Setting up and running an effective Syncope Service

Transcription

1 Setting up and running an effective Syncope Service P Boon Lim Consultant Cardiologist and Electrophysiologist Clinical Lead Syncope Diagnostic Unit Imperial College Healthcare NHS Trust Hammersmith Hospital Boon.lim@imperial.nhs.uk

2 Outline Background of the syncope service at Imperial Essential steps in setting up the service How do we ensure early diagnosis: catching people at first episode of syncope Setting up and running an effective syncope service Communicating the service and increasing referrals Current challenges facing syncope services: consultation duration, prescribing off-license medications, clinical trials.

3 The Syncope Unit at Hammersmith, Imperial

4 Personal experience in syncope My Background : Electrophysiology, with PhD on the role of the autonomic nervous system with arrhythmogenesis from at St Mary s Hospital Prof Richard Sutton was TPD, and lead for syncope service Come to understand his interest in tilt testing and pacemaker trials. Became interested in syncope, tilting, role of the intrinsic cardiac autonomic nervous system in syncope

5 Syncope Service at Imperial Service at Imperial was led by Prof Richard Sutton until 2011 Tilt testing 5 days a week ( tilts pa) 2 half time syncope nurse specialists 1 syncope clinic (30 minutes consultation, 5-7 patients per clinic) Pacemaker clinic once a week On completion of PhD, and with appointment to consultant in 2011, I assumed responsibility for syncope service Tilt testing 5 days a week (650 tilts pa currently) 1 full time syncope nurse specialist, and 2 x 1 PA tilt nurse time (shared from arrhythmia nurse pool) 1 syncope clinic Tilt table service (and syncope unit) based at St Mary s until 2013, before move to Hammersmith site

6 Tilt service at Hammersmith Consultant and syncope nurse specialist Tilting 8 to 5, M-F Approx 4-5 tilts a day Referrals growing (was 500 pa, now >650 tilt tests pa)

7 Essential steps in setting up a service 1 Understand current service provision within the trust is there a falls clinic? Is there is neurology clinic with an interest in syncope? Is there a care of elderly specialist with an interest in falls/syncope? Understand synergy / efficiency in different services Speak with colleagues who are already providing service to discuss management and referral pathways

8 Essential steps in setting up a service 2 Understand the requirements of service you are providing is this a mainly tilt-only service? is this a syncope clinic service? is this an integrated service with MAU / A&E?

9 Essential steps in setting up a service 3 Understanding finances important for supporting business case for tilt / syncope services What is projected demand for tilt services? Will CCGs commission and pay for such services? What is the cost of services?

10 Eg. of syncope business case Costs: Pay: Consultant 4 PA x 10K = 40K Nurses 1 WTE = 42K Non-Pay Stationery/Training = 3K Other overheads = 10K Total fixed costs = 95K Startup costs Aircon, refurb, = 7K Tilt table and finapres = 15K Income: Syncope clinic (46 clinics pa x 10pts x 150) = 69K Tilt tests (300 pa x 200) = 60K +/- other clinic (arrhythmia, AF, etc) =? K Total income = 129K

11 Outline Background of the syncope service at Imperial Essential steps in setting up the service How do we ensure early diagnosis: catching people at first episode of syncope Setting up and running an effective syncope service Communicating the service and increasing referrals Current challenges facing syncope services: consultation duration, prescribing off-license medications, clinical trials.

12 How do we ensure early diagnosis: catching people at first episode of syncope Education Colleagues within the trust: A&E, Neurologists, Acute Medical Team, GPs Junior trainees Nursing staff

13 The burden of syncope Syncope is common with prevalence rising with age 1% emergency room admissions Morbidity and mortality rate varies with cause: >20% for cardiac syncope Soteriades ES, et al. Incidence and prognosis of syncope. N Engl J Med. 2002;347: Neurocardiogenic syncope = normal population risk Prompts numerous investigations and high cost burden

14 The initial evaluation for syncope HISTORY, BP measurement ECG Mereu-R, Lim-PB, Auton Neuroscience 2014

15 Table 3. Syncope scores used for objective risk stratification Study Risk factors Scoring system San Francisco Syncope Rule (Quinn et al., 2006) Abnormal ECG Congestive heart failure Shortness of breath Hematocrit <30% Systolic BP <90mmHg Absence of risk factors = low risk Presence of any risk factors = high risk 98% sensitive and 56% specific for serious events at 7 days OESIL Score (Colivicchi et al., 2003) Abnormal ECG History of cardiovascular disease Lack of prodrome Age >65 years Each item scores 1 point Incidence of severe arrhythmias or arrhythmic death at 1 year based on score: Score 0 0% Score 1 5% Score 2 16% Score 3 or 4 27% Mereu-R, Lim-PB, Auton Neuroscience 2014

16 Why is it important to make early diagnosis of syncope? Risk stratification : Cardiac syncope >20% morbidity and mortality Appropriate patient management Avoid extensive investigations / resources used Data from Imperial (Lim et al, Heart Rhythm 2012 abstract) N=492 referred for HUTT (69% +ve diagnosis) but with average of 3 previous tests (excluding ECG) prior to tilt with v v low yields N= 288 echo (normal in 94%), N= 100 MRI brain (normal in 100%) N= 61 EEG (normal in 100%)

17 How do we ensure early diagnosis: catching people at first episode of syncope Integrated care pathway possibility at Medical Admissions Unit of an enhanced tariff for same-day discharges (up to 25% increase) Lends itself well to syncope, SVT, new-onset AF etc Linking the syncope service into MAU patients Providing training for MAU staff to assess and risk stratify syncope patients Falls and blackouts unit

18 Outline Background of the syncope service at Imperial Essential steps in setting up the service How do we ensure early diagnosis: catching people at first episode of syncope Setting up and running an effective syncope service Communicating the service and increasing referrals Current challenges facing syncope services: consultation duration, prescribing off-license medications, clinical trials.

19 An effective syncope service provides clear education in syncope for staff (esp front-line staff) GP training days Junior medical staff training days A&E and MAU training sessions Grand rounds Speciality rounds ie neurology meetings, has clear visibility across trust and appropriate referral pathways understands synergies in services across trust (first-fit clinics, COE falls clinic no duplication of work)

20 Outline Background of the syncope service at Imperial Essential steps in setting up the service How do we ensure early diagnosis: catching people at first episode of syncope Setting up and running an effective syncope service Communicating the service and increasing referrals Current challenges facing syncope services: consultation duration, prescribing off-license medications, clinical trials.

21 Challenges in syncope services

22 Volume / consultation duration History is key to diagnosis Developing a good patient rapport and trusting relationship is key to effective management Management to a great extent involves emphasizing conservative measures (water, salt, evasive action, isometric counter-pressure manouevers)

23 Training and management Registrar training to train? Challenges in large hospital (>20 SpRs, with random allocation to clinic) Having to review every patient New to f/u ratios are higher in specialist syncope clinics. Management support Waiting list/ breach pressures

24 Medications Most medications have a poor evidence base Beta blockers, fludrocortisone, slow sodium tabs used commonly However, midodrine and ivabradine are non-licensed for use to treat syncope in the UK. From experience, nicely worded letter to GP often gets 50-60% rate of GPs to take on prescribing Patients can influence GP prescribing Have to get support of own trust in allowing these off-license prescriptions!

25 Syncope trials pitfalls Mostly single-centre non-placebo controlled observational studies. Difficulties in recruitment across multiple centres There may be recruitment bias due to the difficult syncope patient usually seen in tertiary syncope referral centres (who leads on the trials) These trials usually are designed with pre-specified end-points that are guessed ie what is the extent syncope reduction, and therefore may be underpowered.

26 Other confounders for syncope trials Variable nature of patient symptoms Symptoms may be tied in toe psychological states or unavoidable environmental triggers Treatments are time-sensitive Treatment requires buy-in for patients Compliance may be low due to strict treatment regimen, which may negatively affect outcomes.

27 Prevention of Syncope Trial (POST) RCT of beta blocker vs placebo in syncope N=208 from 5 countries Recruitment lasted 5 years 3 years to publish after final recruitment NO BENEFIT of beta blockers in syncope However subanalysis showed a trend to benefit of beta-blockers in >42yo

28 Prevention of Syncope Trial 2 (POST 2) Trial design published 2005 RCT placebo-controlled trial of fludrocortisone in syncope To-date not been published

29 Other trials - RCT POST 3 Pacemaker vs loop recorder in syncope prevention in patients with bifascicular block and syncope Registered 2011 (still recruiting) POST 4 RCT placebo-controlled trial of Midodrine in syncope Registered 2012 (still recruiting) Midodrine 10mg tds vs placebo Primary outcome: syncope recurrence in 1 year f/u

30 Other trials - RCT POST 5 Assessment of metoprolol 50mg bd in syncope in aging subjects Age >40yo Primary outcome: time to syncope recurrence Enrolment started April 2014 Closed loop stimulation for neuromediated syncope (SPAIN study) May (still ongoing) Randomized double blind study for pacemakers switched to : CLS vs DDI pacing Primary outcome: reduction in syncope events in 1 year. Inclusion: cardioinhibitory response

31 Other trials observational cohort studies SYNC-YOGA Influence of yoga in syncope Primary outcome: frequency of syncope at 3 m and 1 y compared to baseline Enrolled June 12, still ongoing Yoga is not single approach, but involves changes in breathing, physical exercises and meditation Efficacy of transcatheter ablation using anatomic approach of ganglionated plexi located in the right atrium to prevent syncope & Cardioneuroablation for neurocardiogenic syncope (Ablate NCS) Left atrial ablation in efficacy study

32 Summary An effective syncope unit Provides a streamlined referral pathway for patients with syncope Provides education to staff Is visible with synergies with other services within the trust and wider area