Unités de syncope : état des lieux en France sboveda@clinique-pasteur.com 19 Janvier 2018 Paris
Disclosure Statement of Financial Interest I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Consultant Fees from Medtronic, Boston Scientific and Livanova. Speaker's name: Serge BOVEDA
30-40% of the population will experience a T- LOC in their life ESC Guidelines, EHJ 2009 37,475 pts attending the ER 454 (1,21%) syncope 285 (63%) admitted 169 (37%) discharged 24% no diagnosis (further visit 50%) Internal medicine N = 151 Cardiology N = 65 Neurology N = 44 Other Dpt N= 25 EHJ 2002
Etiology of Syncope Moya A et al. Syncope guidelines, Eur Heart J 2009; 30: 2642
Syncope Outcomes A cardiac etiology doubles the risk of death Soteriades ES. N Engl J Med 2002; 347:878-885
How not to evaluate a Syncope Yesterday Need for «simple» algorithms for syncope evaluation
Saklani et al Circulation. 2013;127:1330-1339 Nowadays
Who SHOULD Access the Syncope Unit T-LOC of suspected syncopal nature who, because of frequency or severity of the episodes, need to establish a diagnosis and to ascertain the need for a specific therapy. Patients with an already established diagnosis in order to receive a specialist s consultancy on the best evidence-based therapy or to start specific treatment Patients who need follow-up to make a final diagnosis or assess efficacy of therapy www.escardio.org/ehra 8
Who SHOULD NOT Access the Syncope Unit Patients with a certain diagnosis and/or an established indication for therapy, e.g., patients with bradycardia with guideline-based indications for cardiac pacing Patients in whom syncope is a symptom secondary to underlying disease which requires urgent and specific diagnostic and therapeutic pathways which cannot be followed within an SU e.g., syncope due to acute myocardial infarction or acute bleeding www.escardio.org/ehra 9
The Missions of a SU Kenny RA et al., Europace 2015
Quality Syncope Unit is not a fixed model Cardiologie Soins externes Urgences Soins externes Cardiologue Gériatre/MG IDE Cardio/neuro MG Urgentiste Cardio/ Gériatre Kenny RA et al., Europace 2015
Quality The Syncope Specialist Responsibility for the comprehensive management of the patient from risk stratification to diagnosis, therapy and follow-up, through a standardized protocol. A physician who has sufficient knowledge to recognize all major T-LOC forms, including mimics, syndromes of orthostatic intolerance. Syncope specialists need not all have the same skill levels, but the SU as a whole must be able to provide a minimum skill set, so a combination of specialty skills is optimal. www.escardio.org/ehra
Quality A Dedicated Equipped Facility Kenny RA et al., Europace 2015
Reducing Costs Blanc et al., 2005 / Education Urgentistes -25% in-patients -11% un-explained syncopes > -20% cost reduction Kenny RA et al., Europace 2015
Management Harmonization Guidelines based assessment Version 2018 Available on www.escardio.org/guidelines Circulation 2017
Management Harmonization Based on Initial Assessment Kenny RA et al., Europace 2015
18 Arrhythmology departments of Tertiary Hospitals in France (JC Deharo JDR 2017) 18 16 14 12 10 8 6 4 2 0 Syncope unit Syncope specialist (if no SU) Fast track from ER Other SU in the region No Yes
Example Chest Pain and Syncope Unit Inexpensive Dept Reorganization Cooperation Boveda S, 2014
HDJ pour syncope : GHM = 05M20Z : 749.35
Take Home Message There is no specific organization for syncope evaluation in France in the majority of the regions There is a lack of knowledge (and of awareness) of the cost of syncope evaluation in France The development of syncope facilities is strongly and urgently needed This development is feasible, inexpensive, needing mostly local department reorganization and cooperation (between specialties, and between MDs and Stakeholders (Administration )