Syncope in Heart Failure Patients How to judge and treat? Jean-Claude Deharo, MD, FESC Marseilles, France
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1 Syncope in Heart Failure Patients How to judge and treat? Jean-Claude Deharo, MD, FESC Marseilles, France
2 Syncope in advanced heart failure: high risk of sudden death N = 491 patients with HF (NYHA III-IV) ICM: 48% 60 pts 431 pts Middlekauff et al., JACC 1993
3 Syncope in advanced heart failure: causes N = 60 patients with HF (NYHA III-IV) and syncope ICM: 45% / LVEF: 21±7% Cardiac N = 29 (48%) Non Cardiac N = 31 (52%) VT = 21 pts Bradyarrhythmias = 5 pts SVT = 1 pt Valvular stenosis = 2 pts Orthostatic = 9 pts Situational = 3 pts Neurologic = 1 pt Undetermined = 18 pts Middlekauff et al., JACC 1993
4 Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope N = 60 patients with HF (NYHA III-IV) and syncope 31 pts 29 pts Middlekauff et al., JACC 1993
5 CAD patients with syncope: influence of inducibility on survival N = 67 patients with CAD LV EF: 39±11% Mittal et al., JACC 1999
6 Value of inducible VF in CAD patients with syncope N = 118 patients with CAD LV EF: 37±13% Mittal et al., JACC 2001
7 Role of ICD in patients with syncope and SHD N = 52 patients with syncope CAD 71% / ICD in inducible patients (N=13) Pezawas et al., Europace 2003
8 Difference in mechanisms and outcomes of syncope in CAD and Idiopathic LV dysfunction NICM / N= 61 pts Days ICM / N= 119 pts Brembillat Perrot et al., JACC 2004
9 Difference in mechanisms and outcomes of syncope in CAD and Idiopathic LV dysfunction ICM / N= 119 pts Inducibility predicts death NICM / N= 61 pts LVEF predicts death Brembillat Perrot et al., JACC 2004
10 Role of ICD therapy in patients with syncope and HF due to NICM N = 147 NICM pts with severe HF and syncope Fonarow et al., Am J Cardiol 2000
11 Amiodarone or an ICD for congestive heart failure (The SCD-HeFT study) Median LV EF = 25% Bardy GH et al., NEJM 2008
12 SCD-HeFT subanalysis: pts with syncope (6% before / 14% after randomization / 2% both) Olshansky et al., JACC 2008
13 SCD-HeFT subanalysis: pts with syncope in the ICD arm 811 pts randomized to ICD 52 pts (6%) had syncope before randomization 759 pts (94%) no syncope before randomization 20 (38%) appropriate ICD shock HR = 1.75, p = (20%) appropriate ICD shock Olshansky et al., JACC 2008
14 SCD-HeFT subanalysis: pts with syncope (6% before / 14% after randomization / 2% both) Syncope before randomization: no increased risk of death Syncope after randomization: increased risk of death Syncope s association with death independently of randomization arm Olshansky et al., JACC 2008
15 ICD indication in patients with syncope and a high risk of sudden cardiac death Ischemic cardiomyopathy with low LVEF or HF refer to ICD / CRT guidelines Non-ischemic cardiomyopathy with low LVEF or HF refer to ICD / CRT guidelines I, A I, A HCM / ARVD: therapy if high risk IIa, C More apppropriate ICD shocks in syncope patients Brugada ICD does type not I: protect ICD from syncope recurrence IIa, B Syncope recurrence carries a higher risk of death Long QT: ICD (+ b-) if high risk IIa, B Moya et al., ESC guidelines 2009
16 ILR for syncope in patients with heart disease (compared to those no heart disease) Previous MI : 12 NICM : 6 Other : 20 Solano et al., Eur Heart J, 2004
17 % free from syncope ILR for syncope in patients with heart disease (compared to those no heart disease) SHD No SHD p = ns Months Solano et al., Eur Heart J, 2004
18 ILR for syncope in patients with heart disease (compared to those no heart disease) ILR final diagnosis * SHD: 1 sudden cardiac death Solano et al., Eur Heart J, 2004
19 ILR for syncope in patients with heart disease (compared to those no heart disease) ILR guided therapy * Solano et al., Eur Heart J, 2004
20 % syncope-free Mechanism of syncope in patients with heart disease and negative electrophysiologic test Heart disease (N=35) LVEF 47%±17% Tilt positive Isolated BBB Log rank p=0.04 Months Menozzi et al., Circulation 2002
21 Mechanism of syncope in patients with heart disease and negative electrophysiologic test No death No severe traumatism ILR-guided therapy: PM : 3 pts ICD : 1 pt AAR drugs : 4 pts Menozzi et al., Circulation 2002
22 Male, 61 y., Traumatic syncope
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24 LV EF 40%
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26
27
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29 Male, 42 y., repeated syncopes
30 LV EF 40-45%
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32 HF patients with syncope Situations in which there is a clear indication for ICD independently of the symptom ICD (but ICD does not protect from syncope recurrences and syncope per se carries a high risk of death) When there is no independent indication for an ICD (intermediate risk), careful investigation may be followed by ILR implant in selected cases In all cases, agressive investigation and treatment of the underlying heart disease is made more necessary in case of syncope
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