Sincope - Sito AcEMC · ESC Guidelines on Management of Syncope –Version 2009 Definition Syncope is a transient loss of consciousness (T-LOC), due to transient global cerebraldue

Quello che le lineeguida non dicono: SincopeSincope

Michele BrignoleCentro Aritmologico Ospedali del Tigullio LavagnaCentro Aritmologico, Ospedali del Tigullio, Lavagna

Eur Heart J. 2009 Nov;30(21):2631-71

Available on www escardio org/guidelinesAvailable on www.escardio.org/guidelines

ESC Guidelines on Management of Syncope – Version 2009

DefinitionSyncope is a transient loss of consciousness (T-LOC), due to transient global cerebral hypoperfusiondue to transient global cerebral hypoperfusion, characterized by:• rapid onset, p ,• short duration and • spontaneous complete recovery

No

Clinical presentation

Loss of consciousness?

No

FallsYes Altered consciousness

No

Transient? Onset rapid?

Duration short? Spontaneous

Yes

T LOC

Coma

precovery?

Aborted SCD

Other

T-LOC

Non-traumatic Traumatic

SEpileptic RF ti lSyncopep p

seizure Rare causesFunctional


T‐LOC suspected syncope

Initial assessment:1. History & Physical exam.2. ECG3. Other tests (when appropriate)

Diagnosis ?

YesNo

Treatment

High short‐term risk ?

Y

Treatment

L h i k

Immediate (in‐hospital)evaluation & treatment

YesNo

Low short‐term risk recurrent episodes

YesNo

Laboratory tests and/or specialist’s consultancy, as appropriate

YesNo further evaluation

Delayed treatment guided by ECG documentation

The initial evaluationECG diagnostic criteria

• Vasovagal syncope is diagnosed if precipitating

g

g y p g p p gevents such as fear, severe pain, emotional distress, instrumentation and prolonged standing are associated p g gwith typical prodromal symptoms.

Si i l i di d if• Situational syncope is diagnosed if syncope occurs during or immediately after urination, defecation, cough

ll ior swallowing.

• Orthostatic syncope is diagnosed when there is a• Orthostatic syncope is diagnosed when there is a documentation of orthostatic hypotension associated with syncope or presyncopewith syncope or presyncope.



Syncope due to cardiac arrhythmia is diagnosed in

g

y p y gcase of:

• Symptomatic sinus bradycardia <40 beats/min or y p yrepetitive sinoatrial blocks or sinus pauses >3 s

• Mobitz II 2nd or 3rd degree atrioventricular blockg• Alternating left and right bundle branch block• Rapid paroxysmal supraventricular tachycardia or p p y p yventricular tachycardia

• Pacemaker malfunction with cardiac pausesp



Syncope due to cardiac ischemia

g

Syncope due to cardiac ischemiais diagnosed when symptoms are present with ECG evidence of acute myocardial ischemia withECG evidence of acute myocardial ischemia with or without myocardial infarction, independently of its mechanism (*)its mechanism ( )

* The mechanism can be cardiac (low output or arrhythmia) fl (B ld J i h fl ) b t t i i ilor reflex (Bezold-Jarish reflex), but management is primarily

that of ischemia




Diagnosis ?

YesNo

Treatment


Y

Treatment

L h i k


YesNo


YesNo




ESC guidelines , Eur Heart J 2009 Canadian Cardiovascular Society Position Paper, Can J Cardiol 2011p

Severe structural or coronary artery disease(heart failure, low ejection fraction or previous myocardial infarction)

Heart failure and history of cardiac disease (ischemic, arrhythmic, obstructive, valvular)

myocardial infarction)ECG features suggesting arrhythmic syncope (non‐sustained ventricular tachycardia, bifascicular‐block , inadequate sinus

Abnormal ECG (any bradyarrhythmia, tachyarrhythmia, or conduction disease; new ischemia or old infarct)bifascicular block , inadequate sinus

bradycardia (< 50 bpm) or sino‐atrial block, pre‐excited QRS complex, ECG findings suggesting an inherited disease)

ischemia or old infarct)

an inherited disease) Clinical features suggesting arrhythmic syncope (syncope during exertion or supine, palpitations at the time of syncope, family

Hypotension (systolic blood pressure <90 mmHg)

p p y p , yhistory of sudden cardiac death)Important co‐morbidities:• Severe anaemia

Minor risk factors deserving an urgent specialist assessment: age >60 years,

• Electrolyte disturbancep g y ,dyspnea, anemia (hematocrit <0.30), hypertension, cerebrovascular disease, family history of sudden death <50 years, syncope while supine, syncope during exercise, syncope with no prodromal symptoms



Diagnosis ?

YesNo

Treatment


Y

Treatment

L h i k


YesNo


YesNo




The initial evaluation: diagnostic strategy

I iti l l ti

T-LOC suspected syncope

Initial evaluation

Syncope T-LOCnon syncopal

Certaindiagnosis

Uncertaindiagnosis

non-syncopal

Cardiac unlikely & recurrent episodes

g

Cardiaclikely

Cardiac unlikely & i drecurrent episodes

Ecg monitoring No further

likely

Confirm withCSM

rare episodes

g gEPS

Stress testLoop recorder

fevaluation

fspecific test or specialist’sconsultancy

Tilt testingLoop recorder

p


Diagnostic flow Evaluation of Guidelines

in SYncope Study 2(EGSYS 2)

541541Ph 1

(EGSYS-2)

541541Enrolled & analyzedEnrolled & analyzed

Phase 1Initial evaluation

272 (50%)272 (50%)DiagnosisDiagnosis

269 (50%)269 (50%)No diagnosisNo diagnosis

76 (14%)Dropped-out

193193Completed evaluationCompleted evaluation

Phase 2Investigations

165 (94%)165 (94%)DiagnosisDiagnosis

28 (6%)28 (6%)No diagnosisNo diagnosisgg gg

Eur Heart J 2006; 27: 76–82

The best managementThe best managementEvaluation of Guidelines in SYncope Study 2 The best managementThe best management(EGSYS-2)

Eur Heart J 2006; 27: 76–82

35% 22%54%

78%100%

65% 78%46%

NMS Ortho Hypo Cardiac Non-lsyncopal

Diagnosis at Initial EvaluationDiagnosis at Initial Evaluation

Diagnosis after Initial Evaluation

Questa è la scienza…………

….e nella pratica clinica ?

Il “gap” fra scienza e pratica clinica nellaIl “gap” fra scienza e pratica clinica nellavalutazione del paziente con sincope

www.gimsi.it

In theory, theory and practiceIn theory, theory and practiceIn theory, theory and practice In theory, theory and practice are the same,are the same,but, in practice, they are but, in practice, they are substatially differentsubstatially differentsubstatially differentsubstatially different

AnonimousAnonimous

In-hospital pathwayEvaluation of Guidelines in SYncope Study 2(EGSYS-2)

465465Evaluable patientsEvaluable patients

( )

281 (60%)281 (60%)Discharged from EDDischarged from ED

184 (40%)184 (40%)HospitalizedHospitalized

120 (26%)120 (26%)Management Management of syncopeof syncope

64 (14%)64 (14%)Trauma or Trauma or comorbiditiescomorbiditiesy py p

6 (1 3%)6 (1 3%)6 (1.3%)6 (1.3%)DiedDied

Eur Heart J 2006; 27: 76–82

Syncope in the emergency department of the University of UTAH.

Daccarett et al

Europace 2011 (ahead of print)

Short‐term outcome of syncope in the emergency departmentdepartment

Average data from 14 studies:

Death within 7 30 days: 0 7%Death within 7‐30 days: 0.7%

Non‐fatal severe outcome while in ED 7.5%

Non‐fatal severe outcome in the next 7‐30 days 4.5%

Canadian Cardiovascular Society Position PaperCan J Cardiol, 2011; 27: 246‐253

Faint evaluation at University of Utah Hospital, 2009

Observed Estimated(according to the

algorithm)

Kappavalue

T l N A i A i T lTotal observed

Not appropriate

Appropriate Appropriate not done

Total estimated

Admission 33 36% 64% 9% 23 0.49Diagnosis atDiagnosis at initial evaluation

29 41% 59% 29% 24 0.51

Evaluation of Patients with “Faint” in an American Teaching Hospital: A Dire Need for a Standardized ApproachBrignole, …., Hamdan. PACE 2011; 34:284–290

Evaluation of Guidelines in SYncope Study

ECGTotal 980 patients

95%Blood chemistry

Chest X-rayH lt /E it i

77%

22%27%

Holter/Ecg monitoringCT/MRI scan

Echocardiogram 18%

22%20%

EchocardiogramCarotid sinus massage

EEGC tid h d l

13%13%

11%Carotid echo-dopplerTilt testing

Abdominal echo7%6%

11%

Abdominal echoEP study

Coronary angiographyE i t t

6%2%

1%1%

Useful by ESC guidelinesExercise test 1% Useful by ESC guidelines

Not useful by ESC guidelinesEuropace 2003; 5: 283-291

Faint evaluation at University of Utah Hospital, 2009

Tests Observed Estimated(according to the

algorithm)

Kappavalue

Total observed

Not appropriate

Appropriate Appropriate not done

Total estimated

Echocardiogram 62 65% 35% 15% 26 0.21

CSM 0 0% 0% 100% 26 0.00

Tilt testing 7 43% 57% 91% 44 0.04

Holter 21 62% 38% 11% 9 0 47Holter 21 62% 38% 11% 9 0.47

ELP 20 50% 50% 44% 18 0.42

ILP 3 0% 100% 62% 8 0.52

Stress test 11 36% 74% 42% 12 0.56

EPS 3 67% 33% 83% 6 0.19

Coronary angio 5 20% 80% 0% 4 0 88Coronary angio 5 20% 80% 0% 4 0.88

Brain CT/MRI 22 59% 41% 0% 9 0.52

Evaluation of Patients with “Faint” in an American Teaching Hospital: A Dire Need for a Standardized ApproachBrignole, …., Hamdan. PACE 2011; 34:284–290

Carotid sinus massage by hospital

50th25th 75th maxminta

lsho

spit

SY

S h

EG

0,00% 10,00% 20,00% 30,00% 40,00% 50,00% 60,00% 70,00%Percent patients

12%3%0% 58%23%

Europace 2003; 5: 283-291

Holter/ECG monitoring by hospital


lsho

spit

SY

S h

EG

19% 90%24% 37%0,00% 20,00% 40,00% 60,00% 80,00% 100,00%Percent patients

19%3% 90%24% 37%

Europace 2003; 5: 283-291

Neurally-mediated syncope by hospital


lsho

spit

SY

S h

EG

34%10% 78%43% 56%0,00% 10,00% 20,00% 30,00% 40,00% 50,00% 60,00% 70,00% 80,00% 90,00%Percent patients

34%10% 78%43% 56%

Europace 2003; 5: 283-291

Cardiac syncope by hospital


lsho

spit

SY

S h

EG

8%0% 43%12% 18%0,00% 10,00% 20,00% 30,00% 40,00% 50,00%Percent patients

8%0% 43%12% 18%

Europace 2003; 5: 283-291

Syncope Unit Project (SUP) Limits of current management (I)

Initial diagnosis Assigned diagnosis

Reflex 39 333

OH 3 4

330

1115

Unknown 603311

33

Cardiac

214 16

Non-sycopal5

5

Brignole et al. Europace 2010; 12: 109–118

Syncope Unit Project (SUP) Limits of current management (II)

Diagnosis at initial evaluation

Early diagnosis with tests

No diagnosisn=159

pvalue

n=191 n=541n 159

Age, median 52 67 73 0.001

Males (%) 54% 51% 62% 0.05

Number of syncopes, median 3 3 3 0.12

History of syncope, years 5 3 2 0.001

No prodromes (%) 9% 30% 43% 0.001No prodromes (%) 9% 30% 43%

Structural heart disease (%) 8% 16% 48% 0.001

ECG b liti (%) 9% 21% 47% 0 001ECG abnormalities (%) 9% 21% 47% 0.001

OESIL risk score, median 0 1 2 0.001

EGSYS risk score, median -1 0 2 0.001

Brignole et al. Europace 2010; 12: 109–118

Recurrence of syncopein 398 patients

Evaluation of Guidelines in SYncope Study 2

(EGSYS-2)

1,001,00

in 398 patients(EGSYS 2)

0,95

pe

0,95

pe

0,90

m sy

ncop

0,90

m sy

ncop

0,85

free

from 0,85

free

from

0 75

0,80

urvi

val f arrhythmic

unexplainedstructural heart diseaseneuroreflex0 75

0,80

urvi

val f arrhythmic

unexplainedstructural heart diseaseneuroreflex

arrhythmicunexplainedstructural heart diseaseneuroreflex

0,70

0,75Su neuroreflexorthostatic

0,70

0,75Su neuroreflexorthostaticneuroreflexorthostatic

0 100 200 300 400 500 600 700 800

Days0 100 200 300 400 500 600 700 800

DaysUngar A et al. Eur Heart J 2010

Why should we need a SyncopeManagement Unit ?

• We are not happy with current strategies:t t d di d- not standardized

- inappropriate use of diagnostic tests- high number of misdiagnosishigh number of misdiagnosishigh number of still unexplained syncope.

• Multiple experiences with Syncope Facilitiesshowed:

- improvement in diagnostic yield - cost effectiveness (ie, cost per reliable di i )diagnosis)

Italian Multidisciplinary Group for the Study ofItalian Multidisciplinary Group for the Study of Syncope:

Established in 2003 by 5 national societies:- arrhythmology, - internal medicine, - emergency medicine,

geriatrics

www gimsi it- geriatrics- neurology

www.gimsi.it

Scopi:Scopi:

1- Valutazione standardizzata e continuità di cura dallavalutazione iniziale fino alla terapia ed al follow-up

2- Ridurre il tasso di ospedalizzazione offrendo al paziente2 Ridurre il tasso di ospedalizzazione offrendo al paziente una alternativa diagnostica sicura e ben definita

www gimsi itwww.gimsi.it

GIMSI-certified Syncope Unit:

total 47 (year 2011)total 47 (year 2011)

SINCOPE2 0 1 1

Complete ?

Loss of consciousness: diagnostic flow

Yes, may be syncope No, consider:

FallsTIA, strokeDizzinessPsychogenicDrop attack

Transient, short duration ?Drop attack

ComaIntoxication

Yes, may be syncope No, consider:

Rapid onset ?

Intoxication

MetabolicI i i

Recovery spontaneous, complete and prompt ?

Yes, may be syncope No, consider: IntoxicationsTIA, strokePsychogenic

EpilepsyNo, consider:Yes, may be syncope

Loss of postural tone ?

Yes, may be syncope No, consider: Epilepsy

Syncope likely

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Sincope - Sito AcEMC · ESC Guidelines on Management of Syncope –Version 2009 Definition Syncope is a transient loss of consciousness (T-LOC), due to transient global cerebraldue