current trends in the evaluation of syncope john d. hummel, m.d professor of clinical internal...
TRANSCRIPT
![Page 1: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/1.jpg)
Current Trends in the Evaluation of Syncope
John D. Hummel, M.DProfessor of Clinical Internal MedicineDirector of Electrophysiology Research
Ohio State University
![Page 2: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/2.jpg)
DefinitionDefinition• a syndrome in which loss of a syndrome in which loss of
consciousness is: consciousness is: – relatively sudden relatively sudden – temporarytemporary– self-terminatingself-terminating– usually rapid recoveryusually rapid recovery
• due to inadequate cerebral due to inadequate cerebral perfusion perfusion
• most often triggered by a fall in most often triggered by a fall in systemic arterial pressuresystemic arterial pressure
![Page 3: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/3.jpg)
Syncope: High Incidence and Likely to Increase
• 7814 participants followed for an average of 17 years, 822 reported syncope
• Estimated 10-year cumulative incidence of syncope was 6%
• The incidence rates increased with age, with a sharp rise at 70 years
• 22% of the study participants with syncope had a recurrence Soteriades et al. NEJM 2002; 347: 878
![Page 4: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/4.jpg)
SyncopeAnnual U.S. Emergency Dept. VisitsAnnual U.S. Emergency Dept. Visits
• ~40% of the population will have at least one syncopal event in their lifetime1
• 10% of falls by elderly are believed due to syncope2
• Major morbidity reported in 6%1 (e.g., fractures, motor vehicle accident)
• Minor injury reported in 29%1
(e.g., lacerations, bruises)
1Kenny RA, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27.2Kapoor W. Medicine. 1990;69:160-175.
![Page 5: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/5.jpg)
SyncopeQOL Impact
0%
25%
50%
75%
100%
73%1
71%2
60%2
37%2
Anxiety/Depression
Alter DailyActivities
RestrictedDriving
ChangeEmployment
1Linzer M. J Clin Epidemiol, 1991;44:1037-1043.2Linzer M. J Gen Int Med, 1994;9:181-186.
Per
cen
t o
f P
atie
nts
![Page 6: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/6.jpg)
Syncope
• In one-third of participants, a cause for syncope could not be assigned
• Risk of death was increased by 31% among all participants with syncope
• Risk of death was doubled among participants with cardiac syncope
• Neurologic syncope (CVA, TIA, seizure) also associated with three-fold risk of stroke
Soteriades et al. NEJM 2002; 347: 878
![Page 7: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/7.jpg)
2• Drug-Induced• ANS Failure
PrimarySecondary
2• Drug-Induced• ANS Failure
PrimarySecondary
Causes of True SyncopeCauses of True Syncope Causes of True SyncopeCauses of True Syncope
OrthostaticOrthostatic CardiacArrhythmia
CardiacArrhythmia
StructuralCardio-
Pulmonary
StructuralCardio-
Pulmonary
1• VVS• CSS• Situational
CoughPost- micturition
3• Bradycardia
Sinus pause/arrestAV block
• TachycardiaVTSVT
• LongQT Synd
4 • Aortic Stenosis• HCM• Pulmonary
Hypertension• Aortic
Dissection
Neurally-Mediated
Reflex
Neurally-Mediated
Reflex
Unexplained Causes = Approximately 10%Unexplained Causes = Approximately 10%
60%60% 15%15% 10%10% 5%5%
![Page 8: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/8.jpg)
• Determine whether the patient is at increased risk for death. • - patients with underlying heart disease• - myocardial ischemia• - Wolff-Parkinson-White syndrome• - life-threatening genetic diseases (LQTS, Brugada)
• Once excluded, the goal becomes identification of the cause of syncope in an attempt to:
• - improve the quality of the patient’s life • - to prevent injury to the patient or others.
AHA/ACCF Scientific Statement on the Evaluation of SyncopeCirculation, February 2006
Goals
![Page 9: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/9.jpg)
The Initial Evaluation:The Initial Evaluation:4 Key Questions4 Key Questions
The Initial Evaluation:The Initial Evaluation:4 Key Questions4 Key Questions
Did the patient suffer ‘true’ Transient Loss of Consciousness (TLOC)?Did the patient suffer ‘true’ Transient Loss of Consciousness (TLOC)?
Was TLOC due to syncope or some other cause?Was TLOC due to syncope or some other cause?
Is heart disease present?Is heart disease present?
Does the medical history (including observations by witnesses) Does the medical history (including observations by witnesses)
suggest a specific diagnosis?suggest a specific diagnosis?
![Page 10: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/10.jpg)
Task Force members, et al. Eur Heart J 2004 25:2054-2072
Syncope vs. Non-Syncopal Events
![Page 11: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/11.jpg)
Strickberger, S. A. et al. Circulation 2006;113:316-327
Flow chart for the diagnostic approach to the patient with syncope
![Page 12: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/12.jpg)
History and Physical: The Most History and Physical: The Most Valuable Part of the Initial Valuable Part of the Initial
EvaluationEvaluation
Prodome/ResiduaActivity/PosturePalpitationsSeizure ActivityMedicationsPrior EpisodesFamily History: Syncope, Sudden Death, Cardiac Disease
H&P yields a diagnosis prior to confirmatory studies in 45% of patients in 7 population based studies (n=1607)
History:
Physical ExamOrthostatic BPMurmurs, Bruits, Pulses, Differential BP’s
![Page 13: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/13.jpg)
ECGECGAbnormal in 50% of patients. Identifies potential cause in 2-11%
• Pre-excitation
• Conduction Delays
• MI
• LVH/RVH (Hypertrophic CM, Aortic Stenosis, Pulmonary HTN)
• QT Interval (QTc=460) should raise suspicion
• Brugada Abnormalities
• Epsilon Waves (ARVD)
![Page 14: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/14.jpg)
Strickberger, S. A. et al. Circulation 2006;113:316-327
ECG changes in the Brugada syndrome
![Page 15: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/15.jpg)
Long QT syndrome-Triggers
• Swimming- LQT1• Auditory/emotional
trigger- LQT2• Inactivity- LQT3
LQT2LQT2
LQT1
LQT3
![Page 16: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/16.jpg)
Strickberger, S. A. et al. Circulation 2006;113:316-327
Different patterns of QT prolongation in LQTS
![Page 17: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/17.jpg)
Kenigsberg, D. N. et al. Circulation 2007;115:e538-e539
Twelve-lead ECG in normal sinus rhythm with epsilon wave
![Page 18: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/18.jpg)
Kenigsberg, D. N. et al. Circulation 2007;115:e538-e539
High-resolution delayed enhanced magnetic resonance image
![Page 19: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/19.jpg)
Neurally Mediated Syncopal Neurally Mediated Syncopal SyndromesSyndromes
The Most Common Cause of The Most Common Cause of SyncopeSyncope
•Vasodepressor Syndrome (Common Faint)
• Micturition/Cough/Sneeze Syncope
• Carotid Hypersensitivity
![Page 20: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/20.jpg)
Reflex Arcs in Neurally Mediated Reflex Arcs in Neurally Mediated SyncopeSyncope
Upright Posture: 15-20% Decrease in Plasma Volume With Upright Posture: 15-20% Decrease in Plasma Volume With Decrease in C.O.Decrease in C.O.
BaroreceptorsMechanoreceptors
Higher Centers(Cortex)
Cranial NervesV, VII, VIII
GI/GUMechanoreceptors
MedullaryVasodepressor Region
Vagus
Reflex ActivationCentral Sympathetic Outflow
Skeletal Muscle& Resp. Pump
![Page 21: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/21.jpg)
Vasodepressor SyncopeVasodepressor SyncopeClinical Syndrome Characterized By:
1. Settings:- young patients, no SHD- Frightening/stressful situation- hunger, fatigue, dehydration, hot room- standing position, sitting occasional
2. Premonitory Signs:- nausea, blurred vision- warmth, diaphoresis- pallor, yawning
3. Syncopal Event:- white, pale- no injury- may be aborted by becoming supine
4. Recovery:- nausea, diaphoresis- fatigue
![Page 22: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/22.jpg)
Tilt TestTilt Test
1. Supine 5 min, 20 min with I.V. pretest2. Tilt 60-70 degrees3. Passive 20-45 minutes4. Isuprel or SL NTG 400 ug spray in neg
for 15-20 minutes5. Endpoint: Syncope or Full Duration
Complete
Rapid Protocols:1. 10 min baseline, Return to supine
and infuse isuprel with HUTT for 20min after 20-25% increase in HR
2. Clomipramine I.V. 5mg (1mg/min) during the first 5 min of 20 min. TTT (spec.93%, sens. 64-83%
![Page 23: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/23.jpg)
Carotid Sinus Massage
• Classification: Cardioihibitory, VDP, Mixed• Abnormal:
– Ventricular pause > 3 seconds or fall in SBP > 50mmHg with symptoms
• Technique:– Recommend continuous ECG and BP monitoring– Assess VDS response with repeat massage after 1 mg of
atropine– Perform CSM with TTT if negative CSM supine: Only
positive in HUTT in 49%• Complications: Neuro in 0.17-0.45%• Contraindicated: Sig. carotid disease• Treatment: PPM for CI, PPM±VDS meds mixed
![Page 24: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/24.jpg)
68 y/o man with a history of CAD, s/p, IMI, 68 y/o man with a history of CAD, s/p, IMI, EF = 45% Presented with 2 recent EF = 45% Presented with 2 recent
syncopal episodes which occurred while syncopal episodes which occurred while sitting without prodrome. sitting without prodrome.
Holter = NSVTHolter = NSVT EPS=NormalEPS=Normal
Right CSM
![Page 25: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/25.jpg)
Echo, Stress Testing
• History and Physical– Presence of definite structural heart disease– Syncope during exertion or when supine– Syncope preceded by palpitations– Family history of SCA– Malignant Syncope– Hx of CADz
• EKG– Bifasicular block or QRS>120 msec– Mobitz I, second degree AV block (off meds)– Asymptomatic Sinus Brady, pause > 3 sec– Long QT, WPW, Brugada, Neg precordial T’s/epsilon– Q waves
EVM, Loop EPS
![Page 26: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/26.jpg)
EchocardiogramEchocardiogram
• Excellent for detecting associated cardiac disease
- Left atrial myxoma- HOCM- Early cardiomyopathy- Valvular disease- Amyloid- Ischemic heart disease- RV abnormalities (+/-)
• Provides key data affecting prognosis and further evaluation
![Page 27: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/27.jpg)
Exercise Testing
• Should be performed in the patient with unexplained syncope, especially if the episode was exercise related.
• Exercise testing – in patients less than 40 years of age, a drop in blood pressure or
failure of blood pressure to rise with exercise raises the question of hypertrophic obstructive cardiomyopathy or left main coronary artery disease.
– In the elderly patient, it may be a manifestation of autonomic failure.
• Exercise testing also screens for catecholaminergic polymorphic ventricular tachycardia and chronotropic incompetence (failure to achieve 100 bpm or 75% MPHR)
• Exercise testing with a functional study can exclude ischemia as a potential cause of syncope
![Page 28: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/28.jpg)
EPS: Indications for Syncope EPS: Indications for Syncope EvaluationEvaluation
Syncope:
Class I:Structural Heart Dz, Unexplained after initial eval.
Palpitations preceding syncope
Palps, Rapid pulse by medical personnelClass II:
Recurrent Unexplained syncope, nl heart and neg TTT
Palps, Inability to obtain recording
Class III:
Known cause of syncope, EPS will not guide Rx
![Page 29: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/29.jpg)
EPS: Catheter Insertion and EPS: Catheter Insertion and TargetsTargets
![Page 30: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/30.jpg)
After IV ProcainamideAfter IV Procainamide
![Page 31: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/31.jpg)
Induction of SMVT – Rate = Induction of SMVT – Rate = 250bpm, SBP < 60250bpm, SBP < 60
![Page 32: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/32.jpg)
WPW: Atrial Fibrillation, WPW: Atrial Fibrillation, Ventricular FibrillationVentricular Fibrillation
![Page 33: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/33.jpg)
Combined Use of EP and Tilt Combined Use of EP and Tilt Table Testing for SyncopeTable Testing for Syncope
Unexplained Syncope (86pts.)
+EPS, 29 (34%) pts. -EPS, 57 (66%) pts.
Tachyarrhythmia Bradyarrhythmia
VT, 21(73%) pts.
-HUT 23(40%) pts.
+HUT 34(60%) pts.
SVT, 5(18%) pts.
SND, 1(3%) pts.
AV Block, 2(6%) pts.
70% of patients were diagnosed with the combined use of EP and Tilt Testing
Sra et al, 1993Sra et al, 1993
![Page 34: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/34.jpg)
Outcome in pts with Unexplained Syncope and Nondiagnostic EPS
1) the incidence of sudden death is low (<2%)
2) the remission rate of syncope is high (80%)
3) the EPS falsely negative in greater than or equal to 20% of patients who continue to have syncope (AV block, SN dysfunction)
![Page 35: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/35.jpg)
Strickberger, S. A. et al. Circulation 2006;113:316-327
Flow chart for the diagnostic approach to the patient with syncope
![Page 36: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/36.jpg)
Types of External Arrhythmia Monitors
• Electrocardiogram: snapshot in time• Holter monitor : 24 to 48 hours of continuous outpatient electrocardiographic
(ECG) recording – Shortcoming: repeated monitoring if an arrhythmia not occur 24-48 hours– Processing can delay action on malignant arrhythmias
• Event recorder: stores 1 to 2 minutes of ECG as soon as the patient activates– Enables much longer period of monitoring– Misses asymptomatic arrhythmias and some symptomatic arrhythmias when pt fails
to activate• Automatic-trigger loop monitors: Records in continuous loop and
automatically captures certain arrhythmias or can be manually activated during symptoms
– Devices can capture detect several types of arrhythmias. – Typically worn for up to 30 days.
• Real-time cardiac surveillance: continuous outpatient ECG monitoring for periods ranging up to several weeks, if necessary.
– Cardiac activity detected by 3 electrodes attached to a ~2 ounce pager-sized sensor or telephone transmitter
– Continuously analyzes the heart rhythm data. If an arrhythmia detected, the monitor automatically transmits data to a central monitoring station for analysis/action
– Any symptoms recorded by the patient are also transmitted.
![Page 37: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/37.jpg)
Kinlay, S. et. al. Ann Intern Med 1996;124:16-20
Cumulative number of patients who sent an electrocardiogram from an event recorder by the number of days needed to record an electrocardiogram during
palpitations
Prospective, randomized crossover comparison 48 hour holter to 30 day EVM
Twice as many symptomatic recordings from EVM as holter
19% of events recorded on EVM required intervention, none from the holter
![Page 38: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/38.jpg)
MCOT Study
• Multicenter randomized controlled trial • 266 pts with palpitations, presyncope,
syncope and nondiagnostic Holter• Randomized to 30 days of MCOT
(Cardionet) or external loop (Loop Group). • Results
– Clinically significant arrhythmias • 55 (41%) pts in the MCOT Group • 19 (14%) patients in the Loop Group (p< 0.001).
Rothman SA, Laughlin JC, Seltzer J, et al. J Cardiovasc Electrophysiol. 2007;18(3):241-247
![Page 39: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/39.jpg)
RAST studyRandomized Assessment of Syncope Trial
• Results:– Primary strategy: diagnostic yield is 47% vs. 20%– Diagnosis overall: 19 vs. 55% (p=0.0014)
39A. Krahn. Circulation 2001; 104: 46-51
![Page 40: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/40.jpg)
ISSUE Study Implications
• HUT outcome was not predictive of vasodepressor vs. cardioinhibitory response– Bradycardia is common in spontaneous VVS -
independent of HUT outcome• Bradycardia is more prevalent in spontaneous
events vs. HUT induced VVS
• Clinical Implication: Consider a strategy of ILR guided evaluation in positive TTT patients unresponsive to medication
Moya A. Circulation. 2001; 104:1261-1267
![Page 41: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/41.jpg)
ISSUE 2Syncopal Episodes per Patient per Year
0.83
0.07 0.05
Non-Specific Therapy
ILR-Based (all patients receiving
antiarrhythmic therapyor pacemaker therapy)
Pacemaker Therapy
Only
Brignole M. Eur Heart J. 2006;27:1085-1092 (ISSUE 2).
Methods:
• A 92% relative reduction in syncope burden and 80% relative reduction in one-year recurrence rate with pacing and antiarrhythmic therapies guided by ILR findings
• 392 patients with suspected neurally-mediated syncope were enrolled
• 103 pts. had an ECG documented syncope, leading to therapy and a follow-up observational period
Results:
![Page 42: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/42.jpg)
Diagnostic Methods & Yield
Test/Procedure Yieldbased on mean time to diagnosis of 5.1
months7
History and Physical (including carotid sinus massage)
49-85% 1, 2
ECG 2-11% 2
Electrophysiology Study without SHD* 11% 3
Electrophysiology Study with SHD 49% 3
Tilt Table Test (without SHD) 11-87% 4, 5
Ambulatory ECG Monitors:
- Holter 2% 7
- External Loop Recorder (2-3 weeks duration) 20% 7
-Insertable Loop Recorder (up to 18 months duration)
65-88% 6, 7
Neurological † (Head CT Scan, Carotid Doppler) 0-4% 4,5,8,9,10
* Structural Heart Disease† MRI not studied
1 Kapoor, et al N Eng J Med, 1983.2 Kapoor, Am J Med, 1991.3 Linzer, et al. Ann Int. Med, 1997.4 Kapoor, Medicine, 1990.5 Kapoor, JAMA, 1992
6 Krahn, Circulation, 19957 Krahn, Cardiology Clinics, 1997.8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.9 Day S, et al. Am J Med. 1982; 73: 15-23.10 Stetson P, et al. PACE. 1999; 22 (part II): 782.
![Page 43: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/43.jpg)
Symptom-Rhythm Correlation
Auto Activation Point
Patient Activation Point
![Page 44: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/44.jpg)
Syncope Diagnosis: Role of an ILR
A. Strickberger et al. Circulation 2006; 113: 316-327
AHA/ACC Scientific Statement on the Evaluation of Syncope:
“This approach (ILRs) is
more likely to identify
the mechanism of
syncope than is a
conventional approach
that uses Holter or
event monitors and EP
testing and is cost-
effective.”
![Page 45: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/45.jpg)
Ideal System for Long Term Cardiac Monitoring
• Subcutaneous placement, simple and fast to implant, excellent safety profile.
• Reliably provides information that can aid selection and titration of therapies– High sensitivity detector in ILR– Signal processing software to remove false positives and extract
information at monitoring center– Human over-read at service center to assure information delivered
to physician is clinically relevant
• Simple for the patient – requires little or no compliance– Long-range telemetry for automated data transfer
• Simple for the physician – maximizes practice efficiency, follow up requires minimal work load– Data download tailored to institution/practice
![Page 46: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/46.jpg)
Sub-Q ILR’s: Evolution
Reveal DX2007
Reveal XT, Sleuth ATConfirm2009
Reveal1998
Reveal Plus2000
Automatic detection added
Longevity and ECG memory increased (to 3 yrs., 49.5
minutes), with episode logs, ICD sensing technology, MRI
labeling, and remote monitoring added
AF detection and long-term trended diagnostics (the Cardiac
Compass and AF Summary Reports) added
Reveal is developed to help diagnose unexplained
syncope
Transoma: the first wireless and automated monitoring system
TransomaSleuth
![Page 47: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/47.jpg)
Transoma‘Sleuth AT”
Medtronic‘Reveal XT’
St. Jude‘Confirm’
Asystole Any single pause >3.0 sec. >1.5, >3.0, >4.5 sec >1.5, >3.0, >4.5 sec
Bradycardia Detection Settings
30, 40, 50 bpm 30, 40, 60 bpm 30, 40, 50 bpm
Tachycardia Detection Settings
120 to 220 bpm, Off 4/4, 6/8, 8/8, 16/16, 32/32 beats
VT = 250 to 520 ms
(115 to 240 bpm)
FVT = 240 to 400 ms
(150 to 250 bpm)
VT = 250 to 520 ms
(115 to 240 bpm)
FVT = 240 to 400 ms
(150 to 250 bpm
AF Detection 20 sec. ECG strips sent to Monitoring Center every 7.5 min.Analysis of ECG data and arrhythmia classification, by Certified Cardiac Techs at Monitoring Center
On board detection algorithm based on R to R variability
On board detection algorithm based on R to R variability but can’t turn on until clinical study is completed and approved by FDA for AF detection
Memory for ECG Data
673 min. between automatic, wireless transmission to the Monitoring Center
ILR: 43 min.
PDM: 630 min.
49.5 minutes total between scheduled office visits
Memory available on ILR only
Download to Carelink
48 minutes total between scheduled office visits
Memory available on ILR only
Download to TTM
ILR Battery Life 18 to 30 months 36 months 36months
Competing ILR’s
![Page 48: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/48.jpg)
RUP Study: Importance of Wireless Download
1.Franco Giada et al.. J Am Coll Cardiol 2007;49:1951–6
Automatic detection mode in the REVEAL was activated, but no significant arrhythmias were recorded: because ILR memory “was always saturated by inappropriate activations.”
![Page 49: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/49.jpg)
Krahn et al, PACE 2004; 27: 657
Loss of tissue contact from shape/form factor
Importance of an Antenna
![Page 50: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/50.jpg)
Medicomp Arrhythmia Access
Patient Activated Report Page
![Page 51: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/51.jpg)
Arrhythmia Access-Sleuth Patient Summary Report
![Page 52: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/52.jpg)
The Value of Advanced Diagnostics
• Daily AF burden
• V-rate during AF
• Avg. day/night HR
• Patient activity
• Heart rate variability (HRV)
Note: All clinic, physician, and patient names and data in this document are fictitious
![Page 53: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/53.jpg)
Value of Advanced Diagnostics
How long do the episodes last?
When did the episodes start?
What is the AF burden?
Note: All clinic, physician, and patient names and data in this document are fictitious
![Page 54: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/54.jpg)
Summary: Current Trends in Arrhythmia Monitoring
• Greater use of external continuous auto-trigger wireless loop recorders
• Greater Use of Implantable Loop Recorders:– Diagnosis of Syncope– Management of Atrial Fibrillation– Evaluation of Cyptogenic Stroke
![Page 55: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/55.jpg)
Reference
• AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascualr Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation in Collaboration With the Heart Rhythm Society. S. Adam Strickberger, et al. JACC. 2006; 47; 473-484
![Page 56: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/56.jpg)
Other References
• Soteriades et al. NEJM 2002; 347: 878• Rothman SA, et al. J Cardiovasc
Electrophysiol. 2007;18(3):241-247• Franco Giada et al.. J Am Coll Cardiol
2007;49:1951–6• A. Krahn, et. Al. Circulation 2001; 104: 46-
51• Moya A, et Al. Circulation. 2001; 104:1261-
1267• Brignole M., et. AL. Eur Heart J.
2006;27:1085-1092
![Page 57: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/57.jpg)
ACC/AHA Guidelines for Pacing With Syncope
• Class I– Third degree AV block with or without Sx’s– Advanced 2nd deg. AV block – Documented sinus brady causing syncope– Sustained Pause dependent VT eliminated by pacing– CSM causing syncope, pauses > 3 seconds min CSM in absence of culprit meds
• Class II– Sinus brady less than 40 bpm or pauses > 3 seconds awake without symptoms– Abnormal Sinus node function on EPS– Neuromuscular diseases (Kearns-Sayre, Erb’s dystrophy, Peroneal Muscular Atrophy) with any
degree AV block (including first degree)– Bifasicular, Trifasicular block (other causes excluded)– SVT resolved only by ATP (RFA and meds failed or not elected)– High risk congenital LQTS patients– Prevention of recurrent drug refractory AF in pts with coexisting SN disease– ASx CSM with > 3 second pause– Significantly symptomatic, recurrent VDS associated with bradycardia– Brady-Tachy syndrome requiring therapy
• Class III– Reversible Causes (drug toxicity, Lyme, non-essential drug Rx causative)– Documentation of syncope in absence of bradycardia– Situational syncope with bradycardia when avoidance effective
![Page 58: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/58.jpg)
ACC/AHA Guidelines for Pacing With Syncope
• Class I– Third degree AV block with or without Sx’s– Advanced 2nd deg. AV block – Documented sinus brady causing syncope– Sustained Pause dependent VT
eliminated by pacing– CSM causing syncope, pauses > 3
seconds CSM in absence of culprit meds with sx’s
![Page 59: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/59.jpg)
ACC/AHA Guidelines for Pacing With Syncope
• Class II– Sinus brady less than 40 bpm or pauses > 3 seconds awake
without symptoms– Abnormal Sinus node function on EPS– Neuromuscular diseases (Kearns-Sayre, Myotonic dystrophy,
Peroneal Muscular Atrophy) with any degree AV block (including first degree)
– Bifasicular, Trifasicular block (other causes excluded)– SVT resolved only by ATP (RFA and meds failed or not elected)– High risk congenital LQTS patients– Prevention of recurrent drug refractory AF in pts with coexisting
SN disease– ASx CSM with > 3 second pause– Significantly symptomatic, recurrent VDS associated with
bradycardia– Brady-Tachy syndrome requiring therapy
![Page 60: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/60.jpg)
ACC/AHA Guidelines for Pacing With Syncope
• Class III– Reversible Causes (drug toxicity, Lyme,
non-essential drug Rx causative)– Documentation of syncope in absence of
bradycardia– Situational syncope with bradycardia
when avoidance effective
![Page 61: Current Trends in the Evaluation of Syncope John D. Hummel, M.D Professor of Clinical Internal Medicine Director of Electrophysiology Research Ohio State](https://reader034.vdocument.in/reader034/viewer/2022051622/56649dd45503460f94acc2fc/html5/thumbnails/61.jpg)