Management of Reflex Syncope

Transcription

1 Management of Reflex Syncope Heart Rhythm Society 2012 Alan Fitchet Salford Royal Hospital Declarations of interest - none

2 Neurally-Mediated Reflex Syncope (NMS) Vasovagal Syncope (VVS) Carotid Sinus Syndrome (CSS) Situational Syncope post-micturition cough swallow defecation blood drawing etc. Fainting, 1744, Pietro Longhi

3 Victorian Fainting Chair

4 Because breathing should never get in the way of looking ladylike.

5 NMS: Clinical Pathophysiology Neurally-mediated physiologic reflex mechanism with two components: Cardioinhibitory ( HR ) Vasodepressor ( BP ) Both components are usually present: Vasodepressor may be masked in the presence of severe bradycardia

6 VVS Initial Treatment Strategy Patient education, reassurance, instruction Reduce/remove exacerbating medications Fluids, salt, diet Salt/Volume Increased dietary salt, Increased volume intake Physical maneuvers Muscle tensing, leg-crossing Standing / tilt-training Support stockings/abdominal binders

7 Physical Counter-Manoeuvre (PCM) Trial 223 patients with prodrome, age 38.6 (± 15.4) yrs Nynke van Dijk et al. JACC 2006

8 VVS: Tilt-Training Objectives Enhance orthostatic tolerance Diminish excessive autonomic reflex activity Reduce syncope susceptibility/recurrences Technique Prescribed periods of upright posture Progressively increased duration

9 VVS: Tilt-Training Variable Clinical Outcomes Non-randomized studies suggest tilt-training can be effective if undertaken daily for 8 to 12 weeks Recent randomized controlled trials have been less encouraging Benefit often short-lived Compliance issues Further studies needed

10 VVS Treatment Psychological Factors Psychological and/or psychiatric factor may contribute to exacerbating VVS susceptibility A high prevalence of minor psychiatric disorders has been reported in VVS patients The relationship between psychiatric conditions and VVS is uncertain, but potential inter-relationships should not be overlooked Giada F et al. Europace 2005 Leftheriotis D, et al. Psychother Psychosom 2008

11 VVS: Pharmacologic Rx Beta-adrenergic blockers 1 positive small RCT (atenolol) Negative large RCT (POST) Fludrocortisone 1 negative RCT (POST2) SSRIs Paroxetine single study Vasoconstrictors 1 negative controlled trial (etilephrine) 2 positive controlled trials (midodrine)

12 Symptom Free Interval Midodrine for VVS Midodrine Fluid p < pts, midodrine vs. fluid, salt tablets & counselling Months Perez-Lugones A et al. J Cardiovasc Electrophysiol. 2001;12(8):

13 VPS I, VASIS, SYDIT Pacing Therapy for VVS Control patients did not receive pacemakers (PM) Pacing benefit in patients with PM vs. unpaced controls VPS II, Synpace Both test group (PM on) and control group (PM off) had pacemakers implanted Pacing benefit not apparent Key difference between study outcomes was whether a device had been implanted

14 Cumulative Risk (%) VPS I North American Vasovagal Pacemaker Study No Pacemaker 54 pts 6 (22%) with PM had recurrence vs. 19 (70%) without PM RRR 84% Pacemaker Time in Months Connolly SJ. J Am Coll Cardiol. 1999;33:16-20.

15 Cumulative Risk VPS II Vasovagal Pacemaker Study II VVS recurrence: 33% with pacing vs. 42% with sensing only (P=NS) Pacemaker complication rate 10% Only Sensing Without Pacing (ODO) 0.2 Dual Chamber Pacing (DDD) Months Since Randomization Connolly S. JAMA. 2003;289:

16 ISSUE 3 International Study on Syncope of Uncertain Etiology 3 Study design Double-blind, randomized placebo-controlled study 29 centres Inclusion criteria Age 40 years 3 syncopal episodes in the prior 2 years Brignole M et al; Circulation. 2012;125:

17 ISSUE 3 International Study on Syncope of Uncertain Etiology 3 Brignole M et al; Circulation. 2012;125:

18 ISSUE 3 International Study on Syncope of Uncertain Etiology 3 ARR 32% RRR 57% Brignole M et al; Circulation. 2012;125:

19 ISSUE 3 International Study on Syncope of Uncertain Etiology 3 All 511 had highly symptomatic, neurally mediated syncope. Asystole seen in 89 (17%) Treatment effect of pacing - 57% reduction in syncope. Therefore just 10% who received the ILR benefitted from pacing. Complications: Lead dislodgements in 4 of 77 pts Vein thrombosis in 1 of 77 pts Pacemaker therapy is suitable for a select group of patients. Brignole M et al; Circulation. 2012;125:

20 75 50 Carotid Sinus Syndrome Pacing 57% Pacing for CICSS AHA - Class I /IIa indication ESC - Class IIa indication Mean follow-up 6 months 25 0 No Pacing %6 Pacing Brignole M, et al. Eur JCPE. 1992;4:

21 Putting it all together

22

23