La nuova frontiera: algoritmi e software interattiviMichele Brignole

Centro Aritmologico, Ospedali del Tigullio, Lavagna

Tigullio Cardiologia - 6° Corso GIMSI

State-of-the-Art paper – JACC 2012New concepts in the assessment of syncope

Michele Brignole and Mohamed H. Hamdan

• Specialized Syncope Units:“The right physician, in the right place, at the right time”

• Algorithms coupled with interactive decision-makingsoftwares:“Second generation Syncope Units”

Evaluation of Guidelines in SYncope Study 2(EGSYS-2)

Standardized care pathway versus usual management of syncope referred in emergency

to general hospitals

Europace 2006; 8, 644–650

Sponsored by

www.gimsi.it

Registro GIMSI 

Comitato Direttivo Registro GIMSIRoma, 24 febbraio 2011

The GIMSI registry

SUP 2 trialGuideline‐based pacing therapy for Reflex Syncope

Principal  Investigator: M. Brignole

Syncope Unit Project 2(SUP 2)

Syncope Unit Project 2(SUP 2)

Study flow

Severe, recurrent, certain or suspected (undetermined) reflex syncope, age ≥40 years

Carotid Sinus Massage

Implant PMCardioinhibitory response

Tilt Table Test

other response

Implant PM

Asystolic (VASIS 2B) response

ILR

other response

Implant PM

Control group

Documented asystole (type 1 ISSUE)

response

other response

EN

RO

LLM

EN

TC

ON

TRO

L G

RO

UP

FU

STU

DY

GR

OU

P FU

Severe, recurrent, certain or suspected (undetermined) reflex syncope, age ≥40 years

Carotid Sinus Massage

Implant PMCardioinhibitory response

Tilt Table Test

other response

Implant PM

Asystolic (VASIS 2B) response

ILR

other response

Implant PM

Control group

Documented asystole (type 1 ISSUE)

response

other response

EN

RO

LLM

EN

TC

ON

TRO

L G

RO

UP

FU

STU

DY

GR

OU

P FU

Faint algorithm at University of Utah

Diagnosis certain ?In‐hospitalevaluation

Treatment

Faint initial assessment:1. H&P exam2. Orthostatic challenge3. ECG

Admission criteria ?

YesNo

Questions

Actions

Yes No

Uncertain faint evaluation

Cardiac syncopeunlikely,

recurrent or severe symptoms ?

Cardiac syncopelikely

or possible ?

Cardiac syncopeunlikely,

single/rare and mild ?

Non‐syncopalfaint likely ?

Cardiac tests& monitoring

Reflex tests& monitoring

Reflex tests Neuro/psychoevaluation

Faint evaluation at University of Utah Hospital, 2010

Daccarett M et al. Syncope in the emergency department: comparison of standardized admission criteriawith clinical practice. Europace 2011; 13: 1632–1638

Clinical practice Faint‐Algorithm

Admitted  Discharged  Admitted  Discharged

Patients (total  n=254) 118 (46%) 136 (54%) 57 (22%) 197 (78%)

Serious Events within 7 days after visit; % 10 (8.5%) 5 (3.7%) 9 (16%) 6 (3.0%)

Faint Algorithm:  Odds ratio for admissions:  ‐67% 

4%

34%

20%

52%

Admission Unexplained syncope(final diagnosis)

StandardizedConventional

p=0.001

Sanders N et al. Standardized-care pathway versus conventional approach in the management of patients presentingwith faint at the University of Utah: the faint and fall clinic experience. (in press)

Standardized vs Conventional care

Faint & Fall Clinic, University of Utah Hospital, 2011

p=0.006

n=154 n=154n=100 n=100

-86

-85

-45

-40

-25

-24

-19

150

230

410

630

-100 0 100 200 300 400 500 600 700

Brain CT scan or MRI

Neurological consultation

External loop recorder

Coronay angiography

EP study

Holter/Ecg monitoring

Stress test

Echocardiogram

Implantable loop recorder

Orthostatic blood pressure

Tilt testing

Carotid sinus massage

% difference

Standardized vs Conventional care

Sanders N et al. Standardized-care pathway versus conventional approach in the management of patients presentingwith faint at the University of Utah: the faint and fall clinic experience. (in press)

Faint & Fall Clinic, University of Utah Hospital, 2011

State-of-the-Art paper – JACC 2012New concepts in the assessment of syncope

Michele Brignole and Mohamed H. Hamdan

• A standardized approach is undoubtedly the mostimportant prerequisite for the delivery of the bestand most cost-effective therapy in patientspresenting with syncope.

• The long-term effects of such a new health caremodel on the rate of diagnosis and survival awaitsfuture studies.