drops >20mm Hg, without symptoms
3. sBP drops >20mm Hg, without symptoms
4. dBP drops >10mm Hg, with symptoms
5. sBP drops <100mm Hg, with symptoms
ESC Recommends active stand during initial evaluation
Risk Stratification
Brignole et al, EHJ 2018 Syncope Guidelines
18 yo man attends clinic, with single episode of syncope after having a shower at the gym, whilst
changing. Felt nauseous, dizzy and lightheaded, and tried to get out of locker to get “fresh air”, but
LOC on way out. Rapid recovery, and not confused after. Had a tendency to postural head rushes
when standing.
Question: “Can I continue driving ?”A) Yes B) No C) No, until assessed and given all clear by syncope specialist.
18 yo man attends clinic, with single episode of syncope 6 weeks ago after having a shower at the
gym, whilst changing. Felt nauseous, dizzy and lightheaded, and tried to get out of locker room to get
“fresh air”, but LOC on way out. Rapid recovery, and not confused after. Had a tendency to postural
head rushes when standing.
Features suggesting uncomplicated faint: 3 P’s
Posture: symptoms related to standing
Provoking factors: phlebotomy, micturition, cough
Prodromal symptoms: sweating, warmth, nausea
Driving in syncope
Reflex syncope = benign, 3P’s
But beware new guidelines : re:
sitting syncope (notify DVLA)
Investigations for syncope
History + clinical examination
Active standing – BP up to 3 minutes standing positive if
symptomatic fall in sBP>20mm Hg
ECG
Investigations for syncope
History + clinical examination
Active standing – BP up to 3 minutes standing positive if
symptomatic fall in sBP>20mm Hg
ECG
THIS MAKES A DIAGNOSIS in >80% CASES, IF DONE
CORRECTLY
Investigations for syncope
History + clinical examination
Active standing – BP up to 3 minutes standing positive if
symptomatic fall in sBP>20mm Hg
ECG
24h tape, echo
Implantable loop recorder
Tilt table test
Tilt testing
Therapy for syncope (largely evidence-free)
Lifestyle measures (6-10g salt, 2-3L fluid, avoid caffeine)
Physical counter-pressure manoeuvres
• Leg crossing, buttock and teeth clenching, tensing of all large muscles in body
• 2 short-term trials, 1 long f/u trial 220pts with long term reduction in syncope
Drugs.
• Beta-blockers, SSRI, disopyramide, scopolamine, ineffective in long term randomised placebo-controlled trials
• Fludrocortisone widely prescribed but no randomised long-term trial, (1 paediatric trial, n=33, which failed to show benefit)
• Midodrine is only drug with evidence base but only v small no pts
Question: “Can I continue driving ?”A) Yes B) No C) No, until assessed and given all clear by syncope specialist.
18 yo man attends clinic, with single episode of syncope 6 weeks ago after having a shower at the gym,
whilst changing. Felt nauseous, dizzy and lightheaded, and tried to get out of locker room to get “fresh
air”, but LOC on way out. Rapid recovery, and not confused after. Had a tendency to postural head
rushes when standing.
But what do you advise?
Therapy for syncope (personal experience)Syncope is not fully “cured” – but patients can cope well with it
Reassurance
Acknowledgement of severity of illness
Understand will have “on” and “off” days
Understanding of pathophysiology
• “Blood pools in legs, heart is empty”
• Important to keep vessels “full”
POTS:
• Physical reconditioning
• Grinch heart – “small” for size
• Low circulating volume – keep working at increasing this over time (salt and water, exercise)
1. A diagnosis of vasovagal syncope can usually be made clearly from the
history, examination and 12 lead ECG
2. Reassurance of a clear diagnosis and simple conservative advice is an
important first-line treatment for patients
3. Pacing is the last resort in syncope, and data only exists for >40yo with
ECG-documented syncopal episodes attributable to bradycardia
Summary
Bradycardia and Syncope
P Boon Lim, MB BChir PhD
Imperial College Healthcare
London, UK