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Short-term Loss of Consciousness:
New European and American syncope guidelines
from the perspective of Emergency Room
Artur Fedorowski
MD, PhD, Assoc. Prof., FESC
Dept. of Cardiology, Skåne University Hospital & Dept of Clinical Sciences, Lund University,
Malmö, Sweden
November 15, 2019 Lodz (Poland)
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ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
Should I be worried?
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ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
Syncope - A Difficult Problem
• Find the cause
• Determine the risk
• Streamline the evaluation
• Prevent recurrence and debilitation
• Reduce hospitalization and mortality
Management - Complex, Confusing, Challenging
Brian Olshansky, 2019
Lifetime prevalence 40%
1-3% ED visits
6% Hospitalizations
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Ricci F, De Caterina R, Fedorowski A. JACC 2015; 66(7): 846-60.
Autonomic failure
(Orthostatic hypotension)
Reflex syncope
(vasovagal)
Cardiac arrhythmias
Structural heart and
great vessels diseases
Baroreceptor
dysfunction
(CSS)
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ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
American and European Syncope Guidelines
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ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
SYNCOPE
Classification & Pathophysiology
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www.escardio.org/guidelines
Definition
Syncope is a transient loss of consciousness (TLOC), due to
transient global cerebral hypoperfusion, characterized by
rapid onset, short duration and spontaneous complete
recovery.
72018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
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www.escardio.org/guidelines
Classification of TLOC
8
Epileptic seizuresSyncope Psychogenic Rare causes
TLOC
TLOC due to head traumaNontraumatic TLOC
Reflex syncope
Orthostatic hypotension
Cardiac
Tonic-clonic seizures Psychogenicpseudosyncope
Subclavian steal syndrome
Vertebrobasilar TIA
Subarachnoid haemorrhage
Cyanotic breath holding spell
2018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
35-40%* 0.6-0.9%*
* Lifetime prevalence Neurology 2017;88:296–303
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www.escardio.org/guidelines
Epidemiology Frequency of the causes of syncope according to age
Age Source Reflex
(%)
Orthostatic hypotension
(%)
Cardiac
(%)
Non syncopal T-LOCs
(%)
Un-explained
(%)
<40 years OldeNordkamp
51 2.5 1.1 18 27
40-60 years
OldeNordkamp
37 6 3 19 34
<65 years Del Rosso 68.5 0.5 12 - 19
>60/65years
Del Rosso 52 3 34 - 11
Ungar 62 8 11 - 14
OldeNordkamp
25 8.5 13 12.5 41
>75 years Ungar 36 30 16 - 9
2018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
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ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
SYNCOPE
Initial Evaluation & Risk Stratification
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www.escardio.org/guidelines
Initial presentation & evaluation of syncopeTLOC present?
(history)
No TLOC Syncope TLOC - non syncopal
Act as needed
Treat appropriately
• Epileptic seizure• Psychogenic TLOC• TLOC, rare cause
Initial syncope evaluation(H&P exam, ECG, supine
and standing BP)
Risk stratification
Uncertain diagnosisCertain or highly likely diagnosis
Start treatment
High-risk ofshort-term
serious events
Early evaluation& treatment
Low-risk but recurrentsyncopes
Ancillary testsfollowed by treatment
Low-risk,single or rarerecurrences
Explanation,no further evaluation
• High-risk !
• Age>65/75 y
• ECG changes
• Heart disease
• No prodrome
• Trauma
• Supine/during
exercise
2018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
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Transient loss of consciousness*
Suspected
syncope
Yes
Evaluation as clinically
indicatedNo
Risk assessmentCause of syncope
certain
Cause of syncope
uncertain
Further evaluationTreatment
Initial evaluation:
history, physical examination,
and ECG
(Class I)
2017 ACC/AHA Syncope Guideline
ESC and ACC/AHA/HRS AGREE
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Initial Evaluation
• Initial evaluation: history, physical
exam (standardized orthostatic
vitals) and 12-lead ECG.
• Additional tests based on
differential diagnosis.
Sheldon et al. CJC. 2011;27:246-253.
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Risk Stratification Low-Risk Features High-Risk Features
History • Reflex syncope: prodrome, triggers, situations
• Positional• No cardiovascular disease
• Syncope during exertion or supine or without prodrome
• History of cardiovascular disease • Concomitant trauma• Family history of sudden cardiac death
(age < 50 years)
Physical exam • Normal • Abnormal vitals, cardiac exam
12-lead ECG • Normal • Abnormal brady/tachy arrhythmia• Conduction disease
Labs • Normal • Elevated biomarkers or abnormal tests with a suspected related diagnosis
Sheldon et al. CJC. 2011;27:246-253.
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Syncope Risk Scores
• Numerous syncope risk scores
• Aid in triage decisions
• Do not reduce unnecessary admissions and costs.
• Do not perform better than clinical judgment.
COR LOE
IIb B
Use of risk stratification tools in the ED may be considered in the management of syncope.
ACC/AHA/HRS &
ESC Guidelines
Sheldon et al. CJC. 2011;27:246-253.
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ARTUR FEDOROWSKI, Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
UNEXPLAINED SYNCOPE
Further evaluation
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www.escardio.org/guidelines
Should not be dischargedfrom the ED
Any high-riskfeatures require intensive
diagnostic approachShould not be discharged
from the ED
Low-riskfeatures only
Can be dischargeddirectly from the ED
Neitherhigh nor low-risk
Syncope out-patientclinic (SU) (if available)
ED or Hospital SyncopeObservational Unit
(if available)
Any high-riskFeature
Admission for diagnosisor treatment
Syncope Management(after initial evaluation in ED)
Likely reflex,situational or orthostatic
Ifrecurrent
172018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
ESC emphasizes the role of “syncope units”
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www.escardio.org/guidelines
Staffing of an SU is composed of:1. One or more physicians who are syncope specialists.2. A support team comprised of trained professionals.
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.
Organizational aspects: Structure of the SU
2. Established procedures for:
– Echocardiography
– Electrophysiological studies
– Stress test
– Neuroimaging tests
3. Specialists’ consultancies (cardiology, neurology, internal medicine, geriatric,psychology), when needed
2018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
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www.escardio.org/guidelines
Certain or highly likely diagnosis
Uncertain diagnosis
Initial syncope evaluation
Start treatment
Cardiac unlikely &recurrent episodes
EchocardiographyECG monitoring
(external or implantable)EP study
Stress testCoronary angiography
No further evaluation
Cardiaclikely
CV autonomic tests&
ECG monitoring(external or
implantable)
Cardiac unlikely &rare episodes
The diagnostic strategy for unexplained syncope
2018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
☞ 10-15% ☞ 70-75%
Cardiac pathway Autonomic pathway
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Evaluation
2017 ACC/AHA Syncope Guideline
ESC and ACC/AHA/HRS AGREE
Cardiac pathwayAutonomic pathway
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www.escardio.org/guidelines
ECG monitoring: indications
Low risk, arrhythmia likely
& recurrent episodes
Not indicated
If negative
Syncope T-LOCnon-syncopal
Unconfirmedepilepsy
Unexplained falls
Low risk &rare episodes
High risk, arrhythmia
likely
In-hospitalmonitoring
(Class I)
ILR(Class I)
Low risk, reflex likely & need for specific
therapy
ELR(Class IIa)
Holter(Class IIa)
ILR(Class I)
ILR(Class IIa)
ILR(Class IIb)
Certain diagnosis/mechanism
Treat appropriately
T-LOC suspected syncope
Uncertain diagnosis/mechanism
2018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
ESC emphasizes more ILR
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www.escardio.org/guidelines
Pacing for reflex syncope: decision pathway
Clinical features
Perform CV autonomic tests
Implant ILR
Severe, reccurentunpredictable syncopes,
age >40 years ?no Pacing not indicated
CI-CSS?
Yes
No
No
No
Asystolictilt test?
Asystole?
Pacing not indicated
Yes & Tilt negative
Yes & Tilt positive
Implant a DDD PM
Implant a DDD PM & counteracthypotensive susceptibility
Yes Implant a DDD PM & counteract hypotensive susceptibility
Implant a DDD PM
Implant a DDD PM & counteracthypotensive susceptibility
Yes & Tilt negative
Yes & Tilt positive
2018 ESC Guidelines on Syncope – Michele Brignole & Angel MoyaEuropean Heart Journal (2018) 39, 1883–1948
Arrhythmia
Normal
Artefacts
CSS/VVS/OH
ESC emphasizes Aut-ILR algorithm
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ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
Take-home message
✓ Reflex syncope (vasovagal and carotid sinus reflex), orthostatic intolerance and cardiac
arrhythmias are the most common syncope diagnoses. Treatment is highly dependent on the
correct diagnosis.
✓ History → Examination (ECG/BP supine/standing/ telemetry) → Risk Stratification →
Admission/Observation/Discharge are the way to go …
✓ Identify syncope experts/units if uncertain and refer the patient (do not let them go home with a
message – “it is benign” – it may be the last time you see the patient alive).
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ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
… and remember ...
• Guidelines are a tool to help you make the most optimal decision in specific
circumstances in regard to specific patient (”guidelines patients” do not exist in the real
world).
• Use your best clinical judgment and common sense, and ask the senior doctor when in
doubt. Guidelines are not a law book!
• Guidelines change as our knowledge and experience develop. Make sure you are
updated!
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ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden
Thank you for your attention!
Special thanks to Bob Sheldon, Win-Kuang Shen and Brian Olshansky for sharing their material.