EP Summit 2014: Syncope: Admit, Discharge, Tilt, Scan, Monitor or Implant?

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Camille Frazier-Mills, MD

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EP Summit 2014: Syncope: Admit, Discharge, Tilt, Scan, Monitor or Implant?

  1. 1. Syncope: Definition, Etiology, and Evaluation Camille Frazier-Mills, MD MHS Assistant Professor, Clinical Cardiac Electrophysiology January 25, 2014
  2. 2. Disclosures •  None related to this talk All Rights Reserved, Duke Medicine 2007
  3. 3. Overview •  •  •  •  Define syncope Understand the etiology Review diagnostic tools Management All Rights Reserved, Duke Medicine 2007
  4. 4. Syncope Transient LOC due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery Strickberger S A et al. Circulation 2006;113:316-327 European Heart Journal (2009) 30, 2631–2671 All Rights Reserved, Duke Medicine 2007
  5. 5. Syncope Strickberger S A et al. Circulation 2006;113:316-327 European Heart Journal (2009) 30, 2631–2671 All Rights Reserved, Duke Medicine 2007
  6. 6. Syncope European Heart Journal (2009) 30, 2631–2671 All Rights Reserved, Duke Medicine 2007
  7. 7. Background-Syncope •  1-2 million patients annually, with a similar incidence in women and men •  1 % of EM encounters resulting in 30% to 40% subsequent admissions, and costs $2.4 billion annually according to the Medicare database •  Recurrent syncope is associated with significant morbidity, negatively impacting QOL by creating anxiety and disruption of normal activities •  Prognosis after syncope ranges from relatively benign for vasovagal to poor for ventricular tachyarrhythmia Moya A, European Heart J. 2009;30:2631–2671 Soteriades ES, N Engl J Med. 2002;347:878–885. Blanc JJ. Eur Heart J. 2002;23:815–820. Alshekhlee A. Am J Med. 2009;122:181–188. Brignole M, Eur Heart J. 2006;27:76–82. All Rights Reserved, Duke Medicine 2007
  8. 8. Initial Evaluation •  Initial evaluation should answer 3 questions? –  Is it syncope? –  Is there a clear etiology? –  Are there any high risk features? All Rights Reserved, Duke Medicine 2007
  9. 9. Is it syncope? All Rights Reserved, Duke Medicine 2007
  10. 10. Classification of Syncope European Heart Journal (2009) 30, 2631–2671 All Rights Reserved, Duke Medicine 2007
  11. 11. Reflex Syncope •  Cardiovascular reflexes that typically control circulation become intermittently inappropriate in response to a trigger, resulting in vasodilatation and/or bradycardia •  Classified based on the efferent pathway most involved Ø  Vasodepressor: hypotension due to a loss of upright vasoconstrictor tone Ø  Cardioinhibitory bradycardia or asystole predominate Ø  Mixed both mechanisms are present European Heart Journal (2009) 30, 2631–2671 All Rights Reserved, Duke Medicine 2007
  12. 12. Orthostatic Hypotension European Heart Journal (2009) 30, 2631–2671 All Rights Reserved, Duke Medicine 2007
  13. 13. Cardiac Syncope All Rights Reserved, Duke Medicine 2007
  14. 14. Syncope Risk Scores European Heart Journal (2009) 30, 2631–2671 All Rights Reserved, Duke Medicine 2007
  15. 15. •  All Rights Reserved, Duke Medicine 2007 This rule has a 96% sensitivity and 62% specificity for serious outcome. Negative predictive value: 99.2%; positive predictive value 24.8%.
  16. 16. High Risk Features of Syncope Strickberger S A et al. Circulation 2006;113:316-327 European Heart Journal (2009) 30, 2631–2671 All Rights Reserved, Duke Medicine 2007
  17. 17. Outcomes and Syncope Utilizing San Francisco Risk Score Emerg Med J 2007;24:270-275 All Rights Reserved, Duke Medicine 2007
  18. 18. From: The ROSE (Risk Stratification of Syncope in the Emergency Department) Study J Am Coll Cardiol. 2010;55(8):713-721. doi:10.1016/j.jacc.2009.09.049 Figure Legend: The ROSE Rule With “BRACES” Mnemonic Aide Memoire A patient should be considered high-risk and admitted if any of the 7 criteria in the ROSE (Risk stratification Of Syncope in the Emergency department) rule are present. BNP = B-type natriuretic peptide; ECG = electrocardiogram. Date of download: 1/7/2014 All Rights Reserved, Duke Medicine 2007 Copyright © The American College of Cardiology. All rights reserved.
  19. 19. SEEDS Trial •  Inclusion Criteria –  Patients with syncope of undetermined etiology undergoing evaluation in the ED –  Intermediate risk for an adverse cardiovascular outcome –  Met the general guidelines for consideration of hospital admission •  Exclusion Criteria –  Patients with an identified cause of syncope –  Any associated condition that would require hospital admission (bradycardia, tachycardia, acute coronary syndrome, stroke, severe hemorrhage, trauma, motor vehicle accident) –  Nonsyncope syndromes Shen WK, Decker WW, Smars P, et al. Syncope Evaluation in the Emergency Department Study (SEEDS): A multidisciplinary approach to syncope management. Circulation. 2004 Nov 9. All Rights Reserved, Duke Medicine 2007
  20. 20. Shen W K et al. Circulation. 2004;110:3636-3645 All Rights Reserved, Duke Medicine 2007
  21. 21. SEEDS Trial Long-term clinical outcomes Shen W K et al. Circulation. 2004;110:3636-3645 All Rights Reserved, Duke Medicine 2007 Copyright © American Heart Association, Inc. All rights reserved.
  22. 22. SEEDS Trial There was no significant difference between the groups with respect to: survival-free death (P = .30) survival free from recurrent syncope (P = .72) survival free from combined mortality and recurrent syncope (P = .39) Shen WK, Decker WW, Smars P, et al. Syncope Evaluation in the Emergency Department Study (SEEDS): A multidisciplinary approach to syncope management. Circulation. 2004 Nov 9 All Rights Reserved, Duke Medicine 2007
  23. 23. Evaluation •  History, Physical and EKG –  Was it a seizure? If so, consider neuro eval –  Consider non-cardiac causes of syncope: SAH, PE, GI bleed, ruptured aneurysm, dissection –  Are there features to suggest structural or arrhythmic etiology? If so, consider admission Concerning EKG, known CAD, fam HX of SCD, associated palpitations, absence of a prodrome –  Assess EKG for arrhythmia, ischemia, preexcitation, Brugada, HOCM, QTc All Rights Reserved, Duke Medicine 2007
  24. 24. Diagnostic Approach to the Syncopal Patient Copyright © American Heart Association All Rights Reserved, Duke Medicine 2007 Strickberger S A et al. Circulation 2006;113:316-327
  25. 25. Diagnostic Tools •  Orthostatic Assessment –  BP in the supine, sitting, and erect position –  Symptomatic fall from baseline of ≥ 20 mm Hg in SBP, ≥ 10 mm Hg in DBP or a decrease to < 90 mm Hg systolic blood pressure within three minutes of standing when compared with blood pressure from the sitting or supine position. All Rights Reserved, Duke Medicine 2007
  26. 26. Carotid Sinus •  Carotid Sinus Massage –  Massage over the point of maximal carotid impulse for 5-10 seconds on each carotid sinus with a 1-minute interval between massages –  Continuously monitor surface ECG and BP •  Positive result if any of the following 3 criteria are met: –  Asystole exceeding 3 seconds (cardioinhibitory) –  Reduction in SBP exceeding 50 mm Hg independent of heart rate slowing (vasodepressor CSH) –  Combination of the above ( mixed CSH) All Rights Reserved, Duke Medicine 2007
  27. 27. Implantable Loop Recorder •  ISSUE evaluated the mechanism of syncope using the ILR in 4 patient groups: –  Structurally normal hearts with neg tilt test –  tilt test positive patients –  Negative EP study but with a BBB on ECG –  Overt heart disease but with a negative EPS Moya, M, ISSUE Investigators et al.Circulation, 104 (2001), pp. 1261–1267 All Rights Reserved, Duke Medicine 2007
  28. 28. ISSUE Trial •  Asystolic pauses (46% in the negative work up group, 62% in the tilt positive group) •  Sinus arrest or complete HB 89% in negative EPS and BBB pts •  VF rare only 1 pt in structural heart disease and negative EP •  Continuous ILR monitoring was more likely to obtain a diagnosis (55% versus 19%, p = 0.0014) compares to external monitor. Moya, M, ISSUE Investigators et al.Circulation, 104 (2001), pp. 1261–1267 All Rights Reserved, Duke Medicine 2007
  29. 29. Implantable loop recorder in the work-up of transient loss of consciousness (T-LOC). Task Force members et al. Europace 2009;11:671-687 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org All Rights Reserved, Duke Medicine 2007
  30. 30. Tilt Table Testing Indications for Syncope •  Recurrent syncope or single syncopal episode in a high risk patient, whether or not the medical history is suggestive of neurally mediated (vasovagal) origin, and no evidence of structural cardiovascular disease •  Structural cardiovascular disease is present, but other causes of syncope have been excluded by appropriate testing •  Part of the evaluation of exercise-induced or exercise-associated syncope JACC Vol. 28, No. 1July 1996:263–75 All Rights Reserved, Duke Medicine 2007
  31. 31. Tilt Table Testing Indications for Syncope •  Differentiating convulsive syncope from epilepsy in patients with recurrent unexplained loss of consciousness with associated tonic–clonic activity in the setting of repeated normal EEG findings and failure to respond to antiseizure medications •  Evaluating patients (especially the elderly) in whom recurrent falls remain unexplained and in whom a history of premonitory symptoms compatible with vasovagal symptoms is not obtained. All Rights Reserved, Duke Medicine 2007
  32. 32. Tilt Table Relatively Contraindicated •  Syncope with clinically –  Severe left ventricular outflow obstruction –  Critical mitral stenosis –  Critical proximal coronary artery stenoses –  Critical cerebrovascular stenoses All Rights Reserved, Duke Medicine 2007
  33. 33. Tilt Protocols Heart 2000;83:564-569 All Rights Reserved, Duke Medicine 2007
  34. 34. Tilt Table Sensitivity and Reproducibility •  Cleveland Clinic indicated that tilt table testing studies reproduced symptoms in 27 (79%) of 34 patients with previously unexplained syncope •  Raviele et al. observed positive tilt outcomes in 15 (50%) of 30 of unexplained syncope pts •  Sra et al. reported a diagnostic test response in 34 (40%) •  Concordant in 20 (87%) of 23 of patients. All Rights Reserved, Duke Medicine 2007
  35. 35. Duke Clinic for Syncope and Dysautonomia •  Collaborative efforts with Electrophysiology, General Cardiology, Psychiatry and Emergency Medicine for the evaluation and management of syncope and dysautonomia patients •  Improved access for syncope referrals from the ER and community physicians •  Clinic will be staffed by EP MDs, Psychiatry and Sleep Medicine MD and Advanced Practice Providers and a nurse clinician in Duke South Clinic 2F/2G for evaluation and follow up All Rights Reserved, Duke Medicine 2007
  36. 36. Summary •  •  •  •  •  •  Syncope is common Risk stratify (high vs low risk) Is there underlying structural heart disease Utilize appropriate diagnostic tools Treat underlying cause Consider multidisciplinary clinic All Rights Reserved, Duke Medicine 2007
  37. 37. Thank you

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