Ενδείξεις ΗΦΜ σε ασθενείς με συγκοπή Δρ. Ηλίας Θ. Ζάρβαλης Επιμελητής Α Καρδιολογική Κλινική Γ.Π.Ν. Παπαγεωργίου 10ο Βορειοελλαδικό Καρδιολογικό Συνέδριο 19-21 Μαϊου 2011 Θεσσαλονίκη
Η επίπτωση της συγκοπής Συχνό πρόβλημα στον γενικό πληθυσμό και στην ιατρική κοινότητα 15-23% του γενικού πληθυσμού αναφέρουν συγκοπτικό επεισόδιο. 1% των επισκέψεων σε ΤΕΠ 40% εισάγονται για διερεύνηση Μέσοςχρόνοςνοσηλείας5.5 ημέρες Η νοσηλεία αποτελεί το 75% του κόστους της διερεύνησης
Διαγνωστικές εξετάσεις για την διερεύνηση της συγκοπής αγνώστου αιτιολογίας Μη επεμβατικές ΗΚΓ Holter Tilt test υπερηχογράφημα Επεμβατικές ΗΦΜ IRL Καρδιακός καθετηριασμός Δοκιμασία κόπωσης
Diagnostic flowchart in patients with suspected T-LOC. The European Society of Cardiology 2009.
Per cent changes in test utilization in the standardized- vs. usual-care group. The mean cost per patient and the mean cost per diagnosis were 19 and 29% lower in the standardized-care group (P=0.001). Brignole M et al. Europace 2006;8:644-650
costs associated with syncope management total annual costs for syncope-related admissions were US$2.4 billion, with a mean cost of US$5400 per hospitalization In the UK, the overall cost per patient was 611, with 74% attributed to the costs of hospital stay. Cost per diagnosis of patients admitted to hospital was 1080
Διαγνωστική αξία της ΗΦΜ στην συγκοπή αγνώστου αιτιολογίας Φύση της νόσου Χαμηλή ευαισθησία και ειδικότητα της ΗΦΜ Ασθενείς με ελαττωμένο ΚΕ αντιμετωπίζονται με ICD ανεξάρτητα από την αιτία της συγκοπής Ανάπτυξη νέων πολύτιμων εργαλείων στην διάγνωση με δυνατότητα μακροχρόνιας παρακολούθησης όπως οι μόνιμοι εμφυτεύσιμοι καταγραφείς βρόγχου (loop recordes) nowadays 2% of patients with unexplained syncope evaluated by cardiologists undergo EPS and even fewer if they are evaluated by other specialists
Φύση της νόσου-δυσκολίες στην διάγνωση Σποραδική και απρόβλεπτη εμφάνιση των επεισοδίων Υποθετικός ο συσχετισμός συμπτωμάτων και κλινικών ευρημάτων Ανύπαρκτη διαγνωστική «μέθοδος εκλογής»
Ευαισθησία και ειδικότητα ΗΦΜ Προγνωστική αξία διαγνωστικών εξετάσεων Θεώρημα του Bayes ευαισθησία εκ προοιμίου πιθανότητα (επιλογή των ασθενών) Ορισμός θετικού αποτελέσματος παθολογικός csnrt, ή HV διάστημα πρόκληση κοιλιακής μαρμαρυγής στην ΗΦΜ Μη ειδικό εύρημα στην ισχαιμική και διατατική μυοκαρδιοπάθεια Ειδικό εύρημα στο σ. Brugada
Chen LY et al. J Interv Card Electrophysioloy Nov. 2005 Score indices for predicting electrophysiologic outcomes in patients with unexplained syncope
Chen LY et al. J Interv Card Electrophysioloy Nov. 2005 Score indices for predicting electrophysiologic outcomes in patients with unexplained syncope
Suspected intermittent bradycardia The pre-test probability of syncope-related bradycardia is relatively high when there is asymptomatic sinus bradycardia (<50 b.p.m.) or sinoatrial block, usually documented by 12-lead ECG or ECG monitoring. The prognostic value of a prolonged sinus node recovery time (SNRT) is not well defined. An abnormal response is defined as 1.6 or 2 s for SNRT or 525 ms for corrected sinus node recovery time (CSNRT) SNRT>1500 1720 ms and/or CSNRT >525 ms is approximately 50 to 80%, while the specificity is >95% patients with a CSNRT 800 ms had an eight times higher risk of syncope than patients with a CSNRT below this value
Syncope in patients with bundle branch block EPS has a low sensitivity and specifity The progression rate to AV block at 4 years was 4, 12, and 24%, respectively, for patients with an HV interval <55 ms (normal), 70 ms and 100 ms The development of intra- or infra-his block on incremental atrial pacing is highly predictive of impending AV block, but has low sensitivity. The development of intra- or infra-his block with pharmacological challenge by class I antiarrhythmic drugs predicts the subsequent development of spontaneous AV block with higher sensitivity about one-third of patients with negative EPS in whom an ILR was implanted developed intermittent or permanent AV block on follow-up
Suspected tachycardia In patients with syncope preceded by sudden-onset brief palpitations suggesting SVT, an EPS may be indicated in order to assess the exact mechanism especially when a curative catheter ablation procedure can be performed In patients with previous myocardial infarction and preserved LVEF, induction of sustained monomorphic VT is strongly predictive of the cause of syncope The absence of induction of ventricular arrhythmias identifies a group of patients at lower risk of arrhythmic syncope Programmed ventricular stimulation has a low predictive value in patients with non-ischaemic cardiomyopathy Middlekauff H, et al. Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. J Am Coll Cardiol 1993; 21: 110 16.
EPS and unexplained syncope Ventricular tachycardia was induced in 21%, and abnormal indices of bradycardia were found in 34% of patients with organic heart disease or an abnormal standard ECG. The corresponding figures were 1 and 10%, respectively, in patients with an apparently normal heart Thus, positive results at electrophysiological study occur predominantly in patients with evidence of organic heart disease
Diagnostic criteria I EPS is diagnostic, and no additional test are required, in the following cases: Sinus bradycardia and prolonged CSNRT>525 msec I/B BBB and either a baseline HV interval of >100 msec, or a second or third degree His-Purkinje block is demonstrated during incremental atrial pacing, or with pharmacological challenge I/B Induction of sustained monomorphic VT in patients with previous myocardial infarction I/B Induction or rapid SVT which reproduces hypotensive or spontaneous symptoms Ι/Β
Diagnostic criteria II An HV interval between 70-100 msec should be considered diagnostic IIa/B The induction of polymorphic VT or ventricular fibrillation in patients with Brugada syndrome, ARVC, and pts resuscitated from cardiac arrest may be considered diagnostic IIb/B The induction of polymorphic VT or VF in pts ischaemic cardiomyopathy or DCM cannot be considered a diagnostic finding III/B
1) Presence of structural heart disease or family history of sudden death 2) abnormal electrocardiogram; 3) significant non-symptomatic arrhythmia on Holter monitoring 4) paroxysmal palpitations immediately before or after syncope. JACC 2003
Internal loop recorders isolated syncope group tilt-positive group suspected bradycardia group (patients with BBB and negative electrophysiological test) suspected tachycardia group International Study of Syncope of Uncertain Etiology (ISSUE)
Use of implantable loop recorders in the diagnosis and management of syncope D.J. Farwell et al. European Heart Journal (2004)
Cost Implications of Testing Strategy in Patients With Syncope Randomized Assessment of Syncope Trial A. Crahn et al. J Am Coll Cardiol 2003
The clinical implication of ILRs in patient with syncope Eastbourne Syncope Assessment Study (EaSyAS) Farwell D J et al. Eur Heart J 2006;27:351-356 The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Farwell D J et al. Eur Heart J 2006 Patient recruitment and randomization.
Farwell D J et al. Eur Heart J 2006 Time to ECG diagnosis
Farwell D J et al. Eur Heart J 2006 Time to first syncope recurrence.
Time to second syncope recurrence. Farwell D J et al. Eur Heart J 2006;27:351-356
EaSyAS study conclusions Use of the ILR has led to significantly more diagnoses of the cause of syncope being achieved, more rapid introduction of therapy and a greater variety of therapies being introduced. Use of the ILR also allows appropriate therapies for syncope to be selected. This results in a significant increase in the time to recurrent syncopal episodes and improved general wellbeing in an unselected population with syncope of unknown cause.
Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry Prospective, multicentre, observational study conducted in 2006 2009 in 10 European countries and Israel. Eligible patients had recurrent unexplained syncope or pre-syncope The percentages of patients with recurrence of syncope were 19, 26, and 36% after 3, 6, and 12 months, respectively. Of 218 events within the study, ILR-guided diagnosis was obtained in 170 cases (78%), of which 128 (75%) were cardiac. Nils Edvardsson, Europace. 2011
PICTURE STUDY a median of 13 tests per patient before considering an implant seems unnecessarily high
PICTURE
The Kaplan Meier estimates of time to syncopal episode (green line) and time to syncopal episode where Reveal played a role in the diagnosis (red line).
Picture study:results Two important findings were the high diagnostic yield from the use of an ILR in the overall population with unexplained syncope. which guided the diagnosis in 78% of patients with recurrent syncope and provided useful information in another 6%. the large number of diagnostic tests that patients underwent before an ILR implant and The results underline that more efforts are needed if better adherence to guidelines are to be obtained. Together, these findings imply that if an ILR is implanted early, as emphasized in the 2009 ESC guidelines, a reduced number of tests might be needed.
ILR indications: Class I In an early phase of evaluation of patients with recurrent syncope of uncertain origin who have: absence of high-risk criteria that require immediate hospitalization or intensive evaluation, And a likely recurrence within battery longevity of the device (Level of evidence A). In high-risk patients in whom a comprehensive evaluation did not demonstrate a cause of syncope or lead to specific treatment (Level of evidence B)
ILR indications: Class II To assess the contribution of bradycardia before embarking on cardiac pacing in patients with suspected or certain neurally mediated syncope presenting with frequent or traumatic syncopal episodes (Level of evidence B)
Guidelines for the diagnosis and management of syncope Recommendations: electrophysiological study The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC) 2009 In pts with ischemic heart disease EPS is indicated when initial evaluation suggests an arrhythmic cause of syncope unless there is already an indication for ICD Class I, Level B In pts with BBB should be considered when non-invasive tests have failed to make the diagnosis. IIa/B In pts with syncope preceded by sudden and brief palpitations, EPS may be performed when other non invasive tests have failed to make the diagnosis IIb/B
Guidelines for the diagnosis and management of syncope Recommendations: electrophysiological study The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC) 2009 In pts with BS, ARVC and HCM an EPS may be performed in selected cases IIb/C In pts with high risk occupations, in whom every effort to exclude a cardiovascular cause of syncope is warranted an EPS be performed in selected cases IIb/C EPS is not recommended in pts with normal ECG, no heart disease and no palpitations III/b