Applying Syncope Guidelines to Clinical Practice

Transcription

1 Applying Syncope Guidelines to Clinical Practice ACC Rockies February 27, 2018 Roopinder K Sandhu Associate Professor of Medicine U of A Director of Edmonton Cardiac Arrhythmia Trials Research Group Visiting Scientist Brigham and Women s Hospital

2 Disclosures Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: CCS Bayer Vascular Resident Award Grant Panel Consulting Fees: None

3 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

4 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

5 Next step? A. Troponin B. CT of head C. MRI of head D. ECG

6 EKG

7 A. Tilt table test B. Echocardiogram Any further diagnostic testing? C. Ambulatory external cardiac monitor D. EP Study E. Nothing, history and physical exam enough for diagnosis

8 Management? A. Admit for further cardiac work- up (telemetry and imaging) B. Admit for empirical PPM C. Discharge from ED with education, reassurance and advice for lifestyle modification D. Discharge from ED with prescription of florinef

9 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: Sun et al. Am J Cardiol 2005;95:668-71

10 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope Win- Kuang Shen, MD, FACC, FAHA, FHRS, Chair Robert S. Sheldon, MD, PhD, FHRS, Vice Chair David G. Benditt, MD, FACC, FHRS* Mitchell I. Cohen, MD, FACC, FHRS Daniel E. Forman, MD, FACC, FAHA Zachary D. Goldberger, MD, MS, FACC, FAHA, FHRS Blair P. Grubb, MD, FACC Mohamed H. Hamdan, MD, MBA, FACC, FHRS* Andrew D. Krahn, MD, FHRS* Mark S. Link, MD, FACC Brian Olshansky, MD, FACC, FAHA, FHRS* Satish R. Raj, MD, MSc, FACC, FHRS* Roopinder Kaur Sandhu, MD, MPH Dan Sorajja, MD Benjamin C. Sun, MD, MPP, FACEP Clyde W. Yancy, MD, MSc, FACC, FAHA 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

11 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:

12 Initial Evaluation Transient loss of consciousness* Suspected syncope No Evaluation as clinically indicated Yes Initial evaluation: history, physical examination, and ECG (Class I) Cause of syncope certain Risk assessment Cause of syncope uncertain Treatment Further evaluation COR LOE Recommendation I B- NR I B- NR A detailed history and physical examination should be performed in patients with syncope. In the initial evaluation of patients with syncope, a resting 12- lead ECG is useful.

13 History Syncope Details Comorbidities Medication Use Family history Age of onset, duration of syncope history, number of syncope spells Timeof day, location, position Relationship to eating, situations, following or during exercise Prodromal symptoms and post- event symptoms Existence of preexisting cardiovascular disease Polypharmacy, QT prolonging medication, anti- hypertensives, diuretics etc.. Syncope, sudden death, drownings, recurrent seizures, SIDS, miscarriages

14 Factors Associated with Cardiac and Noncardiac Causes of Syncope Age > 60 years Male sex CARDIAC Presence of ischemic or structural heart disease, prior arrhythmias, reduce LVEF; congenital heart disease Brief prodrome (palpitations) or sudden LOC without prodrome Exertion Supine position Low # of syncope events (1 or 2) Family Hx inheritable condition/ premature SCD (< 50 years) Younger age NONCARDIAC No known cardiac disease Prodrome Specific and situational triggers Standing Positional change Frequent recurrence, prolonged history of syncope

15 Calgary Syncope Score

16 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.

17 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

18 High- risk ECG Features Bennett and Krahn Heart 2015;101:

19 Additional Evaluation

20 Additional Evaluation Syncope additional evaluation and diagnosis Initial evaluation: history, physical exam, ECG (Class I) Initial evaluation clear Initial evaluation unclear Stress testing No additional evaluation needed* Targeted blood testing Initial evaluation suggests neurogenic OH Initial evaluation suggests reflex syncope Initial evaluation suggests CV abnormalities Options TTE EPS Referral for autonomic evaluation Tilt-table testing Cardiac monitor selected based on frequency and nature (Class I) MRI or CT (Class Ilb) Options Implantable cardiac monitor Ambulatory external cardiac monitor

21 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; 20:781-7 Natale et al Circulation. 1995; 92:54-8

22 Tilt- table testing 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope COR LOE IIa B- R IIa B- NR IIa B- NR IIa B- NR If the diagnosis is unclear after initial evaluation, tilt- table testing can be useful for patients with suspected VVS. Tilt- table testing can be useful for patients with syncope and suspected delayed OH when initial evaluation is not diagnostic. Tilt- table testing is reasonable to distinguish convulsive syncope from epilepsy in selected patients. Tilt- table testing is reasonable to establish a diagnosis of pseudosyncope.

23 Additional Evaluation Syncope additional evaluation and diagnosis Initial evaluation: history, physical exam, ECG (Class I) Initial evaluation clear Initial evaluation unclear Stress testing No additional evaluation needed* Targeted blood testing Initial evaluation suggests neurogenic OH Initial evaluation suggests reflex syncope Initial evaluation suggests CV abnormalities Options TTE EPS Referral for autonomic evaluation Tilt-table testing Cardiac monitor selected based on frequency and nature (Class I) MRI or CT (Class Ilb) Options Implantable cardiac monitor Ambulatory external cardiac monitor

24 Implantable Loop Recorders records up to 3 years auto- activation feature triggered by preprogrammed parameters for tachycardia and bradycardia patient activation feature

25 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/pt and $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. Krahn et al. JACC 2003;42:

26 Additional Evaluation Syncope additional evaluation and diagnosis Initial evaluation: history, physical exam, ECG (Class I) Initial evaluation clear Initial evaluation unclear Stress testing No additional evaluation needed* Targeted blood testing Initial evaluation suggests neurogenic OH Initial evaluation suggests reflex syncope Initial evaluation suggests CV abnormalities Options TTE EPS Referral for autonomic evaluation Tilt-table testing Cardiac monitor selected based on frequency and nature (Class I) MRI or CT (Class Ilb) Options Implantable cardiac monitor Ambulatory external cardiac monitor

27 Testing with NO BENEFIT COR LOE Recommendations III: No Benefit III: No Benefit B- NR 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. 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.

28 Vasovagal Syncope

29 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

30 VVS Education on diagnosis and prognosis (Class I) Options Counter pressure maneuvers (Class IIa) Salt and fluid intake (Class IIb) VVS recurs Options Midodrine (Class IIa) Fludrocortisone (Class IIb) Beta blocker (in patients >42 y) (Class IIb) Orthostatic training (Class IIb) Selected serotonin reuptake inhibitors (Class IIb) Dual-chamber pacemaker therapy (Class IIb)

31 B- Blocker use in VVS Cohort Study POST Study Sheldon et al. Circ Arrhythm Electrophysiol 2012;5:

32 Fludrocortisone use in VVS HR: 0.62; 95% CI: 0.40 to 0.95; p= (HR: 0.51; 95% CI: 0.28 to 0.89; p= 0.019) Sheldon et al. JACC 2016;68:1-9.

33 Reflex- Mediated Syncope:PPM Forest Plot of Meta- analysis of Recurrent Syncope (unblinded studies) VVS CSH CSH VVS VVS CSH Varosy et al. JACC 2017;70:

34 Reflex- Mediated Syncope:PPM Forest Plot of Meta- analysis of Recurrent Syncope (double- blinded studies) VVS VVS Varosy et al. JACC 2017;70:

35 Carotid Sinus Hypersensitivity COR LOE Recommendations IIa IIb 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope B- R B- R Permanent cardiac pacing is reasonable in patients with carotid sinus syndrome that is cardioinhibitory or mixed. It may be reasonable to implant a dual- chamber pacemaker in patients with carotid sinus syndrome who require permanent pacing.

36 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope COR LOE Recommendation IIb B- R SR select population of patients 40 years of age or older with recurrent VVS and prolonged Dual- chamber pacing might be reasonable in a spontaneous pauses.

37 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.