Συγκοπή στην συστολική και διαστολική καρδιακή ανεπάρκεια: ιατρογενή και καρδιακά αίτια και η διαχείρισή τους

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1 Συγκοπή στην συστολική και διαστολική καρδιακή ανεπάρκεια: ιατρογενή και καρδιακά αίτια και η διαχείρισή τους Χριστίνα Χρυσοχόου Επιμελήτρια Α Καρδιολογίας

2 The Significance of Syncope 1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, Blanc J-J, L her C, Touiza A, et al. Eur Heart J, 2002; 23: Day SC, et al, AM J of Med Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:

3 Syncope: A Symptom Not a Diagnosis Self-limited loss of consciousness and postural tone Relatively rapid onset Variable warning symptoms Spontaneous complete recovery

4 Syncope: Etiology Non- Cardiovascular Neurally- Mediated Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary 1 Vasovagal Carotid Sinus Situational Cough Postmicturition 2 Drug Induced ANS Failure Primary Secondary 3 Brady Sick sinus AV block Tachy VT* SVT Long QT Syndrome 4 Aortic Stenosis HOCM Pulmonary Hypertension 5 Psychogenic Metabolic e.g. hyperventilation Neurological 24% 11% 14% 4% 12% Unknown Cause = 34% DG Benditt, UM Cardiac Arrhythmia Center

5 Unexplained Syncope Diagnosis History and Physical Exam Surface ECG ENT Evaluation Neurological Testing Head CT Scan Carotid Doppler MRI Skull Films Brain Scan EEG CV Syncope Workup Holter ELR or ILR Tilt Table Echo EPS Other CV Testing Angiogram Exercise Test SAECG Endocrine Evaluation Psychological Evaluation Adapted from: W.Kapoor.An overview of the evaluation and management of syncope. From Grubb B, Olshansky B (eds) Syncope: Mechanisms and Management. Armonk, NY: Futura Publishing Co., Inc.1998.

6 Syncope Due to Cardiac Arrhythmias Bradyarrhythmias Sinus arrest, exit block High grade or acute complete AV block Tachyarrhythmias Atrial fibrillation / flutter with rapid ventricular rate (e.g. WPW syndrome) Paroxysmal SVT or VT Torsades de pointes

7 Drug-Induced QT Prolongation Antiarrhythmics Class IA...Quinidine, Procainamide, Disopyramide Class III Sotalol, Ibutilide, Dofetilide, Amiodarone, (NAPA) Antianginal Agents (Bepridil) Psychoactive Agents Phenothiazines, Amitriptyline, Imipramine, Ziprasidone Antibiotics Erythromycin, Pentamidine, Fluconazole Nonsedating antihistamines (Terfenadine), Astemizole Others (Cisapride), Droperidol

8 Syncope in Advanced Heart Failure: High Risk of Sudden Death Regardless of Origin of Syncope

9 Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. Syncope is a poor prognostic indicator, whether the cardiomyopathy is ischemic or nonischemic in origin. In addition, the MUSTT registry suggested that a negative EP study was not entirely reassuring in patients with ischemic cardiomyopathy. MADIT II and SCD-HeFT have substantially broadened the indications for prophylactic ICD in patients with significant LV dysfunction, excluding patients with NYHA IV symptoms, except transplantation SCD-HeFT the causal link between syncope and death may be attributable to hemodynamic collapse and terminal pump failure rather than an ICD-treatable ventricular arrhythmia Predictors of (all-cause) syncope in SCD-HeFT were New York Heart Association class III, QRS duration 120 ms, and lack of β-blocker use. J Am Coll Cardiol Jan;21(1):110-6.

10 High Risk of Ventricular Arrhythmias in Patients With Nonischemic Dilated Cardiomyopathy Presenting With Syncope This study compared 108 consecutive patients with NIDC presenting with syncope with 71 consecutive patients with NIDC who presented with sustained ventricular arrhythmias, There was no significant difference between the groups in the 3 outcomes during the follow-up of months. Male gender and ICD therapy predicted increased risk for any ventricular arrhythmias. A reduced left ventricular ejection fraction and increased age were predictive of increased mortality. In conclusion, patients with NIDC presenting with syncope are a high-risk group, with event rates similar to patients with NIDC presenting with sustained arrhythmias, and should be considered for ICD therapy. Am J Cardiol 2006;97:

11 Differences in Mechanisms and Outcomes of Syncope in Patients With Coronary Disease or Idiopathic Left Ventricular Dysfunction as Assessed by Electrophysiologic Testing Electrophysiologic study was performed in 119 patients with coronary disease (group I) and 61 patients with DCM group II) with an EF<40% and syncope. IHD DCM JACC 2004;44:

12 Patients with unexplained syncope, overt heart disease, and negative electrophysiologic study had a favorable mediumterm outcome with no case of death and a low recurrence rate of syncope without related injury Circulation. 2002;105:

13 Syncope caused by arrhythmias is responsible for 40%, whereas 60% of all syncopal events are caused by nonarrhythmic events, such as orthostatic hypotension syncope or vasodepressor reflex syncope Hemodynamic instability and subsequent syncope attributable to slow ventricular arrhythmias bpm were rare High-rate cutoff and delayed activation of ICD treatment resulted in very few syncopal events Both arrhythmogenic and nonarrhythmogenic syncope were significantly associated with increased risk of death These findings suggest that syncope in heart failure patients with ICDs is a significant marker of high risk, despite the cause of the syncopal event. Circulation. 2014;129: ;

14 Differences between SCD-HeFT and MADIT-RIT A post hoc analysis of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) indicated that heart failure patients with syncope had a higher risk of death than those without syncope, and these patients did not benefit from ICD In SCD-HeFT, study data on syncope were not collected systematically to define the temporal relationship between syncope and ICD therapy, and events were not adjudicated by an independent committee in SCD-HeFT, 30% of patients were in New York Heart Association class III compared with 52% in MADIT-RIT. Furthermore, all patients in MADIT-RIT were implanted with an ICD or CRT-D with a backup pacing mode versus only one third of the patients in SCD-HeFT. 39% of all syncopal events in MADIT-RIT were arrhythmogenic compared with 15% in SCD-HeFT The incidence of first-time all-cause syncope in MADIT-RIT was much lower than in SCD-HeFT (4% versus 14%), but with follow-up of 1.4 years versus 3.8 years Circulation. 2014;129:

15 Vasovagal syncope in patients with reduced left ventricular function The Bezold Jarisch reflex is the most commonly cited model used to describe vasovagal syncope Preload reduction results in decreased ventricular volume, thereby stimulating enhanced inotropy, which activates left ventricular mechanoreceptors. Activation of the mechanoreceptors causes reflexively increased parasympathetic activity and decreased sympathetic activity, resulting in marked vasodilatation, varying degrees of bradycardia, and, ultimately, syncope. Clin Auton Res (2007) 17:33 38

16 Syncope in advanced heart failure Orthostatic hypotension is extremely common in these patients, due in large part to the aggressive and complex medical regimens prescribed. Vasodilators and diuretics can result in lightheadedness, near-syncope, or even syncope.

17 Syncope and the role of RV

18 Right and Left ventricle interactions A, typical equalization in RAP and PCWP from enhanced interdependence in a patient with biventricular HF B External pericardial pressure, which restrains left heart filling, can be estimated by RAP C RA pressure is elevated near PCWP, true LV preload volume may be reduced despite marked elevation in left PCWP, because transmural pressure is reduced DUnloading of right heart congestion may enhance leftsided preload Circulation. 2012;126:

19 Mechanisms of RV Dysfunction in Critically Ill Patients JACC Vol. 56, No. 18, 2010

20 Αιτία εισαγωγής- Ατομικό ιστορικό Ασθενής 49 ετών με γνωστή HCM μη αποφρακτικού τύπου εισήχθη στην κλινική για διερεύνηση οξείας νεφρικής ανεπάρκειαςυπονατριαιμίας (8/6/2013) Είχε προηγηθεί νοσηλεία από 22/3-10/4/2013 με επίταση δεξιάς καρδιακής ανεπάρκειας (πλευριτική συλλογή, οιδήματα άκρων και ασκίτης) για τα οποία έλαβε αγωγή με φουροσεμίδη, υδροχλωροθειαζίδη, σπιρονολακτόνη, θυροξίνη, αμιοδαρόνη, καρβεντιλόλη, κουμαρινικό αντιπηκτικό και μετφορμίνη Ατομικό ιστορικό Κολποκοιλιακός βηματοδότης, ΣΔ τύπου ΙΙ, Επεισόδια PAF, Πνευμονική υπέρταση, Ανεπάρκεια μιτροειδούς βαλβίδας

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24 Υπερηχοκαρδιογραφικός έλεγχος Συμπεράσματα Υπερτροφική μυοκαρδιοπάθεια μη αποφρακτικού τύπου με ικανοποιητική συνολική συσπαστικότητα αριστερής κοιλίας Σοβαρού βαθμού ανεπάρκεια μιτροειδούς βαλβίδας (vena contracta 7mm, EROA=0,36cm2, jet area ratio=55%) Σοβαρού βαθμού δυσλειτουργία της δεξιάς κοιλίας

25 Therapeutic Interventions Aimed at Improving RV Function

26 A hypothetical paradigm for the treatment and hospital discharge of patients with ADHF Maisel, A. S. & Choudhary, R. (2012) Nat. Rev. Cardiol. doi: /nrcardio

27 421 patients with undiagnosed syncope Independent Predictors of Abnormal EPS, after Logistic Regression Ann Noninvasive Electrocardiol 2009;14(2):

28 European Heart Journal (2011) 32,

29 The only difference between syncope and sudden death is that in one you wake up. 1 Engel GL. Ann Intern Med 1978; 89: