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La syncope réflexe bénigne existe‐t‐elle dans la cardiopathie sévère?
Haran Burri, PDMédecin Adjoint AgrégéService de Cardiologie
M S. 70 yrs• Syncope at rest in 6.2011• AMI in 10.2010‐ DES in LAD‐ LVEF 40%‐ no chest pain since‐ NYHA II
• HTAVagal syncope in young adulthood
• Rx: ASA 100mg/dClopidogrel 75mg/dMetopropol 100mg/dLisinopril 25mg/d
Current history
• Syncope while watching a televisiondocumentary on myocardial infarction
• Syncope preceded by sweating, nausea• No chest pain, palpitations• Lasted about 1 min according to spouse, without post‐critical state
Physical examination
• BP 130/70mmHg sitting and 120/60mmHg standing, pulse 60 bpm regular
• Cardiac auscultation: S1 S2 normal, PMS 2/6 murmur at apex
• Lung auscultation normal• CSM: no pause or hypotension
SR 60 bpm. PR 200ms. QRS 140ms, NIVCD, QT 450ms
Soteriades ES, et al. NEJM . 2002;347:878‐885.
Etiology and prognosis
• Cardiac cause:
‐ 6‐month mortality >10%‐ > 2x mortality risk
Is the history in this patient enoughto confirm vaso‐vagal syncope?
Yield of diagnostic testsInitial evaluation Yield (%)History, status, ECG, CSM 38-40
Other testsTilt test 27Holter 5-13Insertable Loop Recorder (ILR) 43-883-5
EP study <2-5Stress test 0.5EEG 0.3-0.5
1Alboni P, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001;37:1921‐1928.2Kapoor W. Evaluation and outcome of patients with syncope. Medicine. 1990;69:160‐175.3Krahn AD, et al. Use of an extended monitoring strategy in patients with problematic syncope. Circulation. 1999;99;406‐410.4Krahn AD, et al. Randomized Assessment of Syncope Trial. Circulation. 2001;104:46‐51.5Krahn AD, et al. The high cost of syncope: Cost implications of a new insertable loop recorder in the investigation of recurrent syncope. Am Heart J. 1999;137:870‐877.
History and etiology of syncopeHistory and etiology of syncope
Alboni et al JACC 2001
Less reliable history in elderly patients
Am J Cardiol 2005;96:1431–1435
n = 485
Del Rosso Am J Cardiol 2005;96:1431–1435
46% of elderly patients with heartdisease had neurally‐mediatedsyncope
What is the next test that youwould perform at this stage? Tilt test?
Holter ?
EP study ?
Implantable loop recorder ?
Nothing ?
Tilt‐test
Electrophysiological study
• (Sinus dysfunction)• AV conduction• Inducible tachycardia
CAD patients with syncope: inducibility and survival
Class I indication for an ICD
EPS
• No sinus dysfunction• HV interval normal (<60ms)• No inducible VT (max. 3 ES)
What is the next test that youwould perform at this stage?
Tilt test?
Implantable loop recorder ?
Nothing ?
Tilt‐test
Sensitivity 60‐70% Specificity 92‐94%
Negative tilt‐test
Insertable Loop Recorders (ILR)Insertable Loop Recorders (ILR)
Reveal® Medtronic-manual/auto trigger-remote download (CareLink®)
Sleuth®, Transoma
-manual/auto trigger-wireless data transmission
Confirm®St Jude Medical-manual/auto trigger-remote download
High‐risk patients in whom a comprehensive evaluation did not demonstrate a cause of syncope or lead to specific treatment (Class I, Level of evidence B)
Circulation. 2001;104:2045‐2050
FU 3‐15mo
Median 48 days to documented event
European Heart Journal (2011) 32, 1535–1541
+ EPS if:SNRT>1500 ms; CSNRT>525 msbaseline HV interval ≥70 msHis–Purkinje block during incremental atrial pacing or after intravenous class IC drugs
Phase I:Clinical, ECG, echo, (Holter)
Phase III (ILR)44/108 (41%) pts had a cause treated by a PM/ICD
Patient follow‐up
• ILR implantation in 8.2011
• No recurrence of syncope or abnormalfindings by ILR……yet
Conclusions• Syncope in the presence of structural heart disease
requires intensive evaluation
• History may be less reliable for diagnosing etiology of syncope in elderly patients
• Negative studies do not exclude diagnosis
• >1/3 of patients with BBB and a negative EPS have a diagnosis of bradycardia by an ILR requiring a pacemaker
• Indication of an ICD in patients with low LVEF should beevaluated independantly of presence of syncope
Merci !Merci !
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