Syncope Unit Project A prospective systematic guideline-based evaluation and treatment of patients referred to the Syncope Units of general hospitals
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1 AIAC Associazione Italiana Aritmologia e Cardiostimolazione Syncope Unit Project Syncope Unit Project A prospective systematic guideline-based evaluation and treatment of patients referred to the Syncope Units of general hospitals An official study of Associazione Italiana di Aritmologia e Cardiostimolazione (AIAC) Funded by Medtronic Italy
2 Syncope Unit Project (SUP) End-points Assessment of the organizational model existing in Italy Assessment of the current standard of syncope management (diagnosis and treatment) based on the ESC guidelines.
3 Syncope Unit Project (SUP) Methods Observational prospective registry from 9 Italian Syncope Units Consecutive patients from March 15th to September 15ht, 2008
4 AIAC Associazione Italiana Aritmologia e Cardiostimolazione Syncope Unit Project Syncope Unit Project A prospective systematic guideline-based evaluation and treatment of patients referred to the Syncope Units of general hospitals Steering Committee Michele Brignole, Lavagna (chairman) Fabrizio Ammirati Ostia (co-chairman) Antonello Castro Roma Attilio Del Rosso Empoli Giuseppe De Marchi Alessandria Franco Giada Mestre Michele Gulizia Catania Maurizio Lunati Milano Massimo Santini Roma Andrea Ungar Firenze Participating centres and investigators Alessandria, Osp. Antonio, Biagio e Cesare Arrigo: Ivo Casagranda Catania, Ospedale Gribaldi Nesima: Maura Francese Empoli, Ospedale S Giuseppe: Nunzia Rosa Petix Firenze, Ospedale Careggi: Alessandro Morrione Lavagna, Ospedali del Tigullio: Roberto Maggi Milano, Ospedale Niguarda: Maria Rita Vecchi Ostia, Ospedale Grassi: Roberto Colaceci Roma, Ospedale S. Filippo Neri: Carlo Lavalle Roma, Ospedale Pertini: Massimo Sasdelli
5 Syncope Unit Project (SUP) Selection of Syncope Units Met the requirements of the ESC guidelines Met the requirements for GIMSI certification
6 Syncope management facilities: ESC standards Core equipment: surface ECG recording phasic blood pressure monitoring tilt table testing equipment external and implantable ECG loop recorders 24 hour ambulatory blood pressure monitoring 24 hour ambulatory ECG autonomic function testing ESC Guidelines on Management of Syncope
7 Syncope management facilities: ESC standards Preferential diagnostic access to: echocardiography EP studies stress testing coronary angiography CT and MRI scans electroencephalography ESC Guidelines on Management of Syncope
8 Syncope management facilities: ESC standards Preferential therapy access to: Pacemaker implantation ICD implantation Catheter ablation of arrhythmias and to any eventual therapy for syncope ESC Guidelines on Management of Syncope
9 Syncope management facilities: ESC standards Objectives: Continuity of care. Comprehensive management of the patient from risk stratification to diagnosis, therapy and follow-up Reduction of inappropriate hospitalizations Adoption of standardized guidelines-based approach in adherence with ESC and other appropriate guideline publications ESC Guidelines on Management of Syncope
10 Organizing the Management of Syncope Initial evaluation (Emergency dept., In- and out-hospital service, General practitioner) Diagnosis certain Syncope-like condition Diagnosis suspected or unexplained Discharge or Treatment Refer to Neurology/ Psychiatry as appropriate Syncope facility ( Syncope Unit ) Full access to cardiological and autonomic tests and specialists consultancies ESC Task Force on Syncope - Update 2004
11 Syncope Unit Project (SUP) Syncope Unit description (n=9) Syncope Unit location Public general hospitals with ED and Cardiology dept Syncope Unit location Cardiology dept: #7 Emergency dept: #1 Geriatric dept: #1 Formalized procedure of cooperations with: Cardiologist/s: #2 Neurology dept: #8 Dedicated trained staff All Dedicated ambulatory office with separated All waiting list Dedicated core laboratory Referral from ER, in-hospital and outhospital service; the Syncope Team is not usually involved in the initial evaluation of the patient. Preferential access to hospitalization and any other diagnostic test and eventual therapy Scheduled follow-up program All All All All
12 Syncope Unit Project (SUP) Syncope Unit description (n=9) Maximizing quality of care (according to the standards recommended by ESC) use of a decision making software designed in strict accordance to the Guidelines (Syncope Web software, version 1.0) designation of a syncope expert/s who lead the process of a comprehensive management of the patient from risk stratification to diagnosis, therapy and follow-up trained core technical personnel
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15 Syncope management facilities: ESC standards Who must manage syncope patients? The Syncope Expert The syncope expert is a single physician or the team of physicians who lead the process of a comprehensive management of the patient from risk stratification to diagnosis, therapy and follow-up. They usually perform directly the core laboratory tests and have preferential access to hospitalization and any other diagnostic test and eventual therapy.
16 Syncope Unit Project (SUP) Syncope Unit description (n=9) Syncope experts Personnels (no.) #1 in 4 Units #2 4 in 5 Units Staff #2 in 6 Units #>2 in 3 Units
17 Syncope Unit Project (SUP) Inclusion criteria Patients affected by T-LOC which, on initial evaluation, was attributed to a syncopal condition or because a syncopal condition could not be excluded (non-syncopal T-LOC), who were referred to the Syncope Unit because: there was the need to further investigate the nature of the loss of consciousness; and/or there was the need to confirm a likely diagnosis and administer a proper specific treatment.
18 Syncope Unit Project (SUP) Demographic results Total population (9 Syncope Units) Period of observation March 15, 2008 Sept 15, 2008 Total patients analyzed 891 Median age 66 (46;76) Males 476 (53%) History of recurrent syncopes 646 (72%) Life time number of syncopal episodes 3 (2;5) Duration of history of syncope (yrs) 3 (1;10) Abnormal ECG 214 (24%) Structural heart disease 288 (32%)
19 Syncope Unit Project (SUP) Demographic results Characteristics of the 9 Syncope Units Inhabitants per district of referall * Patients evaluated per year per centre median range interquartile range * total population (3.2% of Italian population)
20 Volume per centre (patients per month) min 25th 50th 75th max Syncope Units Number of patients
21 Volume per centre (patients per 100,000 inhabitants per year) 25th 50th 75th max Old Unit Recent Unit Syncope Units Number of patients
22 Volume per centre (patients per 100,000 inhabitants per year) Mann Whitney test: p=0.03 Old Units Recent Units
23 Syncope Unit Project (SUP) SUP data in perspectives Syncope visits per 100,000 inhabitants/year in different settings General practice 930 Emergency room 379 Syncope Unit 163
24 Syncope Unit Project (SUP) Conclusions A model of comprehensive guideline-based standardized evaluation of the patients with syncope is established in some general hospitals in Italy These results are useful for those who wish to replicate this model in other hospitals
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