Clinical Case 1 A patient with a syncope Panos E. Vardas President Elect of the ESC, Prof of Cardiology, University Hospital of Crete

Transcription

1 Clinical Case 1 A patient with a syncope Panos E. Vardas President Elect of the ESC, Prof. of Cardiology, University Hospital of Crete

2 Case presentation A 64-year-old male smoker, with arterial hypertension and hypercholesterolaemia was admitted to our department after 3 episodes of syncope while seated during the previous 2 months, without any injuries. The initial evaluation medical history physical examination (mid mid-systolic murmur 2/6) BP measurement in both supine and upright position standard ECG failed to demonstrate the cause of syncope.

3 Work-up Echocardiographic examination Asymmetric septal hypertrophy (IVS= 18 mm) SAM of the mitral valve No LV outflow tract t gradient was evident either at rest or during provocative manoeuvres LV systolic function was normal No symptoms of HF (NYHA Class normal (EF=65 65%) Class I)

4 Evaluation The following tests were performed with no pathological findings tilt test carotid sinus massage carotid and vertebrobasilar ultrasound brain CT scan neurological evaluation Ambulatory ECG monitoring detected Isolated monomorpic venticular ectopy One episode of of supraventricular run (4 beats)

5 Evaluation EP study Negative Myocardial perfusion SPECT revealed RI of the anterior septal and inferior i walls of the LV. Coronary angiogram revealed no significant coronary artery stenosis (stenotic lesions less than 40%). Implantation of a loop recorder (Reveal Plus, Medtrocic Inc.), was then desided

6 one year later The patient experienced a new presyncopal episode while seated.

7 IRL interrogation The device recorded episodes of advanced 2 nd degree AV block while the patient was awake, lasting for 4 seconds

8 So. Based on that finding, we decided to implant a permanent DDDR pacemaker

9 Three years later A new episode of syncope with injury took place, during which h the pacemaker s Holter detected 3 selflimited episodes of VT at arate of 200 beats/min, lasting for 4, 6and 11 seconds On the basis of this new evidence, the pacemaker was replaced with an ICD and since then the patient has remained asymptomatic.

10 Definition Syncope is a transient loss of consciousness (T-LOC) due to transient global cerebral hypoperfusion characterized by rapid onset short duration spontaneous complete recovery

11 Conditions incorrectly diagnosed as syncope

12 Epidemiology of syncope May occur in up to 40% of the population during lifetime ~1% of emergency syncope referrals department to are the for 40% of these are hospitalized Initial evaluation is able to define the cause of syncope in 23 50% of patients Even after tilt-table and EP study, 10% to 26% of patients will remain undiagnosed ESC guidelines 2009

13 Frequency of the causes of syncope according to age ESC guidelines 2009

14 High risk criteria requiring prompt hospitalization or intensive evaluation

15 Gold standard for the diagnosis of syncope Documentation of hemodynamic and electrocardiographic behaviour during a spontaneous syncopal episode

16 Electrocardiographic monitoring Implantable loop recorders Revolution in ambulatory electrocardiography Symptom to rhythm correlation Investigation of the aetiology of unexplained syncope 39-58%: diagnostic yield in patients with/without disease structural heart Second generation ILRs have the ability to be activated either by the patient or abystander after asymptomatic episode to achieve symptom-rhythm correlation to be automatically activated in the case of occurrence of predefined arrhythmias even asymptomatic

17 392 patients t with 3 or more clinically i ll severe syncopal episodes in the last 2years Syncope was documented by ILR in 106 (26%) after amedian of 3 months ILR-based specific therapy Pacemaker 47 ICD 1 Catheter ablation 4 Anti-arrhythmic drug 1 The 1-year recurrence rate in the 53 patients assigned to a specific therapy was 10% In the patients without specific therapy it was 41% The implementation ILR based therapy significantly lowered the syncope recurrence rate, especially in pacemaker patients. Brignole M et al, Eur Heart J 2006

18 ILR in syncope: Where in the workup? In the initial experience, the ILR was used as last resort in the evaluation of syncope after all investigations were negative. However, several studies have shown a poor correlation between the responses of tilt testing, ATP test, EP study and the ECG observation at the time of spontaneous syncope. Limited diagnostic value of short-term term monitoring (Holter, external loop recorder) ECG To date, early usage of the ILR soon in an initial phase of the diagnostic work-up is proposed.

19 ILR in the work-up of T-LOC

20 Indications for ILRs in patients with syncope Class I In an early phase of evaluation of patients with recurrent syncope of uncertain origin who have absence of high-risk criteria that require immediate hospitalization or intensive evaluation a likely recurrence within battery longevity of the device (Level of evidence A) In high-risk patients in whom a comprehensive evaluation did not demonstrate a cause of syncope or lead to specific treatment (Level of evidence B) Class IIa To assess the contribution of bradycardia before embarking on cardiac pacing in patients with suspected or certain neurally mediated syncope presenting with frequent or traumatic syncopal episodes (Level of evidence B) Class IIb In patients with T-LOC of uncertain syncopal origin in order to definitely exclude an arrhythmic mechanism (Level of evidence C)

21 Take-home messages Gold standard d for the diagnosis i of syncope: symptom- rhythm correlation Risk stratification is crucial to identify patients in need of hospitalization or intensive evaluation In cases, when the exact nature of a syncopal episode is vague, long-term heart rhythm monitoring is extremely important Early ILR implantation can be safely performed in the initial phase of the diagnostic evaluation, provided that patients at risk of life-threatening events are carefully excluded. d