short-term loss of consciousness: new european and american syncope … · 2019. 11. 15. ·...

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)

ARTUR FEDOROWSKI Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden

Should I be worried?


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

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)


American and European Syncope Guidelines


SYNCOPE

Classification & Pathophysiology

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

http://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


35-40%* 0.6-0.9%*

* Lifetime prevalence Neurology 2017;88:296–303



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




SYNCOPE

Initial Evaluation & Risk Stratification


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



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

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.

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.

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.

ARTUR FEDOROWSKI, Department of Clinical Sciences, Malmö, Lund University and Skåne University Hospital, Malmö, Sweden

UNEXPLAINED SYNCOPE

Further evaluation


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


ESC emphasizes the role of “syncope units”



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




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


☞ 10-15% ☞ 70-75%

Cardiac pathway Autonomic pathway


Evaluation

2017 ACC/AHA Syncope Guideline

ESC and ACC/AHA/HRS AGREE

Cardiac pathwayAutonomic pathway


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


ESC emphasizes more ILR



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


Arrhythmia

Normal

Artefacts

CSS/VVS/OH

ESC emphasizes Aut-ILR algorithm



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).


… 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!


Thank you for your attention!

Special thanks to Bob Sheldon, Win-Kuang Shen and Brian Olshansky for sharing their material.

short-term loss of consciousness: new european and american syncope … · 2019. 11. 15. ·...

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