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
ESC Guidelines on Management of Syncope – Version 2009
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.
ESC Guidelines on Management of Syncope – Version 2009
The initial evaluationECG diagnostic criteria
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
ESC Guidelines on Management of Syncope – Version 2009
The initial evaluationECG diagnostic criteria
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
ESC Guidelines on Management of Syncope – Version 2009
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
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
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 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
ESC Guidelines on Management of Syncope – Version 2009
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
50th25th 75th maxminta
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
50th25th 75th maxminta
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
50th25th 75th maxminta
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 misdiagnosis- high 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