Simposio: “Diagnostica differenziale, stratificazione del rischio e terapia precoce”

Percorso diagnostico-terapeuticoMichele Brignole

Centro Aritmologico & Syncope Unit, Lavagna

Syncope management facilities:Syncope management facilities:Syncope management facilities:Syncope management facilities:ESC standards ESC standards ESC standards ESC standards

1. Standardized assessment and continuity of

care by a syncope specialist

2. Reducing hospitalization by offering the

patient an alternative evaluation-pathway.

Objectives:Objectives:Objectives:Objectives:

ESC Guidelines on Management of Syncope, 2004

…..a designated Syncope

Unit in the ED…..

Circulation 2004;110:3636-3645

…… strict adherence to

the ESC Guidelines……

Eur Heart J 2006; 27, 76–82

Milestones on syncope management in ED

JACC 2008; 51: 276-283

…… admission favorably

influenced short, but not

long-term outcome……

Transient Loss of Consciousness/Syncope

Presenting to Emergency Department

High Risk or meeting ESC

Guidelines for Admission

Risk Stratification

Low Risk:

Dismiss to home

Suspected or Unexplained

diagnosis

ED Syncope Observational Unit

(In ER up to 6 hours or in

hospital up to 24 hours) *

Out-patient Syncope

Management Unit if appropriate

for diagnosis or treatment **

In-hospital Syncope Management

Unit if appropriate for diagnosis

or treatment **

Brignole & Shen, JACC 2008; 51: 284-7

The “Careggi” model

Ungar A et al. Europace 2015, in press

29% 20%

20%

31%

Sincope (PdCT) inspiegata

Cardiopatia nota e

stabile

Grave cronicità

Assenza di malattia

(sincope isolata)

Cardiopatia di nuova diagnosi

Cardiopatia nota ingravescente

Aritmie

Basso rischio Rischio intermedio Alto rischio

Dimissione

(visita presso la Syncope Unit

in casi specifici)

Valutazione Intensiva in OBI

e/o

Fast track alla Syncope Unit

(per la diagnosi o la terapia)

Ricovero o

Valutazione intensiva in OBI

Fast track alla Syncope Unit

(per la diagnosi)

Percorso diagnostico della sincope (PdCT)

inspiegata dopo valutazione iniziale in DEA

Raccomandazioni di consenso

Equipaggiamento, test e funzioni necessarie per la gestione intensiva

della sincope inspiegata in O.B.I.

Monitoraggio ECG e

pressorio

Acquisire e tenere in memoria per 24 ore il monitoraggio ECG e di

pressione arteriosa intermittente non invasiva (NIP) (*)

Standing testTest dell’ortostatismo con misurazione di pressione arteriosa

intermittente non invasiva (NIP) (*)

Massaggio del seno

carotideo

Possibilità di eseguire il massaggio del seno carotideo in clino ed

ortostatismo durante monitoraggio ECG e pressorio secondo il

“Metodo dei Sintomi” (Linee guida ESC) (**) nei soggetti >50 anni ,

quando indicato

Ecocardiogramma Ottenere un esame ecocardiografico, quando indicato

Esami ematochimici Eseguire esami ematochimici, quando indicato

Syncope Expert

Avere la disponibilità di consulenza (***) da parte di un medico

Esperto in Sincope e attivazione di protocollo condiviso di fast track

verso l’ambulatorio sincope o la Syncope Unit

Consulenze

specialistiche

Avere la disponibilità di consulenza (***) specialistica neurologica,

psichiatrica, geriatrica, cardiologica

Utility of in-hospital

telemetry in patients

with suspected

arrhythmic syncope

Diagnostic yield of 4-week ECG monitoring

Start 0-14 day after syncope

Start 15-30 days after syncope

% 100

90

80

70

60

50

40

30

20

10

0

0 7 14 21 28

Days of monitoring

Locati et . External Prolonged Ecg Monitoring In Unexplained Syncope (in press)

ECG monitoring: importance of early start after index syncope

ECG monitoring and syncope

• In-hospital monitoring

• Holter Monitoring

• External loop recorder

• Remote (at home) telemetry

• Implantable loop recorder

ECG monitoring and syncope

• In-hospital monitoring

• Holter Monitoring

• External loop recorder

• Remote (at home) telemetry

• Implantable loop recorder

Same

positivity

Criteria

Syncope

BV m71, Jan 28, 2011

In-hospital monitoring

28/01/2011 18:22

Risk stratification Risk stratification Risk stratification Risk stratification (at the initial evaluation)

• Indication for ICD or PMIndication for ICD or PMIndication for ICD or PMIndication for ICD or PM (independently of a definite diagnosis of the cause of syncope)• Severe structural or coronary heart diseaseSevere structural or coronary heart diseaseSevere structural or coronary heart diseaseSevere structural or coronary heart disease• Arrhythmic syncope likelyArrhythmic syncope likelyArrhythmic syncope likelyArrhythmic syncope likely

• Important comorbidities Important comorbidities Important comorbidities Important comorbidities (severe anemia, electrolyte disturbances, etc)

High riskHigh riskHigh riskHigh risk

Immediate inImmediate inImmediate inImmediate in----hospital evaluation or early intensive evaluation and hospital evaluation or early intensive evaluation and hospital evaluation or early intensive evaluation and hospital evaluation or early intensive evaluation and treatmenttreatmenttreatmenttreatment

� Syncope during exertion or supine� Palpitations at the time of syncope� Heart failure or low EF� NSVT � BBB� Sinus bradycardia <50 bpm� AV block� WPW, long QT, ARVD, Brugada

Unexplained syncope and….Unexplained syncope and….Unexplained syncope and….Unexplained syncope and….

• Correlation between syncope and an ECG

abnormality (brady- or tachyarrhythmia)

• (In the absence of such a correlation):

- ventricular pause >3 sec during waking state

- periods of Mobitz II 2nd or 3rd degree AV block

during waking state

- rapid paroxysmal atrial/ventricular tachycardia

• Correlation between syncope and sinus rhythm

excludes arrhythmic syncope

Positivity criteria

ECG monitoring and syncope

Hospitalization rates in patients referred to ED for syncope

Author Year ED with standard

practice

ED with with

dedicated

syncopeprotocols

Ammirati , G Ital Cardiol 1999 58% -

Del Greco, It Heart J 2001 53% 42%

Blanc, Eur Heart J 2002 63% -

Disertori, EP 2003 49% 43%

Elesberg , Am Heart J 2005 - 57%

Brignole, EP 2006 47% 39%

Bartoletti, Eur Heart J 2006 - 50%

Shiyovich, Isr Med Ass J 2008 44% -

Daccarett, EP 2011 46% -

Grossman ,J Emerg Med 2012 69% 58%

Ungar A et al. Europace, in press