tues 01 sandhu syncope accrockies accrockies.pdfapplyingsyncope(guidelinestoclinical(practice...

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

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


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.



Initial evaluation




(Class IIa)†


neurogenic OH



TTE (Class IIa)†


Tilt-table testing

(Class IIa)†





Options


(Class I)

EPS (Class IIa)†




Options


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.


Initial evaluation




(Class IIa)†


neurogenic OH



TTE (Class IIa)†


Tilt-table testing

(Class IIa)†





Options


(Class I)

EPS (Class IIa)†




Options


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.


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.


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.

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