Improving Patient Outcomes with a Syncope Center. Suneet Mittal, MD

Transcription

1 Improving Patient Outcomes with a Syncope Center Suneet Mittal, MD

2 Improving Patient Outcomes with a Syncope Center: Early Risk Stratification of Patients who Require Device Therapy Suneet Mittal, MD Director, Electrophysiology Laboratory The Arrhythmia Institute at The Valley Hospital Associate Professor of Clinical Medicine Columbia University College of Physicians & Surgeons May 5, 2012

3 Relationship Name of Commercial Company Consulting Fees/Honoraria Speakers Bureau Equity Interests/Stock Options Equity Interests Royalty Income Non-Royalty Payments Officer, Director, or In Any Other Fiduciary Role Ownership/Partnership/Principal Research Grants Fellowship Support Salary Ownership/Partnership/Principal Biosense Webster, Biotronik, Boehringer Ingelheim, Boston Scientific, Daiichi Sankyo, Medtronic, Scottcare None Topera Medical None None None None None Biosense Webster None None None

4 DIAGNOSIS RISK STRATIFICATION

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7 Brignole et al. Heart 2007; 93:

8 Absent Present Structural Heart Disease vasovagal (POTS) (non-cardiac) Age (years)

9 Calgary Syncope Symptom Score Distinguishes between VVS syncope and syncope due to other causes in patients without structural heart disease Scoring criteria History of one of the following: bifascicular block, asystole, supraventricular tachycardia, diabetes (-5) Bystander noted patient tuned blue with faint (-4) Syncopal episodes started at age 35 years or older (-3) Any memory of being unconsciousness (-2) Pre-syncope or syncope with prolonged sitting or standing (+1) Pre-syncope or syncope with pain or in medical settings (+3) If the total point score is -2, the point score correctly diagnosis patients with VVS with 89% sensitivity and 91% specificity Sheldon R et al Eur Heart J 2006; 27:

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11 Initial Triage Patients at high risk for major CV events or SCD need intensive evaluation or prompt hospitalisation: Severe structural or coronary artery disease Heart failure; low ejection fraction; previous myocardial infarction Clinical or ECG features suggesting arrhythmic syncope Syncope during exertion or while supine Palpitations at the time of syncope Family history of sudden cardiac death Non-sustained VT Bifascicular block Inadequate sinus bradycardia Pre-excited QRS complex; short or prolonged QT interval; RBBB pattern with ST elevation (Brugada pattern); negative T waves in right precordial leads, epsilon waves, ventricular late potentials (suggestive of ARVC) Important co-morbidities Severe anemia Electrolytic disturbance Moya et al Eur Heart J. doi: /eurheartj/ehp298

12 Demographics of the Study Population Patients, n 200 Age, years 69 ± 17 Gender, male 103 (52%) Prior syncope 75 (28%) Existing medical conditions Hypertension 127 (64%) Diabetes mellitus 58 (29%) Coronary artery disease 49 (25%) Prior CVA 23 (12%) Existing implantable devices Pacemaker 5 (3%) ICD 10 (5%)

13 Baseline ECG Data Rhythm Sinus 182 (91%) Atrial fibrillation 14 (7%) Paced 9 (5%) Conduction disease RBBB 4 (2%) RBBB + LAFB 4 (2%) LBBB 6 (3%)

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15 Absent Present Structural Heart Disease Brugada syndrome hypertrophic cardiomyopathy short or long QT syndrome ventricular tachycardia or ventricular fibrillation MADIT-II DEFINITE SCD-HeFT Age (years)

16 Absent Present Structural Heart Disease vasovagal (POTS) (non-cardiac) Brugada syndrome hypertrophic cardiomyopathy short or long QT syndrome ventricular tachycardia or ventricular fibrillation sinus node, AV node, and/or His-Purkinje system dysfunction (CSH) (OH) Age (years)

17 ESC Syncope Guidelines: Recommendations for ECG Monitoring Class I (Indications) An early phase of evaluation in patients with recurrent syncope of uncertain origin, absence of high risk criteria, and a high likelihood of recurrence within battery longevity of the device Moya et al Eur Heart J. doi: /eurheartj/ehp298

18 ESC Syncope Guidelines: Recommendations for ECG Monitoring Class I (Indications) An early phase of evaluation in patients with recurrent syncope of uncertain origin, absence of high risk criteria, and a high likelihood of recurrence within battery longevity of the device High risk patients in whom a comprehensive evaluation did not demonstrate a cause of syncope or lead to a specific treatment Moya et al Eur Heart J. doi: /eurheartj/ehp298

19 ESC Syncope Guidelines: Recommendations for ECG Monitoring Class IIa (Indications) An ILR should be considered to assess the contribution of bradycardia before embarking on cardiac pacing in patients with suspected or certain reflex syncope presenting with frequent or traumatic syncopal episodes Moya et al Eur Heart J. doi: /eurheartj/ehp298

20 Additional Diagnostic Data Cardiac testing Echocardiogram 186 (93%) Normal 162 (87%) Stress test 27 (14%) Cardiac catheterization 13 (7%) EP evaluation (TTT, EPS, and/or device interrogation) 24 (12%) Neurological testing Neurology consult 31 (16%) Carotid Doppler s 33 (17%) EEG 32 (16%) Head CT 132 (66%)

21 Diagnosis and Treatment Median length of stay, days 3 (IQR 2, 6) Diagnosis Vasovagal 90 (45%) Unknown 46 (23%) Arrhythmia 35 (18%) Structural heart disease 9 (5%) Toxic-metabolic 7 (4%) Neurological 13 (7%) Cardiac therapy 28 (14%) Catheter ablation 5 (3%) Pacemaker 9 (5%) ICD 8 (4%) ILR 6 (3%)

22 Survival of Patients Presenting with Unexplained Syncope Treated According to a Structured Clinical Pathway

23 Conclusions Patients presenting with unexplained syncope need to undergo rapid risk stratification to guide decisions regarding need for hospital admission and further diagnostic testing A structured clinical approach towards the evaluation and management of these patients is essential Implantation of loop recorders in patients at high risk of recurrent events but low risk of death and ICDs in patients at high risk of death are the new cornerstones for therapy in these patients Initial data suggest that such an approach results in excellent 1-year patient outcomes; however, longer term follow-up data remains elusive in this patient population