Le linee guida Sincope 2018 della Società Europea di Cardiologia La Syncope Unit Multidisciplinare. Andrea Ungar, MD, PhD, FESC

Transcription

1 Le linee guida Sincope 2018 della Società Europea di Cardiologia La Syncope Unit Multidisciplinare Andrea Ungar, MD, PhD, FESC Syncope Unit, Hypertension Centre Geriatric and Intensive care Medicine University of Florence, Italy

2 NEW / REVISED CLINICAL SETTINGS AND TESTS: Tilt testing: concepts of hypotensive susceptibility Increased role of prolonged ECG monitoring Video recording in suspected syncope Syncope without prodrome, normal ECG and normal heart (adenosine sensitive syncope) Neurological causes: ictal asystole (OUT-PATIENT) SYNCOPE MANAGEMENT UNIT: Structure: staff, equipment, and procedures Tests and assessments Access and referrals Role of the Clinical Nurse Specialist Outcome and quality indicators NEW/REVISED CONCEPTS in management of syncope NEW / REVISED INDICATIONS FOR TREATMENT: Reflex syncope: algorithms for selection of appropriate therapy based on age, severity of syncope and clinical forms Reflex syncope: algorithms for selection of best candidates for pacemaker therapy Patients at risk of SCD: definition of unexplained syncope and indication for ICD Implantable loop recorder as alternative to ICD, in selected cases MANAGEMENT IN EMERGENCY DEPARTMENT: List of low-risk and high-risk features Risk stratification flowchart Management in ED Observation Unit and/or fast-track to Syncope Unit Restricted admission criteria Limited usefulness of risk stratification scores 2

3

4 Organizational aspects: Syncope Unit Key components - 1 The syncope unit should take the lead in service delivery for syncope, and in education and training of healthcare professionals who encounter syncope. The syncope unit should be led by a clinician with specific knowledge of TLOC and additional necessary team members (i.e. clinical nurse specialist) depending on the local model of service delivery ESC Guidelines on Syncope Michele brignole & Angel Moya EHJ Doi: /eurheartj/ehy037 4

5 Organizational aspects: Syncope Unit Key components - 2 The syncope unit should provide minimum core treatments for reflex syncope and OH, and treatments or preferential access for cardiac syncope, falls, psychogenic pseudosyncope, and epilepsy. Referrals should be directly from family practitioners, EDs, in-hospital and out-hospital services, or self-referral depending on the risk stratification of referrals. Fast-track access, with a separate waiting list and scheduled follow-up visits, should be recommended. Syncope units should employ quality indicators, process indicators, and desirable outcome targets ESC Guidelines on Syncope Michele brignole & Angel Moya EHJ Doi: /eurheartj/ehy037 5

6 Organizational aspects: Structure of the SU Staffing of an SU is composed of: 1. One or more physicians of any specialty who are syncope specialists. 2. A team comprised of professionals who will advance the care of syncope patients. Equipment: 1. Essential Equipment/tests: 12-lead ECG and 3-lead ECG monitoring, non-invasive beat-to-beat blood pressure monitor, tilt-table, Holter monitors, external loop recorders, follow-up of implantable loop recorders (*), 24-hour blood pressure monitoring, Basic autonomic function tests. 2. Established procedures for: Echocardiography Electrophysiological studies Stress test Neuroimaging tests 3. Specialists consultancies (cardiology, neurology, internal medicine, geriatric, psychology), when needed ESC Guidelines on Syncope Michele brignole & Angel Moya EHJ Doi: /eurheartj/ehy037 6

7 Organizational aspects: Test and assessments in a Syncope Unit Initial assessment Subsequent tests and assessments (only when indicated) Blood tests Provocative tests Monitoring Autonomic function tests Cardiac evaluation Neurological evaluation History & physical evaluation 12-lead standard ECG Electrolytes, Haemoglobin, troponin, BNP, glucose, D-dimer, Hemogasanalysis/O2 saturation. Carotid sinus massage, Tilt table test. External loop recording, Implantable loop recording, Ambulatory 1-7 days ECG monitoring, hour BP monitoring. Standing test, Valsalva manoeuvre, deep breathing test. Established procedures for access to echocardiogram, stress test, electrophysiological study, coronary angiography. Established procedures for access to neurological tests (CT, MRI, EEG, video-eeg). Geriatric evaluation Psychological or psychiatric evaluation Established procedures for access to fall risk assessment (cognitive, gait and balance, visual, environmental). Established procedures for access to psychological or psychiatric consultancy. 7

8

9 Organizational aspects: Role of physician and staff in a SU Procedure or test History taking Structured history taking (e.g., application of software technologies) 12-lead ECG Blood tests Echocardiogram and imaging Carotid sinus massage Active standing test SU Physician Tilt table test (x) x Basic autonomic function test x ECG monitoring (Holter, ELR): administration and interpretation x x Implantable loop recorder x (x) Remote monitoring Others: stress test, electrophysiological study, angiograms Neurological tests (CT, MRI, EEG, video-eeg) Pacemaker and ICD implantation, catheter ablation Patient s education, biofeedback training. and instructions x x Final report and clinic note x Communication with patients, referring physicians x x Follow-up x x x x SU Staff x x x x x Non-SU personnel x x x x 9

10

11

12 Ungar a. et al, Europace 2015

13 Assessment of a novel management pathway for patients referred to the Emergency Department for syncope: results in a Tertiary Hospital (Careggi Hospital - Florence, Italy) ED 295 patients Admitted 85 pz (29%) Short stay 60 pt (20%) Syncope Unit Fast Track 58 pt (21%) Discharded 92 pt (31%) Ungar a et al, 2015

14 Ungar a et al, 2015

15 Destination related to ED suspected diagnosis SYNCOPE Admission Short stay observation Syncope Unit Discharge Refusal n=85 n=60 n=58 n=80 n=12 Cardiac 17 (60.7*) 5 (17.9*) 3 (10.7*) 0 3 (10.7*) Neurally-mediate 13 (10,1*) 26 (20.2*) 20 (15.5*) 67 (51.9*) 3 (2.3*) Pseudosyncope 11 (39.3*) 9 (32.1*) 2 (7.1*) 3 (10.7*) 3(10.7*) Unexplained 44 (40.0*) 20 (18.2*) 33 (30.0*) 10 (9.1*) 3 (2.7*) * % destination related to the diagnosis Ungar a et al, 2015

16 New admissions related to ED destination Estimated hospital re-admission according to multivariable Cox model-destino Admitted Refusal Short stay obs Discharged Syncope Unit Months of follow-up 1 month 12 months Ungar a et al, 2015

17 No patients sent to Syncope Unit was dead within one year Ungar a et al, 2015

18 Syncope (after initial evaluation in ED) Low-risk features only Likely reflex, situational or orthostatic Neither high nor low-risk Should not be discharged from the ED ED or Hospital Syncope Observational Unit (if available) Any high-risk Feature Any high-risk features require intensive diagnostic approach Should not be discharged from the ED Can be discharged directly from the ED If recurrent Syncope out-patient clinic (SU) (if available) Admission for diagnosis or treatment ESC Guidelines on Syncope Michele brignole & Angel Moya EHJ Doi: /eurheartj/ehy037 18

19

20

21

22

23

24 GIMSI - Syncope Unit Ceritication Syncope Unit: 21 Syncope Unit: 47 Syncope Unit: 71 Syncope Unit: 73 Syncope Unit: 69

25 GIMSI 2017 Certificated Syncope Unit (Total = 73) 6 Geriatrics 7 Internal Medicine 2 1 Emergency dpt Neurology Cardiology 57

26

27

28 Le linee guida Sincope 2018 della Società Europea di Cardiologia La Syncope Unit Multidisciplinare Grazie per l attenzione