Dr. Ricardo Ruiz-Granell
This session, under the auspices of the Committee for Practice Guidelines, faced the issue of management of syncope, an old entity under the light of the new Guidelines for the diagnosis and management of syncope (version 2009), recently published and presented in this Congress. The speakers were Dr. A. Moya, Dr. M. Brignole, Dr. A. Ungar and Dr. D.G. Benditt, Chairman, members and external contributor, respectively, of the Task Force of the ESC that has developed the new Guidelines. Dr. J-J. Blanc and I chaired this interesting session. Dr. Moya’s presentation centered on an issue that has been stressed in the new Guidelines: risk stratification. It is well known that the vast majority of patients with syncope have a good prognosis but in a few of them syncope may herald sudden cardiac death. Initial evaluation, risk stratification and long-term electrocardiographic monitoring have become the crucial points in the evaluation of syncope. There is not complete consensus on how to assess the level of risk in particular patients, but the new Guidelines list clinical characteristics that can be very helpful in identifying high risk patients, most of them obtained during the initial evaluation. High risk patients deserve immediate study to exclude potentially lethal causes of syncope, and those fulfilling criteria for device implantation according to current guidelines have to be implanted without delay. Long-term ECG monitoring, especially with implantable loop recorders, is the preferred tool in the next step of diagnosis and has proved to be useful in high risk profile patients with negative evaluation and in low risk profile patients with frequent relapses or with special characteristics (lessive, professional profile, etc.).
Dr. Brignole dealt with whether the syncope units are a utopia or a necessity. He showed scientific evidence on the advantages of syncope units. These units help to dramatically reduce the number of inappropriate and useless diagnostic tests while increasing the yield of the diagnostic process. So, syncope units cut down the cost by patient and by diagnosis, as has been shown with 21 syncope units that are accredited in Italy. Patients with a suspected diagnosis or with unexplained syncope after the initial evaluation should be referred to syncope units, either with the patient admitted to the hospital, or with a preferential appointment on an ambulatory basis. The unit has to be structured with its own facilities and core equipment and with preferential access to usual diagnostic tests and therapeutic techniques. In this setting, the term syncope expert has been introduced to designate a single person or a team that leads the comprehensive management of patients with syncope. Quoting Dr. Brignole: “Syncope units are not a utopia, and are not a necessity: syncope units are a reality”. Next, Dr. Ungar focused on the specific aspects of syncope in the elderly. He taught us that syncope presents with a different profile in the elderly, not only from the etiologic aspect (orthostatic hypotension is highly prevalent in this population) but also the clinical presentation. This makes the diagnostic process more difficult. History taking is often impossible and some findings in usual tests are of little or unknown value. Carotid sinus massage is safe when done to elderly people, as is tilt table test even with nitroglycerin challenge, but one has to be cautious in the interpretation of results. Dr. Ungar stressed the importance of postural blood pressure tests in the diagnostic process, as they probably have the highest diagnostic yield, and the lowest cost. Since orthostatic hypotension is not always reproducible, orthostatic tests should be repeated if negative, especially in patients with Parkinson’s disease or taking diuretics or nitrates. Also ECG monitoring with implantable loop recorders is somewhat different in this population: it is indicated and it is diagnostic in a greater proportion of patients than in younger populations. Finally, an additional problem comes from unexplained falls. Unexplained falls represent about 15% of all falls in an emergency department, but in the elderly population this figure rises to near 37%. The cause of the fall in most of them is syncope. So there is a population of elderly people with unexplained falls that should be referred for syncope investigation. Dr. Benditt closed the session speaking to us about his impressions on the future directions in the diagnosis and management of syncope. The cost of the diagnostic process of syncope is elevated but a significant proportion of patients remain undiagnosed at the end. So it is evident that future directions have to seek cost reduction and improvement in the diagnostic yield. Some elements of the process seem to be candidates for improvement. In the initial evaluation, history taking is the basis of the diagnostic process and maybe structured or computer-based questionnaires overcome the difficulties in obtaining a detailed clinical history. A consensus on risk criteria is needed in order to perform homogeneous risk stratification. Syncope units may become the standard of care for these patients since they have been shown to reduce cost and increment diagnostic efficacy. Without a doubt, diagnostic of syncope would be easier with advanced monitoring devices. Dr. Benditt commented on some experiences with ECG monitoring associated to daily transmission and introduced the necessity of hemodynamic monitoring.
This excellent session focused on management of syncope under the light of the new Guidelines and showed us that despite continuous improvements in the task of diagnosing syncope there are still some shades to be enlightened in the future. Initial evaluation, risk stratification and ECG monitoring are the hinges of the diagnostic process. The quality is guaranteed when the process is led by a dedicated team with dedicated facilities and keeping in mind the peculiarities of special populations.
Syncope 2009: a new perspective for an old entity
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