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Syncope expert and additional members
Michele Brignole
Faint & Fall programmeIRCCS Istituto Auxologico, Milano
Syncope expert and additional members
Michele BrignoleIRCCS, Istituto Auxologico
Founder & board member of GIMSI
www.gimsi.it
Syncopeexpert
The 3 concentric circles of an efficient syncope evaluation
• Neurally mediated / reflex
• Orthostatic
• Arrhythmia
• Structural cardiac disease
1
3
2 • Other real TLC / epilepsy
• Apparent TLC
Neurology
Cardiology
Emergency Internal Med Geriatrics
Psychiatry
Who should manage syncope patients?
'By subject' approach
4 • …and when the cause is unclear ?
SINCOPE2 0 1 9
www.gimsi.it
56
38
23
29
2
0 10 20 30 40 50 60
Cardiologia - Aritmologia
Geriatria
Medicina d'Urgenza
Medicina Interna
Neurologia
GIMSI members per discipline (tot=148)
Who should manage syncope patients?
No cooperation = no sense
www.gimsi.it
Who must manage syncope patients?
The Syncope ExpertThe syncope expert is a single physician or the team of
physicians who lead the process of a comprehensive
management of the patient from risk stratification to diagnosis,
therapy and follow-up. They usually perform directly the core
laboratory tests and have preferential access to hospitalization
and any other diagnostic test and eventual therapy.
Syncope management facilities:
ESC standards
ESC Guidelines on Management of Syncope
www.gimsi.it
Syncopeexpert
Syncope & Fall Unit
The 3 concentric circles of an efficient syncope evaluation
www.gimsi.it
Scopi del GIMSI sono:
1. Migliorare il governo clinico del problema sincope (e più in generale delle perdite transitorie di coscienza) attraverso organizzazione di congressi, formazione e divulgazione delle conoscenze scientifiche.
2. Promuovere la costituzione di unità funzionali per lo studio della sincope negli ospedali italiani (cosìdette “Unità Sincope” o “Syncope Unit”) che rispettino i requisiti di qualità stabiliti dalle lineeguida europee e recepiti dal GIMSI.
3. Promuovere attività scientifica e di ricerca attraverso organizzazione di studi clinici.
4. Attuare programmi scientifici in collaborazione con centri ospedalieri nazionali ed internazionali;
5. Promuovere la formazione, la qualificazione e l’aggiornamento nel campo della sincope e delle Perdite Transitorie di Coscienza.
Established in 2003
www.gimsi.it
Established in 2003
GIMSI certified Syncope Unit
2015
Syncope Unit: 69
20092011
2013
www.gimsi.it
Syncope Unit: 21 Syncope Unit: 47 Syncope Unit: 71
SINCOPE2 0 1 9
www.gimsi.it
Abruzzo = 1
Basilicata = 1
Calabria = 2
Campania = 6
Emilia-Romagna = 8
Friuli-Venezia-Giulia = 1
Lazio = 5
Liguria = 4
Lombardia = 13
Marche = 1
Piemonte = 7
Puglia = 4
Sardegna = 2
Sicilia = 3
Toscana = 5
Trentino - Alto Adige = 2
Umbria = 1
Valle d’Aosta = 1
Veneto = 5
Le 72 Syncope Unit certificate
GIMSI 2019
SUP data in perspectivesSyncope Unit Project
(SUP)
How many SU ?
70 GIMSI SU in Italy, year 2017
Optimal
One SU every
150-300.000 inhabitants
(one each ASL/USL/ASST)
Total (in Italy): 200-400 SU
www.escardio.org/EHRA 17
Europace 2015; 17: 1325-40
ESC GUIDELINES
European Heart Journal (2018) 39, 1883–1948
2018 ESC Guidelinesfor the diagnosis and managementof syncope
www.escardio.org/EHRA 19
Europace 2015; 17: 1325-40
Expected benefits of syncope unit:
• SU reduces underdiagnosis and
misdiagnosis of syncope
• SU reduces hospitalization
• SU reduces costs
EHRA Syncope Unit Europace 2015; 17: 1325-40
Organisational aspects: Syncope Unit
EHRA Syncope Unit Europace 2015; 17: 1325-40
Organisational aspects: Syncope Unit
15/16 studies showed that SU
improve diagnoses and reduce
admissions and costs
www.escardio.org/guidelines
Staffing of an SU is composed of:1. One or more physicians of any specialty who are syncope specialists.2. A team comprised of professionals who will advance the care of
syncope patients.
Equipment:
1. Essential Equipment/tests:
– 12-lead ECG and 3-lead ECG monitoring,
– non-invasive beat-to-beat blood pressure monitor,
– tilt-table,
– Holter monitors,
– external loop recorders,
– follow-up of implantable loop recorders (*),
– 24-hour blood pressure monitoring,
– Basic autonomic function tests.
Organizational aspects: Structure of the SU
22
2. Established procedures for:
– Echocardiography
– Electrophysiological studies
– Stress test
– Neuroimaging tests
3. Specialists’ consultancies (cardiology, neurology, internal medicine, geriatric medicine, psychology)
2018 ESC Guidelines on Syncope – Michele brignole & Angel MoyaEHJ Doi:10.1093/eurheartj/ehy037
Initial assessment
History & physical evaluation
12-lead standard ECG
Subsequent tests and assessments (only when indicated)
Blood tests Electrolytes, Haemoglobin, troponin, BNP, glucose, D-dimer,
Hemogasanalysis/O2 saturation,
Provocative tests Carotid sinus massage, Tilt table test
Monitoring External loop recording, Implantable loop recording,
Ambulatory 1-7 days ECG monitoring, 24-48 hour BP
monitoring
Autonomic function
tests
Standing test, Valsalva manoeuvre, deep breathing test,
Cardiac evaluation Established procedures for access to echocardiogram,
stress test, electrophysiological study, coronary angiography
Neurological
evaluation
Established procedures for access to neurological tests (CT,
MRI, EEG, video-EEG)
Geriatric evaluation Established procedures for access to fall risk assessment
(cognitive, gait and balance, visual, environmental)
Psychological or
psychiatric evaluation
Established procedures for access to psychological or
psychiatric consultancy
Test and assessments available in a SU
EHRA Syncope Unit www.escardio.org/EHRA Europace 2015; 17: 1325-40
EHRA Syncope Unit www.escardio.org/EHRA
Procedure or test SUPhysician
SU Staff Non-SUpersonnel
History taking xStructured history taking (e.g., application of software technologies)
x
12-lead ECG xBlood tests xEchocardiogram and imaging xCarotid sinus massage xActive standing test xTilt table test (x) xBasic autonomic function test xECG monitoring (Holter, ELR): administration and interpretation
x x
Implantable loop recorder x (x) Remote monitoring xOthers: stress test, electrophysiological study, angiograms
x
Neurological tests (CT, MRI, EEG, video-EEG) x
Pacemaker and ICD implantation, catheter ablation x
Patient’s education, biofeedback training. and instructions
x x
Final report and clinic note xCommunication with patients, referring physicians x x
Follow-up x x
The role of physician and staff in performing procedures and tests
Europace 2015; 17: 1325-40
Beyond Syncope Unit: the Faint & Fall Centres
Programma Svenimenti e Cadute (Faint & Fall Clinic)
Programma Svenimenti e Cadute (Faint & Fall Clinic)
Pioneering experiences:
• RA Kenny: Day Case Syncope Evaluation Unit,
Newcastle - UK
• RA Kenny: Fall & Syncope Unit (FASU), Dublin, Ireland
• A. Ungar: Syncope and Fall Unit, Florence, Italy
• M. Hamdan: Faint & Fall Clinic, University of Utah and
University of Wisconsin, USA
Non-accidental Accidental
“slip or trip”
Unexplained Fall,“syncope likely”
Explainedi.e., impaired gait/balance,
lower limb joint abnormalities
cognitive status,
visual status
enviroment hazard
drug interaction
Fall
Same evaluation as for
unexplained syncope
Faint(TLOC)
Faint prevention therapy and FU Fall prevention therapy and FU
Neurological consult
Initial presentation
• Syncope(reflex, OI, cardiac)
• Non-syncopal faint(epilepsy, PPS, others)
Programma Svenimenti e Cadute (Faint & Fall Clinic)
Programma Svenimenti e Cadute (Faint & Fall Clinic)
Prospective observational study:
Inclusion: pts >40 yrs with syncope or fall
Aim: Comparison of 100 unexplained fallsand 100 unexplained syncope
Method:Standardized assessment
www.gimsi.it
Syncopeexpert
Syncope & Fall Unit
Referrals & education
The 3 concentric circles of an efficient syncope evaluation
Europace 2015; 17: 1325-40
Which patients ?
Organizing the Management of Syncope
Initial evaluation
Syncope facility
(“Syncope Unit”)
Diagnosis
certain
Dischargeor
Treatment
Syncope-like
condition
Refer to
Neurology/
Psychiatry
as appropriate
Diagnosis
suspected or unexplained
Full access to cardiological and
autonomic tests
and specialists’consultancies
(Emergency dept., In- and out-hospital service, General practitioner)
ESC Guidelines on Syncope
The “Careggi” model
Ungar A et al. Europace, in press
29% 20%
20%
31%
www.escardio.org/guidelines
Should not be dischargedfrom the ED
Any high-riskfeatures require intensive
diagnostic approachShould not be discharged
from the ED
Low-riskfeatures only
Can be dischargeddirectly from the ED
Neitherhigh nor low-risk
Syncope out-patientclinic (SU) (if available)
ED or Hospital SyncopeObservational Unit
(if available)
Any high-riskFeature
Admission for diagnosisor treatment
Syncope(after initial evaluation in ED)
Likely reflex,situational or orthostatic
Ifrecurrent
2018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEHJ Doi:10.1093/eurheartj/ehy037
Referral source
Syncope Unit Project (SUP)
Emergencyroom
Out-hospital
In-hospital
13%60%
11%
16%
Protected discharge
Management
Brignole et al. Europace 2010; 12: 109–118
Setting Incidence
(per 1000
subject-years)
Relative
frequency
(compared to 100
patients with
syncope)
General population 18−40 100
Seeking any medical
evaluation 9.3–9.5 25−50
Referred for specialty
evaluation3.6 10−20
Referred to emergency
department 0.7–1.8 2−10
Syncope frequency depends on the setting in which
the measurement is made
ESC Guidelines on Syncope – Version 2018
Epidemiology
Who should manage syncope patients?
'By process' approach
Who makes the decisions now?
... but when it is unclear?
• General practioner?
• Ambulance staff? Triage nurses? ER physicians?• Referral easy when cause is evident
o Epilepsy neurologyoArrhythmia cardiologyoPseudo-unconsciousness psychiatryoSyncope in Parkinson or MSA neurology
Education
Education
Education
www.gimsi.it
Basic Competence on Syncope Course
The role of GIMSI …
… organize training activities, such as continuing educational courses, dedicated to physicians and health-care professionals working in the field of
syncope
Certified physicians
Since September 2014
29 training course to date
620 GIMSI certified physicians
www.gimsi.it
1- The tilt testing laboratory
2- The VVS clinic
3- The disautomia laboratory
4- The epilepsy clinic
5- etc, etc…..
What is not SU ?
www.gimsi.it
1- the right physician: syncope specialist
2- the right place: adequate equipment, including
on-line prompting tool, and logistic
3- the right time: optimal organization (fast track,
on-site preferential access to specialized tests)
What is SU ?
