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:
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:
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]