Transcript Identifiable cause?

Patients with suspected syncope
should be investigated by
cardiologists
Dr NR Stout
Syncope
• a transient, self-limited LOC
• onset rapid
• recovery spontaneous, complete, and
usually prompt
• transient global cerebral hypoperfusion
Classification of syncopal
disorders
Real or apparent LOC
Syncope
Reflex mediated
OH
Cardiac
Cerebrovascular
Non-syncopal
With LOC
(e.g. seizures)
Without LOC
(e.g. NEAD)
Soteraides et al NEJM 347:878-885
Soteraides et al NEJM 347:878-885
Causes of syncope by age
Parry, S. W et al. BMJ 2010;340:c880
Copyright ©2010 BMJ Publishing Group Ltd.
What happens to patients with
syncope?
• About 50% do not seek medical attention
• GP, A&E
• Secondary care
– Cardiologists
– Geriatricians
– Physicians
– Neurologists
Misdiagnosis of Epilepsy
74 patients with epilepsy
Mean age 40 years
Continued attacks despite
adequate drug treatment
(n= 36)
Uncertainty about the
diagnosis (n=38).
HUT & CSM – ECG,BP &
EEG monitor
10 patients ILR
Alternative diagnosis
was found in 31 patients
(41.9%)
19 positive HUT
10 other cardiac causes
2 psychogenic seizures
Zaidi et al J Am Coll Cardiol 2000;36:181– 4
Differences between diagnoses made in the emergency department and by the Steering
Committee.
Baron-Esquivias G et al. Europace 2010;12:869-876
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2010. For permissions please email: [email protected].
www.escardio.org/
guidelines
Heart 2008;94;1620-1626
Sensitivity 95%
Specificity 61%
Heart 2008;94;1620-1626
NICE Draft Guidelines
Serious
condition?
Yes
Urgent
cardiology
No
Identifiable
cause?
Yes
Treat
VVS/OH
No
No
Cardiology
Epilepsy
features?
Yes
Neurology
ECG abnormality
Heart failure
No
TLoC
on exertion
FH of SCD
Yes <40 years
Treat
Age>65 yearsVVS/
and
no
OH
No
prodromal symptoms
Yes
New or unexplained
Neurology
SOB
Heart murmur
Heart block.
Persistent bradycardia.
Ventricular arrhythmia
(QT syndromes).
No
Brugada.
WPW. Yes
Treat
L/R ventricular
VVS/
hypertrophy.OH
Abnormal T wave
inversion.
Pathological Q waves.
Atrial arrhythmia.
Paced rhythm.
NICE Draft Guidelines
Serious
condition?
Yes
Admit
No
Identifiable
cause?
Yes
Treat
VVS/OH
No
Cardiology
No
Epilepsy
features?
Yes
Neurology
Unexplained syncope
• A proportion will have cardiac cause
• NICE recommend heart rhythm monitoring
depending on frequency of symptoms
• 24 hr ECG, external loop recorder or ILR
• Preceeded by CSM if over 60 years old
ILR in unexplained syncope
• DGH setting in UK
• 201 patients with
unexplained syncope
• Mean age 74
• randomised after a basic
clinical workup to ILR or
conventional
investigation.
• F/u over at least 6
months
• outcome time to ECG
diagnosis
• ECG diagnosis in 33%
ILR vs 4% conventional
• (HR 8.93,p<0:0001).
• ILR group
–
–
–
–
Quicker ECG diagnosis
Fewer investigations
Fewer hospital days
Reduced costs
Cardiologists should investigate
syncope because:
• Cardiac syncope forms a significant proportion
of syncope presentations
• Associated with increased mortality
• Validated pathways for syncope management
aimed at identifying cardiac causes for syncope
• Misdiagnosis is common
• Cardiology have the expertise and resources to
identify syncope due to cardiac disease and
investigate unexplained syncope
“Receiving treatment they don’t
need which fails to control a
condition they don’t have”