Bradycardia and Syncope. P Boon Lim, MB BChir PhD Imperial College Healthcare London, UK

Transcription

1 Bradycardia and Syncope P Boon Lim, MB BChir PhD Imperial College Healthcare London, UK

2 Disclosures Medtronic: Research Grant Boston Scientific: Consulting Fee, Research Grant Biosense Webster: Consulting Fee St Jude Medical: Consulting fee Sanofi Speaker fee for BJCA meeting Bayer Speaker fee for BJCA meeting

3 Bradycardia

4 Q: A 75 yo man had a PPM implant on the ward for 2:1 HB, and has palpitations the day after implant. What is the diagnosis? 1) Atrial flutter with PPM tracking 2) Atrial tachycardia with PPM tracking 3) Pacemaker mediated tachycardia 4) Ventricular tachycardia Lead II

5 Q: Why does this initiate? 1) VA conduction 2) Atrial non-capture 3) PVARP too short 4) All of the above Lead II

6 Pacemaker mediated tachycardia UR Interval UR Interval VACT VACT Retro P Retro P AVI AVI Asense Asense Vpace Vpace Vpace Rate PMT < Upper rate VACT = VA conduction time, AVI = AV interval

7 Q: Why does this terminate? DDD pacemaker atrial non capture induced 1) VA conduction block occurs spontaneously 2) VA conduction for one beat is rapid falling within PVARP 3) PVARP is extended 4) Pacemaker switches to non-atrial sensing mode (VVI)

8 DDD pacemaker atrial non capture induced Extension PVARP For 1 cycle Tachycardia termination algorithm

9 Tachycardia terminating algorithm UR Interval UR Interval PVARP Extended PVARP AVI VACT VACT Retro P Retro P AVI Prolonged AVI Asense P Ingnored Apace Vpace Vpace Vpace VACT = VA conduction time, AVI = AV interval PVARP + AVI = Total atrial refractory period

10 Bradycardia

11 Anatomy of the conducting system - bradycardia Sinus bradycardia Sinus arrest Sick sinus syndrome Carotid sinus hypersensitivity 1st degree heart block 2nd degree heart block - Wenkebach - Mobitz II 3rd degree heart block Trifascicular block

12 Anatomy of the conducting system - bradycardia Sinus bradycardia Sinus arrest Sick sinus syndrome Carotid sinus hypersensitivity 1st degree heart block 2nd degree heart block - Wenkebach Above AV node: Vagal tone HIGH THRESHOLD FOR PACING Below AV node: Fibrosis/disease LOW THRESHOLD FOR PACING -Mobitz II 3rd degree heart block Trifascicular block

13 Questions: What are these rhythms?

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15 Reversible causes Do not pace ESC pacing guideline 2013, EHJ

16 Reversible causes Do not pace Reversible causes Do not pace

17 65 yo man received a VVI (single chamber) pacemaker last month but remains very short of breath. What needs to be done now? 1. Echocardiogram 2. Upgrade pacemaker to DDD 3. Urgent pacemaker check 4. Upgrade pacemaker to CRTP

18 65 yo man received a VVI (single chamber) pacemaker last month but remains very short of breath. What was likely previous underlying rhythm? 1. AF with CHB 2. Atrial flutter with pauses 3. AF with offset pauses 4. Trifascicular block

19 Q: A 56 yo man with sinus arrest only, with 10 second pauses and unheralded syncope, with PR interval of 140ms, and otherwise normal 12 lead ECG is recommended for PPM. What device should he receive? 1. AAI pacemaker 2. DDD pacemaker 3. DDD Pacemaker with AV delay management 4. DDDR pacemaker 5. DDDR pacemaker with AV delay management

20 ESC pacing guideline 2013, EHJ

21 Q: A 36 yo man with reflex syncope, with 12 second pauses on Holter, with PR interval of 140ms, and otherwise normal 12 lead ECG is recommended for PPM. Normal and echo ETT. He is recommended for pacing. What device should he receive? 1. DDD pacemaker 2. DDD pacemaker with AV delay management 3. DDDR pacemaker 4. DDDR pacemaker with AV delay management 5. Do not put in a pacemaker refer to specialist syncope unit

22 Q: A 36 yo man with reflex syncope, with 12 second pauses on Holter, with PR interval of 140ms, and otherwise normal 12 lead ECG is recommended for PPM. Normal and echo ETT. What other questions would you ask to determine pace or not?

23 Q: A 36 yo man with reflex syncope, with a 12 second pause on Holter, with PR interval of 140ms, and otherwise normal 12 lead ECG is recommended for PPM. Normal and echo ETT. He is recommended for pacing. What device should he receive? What other questions would you ask to determine pace or not? 1. Frequency of symptoms 2. Trigger 3. Warning / prodromal symptoms 4. What was he doing at the time of 12s pause 5. What is hydration / salt state

24 Shades of grey Brignole et al, EHJ 2018 Syncope Guidelines

25 82 yo man presents to GP with unexplained syncope without prodrome with negative Holter, normal echo and normal tilt. What is next management step? 1. ILR implant 2. PPM insertion 3. EP study 4. 7 day Holter

26 ESC pacing guideline 2013, EHJ

27 Old patients with BBB and unexplained syncope after a reasonable work-up might benefit from empirical PM, especially if syncope is unpredictable (with no- or short prodrome) or has occurred in supine position or during effort. ESC pacing guideline 2013, EHJ

28 EP MDT meetings can be useful in grey cases

29 65yo man with previous MI, EF 34%, with NYHA 3 on best medical Rx with no syncope what is next appropriate step? 1. CRT 2. CRT-D 3. VT stim? VT to guide therapy 4. Prolonged holter monitoring to look for NSVT

30 EF <35% LBBB + QRS >120 CRT

31 EF <35% NON-LBBB QRS >150 CRT NON-LBBB QRS >120? CRT

32 QRS < 120 NO CRT

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34 ESC task force guidance 2013 CRTP vs CRTD The evidence from RCTs is insufficient to show the superiority of combined CRT and ICD over CRT alone. Owing to the potential incremental survival benefit of CRT-D over CRT-P, the prevailing opinion among the members of this Task Force is in favour of a superiority of CRT-D in terms of total mortality and sudden death. Nevertheless trial evidence is usually required before a new treatment is used routinely. In the absence of proven superiority by trials and the small survival benefit, this Task Force is of the opinion that no strict recommendations can be made, and prefers to merely offer guidance regarding the selection of patients for CRT-D or CRT-P, based on overall clinical condition, device-related complications and cost (Tables 17 and 18).

35 What about patients with EF<35% and permanent AF?

36 What about patients with EF<35% and permanent AF?

37 More greyness

38 Q: A 64yo man has just undergone TAVI, and after d4, remains epicardially-pacing dependent with an escape junctional rhythm of 37bpm, with good BP with this escape rhythm with no dizziness. What is next appropriate management? 1. Depends on the day of week 2. Depends on the surgeon 3. DDD Pacemaker insertion 4. Wait until day 7, then reassess, so long as epicardial wires are checked daily 5. All of the above are reasonable

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40 A 46 yo man with HCM with LVOTO is paced following unsuccessful septal alcohol ablation for post-operative AV block which is now recovering. How should the pacemaker be set? 1. Minimise Ventricular pacing mode (ie AAI with MVP) 2. DDD-R 3. DDD with long AV delay 4. DDD with short AV delay

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42 Syncope

43 Syncope and Transient Loss of Consciousness Brignole et al, EHJ 2018 Syncope Guidelines

44 Syncope Syncope = transient loss of consciousness due to global cerebral hypoperfusion This is usually caused by a combination of:- reduced Cardiac output (i.e. Asystole > 6s pause, or BP<60mm Hg) AND/OR reduced peripheral vascular resistance

45 Brignole et al, EHJ 2018 Syncope Guidelines

46 Tachycardia (VT) Bradycardia (CHB) Structural (AS/HCM) Channelopathies (Brugada, Long QT) ECG Echo 24h tape Other Ix cardiac MRI, ILR, ajmaline or adrenaline challenge, EPS

47 Blood loss Dehydration Orthostatic intolerance(oi) = inability to maintain BP on standing a) Early OI, initial BP drop, then recovery b) Delayed OI, common in elderly due to inability to maintain compensatory reflexes c) POTS

48 Primary and secondary autonomic failure syndromes Multiple syst atrophy Parkinson s Diabetes, Amyloid Alcohol, diuretics, vasodilators

49 Situational (cough, sneeze, micturition, post-prandial / exercise, laugh) Carotid sinus syncope Vasovagal (mediated by emotional stress, fear, pain, blood phobia, orthostatic stress)

50 How to diagnose syncope? 1. History 2. History 3. History (unrushed, with an open trusting patient-physician relationship) Key points: Posture immediately before event Provoking factors (dehydration, warm environment, stress) Warning symptoms, appearance, colour Abnormal movements / behaviour Injury Confusion after recovery

51 A 24 yo woman presents with syncope whilst on a flight back from USA. She has history of childhood syncope. What is the next appropriate management step? 1. History, Echo, ECG, Holter and Tilt test 2. History, Holter, ECG 3. History, BP measurements, physical exam 4. History, active stand, ECG, physical exam 5. History, BP measurements, ECG, physical exam, tilt test

52 A positive active stand for orthostatic hypotension is: 1. sbp drops >30mm Hg, without symptoms 2. dbp drops >20mm Hg, without symptoms 3. sbp drops >20mm Hg, without symptoms 4. dbp drops >10mm Hg, with symptoms 5. sbp drops <100mm Hg, with symptoms

53 ESC Recommends active stand during initial evaluation

54 Risk Stratification Brignole et al, EHJ 2018 Syncope Guidelines

55 18 yo man attends clinic, with single episode of syncope after having a shower at the gym, whilst changing. Felt nauseous, dizzy and lightheaded, and tried to get out of locker to get fresh air, but LOC on way out. Rapid recovery, and not confused after. Had a tendency to postural head rushes when standing.

56 Question: Can I continue driving? A) Yes B) No C) No, until assessed and given all clear by syncope specialist. 18 yo man attends clinic, with single episode of syncope 6 weeks ago after having a shower at the gym, whilst changing. Felt nauseous, dizzy and lightheaded, and tried to get out of locker room to get fresh air, but LOC on way out. Rapid recovery, and not confused after. Had a tendency to postural head rushes when standing.

57 Features suggesting uncomplicated faint: 3 P s Posture: symptoms related to standing Provoking factors: phlebotomy, micturition, cough Prodromal symptoms: sweating, warmth, nausea

58 Driving in syncope Reflex syncope = benign, 3P s But beware new guidelines : re: sitting syncope (notify DVLA)

59 Investigations for syncope History + clinical examination Active standing BP up to 3 minutes standing positive if symptomatic fall in sbp>20mm Hg ECG

60 Investigations for syncope History + clinical examination Active standing BP up to 3 minutes standing positive if symptomatic fall in sbp>20mm Hg ECG THIS MAKES A DIAGNOSIS in >80% CASES, IF DONE CORRECTLY

61 Investigations for syncope History + clinical examination Active standing BP up to 3 minutes standing positive if symptomatic fall in sbp>20mm Hg ECG 24h tape, echo Implantable loop recorder Tilt table test

62 Tilt testing

63 Therapy for syncope (largely evidence-free) Lifestyle measures (6-10g salt, 2-3L fluid, avoid caffeine) Physical counter-pressure manoeuvres Leg crossing, buttock and teeth clenching, tensing of all large muscles in body 2 short-term trials, 1 long f/u trial 220pts with long term reduction in syncope Drugs. Beta-blockers, SSRI, disopyramide, scopolamine, ineffective in long term randomised placebo-controlled trials Fludrocortisone widely prescribed but no randomised long-term trial, (1 paediatric trial, n=33, which failed to show benefit) Midodrine is only drug with evidence base but only v small no pts

64 Question: Can I continue driving? A) Yes B) No C) No, until assessed and given all clear by syncope specialist. 18 yo man attends clinic, with single episode of syncope 6 weeks ago after having a shower at the gym, whilst changing. Felt nauseous, dizzy and lightheaded, and tried to get out of locker room to get fresh air, but LOC on way out. Rapid recovery, and not confused after. Had a tendency to postural head rushes when standing. But what do you advise?

65 Therapy for syncope (personal experience) Syncope is not fully cured but patients can cope well with it Reassurance Acknowledgement of severity of illness Understand will have on and off days Understanding of pathophysiology Blood pools in legs, heart is empty Important to keep vessels full POTS: Physical reconditioning Grinch heart small for size Low circulating volume keep working at increasing this over time (salt and water, exercise)

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72 Summary 1. A diagnosis of vasovagal syncope can usually be made clearly from the history, examination and 12 lead ECG 2. Reassurance of a clear diagnosis and simple conservative advice is an important first-line treatment for patients 3. Pacing is the last resort in syncope, and data only exists for >40yo with ECG-documented syncopal episodes attributable to bradycardia

73 Bradycardia and Syncope P Boon Lim, MB BChir PhD Imperial College Healthcare London, UK