Estratificacin de RiesgoBajo Riesgo

Edad < 50 aosSin historia cardiovascular previaSntomas compatibles con sncope reflejo (vasovagal)Examen cardiovascular normalECG normalFuente: Shen et al. SEEDS Circulation 2004; 110:3636

Score OESIL(Observacin Epidemiolgica del Sncope en Lazio)

Edad > 65 aos Antecedente de enfermedad cardiovascular (por la historia clnica) Sncope sin prdromos (= trauma severo)Electrocardiograma anormal

Fuente: Colivicchi F, Ammirati F, Melina D, Guido V, Imperoli G, Santini M. European Heart Journal 2003; 24: 811-819

ECG ANORMAL EN OESILRhythm abnormalities (atrial fibrillation orflutter, supraventricular tachycardia, multifocalatrial tachycardia, frequent or repetitivepremature supraventricular or ventricular complexes,sustained or non-sustained ventriculartachycardia, paced rhythms),2. Atrioventricular or intraventricular conductiondisorders (complete atrioventricular block,Mobitz I or Mobitz II atrioventricular block,bundle branch block or intraventricular conductiondelay),3. Left or right ventricular hypertrophy,4. Left axis deviation,5. Old myocardial infarction,6. ST segment and T wave abnormalities consistentwith or possibly related to myocardialischemia.

ECG Anormal que SugiereSncope Arrtmico

1.Bloqueo bifascicular (BRIzq o BRDer + HBAI o HBPI) con o sin PR largo2.Otros trastornos de la conduccin IV, QRS >120 ms3.BAV 2do grado 2:1 o Mobitz 14.Bradicardia sinusal asintomtica ( 3 seg.

ECG Anormal que SugiereSncope ArrtmicoComplejos QRS pre-excitados (WPW)7.Intervalo QT prolongado8.Patrn de BRDer con ST en V1-3 (Sndrome Brugada)9.Onda T neg en precordiales, onda epsilon (displasia arritmognica de VDer)10.Ondas Q sugestivas de infarto de miocardio

PROTOCOLO de EVALUACIN del MECANISMO del SNCOPE en PACIENTES con BLOQUEO de RAMA

1.ECG 12 derivaciones2.Ecocardiograma3.Holter 24-48 hrs4.Si el sncope ocurre durante ejercicio o hay evidencias de isquemia Ergometra5.Estudio electrofisiolgico

La secuencia se interrumpe cuando el test realizado confirma el diagnstico.Europace 2002; 4:357-360

Sncope y Bloqueo de RamaEn pacientes con BR sin sncope la incidencia de BAVC es 2%En pacientes con BR con sncope la incidencia de BAVC es 17%Intervalo HV >100 ms, riesgo de progresin a BAV 24% en 4 aosEn pacientes con sncope + BRama e historia de IM se recomienda realizar EEF, s/t si FEVI

ISSUE Patients with Bundle Branch Block and Negative EP Test:ConclusionIn patients with BBB and negative EP study, most syncopal recurrences have a homogeneous mechanism that is characterized by prolonged asystolic pauses mainly attributable to sudden-onset paroxysmal AV block.

Brignole M. Circulation. 2001;104:2045-2050.

Progresin a BAV en pacientes portadores de MP y Bloqueo de Rama SintomticoSeguimiento medio 62 41 meses 17/60 pac(28%) progresaron a BAV 2do (n = 4) o 3er grado (n = 13) Tasa progresin a BAV a 5 y 10 aos de 25% y 58% respectivamente El BRDer + HBAIzq tiene ms riesgo de progresin a BAV comparado con BRDer o BRIzq (riesgo 42% vs14%, p =0.06)

GaggioliG, BottoniN, BrignoleM, y cols. Progressionto2d and3d grade atrioventricularblockin patientsafterelectrostimulationforbundle-branchblockandsyncope a long-termstudy. G ItalCardiol. 1994, 24:409-16

Estratificacin de Riesgo

Alto Riesgo

Dolor precordial con Sndrome coronario agudoElementos de falla cardacaEnfermedad valvular moderada a severaHistoria de arritmias ventricularesElementos ECG compatibles con isquemiaQT prolongado >500 msBloqueo trifascicular o pausas >2 segundosBradicardia sinusal persistente entre 40-50 pmFibrilacin auricular con TV no sostenida sin sntomasDispositivos cardacos (MP o CDAIs) disfuncionantes

Fuente: Shen et al. SEEDS Circulation 2004; 110:3636

Riesgo Intermedio

1.Edad >50 aos2.Sin historia CV previa3.Bloqueo de rama u onda Q sin cambios agudos en el ECG4.Historia familiar de muerte sbita cardaca prematura (

Estrategia Diagnstica

Arritmias como posible Causa de Sincope

Holter monitoring (AECG)e Implantable Loop Recorder (ILR)

EEF: indicaciones en sincope

Hallazgos de Valor Diagnostico

Confirmacin DiagnsticaENFERMEDAD DE NODO SINUSALBloq AV DE ALTO GRADO: transitorio ( especialmente ante Brama)Bloq TrifascicularBloq Bi fascicular alternante/intermitenteTaquicardias SVP y otras SVTaquicardias Ventriculares

Electrocardiograma Anormal y EEF negativo

Bloqueo Rama DerechaBloqueo Rama IzquierdaHemibloqueosCombinaciones

Estas fueron las nicas variables capaces de predecir un evento arrtmico en pacientes con sncope o pre-sncope con EEF negativo. Modificado de int. J Cardiol 2006; 109:28-33

Tilt Test

Tilt Test

INDICACION CON PROPOSITO DIAGNOSTICO

SINCOPE INEXPLICADO . AISLADO O RECURRENTE EN AUSENCIA DE CARDIOPATIA EN SUBGRUPO DE ALTO RIESGO

SINCOPE INEXPLICADO AISLADO O RECURRENTE EN PRESENCIA DE CARDIOPATIA ESTRUCTURAL, LUEGO DE DESCARTAR CAUSA CARDIACA

SINCOPE CON ETIOLOGIA ESTABLECIDA, PERO DEMOSTRAR SUCEPTIBILIDAD MEDIANA REFLEJA-NEURAL PUEDE ALTERAR EL TRATAMIENTO

A la Onda P le sigue QRSPausa > de 3 segundosPARO-PAUSA SINUSAL

BRUGADA

Taquicardia Helicoidal

QTC CORTO : menor 320 a 300 mseg

MEDICION

Ejercicio y sincope

Major FindingsIn this prospectively designed, single-center, randomizedstudy, the effectiveness of a designated syncope unit in theemergency department was examined for patients who presentedwith unexplained syncope with intermediate risk ofincreased cardiovascular mortality and morbidity. The mainfindings are as follows: (1) There was a significantly higherdiagnostic yield and a decreased hospital admission rate forpatients in the syncope unit group compared with those in thestandard care group. (2) At the conclusion of the evaluation ofthe index event, the net diagnostic yield was similar for the 2randomized groups. The total length of patient-hospital dayswas reduced by 50% for patients in the syncope unit group.(3) The reduced total length of hospital stay was relateddirectly to the decreased hospital admission rate, whereas themean length of stay was similar for the 2 study groups. (4)Follow-up outcomes for all-cause mortality and recurrentsyncope were also similar for the 2 groups. These observationssuggest that a syncope unit in the emergency department,with a multidisciplinary effort and appropriate resources,provides effective and efficient care for selectedpatients. The information from the present single-center studycould provide benchmark data to assess whether this approachcould be adopted in a more broad-based communityhospital setting.Syncope Unit DesignThe high incidence, multiple causes, and sporadic nature ofsyncope in a highly heterogeneous population make thediagnosis of syncope difficult. Several diagnostic protocols,pathways, and guidelines have been proposed to streamlinethe evaluation of syncope in both inpatient and outpatientsettings.2,12-14,16-18,36-38 Despite these efforts, there is no uniformstrategy. Clinical evidence for effective triage of patientsin the emergency department who have syncope islimited.19 Although the diagnostic tools for evaluating syncopecontinue to evolve and improve,35 it is not knownwhether any of these diagnostic modalities could be used inthe emergency department and how clinical outcomes may beinfluenced.The design of the syncope unit in the present study wasbased on the common causes of syncope and the availablediagnostic tools suitable for emergency department practice.Multidisciplinary collaboration is not only useful but neededfor the evaluation in the emergency department of patientswith syncope, as evidenced by the numerous causes ofsyncope that require the attention of emergency departmentphysicians, cardiologists, and electrophysiologists who shareexpertise in triage, diagnosis, therapy, and education. Aneurological evaluation was not required in the present studybecause neurological conditions such as seizure and stroke,which are differentiated from syncope mainly by clinicalpresentation,2 were excluded by the study design.Continuous cardiac monitoring for up to 6 hours in thesyncope unit may allow transient arrhythmias to be documented.During evaluation in the syncope unit, an arrhythmogeniccause was documented in 2 patients (4%). Althoughthe diagnostic yield was seemingly low, and an inpatientevaluation would likely have documented an arrhythmogeniccause, earlier diagnosis could result in expedited inpatientmanagement of this small segment of the population.The 12% prevalence of carotid sinus hypersensitivityamong the patients in the syncope unit group is important.Although the prevalence of carotid sinus hypersensitivity hasnot been determined precisely and is expected to be populationdependent,3941 physicians should be aware that thiscondition is not uncommon among the elderly population.Results of the present study demonstrate that the diagnosiscan be made in the emergency department when carotid sinusmassage is performed in conjunction with continuous beatto-beat heart rate and blood pressure monitoring in patientsboth supine and upright, as required in this study.Results from tilt-table testing highlighted that for patientswith an intermediate-risk profile for a poor cardiovascularprognosis, the most common cause of syncope is neurocardiogenic.This observation is similar to findings from aprevious study in patients with suspected or confirmed heartdisease.28 Echocardiography provided quantitative informationabout cardiac function and demonstrated an ejectionfraction 0.40 in 3 patients who then were admitted to thehospital. The information on normal cardiac structure andfunction was reassuring because most of the patients weretriaged to outpatient evaluation. Electrophysiology consultationprovided expertise in the interpretation of test results andcontributed to the overall management of patients. Althoughthe differential value of each component in the syncope unitcould not be determined precisely, the combination of theseresources increased diagnostic yield from 10% for patients inthe standard care group to 67% for those in the syncope unitgroup. Our observations provide compelling evidence thatwhen additional time and appropriate resources are providedin a syncope unit, the diagnostic yield increases, and thehospital admission rate decreases significantly.Several authors have shown that between 32% and 71% of patients with syncopeand bifascicular bundle-branch block (BBBB) have structural heart diseases[1, 2]. ForThe most frequent etiology of syncope in patients with syncope and BBBBis paroxysmal AV block.Major FindingsIn this prospectively designed, single-center, randomizedstudy, the effectiveness of a designated syncope unit in theemergency department was examined for patients who presentedwith unexplained syncope with intermediate risk ofincreased cardiovascular mortality and morbidity. The mainfindings are as follows: (1) There was a significantly higherdiagnostic yield and a decreased hospital admission rate forpatients in the syncope unit group compared with those in thestandard care group. (2) At the conclusion of the evaluation ofthe index event, the net diagnostic yield was similar for the 2randomized groups. The total length of patient-hospital dayswas reduced by 50% for patients in the syncope unit group.(3) The reduced total length of hospital stay was relateddirectly to the decreased hospital admission rate, whereas themean length of stay was similar for the 2 study groups. (4)Follow-up outcomes for all-cause mortality and recurrentsyncope were also similar for the 2 groups. These observationssuggest that a syncope unit in the emergency department,with a multidisciplinary effort and appropriate resources,provides effective and efficient care for selectedpatients. The information from the present single-center studycould provide benchmark data to assess whether this approachcould be adopted in a more broad-based communityhospital setting.Syncope Unit DesignThe high incidence, multiple causes, and sporadic nature ofsyncope in a highly heterogeneous population make thediagnosis of syncope difficult. Several diagnostic protocols,pathways, and guidelines have been proposed to streamlinethe evaluation of syncope in both inpatient and outpatientsettings.2,12-14,16-18,36-38 Despite these efforts, there is no uniformstrategy. Clinical evidence for effective triage of patientsin the emergency department who have syncope islimited.19 Although the diagnostic tools for evaluating syncopecontinue to evolve and improve,35 it is not knownwhether any of these diagnostic modalities could be used inthe emergency department and how clinical outcomes may beinfluenced.The design of the syncope unit in the present study wasbased on the common causes of syncope and the availablediagnostic tools suitable for emergency department practice.Multidisciplinary collaboration is not only useful but neededfor the evaluation in the emergency department of patientswith syncope, as evidenced by the numerous causes ofsyncope that require the attention of emergency departmentphysicians, cardiologists, and electrophysiologists who shareexpertise in triage, diagnosis, therapy, and education. Aneurological evaluation was not required in the present studybecause neurological conditions such as seizure and stroke,which are differentiated from syncope mainly by clinicalpresentation,2 were excluded by the study design.Continuous cardiac monitoring for up to 6 hours in thesyncope unit may allow transient arrhythmias to be documented.During evaluation in the syncope unit, an arrhythmogeniccause was documented in 2 patients (4%). Althoughthe diagnostic yield was seemingly low, and an inpatientevaluation would likely have documented an arrhythmogeniccause, earlier diagnosis could result in expedited inpatientmanagement of this small segment of the population.The 12% prevalence of carotid sinus hypersensitivityamong the patients in the syncope unit group is important.Although the prevalence of carotid sinus hypersensitivity hasnot been determined precisely and is expected to be populationdependent,3941 physicians should be aware that thiscondition is not uncommon among the elderly population.Results of the present study demonstrate that the diagnosiscan be made in the emergency department when carotid sinusmassage is performed in conjunction with continuous beatto-beat heart rate and blood pressure monitoring in patientsboth supine and upright, as required in this study.Results from tilt-table testing highlighted that for patientswith an intermediate-risk profile for a poor cardiovascularprognosis, the most common cause of syncope is neurocardiogenic.This observation is similar to findings from aprevious study in patients with suspected or confirmed heartdisease.28 Echocardiography provided quantitative informationabout cardiac function and demonstrated an ejectionfraction 0.40 in 3 patients who then were admitted to thehospital. The information on normal cardiac structure andfunction was reassuring because most of the patients weretriaged to outpatient evaluation. Electrophysiology consultationprovided expertise in the interpretation of test results andcontributed to the overall management of patients. Althoughthe differential value of each component in the syncope unitcould not be determined precisely, the combination of theseresources increased diagnostic yield from 10% for patients inthe standard care group to 67% for those in the syncope unitgroup. Our observations provide compelling evidence thatwhen additional time and appropriate resources are providedin a syncope unit, the diagnostic yield increases, and thehospital admission rate decreases significantly.Major FindingsIn this prospectively designed, single-center, randomizedstudy, the effectiveness of a designated syncope unit in theemergency department was examined for patients who presentedwith unexplained syncope with intermediate risk ofincreased cardiovascular mortality and morbidity. The mainfindings are as follows: (1) There was a significantly higherdiagnostic yield and a decreased hospital admission rate forpatients in the syncope unit group compared with those in thestandard care group. (2) At the conclusion of the evaluation ofthe index event, the net diagnostic yield was similar for the 2randomized groups. The total length of patient-hospital dayswas reduced by 50% for patients in the syncope unit group.(3) The reduced total length of hospital stay was relateddirectly to the decreased hospital admission rate, whereas themean length of stay was similar for the 2 study groups. (4)Follow-up outcomes for all-cause mortality and recurrentsyncope were also similar for the 2 groups. These observationssuggest that a syncope unit in the emergency department,with a multidisciplinary effort and appropriate resources,provides effective and efficient care for selectedpatients. The information from the present single-center studycould provide benchmark data to assess whether this approachcould be adopted in a more broad-based communityhospital setting.Syncope Unit DesignThe high incidence, multiple causes, and sporadic nature ofsyncope in a highly heterogeneous population make thediagnosis of syncope difficult. Several diagnostic protocols,pathways, and guidelines have been proposed to streamlinethe evaluation of syncope in both inpatient and outpatientsettings.2,12-14,16-18,36-38 Despite these efforts, there is no uniformstrategy. Clinical evidence for effective triage of patientsin the emergency department who have syncope islimited.19 Although the diagnostic tools for evaluating syncopecontinue to evolve and improve,35 it is not knownwhether any of these diagnostic modalities could be used inthe emergency department and how clinical outcomes may beinfluenced.The design of the syncope unit in the present study wasbased on the common causes of syncope and the availablediagnostic tools suitable for emergency department practice.Multidisciplinary collaboration is not only useful but neededfor the evaluation in the emergency department of patientswith syncope, as evidenced by the numerous causes ofsyncope that require the attention of emergency departmentphysicians, cardiologists, and electrophysiologists who shareexpertise in triage, diagnosis, therapy, and education. Aneurological evaluation was not required in the present studybecause neurological conditions such as seizure and stroke,which are differentiated from syncope mainly by clinicalpresentation,2 were excluded by the study design.Continuous cardiac monitoring for up to 6 hours in thesyncope unit may allow transient arrhythmias to be documented.During evaluation in the syncope unit, an arrhythmogeniccause was documented in 2 patients (4%). Althoughthe diagnostic yield was seemingly low, and an inpatientevaluation would likely have documented an arrhythmogeniccause, earlier diagnosis could result in expedited inpatientmanagement of this small segment of the population.The 12% prevalence of carotid sinus hypersensitivityamong the patients in the syncope unit group is important.Although the prevalence of carotid sinus hypersensitivity hasnot been determined precisely and is expected to be populationdependent,3941 physicians should be aware that thiscondition is not uncommon among the elderly population.Results of the present study demonstrate that the diagnosiscan be made in the emergency department when carotid sinusmassage is performed in conjunction with continuous beatto-beat heart rate and blood pressure monitoring in patientsboth supine and upright, as required in this study.Results from tilt-table testing highlighted that for patientswith an intermediate-risk profile for a poor cardiovascularprognosis, the most common cause of syncope is neurocardiogenic.This observation is similar to findings from aprevious study in patients with suspected or confirmed heartdisease.28 Echocardiography provided quantitative informationabout cardiac function and demonstrated an ejectionfraction 0.40 in 3 patients who then were admitted to thehospital. The information on normal cardiac structure andfunction was reassuring because most of the patients weretriaged to outpatient evaluation. Electrophysiology consultationprovided expertise in the interpretation of test results andcontributed to the overall management of patients. Althoughthe differential value of each component in the syncope unitcould not be determined precisely, the combination of theseresources increased diagnostic yield from 10% for patients inthe standard care group to 67% for those in the syncope unitgroup. Our observations provide compelling evidence thatwhen additional time and appropriate resources are providedin a syncope unit, the diagnostic yield increases, and thehospital admission rate decreases significantly.Ventajas y limitacionesCorelacion sincope y EC es baja de 6 a 20% maximo hasta 1% de los diagnosticos.Presencia de arritmias sin sincope no necesariamente explican esteUtilizad diagnostico de 25-40%, colocado 8 a 10 meses

absence of an abnormal finding at EPS does not exclude an arrhythmic etiologyof syncope as evidenced by the International Study on Syncope of UncertainEtiology (ISSUE) findings [8]. In one component of the multicenter, multifacetedISSUE study, an implantable loop recorder (ILR) was implanted insyncope patients with BBBB and both a normal EPS and a preserved left ventricularejection fraction. Paroxysmal AV block was documented in up to 50%of those who had recurrent syncope. In addition, 25% of the patients showed anasystolic pause preceded by progressive sinus bradycardia, strongly suggestiveof a neurally-mediated reflex origin to the bradyarrhythmia and syncope.These data confirm that a negative EPS does not exclude an arrhythmia asa cause of syncope and that a neurally-mediated reflex syncope can also bepresent in patients with BBBB.