Is Left Ventricular Diastolic Dysfunction a clinical predictor of Syncope?

Transcription

1 Is Left Ventricular Diastolic Dysfunction a clinical predictor of Syncope? Abdul Jawwad Samdani, MBBS Mentor: Mrinalini Meesala, MD Yuji Saito, MD

2 What is Syncope? Why it is important? Common clinical problem Introduction % of all emergency room visits 1 6 % of hospital admissions annually in the US Incidence increasing with age Maybe disabling Trivial to Life threatening causes. Challenging differential diagnoses Extensive testing with enormous financial burden.

3 Introduction Causes Of Syncope Reflex/ Neurally- Mediated Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary 1 Vasovagal Syncope Carotid sinus syndrome Situational Cough Post- Micturition 2 Drug-Induced Dehydration/ Hypovolemia ANS Failure Primary Secondary 3 Brady SN Dysfunction AV Block Tachy VT SVT Long QT Syndrome 4 Acute MI AS or MS HCM PulmHTN/ PE Aortic Dissection Cardiac tumor/ thrombus Unexplained Causes = Approximately 1/3 DG Benditt, MD. U of M Cardiac Arrhythmia Center

4 Introduction What is the utility of echocardiogram in evaluation of syncope? An echocardiogram has been described as an important tool with variable utility in the workup of syncope. Traditionally mainly used for identifying and quantifying an underlying structural heart disease (LVOT obstruction, valvular heart disease and cardiomyopathy).

5 Introduction Echocardiography can provide additional information for diagnostic and risk stratification purposes. Certain recent studies suggest that a small left atrial volume and lower mitral A velocity (a measure of atrial kick in LV filling) can predict positive Head up Tilt Test seen in neurocardiogenic syncope. Other studies suggest that LVDD may have a PARTIAL role in pathogenesis of syncope in patients with HOCM and Severe AS

6 Introduction No direct studies to date to evaluate possible role of LVDD in pathophysiology of syncope There is an overlap in risk factor associated with syncope and LVDD (Age, obesity, HTN, DM) Pathophysiologically, we know that LVDD results in a smaller stroke volume and hence a lower cardiac output that may facilitate causation of syncope.

7 Objectives To elucidate If Left Ventricular Diastolic Dysfunction (LVDD) is a clinical predictor of Syncope If Echocardiography plays a role in risk stratifying patients presenting with syncope in the absence of underlying structural heart disease.

8 METHODOLOGY

9 Methodology Retrospective Chart Review Single center: SOCH Duration: January 2011 to Dec 2012 Adult patients 18 years 2 groups; Syncope and Comparison group (Control) IRB Approval obtained No conflicts of interest or financial disclosures

10 Methodology: Sample Selection Echocardiography database searched by Syncope Echocardiography database searched by Routine Pre op and Evaluate Cardiac/ LV function N = 421 N = 463 Exclusion Diagnoses of Seizure, TIA, Fall, Presyncope Exclusion EF < 50% Severe Aortic (AS) and Mitral Valve disease HOCM AFib/ Flutter Acute coronary syndrome CHF exacerbation Limited Echo Exclusion Diagnosis of Syncope. Incomplete data Syncope Cases: N = 197 Control Group: N = 170

11 Methodology: Data Collection Performa Demographics Co morbids and medications 2 D Echocardiographic parameters Cause of syncope per discharge summary

12 Methodology: Data Collection Echocardiographic measurements and grading of LVDD per American Society of Echocardiography guidelines.

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15 Methodology Statistical Analysis: SPSS version 20 Chi square 2 sample independent t test One way ANOVA p value of <0.05 considered significant

16 RESULTS

17 Results Demographics p = Cases Controls

18 Results Co morbids Cases Controls Percentages

19 Results Medications Drugs Syncope (n=197) Control (n=170) p value Beta Blockers % CCBs % Diuretics % ACEI/ARB % Nitrates % Hydralazine % Clonidine %

20 Results LVDD Frequency Percentages p< 0.001** p= 0.004** LVDD Grade 1 Grade 2 Grade 3 Cases Controls **P-value adjusted for Age, BMI, Gender, Race, HTN and DM

21 Results Other Cardiac Parameters Means 4 3 Syncope Control 2 p= p = E Velocity (m/s) A Velocity (m/s) E/A E' Velocity (m/s) E/E'

22 Results Other Cardiac Parameters Cardiac Parameters Syncope (n=197) Control (n=170) p value HR (Mean ± SD) 70.9 ± ± LVEF (Mean ± SD) 62.8 ± ± LVIDd (Mean ±SD) 4.5 ± ± LVM index (Mean ± SD) 87.8 ± ± LVH % LA size (Mean ±SD) 3.5 ± ± ** LA volume index (Mean ± SD) 24.3 ± ± E Velocity (Mean ± SD) 0.77 ± ± ** A (Mean ± SD) 0.84 ± ± E/A (Mean ± SD) 1.0 ± ± DT (Mean ± SD) ± ± IVRT (Mean ± SD) 88.7 ± ± E Velocity (Mean ± SD) 0.12 ± ± ** E/E (Mean ±SD) 6.8 ± ± LA pressure (Mean ± SD) 10.3 ± ±

23 Results Sub group Analysis Orthostatic 17% Causes of Syncope Cardiac 14% Undiagnosed 46% Reflex/Neural 23%

24 Subgroup Analysis LVDD Frequency Percentage p= p= LVDD Grade 1 Grade 2 Grade 3 Reflex/ Neural Cardiac Orthostatic

25 Comparison between Causes of Syncope p< p< p= p= p < Age (mean) HTN (%) DM (%) CAD (%) CHF (%) Reflex/ Neural Cardiac Orthostatic

26 Comparison between Causes of Syncope p= p= p = p< p= LVM index (gm/kg2) LVH (%) LA volume index cm3/ kg2 A (cm/s) E/E' Reflex/ Neural Cardiac Orthostatic

27 Results Comparison between Causes Variables of Interest Reflex Cardiac Orthostatic p value n=45 n=27 n=34 Age (Mean) <0.001 BMI (Mean) HTN % <0.003 DM % CAD % CHF % <0.001 LVEF (Mean) LVIDd (Mean) LVM index (Mean) LVH % LA size (Mean) <0.001 LA volume index (Mean) <0.001 E Velocity (Mean) A Velocity (Mean) E/A (Mean) DT (Mean) IVRT (Mean) E Velocity (Mean) LA pressure (Mean) RVSP (Mean) LVDD % Normal % Grade 1 % Grade 2 % Grade 3 % 0 4 0

28 Conclusion Our results show that LVDD is more common in patients with syncope than the control group reaching statistical significance Hence LVDD is likely a predictor of syncope. Also, presence of LVH, larger LAV index, higher mitral A velocity, larger E/E and presence of LVDD are significant predictors of cardiac syncope in the absence of structural heart disease

29 Implications/ Future Considerations Hypothesis generation for future studies to explore the link between LVDD and Syncope Echocardiography may have additional role in the evaluation of syncope. Parameters like LVH, LAVI, A velocity and LVDD can likely be incorporated in the risk stratification tools/ score systems in evaluation of syncope and can be further studied.

30 Limitations Retrospective design Causal association can not be definitely established Hospital based data lacking generalizability

31 References 1. Manganelli F, Betocchi S, Ciampi Q, Storto G, Losi MA, Violante A, et al. Comparison of hemodynamic adaptation to orthostatic stress in patients with hypertrophic cardiomyopathy with or without syncope and in vasovagal syncope. Am J Cardiol 2002;89(12): Folino AF, Russo G, Buja G, Iliceto S. Contribution of decreased atrial function in the pathogenesis of neurally mediated syncope. Am J Cardiol 2006;97(7): Sarasin FP, Junod AF, Carballo D, Slama S, Unger PF, Louis Simonet M. Role of echocardiography in the evaluation of syncope: a prospective study. Heart 2002;88(4): Moon J, Shim J, Park JH, Hwang HJ, Joung B, Ha JW, et al. Small left atrial volume is an independent predictor for fainting during head up tilt test: the impact of intracardiac volume reserve in vasovagal syncope. Int J Cardiol 2013;166(1): Park SJ, Enriquez Sarano M, Chang SA, Choi JO, Lee SC, Park SW, et al. Hemodynamic patterns for symptomatic presentations of severe aortic stenosis. JACC Cardiovasc Imaging 2013;6(2): Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelista A. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr Feb;22(2): doi: /j.echo Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ; Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr Dec;18(12): Puppala VK, Dickinson O, Benditt DG. Syncope: classification and risk stratification. J Cardiol Mar;63(3): doi: /j.jjcc Epub 2014 Jan Puppala VK, Dickinson O, Benditt DG. Syncope: classification and risk stratification. J Cardiol Mar;63(3): doi: /j.jjcc Epub 2014 Jan Thiruganasambandamoorthy V, Stiell IG, Sivilotti ML, Murray H, Rowe BH, Lang E, McRae A, Sheldon R, Wells GA. Risk stratification of adult emergency department syncope patients to predict short term serious outcomes after discharge (RiSEDS) study. BMC Emerg Med Mar 14;14:8. doi: / X 14 8.

32 Thank you Questions?

33 Supplementary Slides

34 Results Demographics Syncope (n=197) Control (n=170) p value Age (Mean ±SD) 66.5 ± ± Gender Male % Female % Race Caucasians % African Americans % Other % BMI (Mean ±SD) 27.8 ± ± **

35 Results Comorbids Syncope (n=197) Control (n=170) p value HTN % DM % CAD % CHF % CVA % Paroxysmal Afib % COPD/ Asthma % DL % Active Tobacco % CKD % Previous Syncope %

36 RESULTS SUBGROUP ANALYSIS CAUSE of SYNCOPE Unknown n (%) 91 (46.2) Reflex/ Neural n (%) 45 (22.8) Cardiac n (%) 27 (13.7) Orhtstatic n (%) 34 (17.3)

37 RESULTS LVDD Frequency Syncope (n=197) Control (n=170) p value LVDD % ** Adjusted*** <0.001** Grade 1 % Grade 2 % ** Grade 3 % Adjusted*** 0.004** *** Adjusted for Age, Gender, Race, HTN, DM and BMI

38 Results Comparison between Causes Unknown Reflex Cardiac Orthostatic p value Age (Mean) <0.001** HTN % <0.001** DM % ** CAD % ** CHF % <0.001** LVEF (Mean) LVIDd (Mean) LVM index (Mean) ** LVH % ** LA size (Mean) <0.001** LA volume index (Mean) <0.001** E Velocity (Mean) A (Mean) ** E/A (Mean) DT (Mean) IVRT (Mean) E Velocity (Mean) E/E (Mean) LA pressure (Mean) LVDD % ** Grade 1 % Grade 2 % ** Grade 3 %

39 Methodology: Sample Selection Echocardiography database searched by Syncope N = 421 Echocardiography database searched by Routine Pre op and Evaluate Cardiac/ LV function N = 463 Exclusion Diagnoses of Seizure, TIA, Fall, Presyncope Exclusion EF < 50% Severe Aortic (AS) and Mitral Valve disease HOCM AFib/ Flutter Acute coronary syndrome CHF exacerbation Limited Echo Incomplete data Exclusion EF < 50% Severe Aortic (AS) and Mitral Valve disease HOCM AFib/ Flutter Acute coronary syndrome CHF exacerbation Limited Echo Incomplete data Exclusion Diagnosis of Syncope. Syncope Cases: N = 197 Control Group: N = 170