Syncope: An Evidence-Based Approach

334 Pages·2020·9.324 MB·English

by  Michele Brignole (editor), David G. Benditt (editor)

Syncope
An Evidence-Based Approach
Michele Brignole
David G. Benditt
Editors
Second Edition
123
Syncope
Michele Brignole • David G. Benditt
Editors
Syncope
An Evidence-Based Approach
Second Edition
Editors
Michele Brignole David G. Benditt
Faint & Fall Programme University of Minnesota, MMC 508
IRCCS Istituto Auxologico Italiano Minneapolis
Ospedale San Luca MN
Piazzale Brescia USA
Milano
Italy
ISBN 978-3-030-44506-5 ISBN 978-3-030-44507-2 (eBook)
https://doi.org/10.1007/978-3-030-44507-2
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Foreword
The authors of this new edition of an evidence-based approach to syncope are all
distinguished in their field. For example, since 2001, many of the authors have con-
tributed to four consecutive evidence-based guidelines for the management of syn-
cope, published by the European Society of Cardiology (ESC) and latterly the
American College of Cardiology/American Heart Association/Heart Rhythm
Society (2017). At each stage, gaps in evidence were identified and subsequent
research evolved to inform future iterations. Consequently, these authors have taken
this field to a new level of understanding and management, driven by the commit-
ment of all but in particular, the ESC panel chairman and co-editor of this edition,
Michele Brignole.
From a personal perspective, after setting up a dedicated UK syncope service in
1992, it became clear that syncope involved multiple disciplines, pertinent to all
ages, for which at the time, there were no clear care pathways, training or education
programmes. To all intents and purposes, syncope was a new ‘discipline’. Skills in
aspects of cardiology, emergency medicine, internal medicine, physiology, neurol-
ogy and autonomic diseases, geriatric medicine and paediatrics were required to
cover the breadth of causes, cohorts and service models. In this regard, representa-
tion on the both the ESC and American syncope guidelines panels evolved to reflect
this multidisciplinarity, including the role of nursing in service delivery, coupled
with new practical instructions on how to establish syncope services aimed at reduc-
ing hospitalizations, under- and misdiagnoses and costs of care.
Why Syncope? Syncope is one of the most common symptoms that physicians
and health care services encounter; a lifetime prevalence of over 40%. Even very
young children will experience episodes of apparent syncope. The incidence peaks
between ages 10 and 30 and again after age 70 years. The majority of events are
caused by well-recognized triggers and constitute the common ‘faint’—vasovagal
syncope. Such patients may experience lifelong episodes which tend to cluster.
These patients have a lower threshold for what is otherwise a normal physiological
response—a response that humans and animals exhibit under situations of physio-
logical stress (e.g., haemorrhage, emotional distress, etc.). Nonetheless, speedy rec-
ognition and management are important for these patients to curtail unnecessary
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vi Foreword
worry and costs including cost of care due to collapse-related injury. Alternatively,
as detailed in this edition, syncope may be due to structural or arrhythmic cardiac
disease or albeit infrequently certain neurological disorders necessitating alternative
evidence-based approaches.
Given that syncope is responsible for up to 5% of emergency department visits,
with varying hospitalization rates up to 40%, risk stratification in the ED setting is
a priority and a new addition to this new edition. Even with comprehensive guide-
lines on either side of the Atlantic, there remains widespread disparity in the man-
agement of syncope. Excessive service utilization and associated costs are, in the
main, due to inappropriate hospital admission and overzealous investigation.
One of the commonest challenges in the management of syncope and related
disorders is the older patient, due to atypical presentations, difficulties in attaining
witness accounts, variation in tolerance of medications and interventions and high
rates of comorbidities. Ageing demographics are rapidly changing worldwide. For
most of history, 3% of persons lived to 65 or over. Today 26% of Japanese, 20% of
Europeans and 17% US citizens are over 65. The fastest population increase in the
coming years will be in those over 80. Because of successful survival from midlife
cardiovascular disorders and more aggressive management of cardiovascular disor-
ders in this rapidly rising demographic, prevalence of syncope and related disorders
are increasing and will continue to rise. This challenge may be addressed by new
strategies for personalized interventions, as yet unresolved.
Who is responsible for the discipline of Syncope? Despite evidence for benefits
to the individual and health care systems of a structured approach to syncope, the
development of comprehensive services, as recommended by the guidelines, is not
yet widespread. Because of the multidisciplinary nature of syncope, no single spe-
ciality currently has responsibility for training and education. Consequently, as
training schemes for individual disciples have become more streamlined and struc-
tured, responsibility for certification of clinicians for syncope remains undeter-
mined. Other barriers include disparity in cost structures in different health care
systems, which influence drivers for new services. Until these are resolved, we rec-
ommend that a leader from any pertinent specialty should engage with local stake-
holders and employ a care model which best fits local needs and systems with
privileged access to sub-specialities as necessary; these concepts are reflected in this
new edition.
One of my great personal pleasures, as we have progressed syncope management
over the past number of years, is the cross country collaborations, close partnerships
and friendships that have developed. The authors of this new edition are committed
experts and collaborators who herewith present a refreshed and pragmatic approach
to syncope, embedded in evidence but highlighting, where relevant, gaps in evi-
dence. We encourage the new generations to engage with this fascinating field.
Rose Anne Kenny
National Syncope Unit, Faculty of Health Sciences
School of Medicine, Trinity College
Dublin, Republic of Ireland
Preface
Rationale for the Second Edition
The First Edition of this book was published in 2011. Utilizing an evidence-based
approach, it offered practical guidance for the wide range of medical practitioners
involved in the care of patients who present with transient loss of consciousness.
This Second Edition was initiated after publication (in the years 2017 and 2018,
respectively) of the new American and the most recent European guidelines on the
management of syncope and collapse. The editors, both of whom participated as
contributing guidelines authors, realized that there were in the latest guideline rec-
ommendations enough new concepts to justify an updated edition of the book.
Although, not unexpectedly, when dealing with comparable topics, most of the rec-
ommendations within the two practice guidelines are very similar to each other,
there are some interesting differences that are worthy of discussion. Additionally,
there remain certain unresolved topics that merit being addressed. Thus, the second
edition has several goals: (1) to offer a multidisciplinary update taking advantage of
the best evidence provided by the two recent guidelines, (2) to provide explanation
and practical advice for those issues in which the two guidelines differ and (3) to
highlight where solid information is lacking and towards which further research
may be profitably directed.
Since syncope and collapse are very common clinical problems in need of mul-
tidisciplinary consideration, the editors have assembled a team of key opinion lead-
ers in the study and management of syncope/collapse which is not only international
in nature but also represents a wide range of specialities including cardiology, neu-
rology, internal medicine, emergency medicine and geriatrics. Many of the authors
participated as members of the tasks forces that not only wrote the guidelines men-
tioned above but have also contributed to the critical and growing research founda-
tions of the field. We are grateful to all of them for their voluntary, timely and
unconditional support.
While all the chapters of the First Edition were written by the two editors, in this
Second Edition each chapter has been written by individuals who have
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viii Preface
demonstrated interest and expertise in the specific topic being addressed. The edi-
tors prepared the table of contents, defined the format and reviewed the chapters in
order to minimize inconsistencies and duplication while at the same time allowing
for differences of opinion where that was deemed appropriate. A diverse geographi-
cal distribution was purposely sought in order to achieve balanced conclusions. The
table of contents differs substantially from the first edition; specifically, while some
chapters required primarily deep revision and update of their content, many others
are completely new.
Aims and Scope
Syncope/collapse has many possible causes, and a multidisciplinary approach is
most effective for evaluation and treatment. Often the expertise of cardiologists,
neurologists, emergency medicine specialists, general practitioners, geriatricians
and other clinicians is needed; the critical need for broad-ranging expertise is
emphasized herein. However, unfortunately, each of these sub-specialties has tended
to develop and use different terminology, methodology and management guide-
lines; these differences have complicated effective interaction among the various
caregivers and have made evaluation and treatment of affected patients more com-
plex. One of the aims of this Second Edition is to try to provide a viewpoint that can
be adopted effectively across specialties.
In summary, this volume represents a comprehensive multidisciplinary review of
the subject, offering recommendations based on the most recently published prac-
tice guidelines as well as experience derived from the various sub-specialties. It
begins by discussing the scientific basis behind the diverse pathophysiology of con-
ditions that may cause syncope/collapse and reviews optimal clinical management
pathways. Later sections of the book then take a more practical approach, defining
recommendations for the practice of syncope/collapse management. The most com-
mon procedures and tests are discussed along with their indications, methodology,
interpretation and limitations.
The Second Edition has been designed to fulfil the needs of the wide range of
medical practitioners involved in the care of syncope/collapse patients. All special-
ties will benefit from the concentration on the importance of medical history taking.
Emergency room physicians and internists will be aided by the focus on the initial
evaluation and risk stratification. The general practitioner will be aided in the care
of their patients by the focus on the initial history taking and advice regarding the
most appropriate initial tests and avoidance of low yield diagnostic procedures.
Cardiologists and cardiac electrophysiologists will find up-to-date recommenda-
tions regarding the indications for and appropriate interpretation of non-invasive
and invasive cardiac testing. Finally, geriatricians, neurologists and psychiatrists
will find useful the sections exploring the often-difficult topic of distinguishing true
syncope from other important conditions that may present as transient loss of con-
sciousness or mimics of transient loss of consciousness.
Preface ix
In closing, the editors wish to thank their many friends and colleagues (and espe-
cially those who served on the major professional society Syncope Guidelines
Committees) for their crucial input through invaluable discussions and debates over
many years. These individuals have educated us and influenced our thinking; inevi-
tably their ideas and contributions have made their way into and substantially
improved this work.
Milan, Italy Michele Brignole
Minneapolis, MN, USA David G. Benditt
Contents
Part I T LOC/Collapse: Pathophysiologic and Epidemiologic Features
1 Syncope: Definition and Classification-Contrasting
the American and European Guidelines . . . . . . . . . . . . . . . . . . . . . . . . 3
Noah N. Williford and Brian Olshansky
2 The Meaning of ‘Consciousness’ in Syncope
and Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
J. Gert van Dijk
3 Prognosis of Syncope Across the Diagnostic Spectrum . . . . . . . . . . . . 33
Steve W. Parry
4 The Economic Impact of Syncope: Direct and Indirect Costs . . . . . . 45
Aalap D. Narichania and Mohamed H. Hamdan
Part II B asic Clinical Features
5 Determining the Cause of TLOC/Collapse:
The Initial Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Angel Moya and Patricia Fumero
6 Seizures vs Syncope: Distinguishing Features for the Clinic . . . . . . . 69
Robert S. Sheldon and Satish R. Raj
7 Reflex Syncope: The Common and Less Common Variants . . . . . . . . 83
Ritsuko Kohno and Haruhiko Abe
8 Orthostatic Hypotension Variants, POTS,
and Less Well-Defined Autonomic Dysfunction . . . . . . . . . . . . . . . . . . 95
Artur Fedorowski
9 Bradycardias and Tachycardias: Acquired and Inheritable . . . . . . . . 109
Matthew T. Bennett, Thomas M. Roston, Shubhayan Sanatani,
and Andrew D. Krahn
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