First Vs Recurrent Syncope In Patients With Structural Heart Disease Or Bundle Branch Block

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitari Vall d"Hebron - Vall d"Hebron Institut de Recerca. CIBERCV BACKGROUND Patients with structural heart disease (SHD) or bundle branch block (BBB) are at high risk of having an arrhythmic syncope (AS). In patients with recurrent syncope episodes (RSE) complete work-up including electrophysiological study (EPS) and/or implantation of a loop recorder (ILR) is recommended, however patients with their first episode may also be at risk of an AS. AIM To determinate if the patients with SHD or BBB with a single syncope episode (SSE) are at high risk of having an AS and compare it with patients with recurrent episodes (RSE). METHODS Cohort study carried out in a tertiary hospital that is a reference centre for syncope. From January 2008 to August 2020 patients with SHD or BBB with syncope of unknown origin after the initial evaluation and without direct indication of an ICD were included. They were managed according the current ESC guidelines. RESULTS 417patients were included (74 ±11 y. o; 39% female). Mean follow up was 2.5 ±1 y. 223 patients were diagnosed from an AS [113 (53%) in SSE group and 110 (54%) in RSE group, p = 0.9], 210 were due to bradyarrhythmia (AV block or sinus arrest). No differences in baseline characteristics where found comparing both groups, except that BBB was slightly more prevalent in patients with RSE (81% vs 90%, p = 0.01) (FIGURE- PANEL A). Risk of AS was 53% in patients with SE and 54% (p = 0.9). RSE were not associated with an increased risk of AS in univariate analyses (OR 1.01 IC95% 0.7-1.5) neither in the multivariate (FIGURE- PANEL B). EPS and ILR diagnostic yield was 45% / 32% respectively in SSE group and 44% / 33% in RSE group (p = 0.8) (FIGURE - PANEL C). After appropriate treatment, recurrence syncope rate was 10% in SSE group and 9% in RSE group (p = 0.8). No significant differences in mortality rate were found. CONCLUSIONS Patients with SHD or BBB and single syncope episode are at a high risk of having AS, and similar to those with RSE. EPS and ILR offer a similar diagnostic yield in both groups. Complete syncope work-up must be recommended in these patients despite having had only a single episode. Abstract Figure

Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation

Aims Previous reports have suggested that cardioneuroablation (CNA) can be effective in reducing syncopal recurrences in patients with vasovagal syncope (VVS). This study assessed the efficacy of CNA in preventing a positive response to head-up tilt testing (HUT). Methods and results This is a single-centre retrospective study reviewing prospectively collected data. Fifty-one consecutive patients with VVS were included in the study. After confirmation of >3 s asystole on HUT, all patients underwent CNA. Head-up tilt testing was repeated 1 month after CNA. The main outcome measures were recurrence of syncope episode and positive response on HUT. During a median follow-up period of 11 months (interquartile range 3–27 months), all but 3 (5.8%) of 51 patients were free of syncope. Repeated HUTs were negative in 44 (86.2%) patients. When patients with recurrent syncope were excluded, vasodepressor response was seen in three cases and cardioinhibitory response in one case, respectively. Cardioneuroablation caused significant and durable shortening of RR interval in all cases. This effect was significantly higher in patients without positive HUT responses. Conclusion This pilot study shows that CNA can effectively prevent recurrent syncopal episodes in patients with refractory VVS. Head-up tilt testing seems as a valuable diagnostic tool not only to select suitable candidates and but also to evaluate success of CNA.

P1092Syncope in the emergency department: can 24-hour holter monitoring be of any help?

Background Syncope is a very common reason for presenting to the emergency department (ED). The existence of a telemetry unit is crucial but it is not the reality in some hospitals. In order to avoid unnecessary ward admission, 24-hour Holter (24HH) monitoring could be useful to help with the diagnosis (when the arrhythmic etiology is suspected and the symptoms are frequent enough) and also be important to safely discharge a patient. Purpose The purpose of this study is to evaluate the diagnostic performance of 24HH monitoring, during a syncope episode in the ER, and to compare the readmission rates between patients with normal and abnormal not diagnostic 24HH monitoring. Methods A cohort study of consecutive patients (P) who were monitored with 24HH in one hospital in the ED, between January 2015 and December 2017, were included. All the 24HH results were seen by a senior cardiologist and divided in three groups: A - normal, B - abnormal Holter study unlikely to explain syncope and C- Holter study considered to be diagnostic. Groups A and B were compared using chi-square independence test to evaluate association between the result of the 24HH and readmission rates at 30 days and 1 year, as well as mortality and device implantation at 1 year. Multivariate logistic regression was used to look for other confounders. Results A total of 111 P were included in this study. Mean age was 75 ± 14 years old, with 55.6% male patients. A previous emergency episode with syncope was present in 56.9% of P. The mortality at one-year follow-up was 11.9%. The 24HH was considered diagnostic in 25.2% of P (28 P), with 18.9% of all the P with necessity of pacemaker (PM) implantation. In the patients with a non-diagnostic 24HH, 6,4% implanted a loop recorder before discharge. Group B patients had a higher 30-day readmission rate to the ED when compared with group A (OR = 4.050 CI 95 [1.13 – 14.497], p = 0.033), but no difference in one-year readmission rate (p= 0.065). There was no difference in one-year mortality between the two groups (p= 0.731) or in one-year implantation of pacemaker (p= 0.431). Conclusion The use of 24HH in the ED could be a valuable tool in the diagnosis of rhythm disorders that cause syncope. An abnormal non diagnostic result can still be a predictor of 30-day readmission to the ED with similar complaints.

Syncope as a sign of occult cancers: a population-based cohort study

Background We examined if syncope was a marker of an occult cancer by comparing the risk in patients with a syncope episode with that of the general population. Methods Using Danish population-based medical registries, we identified all patients diagnosed with syncope during 1994–2013 and followed them until a cancer diagnosis, emigration, death or end of follow-up, whichever came first. We computed cumulative risks and standardised incidence ratios (SIR) with 95% confidence intervals (CI). Results Among 208,361 patients with syncope, 20,278 subsequent cancers were observed. The 6-month cumulative risk of any cancer was 1.2%, increasing to 17.9 % for 1–20 years of follow-up. The highest cumulative risks after 6 months of follow-up were lung cancer (0.2%), colorectal cancer (0.2%), prostate cancer (0.1%) and brain cancer (0.1%). The 6-month SIR were 2.7 (95% CI: 2.4–3.0) for lung cancer, 2.0 (95% CI: 1.8–2.2) for colorectal cancer, 1.7 (95% CI: 1.5–1.9) for prostate cancer and 10.0 (95% CI: 8.6–11.4) for brain cancer. Conclusions Syncope was a weak marker of an occult cancer. In short-term the highest cumulative risks were observed for lung, colorectal, prostate and brain cancers. An aggressive search for occult cancer in a patient with syncope is probably not warranted.

Syncope in a Working-Age Population: Recurrence Risk and Related Risk Factors

Syncope in a worker undertaking risky tasks may result in fatalities for the individual or for third parties. We aimed at assessing the rate of syncope recurrence and the risk factors underlying the likelihood of syncope relapse in a working-age population. A prospective cohort of all patients aged 18–65 years consecutively admitted to the Emergency Department for syncope was enrolled. Risk of syncope relapse was assessed at a six-month, 1-year, and 5-year follow-up. Predictors of syncope recurrence have been evaluated at six months and 1 year from the syncope index by a multivariable logistic regression analysis. 348 patients were enrolled. Risk of syncope relapse was 9.2% at 6 months, 11.8% at 1 year, and 23.4% at 5 years. At 6-month follow-up, predictor of syncope recurrence was ≥3 prior lifetime syncope episodes. At 1-year, ≥3 prior lifetime syncope episodes, diabetes mellitus, and anaemia were risk factors for syncope relapse. There was an exceeding risk of recurrence in the first 6 months and a reduced risk of 3.5% per year after the first year. Anaemia, diabetes mellitus, and prior lifetime syncope burden are of importance when giving advice about the resumption of “high risk” jobs following a syncope episode.

Von Hippel-Lindau Syndrome: Diagnosis and Management of Hemangioblastoma and Pheochromocytoma

Introduction. Von Hippel-Lindau (VHL) syndrome is a pathological condition that causes various clinical symptoms and is difficult to diagnose. The most common pathological lesions are hemangioblastomas of the central nervous system, retinal angiomas, renal clear cell carcinomas, and pheochromocytomas.Case Report. A 23-year-old female had a syncope episode in 2008. Magnetic resonance imaging (MRI) revealed a right temporal hemangioblastoma, which was treated surgically. Genetic screening identified a VHL gene mutation, and computed tomography (CT) revealed a left adrenal mass. Since it was unclear whether the mass was a pheochromocytoma, or another benign or malignant tumors, laparoscopic adrenalectomy was performed. A month after surgery, the patient complained of general fatigue, poor concentration, loss of appetite, and insomnia. After careful clinical investigation, the patient was referred to a psychiatrist due to suspected depression, which was confirmed.Conclusions. VHL genetic screening should be performed in cases of hemangioblastoma. In VHL syndrome cases, pheochromocytoma cannot always be diagnosed by biochemical catecholamine analyses; therefore, CT or MRI scanning of the abdomen must be performed. Due to the long treatment period, some patients may develop episodes of depression, which can simulate VHL syndrome.