Transcript Slide 1

"Blackouts”
Dr Paul Venables
Consultant Cardiologist
[email protected]
Blackouts
 Introduction
 Epidemiology
 NICE Clinical Guideline
 Historic standard of care
 Key recommendations
 Practice points
 Red Flags
Blackout: Definition
Character:
 Loss of consciousness
 Rapid onset
 Transient/Short duration
 Spontaneous recovery
Epidemiology
 Increase with old age
 Peak in teenage²
 Incidence 2.6 -19.5/1000¹
Incidence according to
age and sex
 Often unreported
 Affects half population
during lifetime
1.
2.
Soteriades et al. NEJM 2002
Ganzeboom et al. J Cardiovasc Electrophysiol 2006
Blackout in the UK: Scale
 4% ED attendances
 550,000 per annum
 Primary care
Finished consultant episodes:
Syncope /collapse
 6% Acute admissions
 >100,000 per annum¹
 Average Length of stay 3.9
days
 Falls not included
1 .NHS Health and Social care information centre
(2009): Hospital episode statistics
Blackout: Causes
 Reflex syncope
 Orthostatic Hypotension
56-73%
1-10%
 Cardiac
 Neurological
 Unexplained
 Psychogenic
 Rare
6-37%
1-6%
5-20%
Survival after presentation
Soteriades et al. NEJM 2002
NICE Clinical Guideline 109:
Historic standard of care
 Range of clinicians
 Non-Standardised investigation:
 Underuse of ECG
 Overuse of EEG
 Poor Referral:
 Wrong speciality or unnecessary
 Delayed diagnosis: Dangerous conditions missed
 Inaccurrate: 20-30% “epilepsy” had cardiac cause¹
 Inefficient: Resource implications
1. NICE CG20 Epilepsy in adults and
children 2004
NICE Clinical Guideline: Key priorities
 Define pathways:
 Algorithm
 Initial assessment:
 History
 ECG
 Risk stratification
 Appropriate referral
for specialist
assessment
Initial assessment: History and examination
• Exact history of event:
• Personal and collateral history
• Posture, prodrome etc
• Previous blackout?
• Medical history and family history
• Medication
• Examination
• Vital signs
• Other cardiovascular and neurological signs
+/- Lying and standing blood pressure
1.1.4.2 Red flags: Urgent assessment and treatment
 Refer for specialist cardiovascular assessment
within 24 hours, patients with:
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ECG abnormality
Heart failure
TLoC during exertion
Family history of SCD <40 or ICC
New or unexplained breathlessness
Heart murmur
Consider referring >65 years and TLoC without prodromal
symptoms
1.1.2.3 ECG “Red Flags"
 Use automated interpretation......
 if not possible obtain expert opinion!
 Conduction abnormality
 Inappropriate persistent bradycardia
 Any ventricular arrhythmia (including ventricular ectopic beats)
 Long QT (corrected QT > 450 ms) and short QT (corrected QT < 350 ms)
 Brugada syndrome
 Ventricular pre-excitation
 Left or right ventricular hypertrophy
 Abnormal T wave inversion
 Pathological Q waves
 Atrial arrhythmia (sustained)
 Paced rhythm
Diagnosis based on the initial assessment:
 Diagnose uncomplicated faint when:
 There are features suggestive of uncomplicated faint such as:
 Posture
 Provoking factors (such as pain or a medical procedure)
 Prodromal symptoms
 Diagnose situational syncope when:
 Syncope is clearly and consistently provoked by straining during micturition or
by coughing or swallowing
 Diagnose orthostatic hypotension when:
 The history is typical
 and Lying and standing blood pressure confirms postural drop
1.2.3 Referral for specialist cardiovascular assessment
 Refer all people with TLoC for a specialist cardiovascular
assessment except:
 Uncomplicated faint
 Situational syncope
 Orthostatic hypotension
 Presentation is strongly suggestive of epileptic seizures
1.3.2 Diagnostic tests for different types of syncope
 Ambulatory ECG:
 Arrhythmic cause
 Unexplained cause (after
CSM where appropriate)
 Exertional syncope: Initial
investigations negative
Criteria to determine type of ambulatory ECG:
 TLoC at least several times a week:
 Holter monitoring
 If no TLoC occurs during monitor, offer external event recorder
 TLoC every 1–2 weeks:
 External event recorder
 Further TLoC outside the period of external event recording, offer an ILR
 TLoC less than once every 2 weeks:
 Offer an ILR
 Holter monitor should not usually be offered unless there is evidence of a
conduction abnormality on the 12-lead ECG
Implantable loop recorders
 Subcutaneous
 Patient and automatic
activation
 Stores EGM
 Lasts 2 years
 Home monitoring
NICE: ILR vs “Conventional testing”
 Low diagnostic yield with
external recorders
 Much better symptom–ECG
correlation with ILR
 High initial cost
 May be more cost-effective
Tilt Test
 Vasovagal syncope:
 Consider a tilt test only
if:
 Recurrent
 and affecting their quality
of life,
 or high risk of injury
 Pacing considered
Advice for patients:
 Condition appropriate
advice
 Driving
 Safety at work
Summary: Practice points
 History and ECG:
 Red flags: Refer “urgently”
 Epilepsy: Refer to Neurology
 Unclear Cause: Refer to Cardiology
 Reflex syncope, Situational syncope and Orthostatic
hypotension:
Advise and Reassure
Summary:
 Loads more ECG’s:
 ECG red flags
 Robust diagnosis:
 Diagnose and treat severe cardiac conditions
 Avoid misdiagnosis, especially epilepsy
Blackouts: Clinical
 ECG’s not to be missed
 Sudden cardiac death
 Inherited cardiac conditions
80F unwitnessed fall ? blackout
a) Reassure? b) Emergency admission? c) Refer to Specialist?
Complete Heart Block
 Class 1 indication for pacemaker
73M brief blackout standing in church
a) Reassure? b) Emergency admission? c) Refer to Specialist?
Conduction system disease
RBBB, left axis deviation
 2a indication for pacemaker if other causes excluded
24 male with palpitations and blackout:
a) Reassure? b) Emergency admission? c) Refer to Specialist?
Wolff-Parkinson-White syndrome (WPW)
 Common
 0.1% prevalence
 AVRT
 Sudden Cardiac Death:
- 0.15 – 0.25% per year
 Pre-excited AF
 VF induced by “R on T”
 Avoid AV Node blocking
drugs
Pre-excited AF
Fast
Broad
Irregular
29M blackout playing football
a) 24 hour tape? b) Refer to specialist? c) Admission?
Hypertrophic cardiomyopathy
©2011 by BMJ Publishing Group Ltd and British Cardiovascular Society
Brugada Syndrome
 Gene defect of cardiac Sodium Ion-channels (SCN5A)
 Associated with SCD
 Development of VF
 ICD:
 Syncope aborted SCD
 EPS inducibility
 Identification of families
©2011 by BMJ Publishing Group Ltd and British Cardiovascular Society
Long QT-Syndrome
 QTc >450ms
 Genetic Ion-channel defect
 Syncope (seizures) and SCD
 Drugs
Triggered activity
 Dispersion of refractoriness
 After depolarisations in
phase 3 or 4
 Exceed threshold
 Trigger further
depolarisation
 Torsades de points in LQTS
Arrythmogenic Right Ventricular
Cardiomyopathy (ARVC)
 Multiple gene defects:
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Desmosomes
AD
Syncope
SCD
Palpitation
HF
Sudden cardiac death
 CHD
 Cardiomyopathy:
 Hypertrophic
cardiomyopathy
 Channelopathies:
 Long QT syndrome
 Brugada syndrome
 “Electrical” diseases:
 Wolff-Parkinson-White
5% Other*
15%
Cardiomyopathy
80%
Coronary
Heart Disease
Prevention of SCD
 >95% patient die after out of hospital cardiac arrest
 Identify patients at risk before it occurs
 ICD is proven to improve survival as a primary preventative
treatment in:
 Ischaemic/non-ischaemic cardiomyopathy
 Inherited cardiac conditions
Sudden death syndromes:
Technology
Impact
 Diagnostic devices
 Prevention of SCD
 Pacemakers
 Cure
 Implantable defibrillators
 Stroke prevention
 Catheter Ablation
 Patient reassurance
Thankyou
 www.guidance.nice.org.uk/CG109
 www.arrhythmiaalliance.org.uk
 www.dft.gov.uk/dvla/medical/ataglance.aspx
 [email protected]