Carole MAUPAINPitié Salpêtrière hospitalCardiology departement

Fast Track Syncope

NO CONFLICT OF INTEREST

ESC guidelines 2009

- Transient lost of consciousness- Transient global cerebral hypoperfusion- Characterized by rapid onset- Short duration- Spontaneous complete recovery

=> short cardiac arrest 6-8s=> sBP < 60mmHg

DEFINITION

ESC guidelines 2009

INCIDENCE

• Population <18 ans

• Marins 17- 46 ans

• Population 40-59 ans*

• Population >70 ans*

15%

20-25%

16-19%

23%

Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306.

*over 10 years

# 1% cause of consultation in the emergency departement

# 1% cause of consultation in the emergency departement

INCIDENCE

Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306.

0,9% of emergency in Italy (OESIL 1997)1,21% of emergency in Brest, France (JJBlanc 2000)1 à 6% of all-cause hospitalisations (JJ Blanc 2002)

DIFFERS FROM…

Partial or complete LOC but without global cerebral

hypoperfusion

Epilepsy

Metabolic disorders

(hypoglycaemia, hypoxia…)

Intoxication

Vetebrobasilar TIA

Without impairment of consciousness

CataplexyDrop attacks

FallsFunctionnal (psychogenic

neurosyncope)TIA of carotid origin

CLASSIFICATION

ESC guidelines 2009

CLASSIFICATION

ESC guidelines 2009

THE dilemna : risk of sudden cardiacdeath or invalid symptom ?

« The only difference between syncope

and sudden cardiac death is that we

wake up in one of them...» (Engel GL Ann

Intern Med 1978; 89: 403-412).

A syncope = a police investigation!

CLINICAL DIAGNOSIS

Where is the victim ?

Where are the witnesses ?

Clinical examination

« POLICE INTERVIEW »

- Precise circumstances of syncope- Precipitating factors- Family history of sudden cardiac death- Symptoms before syncope ?- Position : standing ? supine ?- Structural heart disease ?- Medication- …

« POLICE EXAMINATION »

- Medical clinical examination

- Carotid sinus massageShould be avoided

TIA or stroke < 3 moisCarotid bruits

-> Indicated in patients > 40yo with syncope of unknown aetiology after initial evaluation (1b)

-> Diagnostic if syncope is reproduced in the presenceof asystole > 3s

« POLICE EXAMINATION »

- Active standing

-> Diagnostic when a symptomatic fall of sBP>20mmHg or dBP > 10mmHg or a decrease in sBP < 90mmHg (1b)

-> Indicated as initial evaluation when orthostatichypotension is suspected (1b)

When to admit urgently ?

SYNCOPE : CAN LEED TO FATAL EVENTS

- Increases risk of all-cause mortality by 1.31 (Framingham)- 1-year mortality of cardiovascular syncope : 18 - 33%- 1-year mortality of non-cardiovascular syncope : 0 -12%- Predictive factor of sudden cardiac death for cardiomyopathy patients (HCM, ARVC…)

Soteriades et al, NEJM 2002

Framingham

HIGH RISK PATIENT IDENTIFICATION

- Clear indication for ICD : syncopal VT

- Severe structural heart disease

- Palpitation, syncope at exertion or supine

- Family history of sudden cardiac death

- ECG features : BBB, sinus bradycardia, WPW, channelopathies

- Severe comorbidities ESC guidelines 2009

- Pulmonary embolism* * Prandoni P and Al., NEJM 2016

When to admit urgently : high risk patients

17,3%

EGSYS Score

- Palpitations before syncope (+4)

- Abnormal ECG and/or heart disease (+3)

- Syncope during effort (+3)

- Syncope while supine (+2)

- Autonomic prodrome (-1)

- Predisposing and/or precipitating factors (-1)

Del Rosso A. and Al, Heart 2008

EGSYS Score- Palpitations before syncope (+4)

- Abnormal ECG and/or heart disease (+3)

- Syncope during effort (+3)

- Syncope while supine (+2)

- Autonomic prodrome (-1)

- Predisposing and/or precipitating factors (-1)

2-year mortality : 2% score <321% score 3

Cardiac syncope probability : 2% score <313% score 333% score 477% score > 4

Del Rosso A. and Al, Heart 2008

28 years old, syncope at exertion, football > 6h/week

35 years old, syncope at exertion

Diagnostic tests

Suspected syncope

Initial evaluation

Certain diagnosis

Syncope T-LOC non syncopal

Uncertain diagnosis

Risk stratification

High Risk Intermediate, Low Risk

Dianostic tests

ESC guidelines 2009

Appropriatemanagement

INTERMIDIATE / LOW RISK PATIENTSLOW RISK HIGH RISK

Age < 40yo

Predisposing and/or precipitating factors (standing position, nausea, vomiting…)

Supine position, duringexertion, palpitations

No associated signs or symptoms

Hb < 9g/dLBradycardia <40/minsBP < 90mmHg

Prolonged history of syncope Family hystory of suddencardiac death, structural heartdisease

Normal ECG Abnormal ECG

Syncope clinical management in the ED, Costantino G And Al. European Heart Journal 2016

LOW RISK HIGH RISK

Age < 40yo

Predisposing and/or precipitating factors(standing position, nausea, vomiting…)

Supine position, duringexertion, palpitations

No associated signs or symptoms

Hb < 9g/dLBradycardia <40/minsBP < 90mmHg

Prolonged history of syncope

Family hystory of suddencardiac death, structural heart disease

Normal ECG Abnormal ECG

Syncope clinical management in the ED, Costantino G And Al. European Heart Journal 2016

= 1 low risk factor +

0 high risk factor

INTERMEDIATE RISK

= 0 low /high riskOr

Just one comorbidityOr

Atypic low risk syncope

Syncope UNIT

Guided by the initial evaluation

Syncope clinical management in the ED, Costantino G And Al. European Heart Journal 2016

- Syncope < 40 yo !- Family history of sudden cardiac death- Atypic vaso-vagal syncope- ECG : can be normal ! Needed to be repeted- Stress test ++

- => Brugada syndrom, long QT syndrom, short QT syndrom, polymorphic catecholergic VT

WHEN TO SUSPECT CHANNELOPATHIES ?

WHEN TO SUSPECT CHANNELOPATHIES ?

46 yo, syncope during fever

CONCLUSION

CONCLUSION

- Police investigation

- Risk stratification

- Avoid pitfalls : channelopathies, inheritedcardiomyopathies

- Syncope unit

Vaso-vagal

Aborted cardiac arrest

THANK YOU !