Stato dell arte La Diagnosi della Sincope

Transcription

1 Milano, 5 febbraio 2015 Stato dell arte La Diagnosi della Sincope Michele Brignole Syncope Unit, Ospedali del Tigullio Lavagna

2 Eur Heart J Nov;30(21): SINCOPE Available on

3 The initial evaluation: diagnostic strategy T-LOC suspected syncope Initial evaluation Syncope T-LOC non-syncopal Certain diagnosis Uncertain diagnosis Cardiac likely Cardiac unlikely & recurrent episodes Cardiac unlikely & rare episodes Cardiac tests & Ecg monitoring Reflex tests & ECG monitoring No further Confirm with specific test or specialist s consultancy ESC Guidelines on Management of Syncope Version 2009

4 Syncope Unit Project (SUP) Case mix Reflex Orthostatic hypotension Cardiac Arrhythmia Structural Cardio- Pulmonary Non-syncopal 1 Vasovagal CSS Situational Atypical Likely reflex 2 Classical OH form Delayed OH form (progressive) 3 Brady! Sick sinus! AV block! PM dysf * Tachy! VT! SVT High risk of SCD 4 ACS Aortic Stenosis Atrial myxoma Pulmonary embolism Others 5 Metabolic Epilepsy Intoxications Drop-attacks Psychogenic TIA Falls 67% 4% 5% 1% 5% Unknown Cause = 18% SINCOPE Brignole et al. Europace 2010; 12:

5 SINCOPE ESC Guidelines on Management of Syncope Version 2009 Treatment of syncope Diagnostic evaluation Reflex and Orthostatic Intolerance Cardiac Unexplained and high risk of SD Unpredictable or highfrequency Predictable or low-frequency Cardiac arrhythmias Structural (cardiac or cardiopulmonary) i.e., CAD, DCM, HOCM, ARVC, Channelopathies Consider specific therapy or delayed treatment (guided by ECG documentation) Education, reassurance avoidance of triggers usually sufficient Specific therapy of the culprit arrhythmia Treatment of underlying disease Consider ICD therapy according current ICD guidelines

6 EvaluaNon of Guidelines in SYncope Study 2 (EGSYS- 2) Recurrence of syncope in 398 patients 1,00 Survival free from syncope 0,95 0,90 0,85 0,80 0,75 arrhythmic unexplained structural heart disease neuroreflex orthostatic 0, Days SINCOPE Ungar A et al. Eur Heart J 2010

7 Different ways to classify syncope By enology (clinical forms) Reflex (neurally- mediated) Vasovagal SituaNonal CaroNd sinus Atypical forms (Nlt- posinve) OrthostaNc hypotension Primary autonomic failure Secondary autonomic failure Drug- induced Volume deplenon Cardiac cardiovascular Arrhythmia as primary cause Bradycardia Tachycardia Drug- induced Structural cardiac (e.g., aornc stenosis, atrial mixoma, etc) By mechanism (ECG/BP documentanon) Bradycardia Asystole Sinus arrest Sinus brady plus AV block AV block Bradycardia (sinus) Tachycardia Progressive sinus tachycardia Atrial fibrillanon Atrial tachycardia (except sinus) Ventricular tachycardia Hypotension (No or slight rhythm varianons) Brignole & Hamdan JACC 2012; 59:

8 SINCOPE Take home message The efficacy of therapy is largely determined by the mechanism of syncope rather than its enology

9 SINCOPE Diagnosis by mechanism Bradycardia/tachycardia Hypotension

10 DiagnosNc yield of very prolonged ILR observanon Arrhyhmologic Centre - Lavagna ISSUE classification Type 4: Tachycardia 12% Type 3: Normal SR 34% 51% Type 1: Asystole 3% Type 2: Bradycardia Furukawa T et al. Additional diagnostic value of very prolonged observation by ILR in patients with unexplained syncope. J Cardiovasc Electrophysiol 2011

11 Eastbourne Syncope Assessment Study (EaSyAS) European Heart Journal 2006; 27, ILR (101 pts) P=0.04 Conv (97 pts) Time to second syncope recurrence

12 CumulaNve incidence % Long term outcome ager specific therapy guided by ILR Arrhyhmologic Centre - Lavagna Actuarial recurrence rate Months 1 year 5 year Total 3% 8% Pacemaker 4% 4% Total PM Total panents Pacemaker Furukawa et al. J Cardiovasc Electrophysiol 2011

13 The GIMSI registry Syncope Unit Project 2 (SUP 2) SUP 2 trial Assessment of a standardized algorithm for cardiac pacing in older panents affected by severe unpredictable reflex syncope Performed by the GIMSI- cernfied Syncope Units of: Lavagna (Brignole) OsNa (AmmiraN) Catanzaro (Arabia) Reggio Emilia (QuarNeri) Bolzano (Tomaino) Firenze (Ungar) Milano (LunaN) Taranto (Russo) Empoli (Del Rosso) Genova (Gaggioli) European Heart Journal 2015, in press

14 SINCOPE Diagnosis by mechanism Bradycardia/tachycardia Hypotension

15 Tilt table testing: limitations Too often negative in pts with likely VVS ( low sensitivity ) Too often positive in pts without VVS syncope ( low specificity ) No value in assessing efficacy of treatment with drugs or pacemaker Someone stopped to perfom it ( clinical history better than tilt table testing )

16 Tilt tesnng: posinvity rate 92% Typical VVS, emononal trigger (Clom) 78% Typical VVS, situanonal trigger (TNT) 73%- 65% Typical VVS, miscellaneous (Clom) (TNT) 56%- 51% Likely reflex, atypical (TNT) 47% Cardiac syncope (TNT) 45% Likely tachyarrhythmic syncope (Passive) 36%- 30% Unexplained syncope (TNT) (Clom) 13%- 8% Subjects without syncope (Passive) (Clom) (TNT) SINCOPE SuKon & Brignole. Eur Heart J 2014; 35:

17 A positive tilt test suggests the presence of a hypotensive susceptibility, which plays a role in causing syncope irrespective of the etiology and mechanism of syncope. SINCOPE SuKon & Brignole. Eur Heart J 2014; 35:

18 ISSUE 3" SYNCOPE" ISSUE 3 International Study on Syncope of Uncertain Etiology 3 Tilt Test & ILR: insights from ISSUE 3 trial & registry SINCOPE

19 SYNCOPE" ISSUE 3" ILR screening phase Study design Pts affected by severe, recurrent reflex syncopes, aged >40 yrs Tilt Table TesNng (Passive + TNT) ILR implantanon (Reveal DX/XT) ILR follow- up (max 2 yrs) ISSUE 3 therapy phase ILR eligibility criteria: Asystolic syncope 3 s, or Non- syncopal asystole 6 s R CirculaNon 2012;125: Pm ON Pm OFF

20 ISSUE 3" SYNCOPE" ISSUE 3 population Asystole = 12 s #8_4, 30/01/2009

21 ISSUE 3" SYNCOPE" Freedom from syncopal recurrence Number at risk Pm OFF Pm ON First syncope recurrence Kaplan-Meier (intention-to-treat) survival estimates 25% 37% log rank: p=0.039 RRR at 2 yrs: 57% 25% 57% Months Pm ON Pm OFF Brignole et al. Circulation 2012;125:

22 SYNCOPE" ISSUE 3" Syncope recurrence ager PM therapy according to Nlt test results % vs 55% at 21 months log rank: p= Months Number at risk PM TT PM TT NO THER Brignole M et al. Circ Arrhythm Electrophysiol 2014;7:10-16 PM, TT PM, TT + No PM

23 SINCOPE Am J Cardiol 1995; 76: 720

24 Solari D et al. Europace 2013 Recurrence of syncope according to Nlt test results Log rank: p=0.008 Non- CI forms NegaNve or not performed CI form

25 Reflex syncope: Dual-action model 1) Hypotensive suscepnbility YES (Tilt +) Low reflex threshold NO (Tilt - ) High reflex threshold ) Trigger (neuro and/or humoral) Vasovagal syncope (hypotension- bradycardia) Cardio- inhibitory reflex syncope Hypotension phenotype domain (pacing low responder) Bradycardia phenotype domain (pacing high- responder)

26 Changed indications for Tilt Table Testing Old (ininal) indicanons Diagnosis of VVS IdenNficaNon of candidates for permanent pacing (CI form) New indicanons SuscepNbility to orthostanc stress, irrespecnve of the enology of syncope IdenNficaNon of non- responder to cardiac pacing (any posinve response) SINCOPE Sutton & Brignole. Eur Heart J 2014; 35:

27 Therapy based on Tilt Table Test results Old (ininal) indicanons Vasoconstrictor drugs for mixed/ VD forms Cardiac pacing in CI forms New indicanons DisconNnuaNon of vasoacnve therapies in posinve forms ElasNc stockings and vasoacnve drugs in delayed orthostanc hypotension As part of the Biofeedback training program for Counterpressure manoeuvre therapy To discourage cardiac pacing when TT is posinve SINCOPE Sutton & Brignole. Eur Heart J 2014; 35:

28 The GIMSI registry STOP- VD trial STOP- VD: studio randomizzato controllato sulla sospensione dei farmaci vasoaqvi nella sincope riflessa vasodepressiva Syncope Unit di: - Lavagna - Firenze- Careggi - Bolzano - Genova ASL3

29 SINCOPE Challenge 2015 The ulnmate goal of syncope evaluanon is not diagnosnc yield (which is somehow a surrogate goal) but rather the prevennon of syncope recurrences