Υποτροπιάζουσα συγκοπή και LBBB σε ηλικιωμένο ασθενή: Tilt testing, ILR, ηλεκτροφυσιολογικός έλεγχος ή απευθείας εμφύτευση βηματοδότη;

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1 Υποτροπιάζουσα συγκοπή και LBBB σε ηλικιωμένο ασθενή: Tilt testing, ILR, ηλεκτροφυσιολογικός έλεγχος ή απευθείας εμφύτευση βηματοδότη; Σκεύος Σιδερής Διευθυντής Καρδιολογικό Τμήμα Ιπποκράτειο Νοσοκομείο Αθηνών

2 ΣΥΓΚΟΠΗ Ως συγκοπή ορίζεται η παροδική απώλεια της συνείδησης που οφείλεται σε παροδική γενικευμένη ατελή εγκεφαλική αιμάτωση και χαρακτηρίζεται από απότομη έναρξη, μικρή διάρκεια και αυτόματη πλήρη αποκατάσταση.

3 ΣΥΓΚΟΠΗ Η συγκοπή είναι συχνό σύμπτωμα και ευθύνεται για το 1-6% των εισαγωγών στα νοσοκομεία και μέχρι 3% των προσελεύσεων στα τμήματα επειγόντων περιστατικών. Η απώλεια της συνειδήσεως είναι επίσης συχνή σε υγιείς νέους ενήλικους (12-48%), αν και οι περισσότεροι δεν αναζητούν ιατρική βοήθεια. Η συγκοπή είναι συχνό σύμπτωμα στη μεγάλη ηλικία.

4 Η σημασία της ύπαρξης καρδιακής νόσου Στην εκτίμηση της συγκοπής η παρουσία της καρδιακής νόσου είναι ο ποιο σπουδαίος παράγοντας που προδικάζει το θάνατο και την πιθανότητα αρρυθμιών. Ασθενείς με καρδιακή νόσο ή με αλλοιώσεις στο Η.Κ.Γ. έχουν αυξημένο κίνδυνο για θάνατο μέσα σε ένα χρόνο και ο μεγαλύτερος αριθμός αρρυθμιολογικών επεισοδίων ευρίσκονται σ αυτούς τους ασθενείς. Μελέτες έδειξαν ότι η υποκείμενη καρδιακή νόσος, ανεξάρτητα από την αιτία της συγκοπής, είναι ο παράγοντας ο οποίος συσχετίζεται με την αύξηση του κινδύνου για θάνατο. Am J Med 1996;100:646-55

5 K. Gatzoulis, S. Sideris et al Ann Noninvasive Electrocardiol, 2009

6 Syncope-BBB For patients with unexplained syncope and BBB, the main diagnosis to consider is transient advanced or complete atrioventricular block. Less than half of the patients with BBB and syncope have a final diagnosis of cardiac syncope A similar percentage have a final diagnosis of reflex syncope and, in about 15% the cause remains unexplained at the end of a complete work-up Eur Heart J 2011;32:

7 Syncope-BBB This issue has posed many problems in the past. Today, due to the advent of the ILR, two studies specifically addressed the problem of BBB and syncope. The ISSUE study and the Bradycardia detection in Bundle Branch Block (B4) study. Eur Heart J 2011;32:

8 Syncope-BBB B4 study Eur Heart J 2011;32:

9 Syncope-BBB B4 study Eur Heart J 2011;32:

10 Syncope-BBB B4 study Of the 215 patients in whom diagnosis was achieved and who were treated according to the findings, a syncopal recurrence was observed in 7% in contrast, syncope recurrent in 33% of 52 untreated patients. Mortality was 6% during 19 months of follow-up, mostly nonarrhythmic. Eur Heart J 2011;32:

11 Syncope-BBB SPRITELY This trial will provide high-level and generalizable evidence for the use of either permanent pacing or implantable loop recorders as a first line intervention for patients with syncope, preserved systolic function, and bifascicular block. Europace 2012;14:

12 Syncope-BBB EPS The prognostic value of the HV interval was prospectively studied. The progression rate to AV block at 4 years was In patients with HV interval <70ms was 4% In patients with HV interval ms was 12% In patients with HV interval >100ms was 24% A J Cardiol 1982;50:

13 Syncope-BBB EPS The development of intra-or infra-his block at incremental atrial pacing is highly predictive of impending AV block, but is rarely observe and has low sensitivity. HV prolongation of > 10ms was observed in 6% Induction of second degree AV block in 5% Complete AV block in developed in 40% of these patients during a mean follow-up of 42 months. J Ital Cardiol 1984;14:

14 Syncope-BBB EPS In patients with both syncope and BBB, syncope is suspected to be attributed to atrioventricular AVB, with EPS being able to predict the development of AVB in 87% of patients. In patients with BBB and negative EPS, the risk of developing a stable AVB was shown to be close to 20% after 4 years, with the risk of syncope recurrence being close to 40% at 3 years. Am J Cardiol 1999;83:1334-7

15 Syncope-BBB EPS The positive predictive value is 80% to identify the patients who will developed AV block. That show a significant reduction in syncopal recurrences in patients with positive EPS treated with PM, compared with a control group of untreated patients with negative EPS. These results justify a recommendation upgrade from Class IIa to I. Eur Heart J 2011;32: Eur Heart J 2009;30:

16 Alternating-BBB LBBB RBBB+LAFB RBBB RBBB+LPFB These patients progress rapidly toward AV block. Therefore a PM is usually implanted as soon as the alternating BBB is detected, even in the absence of a history of syncope. Eur Heart J 2005;46: Pacing Clin Electrophysiol 2012;35:

17 Syncope-BBB ILR The prevalence of arrhythmic events that were detected using ILR was 36.6% at 2.5 years versus 10.8% for conventional follow-up. This observation highlights the usefulness of early monitoring in patients with BBB and negative EPS even after the first syncope episode. Archives of Cardiovascular Disease 2013;106:

18 Syncope-BBB TTT Vasovagal syncope (VVS) is the most common cause of syncope accounting for 20%-65% of cases in populationbased series. There is a bimodal distribution with peaks in teenage years and in those over 65 years. The clinical course is often self-limiting particularly in those <30 years and the prognosis is generally benign. N Engl J Med 2002;347: J Cardiovasc Electrophysiol 2008;19:48-55

19 Unexplained Syncope-BBB The decision to implant a PM is determined by an individual risk-benefit evaluation. There are subsets of patients who might receive a favorable cost-effective benefit from this strategy; for example, old patients which unpredictable and recurrent syncope that expose them to high risk of traumatic recurrences.

20 Asymptomatic-BBB Permanent PM implantation is not indicated for BBB without symptoms, with the exception of alternating BBB, because only a small minority of these patients will develop AV block (1-2% per year) and because cardiac pacing has not been proven to reduce mortality. N Engl J Med 1982;307: Am J Med 1979;66:

21 Syncope-BBB The triple combination of first-degree AVB, RBBB, and LPFB was linked to patients eventually requiring PM implantation in 100% of cases so this particular finding might justify PM implantation without previous investigation with EPS. Canadian J of Cardiol 2014;30:

22 Eur Heart J 2013;34:

23 Eur Heart J 2013;34:

24 Σας Ευχαριστώ για την Προσοχή σας

25 LBBB

26 RBBB

27 Left anterior fascicular block

28 Left posterior fascicular block

29 RBBB and LAH

30 Syncope-BBB Syncope is not associated with an increased incidence of sudden death in patients with preserved cardiac function, a high incidence of total deaths was observed in patients with BBB, especially those with HF, previous myocardial infraction or low ejection fraction. JACC 1995;26: J Intern Med 2006;260:31-38

31 Syncope-BBB For patients with unexplained syncope and BBB, the results of EPS investigations are dependent on the ECG features of conduction disturbances. However, no ECG parameters could be shown to consistently predict which patients go on to demonstrate normal or abnormal findings on EPS investigation. This emphasizes the need to carry out EPS investigators to guide PM implantation in these patients. Canadian J of Cardiol 2014;30: