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Applying Syncope Guidelines to Clinical Practice
ACC RockiesFebruary 27, 2018 Roopinder K Sandhu
Associate Professor of Medicine U of ADirector of Edmonton Cardiac Arrhythmia Trials Research Group
Visiting Scientist Brigham and Women’s Hospital
Disclosures• Relationships with commercial interests:– Grants/Research Support: None– Speakers Bureau/Honoraria: CCS Bayer Vascular Resident
Award Grant Panel– Consulting Fees: None
Your Patient• A 56 year old male who presents to the ED for evaluation of syncope.
• HPI: woke up in the morning in usual state of health and drove 2 hours to Edmonton to spend Thanksgiving with daughter.
-‐ daughter was giving him a haircut (sitting 1 hour in chair); began to drift off and then felt nauseous – so overwhelming that he told his family; +LOC
-‐ wife who is a nurse lowered him down to the ground; did not feel a pulse and began CPR; 911 called
-‐ 10s regained consciousness; aware but felt tired
Your Patient-‐ EMS pt AAO x 3 115/70 (sit) and 98/58 (stand); felt nauseous again and HR noted from 60’s to 20’s –patient was laid down to ground; no syncope
• Past Med Hx:-‐ no prior episodes of pre-‐syncope or syncope-‐ very active; trip with students to Banff; 8 hour hike-‐ 100% vegan; usually drinks at least 2 L of water a day and that morning 1/3 of a liter and nothing else; Borderline sleep apnea
• ED 146/72 HR 70 (lying); 152/88 HR 88 (standing)-‐ exam normal
Next step?
A. TroponinB. CT of headC. MRI of headD. ECG
EKG
Any further diagnostic testing?
A. Tilt table testB. EchocardiogramC. Ambulatory external cardiac monitorD. EP StudyE. Nothing, history and physical exam enough
for diagnosis
Management?A. Admit for further cardiac work-‐up (telemetry
and imaging)B. Admit for empirical PPMC. Discharge from ED with education,
reassurance and advice for lifestyle modification
D. Discharge from ED with prescription of florinef
The Challenge of Syncope • Syncope may be the final common presentation for a variety of conditions ranging from benign to life-‐threatening and determining etiology can often be challenging.
• This prognostic uncertainty leads to hospitalizations, widespread use of testing and specialist evaluation, often in an unstructured approach.
• In the US, an estimated total annual costs for syncope-‐related admissions were $2.4 billion.
Edvardsson et al. Europace 2011;13:262-‐69.Sun et al. Am J Cardiol 2005;95:668-‐71
Win-‐Kuang Shen, MD, FACC, FAHA, FHRS, Chair†Robert S. Sheldon, MD, PhD, FHRS, Vice Chair
David G. Benditt, MD, FACC, FHRS*‡ Mark S. Link, MD, FACC‡
Mitchell I. Cohen, MD, FACC, FHRS‡ Brian Olshansky, MD, FACC, FAHA, FHRS*‡
Daniel E. Forman, MD, FACC, FAHA‡ Satish R. Raj, MD, MSc, FACC, FHRS*§
Zachary D. Goldberger, MD, MS, FACC, FAHA, FHRS‡ Roopinder Kaur Sandhu, MD, MPH‡
Blair P. Grubb, MD, FACC§ Dan Sorajja, MD‡
Mohamed H. Hamdan, MD, MBA, FACC, FHRS*‡ Benjamin C. Sun, MD, MPP, FACEP║
Andrew D. Krahn, MD, FHRS*§ Clyde W. Yancy, MD, MSc, FACC, FAHA‡¶
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Developed in Collaboration with the American College of Emergency Physicians and Society for Academic Emergency Medicine
Endorsed by the Pediatric and Congenital Electrophysiology Society© American College of Cardiology Foundation, American Heart Association, and the Heart Rhythm Society
Syncope Definition
:is a symptom that presents with abrupt, transient, complete loss of consciousness, associated with inability to maintain postural tone, with rapid and spontaneous recovery.
Shen WK et al. JACC 2017;70:620-‐663.
Transient loss of consciousness*
Suspected syncope
Yes
Evaluation as clinically indicatedNo
Risk assessmentCause of syncope certain
Cause of syncope uncertain
Further evaluationTreatment
Initial evaluation:history, physical examination,
and ECG(Class I)
Initial Evaluation
COR LOE Recommendation
I B-‐NR A detailed history and physical examination should be performed in patients with syncope.
I B-‐NR In the initial evaluation of patients with syncope, a resting 12-‐lead ECG is useful.
HistorySyncope Details Age of onset, duration of syncope history,
number of syncope spellsTime of day, location, positionRelationship to eating, situations, following or during exerciseProdromal symptoms and post-‐event symptoms
Comorbidities Existence of preexisting cardiovascular disease
Medication Use Polypharmacy, QT prolonging medication, anti-‐hypertensives, diuretics etc..
Family history Syncope, sudden death, drownings, recurrent seizures, SIDS, miscarriages
Factors Associated with Cardiac and NoncardiacCauses of Syncope
CARDIACAge > 60 years
Male sexPresence of ischemic or structural heart disease, prior arrhythmias, reduce LVEF; congenital heart diseaseBrief prodrome (palpitations) or sudden LOC without prodromeExertionSupine positionLow # of syncope events (1 or 2)
Family Hx inheritable condition/premature SCD (< 50 years)
NONCARDIACYounger age
No known cardiac disease
ProdromeSpecific and situational triggers
StandingPositional changeFrequent recurrence, prolonged history of syncope
Calgary Syncope Score
Physical Exam• Should include orthostatic blood pressure and heart rate changes in the lying and sitting positions, on immediate standing and after 3 minutes of upright posture.
• Cardiac exam focus on rhythm, presence of murmurs, gallops, rubs and basic neurological exam should be performed.
Carotid Sinus Massage• Triggers baroreceptor reflex
increasing vagal tone affecting SA and AV node.
• Contraindicated: carotid bruit, recent TIA, stroke and MI
• CSM performed in the supine and erect positions with continuous ECG and serial BP monitoring.
• Carotid Sinus Hypersensitivity: ventricular pause > 3 seconds and/or drop in systolic blood pressure > 50 mmHg
High-‐risk ECG Features
Bennett and Krahn Heart 2015;101:1591-‐99.
Additional Evaluation
Additional Evaluation
Initial evaluation
suggests reflex syncope
Initial evaluation unclear
Targeted blood testing
(Class IIa)†
Initial evaluation suggests
neurogenic OH
Initial evaluation suggests CV abnormalities
Referral for autonomic evaluation(Class IIa)†
TTE (Class IIa)†
Stress testing (Class IIa)†
Tilt-table testing
(Class IIa)†
Cardiac monitor selected based on frequency and nature (Class I)
Implantable cardiac monitor(Class IIa)†
Ambulatory external cardiac
monitor (Class IIa)†
Options
Initial evaluation: history, physical exam, ECG
(Class I)
EPS (Class IIa)†
Initial evaluation clear
MRI or CT (Class Ilb)†
No additional evaluation needed*
Options
Syncope additional evaluation and diagnosis
Tilt-‐table testing
• Tilt-‐table testing has moderate sensitivity, specificity and reproducibility; presence of false-‐positive response in controls.
• Utility is highest in patients with VVS when syncope is recurrent (sensitivity 78%–92%).
Grubb, Kosinski D. l. Pacing Clin Electrophysiol. 1997; 20:781-‐7Natale et al Circulation. 1995; 92:54-‐8
Tilt-‐table testing
COR LOE
IIa B-‐RIf the diagnosis is unclear after initial evaluation, tilt-‐table testing can be useful for patients with suspected VVS.
IIa B-‐NRTilt-‐table testing can be useful for patients with syncope and suspected delayed OH when initial evaluation is not diagnostic.
IIa B-‐NRTilt-‐table testing is reasonable to distinguish convulsive syncope from epilepsy in selected patients.
IIa B-‐NR Tilt-‐table testing is reasonable to establish a diagnosis of pseudosyncope.
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Additional Evaluation
Initial evaluation
suggests reflex syncope
Initial evaluation unclear
Targeted blood testing
(Class IIa)†
Initial evaluation suggests
neurogenic OH
Initial evaluation suggests CV abnormalities
Referral for autonomic evaluation(Class IIa)†
TTE (Class IIa)†
Stress testing (Class IIa)†
Tilt-table testing
(Class IIa)†
Cardiac monitor selected based on frequency and nature (Class I)
Implantable cardiac monitor(Class IIa)†
Ambulatory external cardiac
monitor (Class IIa)†
Options
Initial evaluation: history, physical exam, ECG
(Class I)
EPS (Class IIa)†
Initial evaluation clear
MRI or CT (Class Ilb)†
No additional evaluation needed*
Options
Syncope additional evaluation and diagnosis
Implantable Loop Recorders
• records up to 3 years• auto-‐activation feature – triggered by preprogrammed parameters for tachycardia and bradycardia
• patient activation feature
Krahn et al. JACC 2003;42:495-‐501.
• 60 patients with recurrent unexplained syncope or single episode of syncope associated with injury were randomized to conventional testing (external loop, tilt and EPS) versus prolonged monitoring (ILR).
• Primary strategy (ILR) of monitoring dx 47%; $2,731+ $285 cost/ptand $5,852 + $610 cost/dx
• Conventional strategy dx 20%; $1,683 + $505 cost/pt (p=0.0001) and $8,414 + $2,527 cost/dx (p=0.0001).
• The incremental cost-‐effectiveness ratio (ICER) for an ILR strategy of monitoring was $3,930.
Additional Evaluation
Initial evaluation
suggests reflex syncope
Initial evaluation unclear
Targeted blood testing
(Class IIa)†
Initial evaluation suggests
neurogenic OH
Initial evaluation suggests CV abnormalities
Referral for autonomic evaluation(Class IIa)†
TTE (Class IIa)†
Stress testing (Class IIa)†
Tilt-table testing
(Class IIa)†
Cardiac monitor selected based on frequency and nature (Class I)
Implantable cardiac monitor(Class IIa)†
Ambulatory external cardiac
monitor (Class IIa)†
Options
Initial evaluation: history, physical exam, ECG
(Class I)
EPS (Class IIa)†
Initial evaluation clear
MRI or CT (Class Ilb)†
No additional evaluation needed*
Options
Syncope additional evaluation and diagnosis
Testing with NO BENEFIT
COR LOE Recommendations
III: No Benefit B-‐NR
MRI and CT of the head are not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings or head injury that support further evaluation.
III: No Benefit B-‐NR
Carotid artery imaging is not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings that support further evaluation.
Vasovagal Syncope
VVS : syndrome that usually (1) occurs with upright posture held for more than 30s
or with exposure to emotional stress, pain or medical setting;
(2) features diaphoresis, warmth, nausea, pallor; (3) is associated with hypotension and relative
bradycardia, when known; and (4) is followed by fatigue.
Sheldon et al. Heart Rhythm. 2015; 12:e41-‐e63
VVS
Education on diagnosis and prognosis
(Class I)
Counter pressure maneuvers (Class IIa)
Salt and fluid intake
(Class IIb)
VVS recurs
Selected serotonin reuptake inhibitors
(Class IIb)
Midodrine (Class IIa)
Beta blocker (in patients >42 y)
(Class IIb)
Orthostatic training (Class IIb)
Dual-chamber pacemaker therapy
(Class IIb)
Fludrocortisone (Class IIb)
Options
Options
B-‐Blocker use in VVS
Cohort Study POST Study
Sheldon et al. Circ Arrhythm Electrophysiol 2012;5:920-‐26.
Sheldon et al. JACC 2016;68:1-‐9.
HR: 0.62; 95% CI: 0.40 to 0.95; p= 0.029 (HR: 0.51; 95% CI: 0.28 to 0.89; p= 0.019)
Fludrocortisone use in VVS
Reflex-‐Mediated Syncope:PPM
Varosy et al. JACC 2017;70:664-‐679.
Forest Plot of Meta-‐analysis of Recurrent Syncope (unblinded studies)
VVS
VVS
VVS
CSH
CSH
CSH
Varosy et al. JACC 2017;70:664-‐679.
Forest Plot of Meta-‐analysis of Recurrent Syncope (double-‐blinded studies)
VVS
VVS
Reflex-‐Mediated Syncope:PPM
Carotid Sinus Hypersensitivity
COR LOE Recommendations
IIa B-‐RPermanent cardiac pacing is reasonable in patients with carotid sinus syndrome that is cardioinhibitory or mixed.
IIb B-‐R
It may be reasonable to implant a dual-‐chamber pacemaker in patients with carotid sinus syndrome who require permanent pacing.
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
COR LOE Recommendation
IIb B-‐R SRDual-‐chamber pacing might be reasonable in a select population of patients 40 years of age or older with recurrent VVS and prolonged spontaneous pauses.
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Take Home Points• An initial evaluation (detailed history, physical exam
and ECG) can be helpful for diagnosis, risk assessment and disposition.
• Additional testing should be guided by clinical suspicion.
• Treatment for VVS should focus on education, reassurance and conservative therapies.
• Medical treatment and PPM should be considered in select patient sub-‐groups.
Recommended