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Syncope
Steen Juul-Möller, MD, PhD, FESC Dpt. of Cardiology Skane University Hospital, Malmö, Sweden
”ECG Monitoring”
…there are many kinds…
…some TLOC`s have a permanent impact…
…others are of a more paroxysmal nature…
… and some are mostly to show the world …
..that I am a misunderstood Darling!
The first quesEon is
Why? Vessel tone?
Heart? Europace, 2002;4:351-‐356
56%
14%
Heart! Structural
or
Arrhythmia
Europace, 2002;4:351-‐356
3%
11%
Arrhythmia?
Only one requirement! You need an
ECG-‐strip from the event! As always, a few excepEons: • Slow AF or AFl • AV block 2-‐3 • Extreme sinus bradycardia • Trifascicular block • WPW/Brugada Syndrome, etc.
Our methods:
• 12-‐lead ECG
Our methods:
• 12-‐lead ECG • 1/2/7 days Ambulatory ECG (Holter)
The original Holter biotelemetry Apparatus. From 1947, Weighing 38 kg
The original Holter biotelemetry Apparatus In 1947, weighing 85 lb (38 kg)
118 g splashproof
The original Holter biotelemetry Apparatus. From 1947, Weighing 38 kg
Our methods:
• 12-‐lead ECG • 1/2/7 days Ambulatory ECG (Holter)
• External Loop Recorder
Our methods:
• 12-‐lead ECG • 1/2/7 days Ambulatory ECG (Holter)
• External Loop Recorder • Ambulatory short-‐strip ECG
Our methods:
• 12-‐lead ECG • 1/2/7 days Ambulatory ECG (Holter)
• External Loop Recorder • Ambulatory short-‐strip ECG
• Implantable Cardiac Monitor
Our methods:
• 12-‐lead ECG • 1/2/7 days Ambulatory ECG (Holter)
• External Loop Recorder • Ambulatory short-‐strip ECG
• Implantable Cardiac Monitor
• Pacemaker/ICD
• In-‐Hospital ECG monitoring
We want to get the culprit-‐ECG as easy and efficient as we can!
At the ECG-‐lab in Malmö we perform 3400 Holters/year. We perform all kind of
ECG-‐invesEgaEons.
This report demonstrates the
diagnosEc efficacy 2008-‐2009.
StaEsEcs 2008-‐2009 n=6250
24 hours Holter 62%
48 hours 23%
7 days 15%
External Loop Recorder 60/year
ICM 18/year
The DiagnosEc QuesEons > one question in 20%
Syncope: Types
22 Europace, 2002;4:351-‐356
Syncope: Types
23 Europace, 2002;4:351-‐356
Syncope: Types
24 Europace, 2002;4:351-‐356
Did we answer the clinical quesEon? (All invesEgaEons from 2009; n=3200)
Next step: External Loop-‐recorder! 2008-‐9 years invesEgaEons; n=120
No symptoms: No ECG Mean dura4on: 4.2 weeks (2-‐14 wks)
ECG during symptoms
Next step: External Loop-‐recorder! 2008-‐9 years invesEgaEons; n=120
No symptoms: No ECG Mean dura4on: 4.2 weeks (2-‐14 wks)
ECG during symptoms
Next step: External Loop-‐recorder! 2008-‐9 years invesEgaEons; n=120
No symptoms: No ECG Mean dura4on: 4.2 weeks (2-‐14 wks)
ECG during symptoms
18 of the 120 paEents w/ External Loop-‐Recorder had syncope during
the test.
Bradycardia: 2 paEents (11%)
18 of the 120 paEents w/ External Loop-‐Recorder had syncope during
the test.
Normal sinus rhythm: 72%
Single extra beats: 17%
Bradycardia: 2 paEents (11%)
… the last resort … Implantable Cardiac Monitor
6250 Holters
Arrhythmia (63%)
Syncope (n=25%)
Inconclusive in 35%
Ischemia (25%)
Other (6%)
External Loop Recorder (n=120) Inconclusive in 29%
ICM (n=36) 5% of all Syncope patients
For the years 2008-‐9:
The diagnosEc efficacy of ICM has been evaluated in the
PICTURE-‐study
Primary Objec4ve • To evaluate the Eme to diagnosis in relaEon to the Eming of the Reveal implant during the diagnosEc workup.
Secondary Objec4ves • Determine diagnosEc yield • Describe the standard care pathway • Evaluate the total burden of diagnosEc tests (early use vs. late use) • Determine the raEo between diagnosis “cardiac related” and “non-‐cardiac
related”. • RelaEonship between results of diagnosEc tests and Reveal diagnosis. • Differences in recurrence rate syncope vs. presyncope • Determine the relaEonship between # preceding syncopal events vs. Eme to
diagnosis.
PICTURE – Primary and secondary objecEves
PICTURE study plan
• PICTURE was a prospecEve, mulE-‐centre, observaEonal post-‐markeEng study conducted from November 2006 unEl October 2009
• 88 parEcipaEng sites in 11 countries (Austria, the Czech Republic, Denmark, Finland, France, Germany, Israel, The Netherlands, the Slovak Republic, Sweden and Switzerland). A total of 72 sites contributed to paEent enrolment.
PICTURE study plan • PaEents were eligible if they had recurrent unexplained syncope or pre-‐syncope.
• PaEents were followed up unEl the first recurrence of a syncopal event leading to a diagnosis or for at least 1 year.
• 650 paEents enrolled (2006-‐2008)
• 570 paEents followed-‐up
• Average Follow-‐Up Eme: 10±6 months
Time to recurrence of syncope, ater Reveal implant
• During follow-‐up a total of 218 paEents (38% of the populaEon) experienced an episode of syncope, 149 with prodromal symptoms
• The percentages of paEents that had a recurrence of syncope were 19%, 26% and 36% ater 3, 6 and 12 months respecEvely (black line)
• 10% of paEents with an episode during follow-‐up had associated severe trauma.
Recurrence of Syncope, first year: 36%
DiagnosEc yield of Reveal • Time to a syncopal event where
Reveal played a role in the diagnosis showed the recurrence of diagnosis within 180 days as 20%, within 365 days as 30% and within 462 days as 38% (grey line)
• The esEmated rate of syncope ater 30 days of follow-‐up was 10% and the esEmated rate of diagnosis where Reveal played a role at this Eme of follow-‐up was 9%
ICM played a diagnosEc role, first year: 30%
Conclusion: • 11% of paEents with Syncope have Arrhythmogenic Syncope.
• The majority (67%) can be evaluated using Holter. DiagnosEc in 65%.
• External Event Recorder is needed by 25%. DiagnosEc in 11% of those with Syncope.
• ICM is indicated in 5% of the Syncope paEents in whom a diagnosis can be obtained in
30% within 1 year .
Arrhythmic Syncope EvaluaEon:
11%
89%
100%
67%
25%
5%
Arrh. Syncope
Other Syncope
1-‐7 d Holter
External Event Recorder
Implantable Cardiac Monitor
1-‐7 d
4 weeks
> 1 year
Conclusion:
We get them all…
eventually!!
Thank You For your attention!
It is over!!