Latest approach and treatment strategies for syncope DR SOFIAN JOHAR CONSULTANT CARDIOLOGIST AND ELECTROPHYSIOLOGIST RIPAS HOSPITAL AND GLENEAGLES JPMC BRUNEI DARUSSALAM SYNCOPE • Syncope is a T-LOC due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery Classification of syncope • Reflex (neurally-mediated syncope) – Vasovagal • Mediated by emotional distress: fear, pain, instrumentation, blood phobia • Mediated by orthostatic stress – Situational • • • • • • Cough, sneeze Gastrointestinal stimulation (swallow, defecation, visceral pain) Micturition (post-micturition) Post-exercise Post-prandial Others (e.g laughter, weightlifting) – Carotid sinus syncope – Atypical forms Syncope due to orthostatic hypotension • Primary autonomic failure – Pure autonomic failure, multiple system atrophy, Parkinson’s disease with autonomic failure, Lewy body dementia • Secondary autonomic failure – Diabetes, amyloidosis, uraemia, spinal cord injuries • Drug-induced orthostatic hypotension – Alcohol, vasodilators, diuretics, phenothiazines, antidepressants • Volume depletion – Haemorrhage, diarrhoea, vomiting, etc Cardiac syncope (cardiovascular) • Arrhythmia as primary cause – Bradycardia • Sinus node dysfunction (including bradycardia/tachycardia syndrome) • Atrioventricular conduction system disease • Implanted device malfunction – Tachycardia • Supraventricular • Ventricular (idiopathic, secondary to structural heart disease or channelopathies) – Drug-induced bradycardia and tachyarrhythmias • Structural disease – Cardiac: cardiac valvular disease, acute myocardial infarction, ischaemia, HCM, cardiac tumours, pericardial disease, prosthetic valve dysfunction, congenital anomalies of coronary arteries – Others: Pulmonary embolus, acute aortic dissection, pulmonary hypertension Prevalence of syncope High prevalence 10-30 years 47% in females and 31% in males by age 15 • Reflex syncope most common • Syncope from cardiovascular causes 2nd most common How to diagnose – ask a few questions! • Was the loss of consciousness complete? • Was the loss of consciousness with rapid onset and short duration? • Did the patient recover completely and without sequelae? • Did the patient lose postural tone? If the answers are positive – likely syncope If one or more negative – consider alternatives Is it serious? Exclude cardiovascular syncope • Presence of definite structural heart disease • Family history of unexplained sudden death or channelopathy • During exertion, or supine • Abnormal ECG • Sudden onset palpitations immediately followed by syncope • ECG findings – E.g bifascicular block, Q waves, Negative T waves V1-V3 suggestive of ARVC, Long or short QT intervals, Brugada ECG, Pre-excitation, Mobitz 1, asymptomatic inappropriate sinus bradycardia etc Overt pre-excitation Typical flutter UNEXPLAINED SYNCOPE in patients at high risk of sudden cardiac death • ICDs with or without medications • Electrophysiological studies can be done if diagnosis is unclear and e.g LVEF between 30 and 40% Treatment – reflex syncope • Avoid triggers • Avoid dehydration • Physical counterpressure manoeuvers – leg crossing, hand grip – require prodromal symptoms to be effective • Tilt training • Drugs – largely disappointing – midodrine, fludrocortisone, beta blockers, paroxetine • Pacing – may help – if asystolic pause >3s with symptoms or >6s without symptoms (ISSUE-3) Therapy Therapy Clinical studies based on Tilt Test findings Clinical studies based on Implantable Loop Recorder findings ISSUE-2 • Patients with three or more clinically severe syncopal episodes in the last years without significant electrocardiographic and cardiac abnormalities were included • One hundred and three patients had a documented episode and entered Phase II: 53 patients received specific therapy [47 a pacemaker because of asystole of a median 11.5 s duration and six anti-tachyarrhythmia therapy (catheter ablation: four, implantable defibrillator: one, anti-arrhythmic drug: one)] and the remaining 50 patients did not receive specific therapy • The 1-year recurrence rate in 53 patients assigned to a specific therapy was 10% (burden 0.07±0.2 episodes per patient/year) compared with 41% (burden 0.83±1.57 episodes per patient/year) in the patients without specific therapy (80% relative risk reduction for patients, P=0.002, and 92% for burden, P=0.002) • The 1-year recurrence rate in patients with pacemakers was 5% (burden 0.05±0.15 episodes per patient/year) Severe trauma secondary to syncope relapse occurred in 2% and mild trauma in 4% of the patients Time to first recurrence of syncope according to the intention-to-treat analysis Michele Brignole et al Circulation 2012;125:2566-2571 Copyright © American Heart Association, Inc All rights reserved Clinical studies based on Implantable Loop Recorder findings Conclusion • Syncope is very common! • Good history and examination key • Treatment dictated by structurally normal /abnormal heart / genetic disorders • Medical therapy is possible but generally limited efficacy • Role of pacemaker therapy limited for vasovagal syncope