Improving the approach to non-cardiac syncope in the emergency department observation unit

doi:10.5847/wjem.j.1920-8642.2023.017

Abstract

Filippo Numeroso, Ivo Casagranda. Improving the approach to non-cardiac syncope in the emergency department observation unit[J]. World Journal of Emergency Medicine, 2023, 14(2): 128-132.

Figures/Tables 4

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References 14

[1]	Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018; 39(21): 1883-948. doi: 10.1093/eurheartj/ehy037 pmid: 29562304
[2]	Brignole M, Menozzi C, Bartoletti A, Giada F, Lagi A, Ungar A, et al. A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J. 2006; 27(1): 76-82. pmid: 16272210
[3]	Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, et al. Practical Instructions for the 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018; 39(21): e43-e80. doi: 10.1093/eurheartj/ehy071
[4]	Numeroso F, Mossini G, Lippi G, Cervellin G. Evaluation of the current prognostic role of cardiogenic syncope. Intern Emerg Med. 2013; 8(1): 69-73. doi: 10.1007/s11739-012-0889-3 pmid: 23247682
[5]	Thiruganasambandamoorthy V, Hess EP, Turko E, Perry JJ, Wells GA, Stiell IG. Outcomes in Canadian emergency department syncope patients—are we doing a good job? J Emerg Med. 2013; 44(2): 321-8.
[6]	Ruwald MH, Hansen ML, Lamberts M, Hansen CM, Vinther M, Køber L, et al. Prognosis among healthy individuals discharged with a primary diagnosis of syncope. J Am Coll Cardiol. 2013; 61(3): 325-32. doi: 10.1016/j.jacc.2012.08.1024 pmid: 23246392
[7]	Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version). Eur Heart J. 2009; 30(21):2631-71 doi: 10.1093/eurheartj/ehp298
[8]	Brignole M, Rivasi G. New insights in diagnostics and therapies in syncope: a novel approach to non-cardiac syncope. Heart. 2021; 107(11):864-73. doi: 10.1136/heartjnl-2020-318261 pmid: 33462120
[9]	Rivasi G, Ungar A, Moya A, Brignole M, Sutton R, Fedorowski A. Syncope: new solutions for an old problem. Kardiol Pol. 2021; 79(10): 1068-78. doi: 10.33963/KP.a2021.0138
[10]	Numeroso F, Casagranda I. How to simplify the implementation of Syncope ESC Guidelines in the Emergency Department and get on the road to achieve zero inappropriate admissions. Minerva Med. 2022; 113(2): 228-33.
[11]	Frith J. Diagnosing orthostatic hypotension: a narrative review of the evidence. Br Med Bull. 2015; 115(1): 123-34. doi: 10.1093/bmb/ldv025
[12]	Vanbrabant P, van Ouytsel V, Knockaert D, Gillet J. Diagnostic yield of syncope investigation (initiated) in the emergency department: a pilot study. Acta Clin Belg. 2011; 66(2): 110-5. pmid: 21630607
[13]	Sutton R, Brignole M. Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis. Eur Heart J. 2014; 35(33): 2211-2. doi: 10.1093/eurheartj/ehu255 pmid: 24980488
[14]	Ministerial Decree 70/ 2015, Official Gazette of the Italian Republic, Generale Series n. 127, 4/6/2015. Available at: https://www.gazzettaufficiale.it/eli/id/2015/06/04/15G00084/sg

Phenotype	Pathophysiology	Clinical features	Diagnostic tests
Hypotensive	●Hypotensive susceptibility (constitutional or acquired) ●Autonomic failure (primary or secondary)	●Any form of reflex syncope with dominant vasodepressor component ●Orthostatic hypotension ●BP below target range according to age and clinical conditions ●Systolic BP drops below target range during BP monitoring	●Active standing test ●Tilt table test ●Carotid sinus massage ●Home BP monitoring ●24-hour ABPM ●CV autonomic function tests (Valsalva, deep breathing test, etc.)
Bradycardic	●Abnormal cardioinhibitory reflex ●Low plasma adenosine with low expression of A_2A receptors	●Any form of reflex syncope with dominant cardioinhibitory component ●ECG documentation of spontaneous pauses due to likely vagal mechanism ●Idiopathic paroxysmal AV block in patients without prodromes and normal heart	●Tilt table test ●Carotid sinus massage ●Prolonged cardiac monitoring (ILR, ELR) ●Plasma adenosine level

Diagnostic findings	Suggestive features
ECG findings Persistent sinus bradycardia <40 beats per minute (bpm) or sinus pause >3 s Mobitz II second-degree and third-degree AV block Alternating left and right BBB VT or rapid paroxysmal SVT Non-sustained episodes of polymorphic VT and long or short QT interval Pacemaker or ICD malfunction with cardiac pauses	ECG findings - Bifascicular block or other intraventricular conduction abnormalities with QRS duration ≥0.12 s - Mobitz I second-degree AV block and one-degree AV block with markedly prolonged PR interval - Asymptomatic mild inappropriate sinus bradycardia (40-50 bpm) or slow atrial fibrillation (40-50 bpm) - Non-sustained VT - Pre-excited QRS complexes - Long or short QT intervals - ST-segment elevation with type 1 Brugada pattern - Negative T waves in right precordial leads, epsilon waves suggestive of ARVC - Left ventricular hypertrophy suggesting hypertrophic cardiomyopathy
Cardiac ischaemia-related syncope if there is evidence of acute myocardial ischaemia with or without myocardial infarction	Clinical features - Syncope during exertion or when supine - Sudden onset of palpitations immediately followed by syncope
Syncope due to structural cardiopulmonary disorders if there is evidence of prolapsing atrial myxoma, left atrial ball thrombus, severe aortic stenosis, pulmonary embolus or acute aortic dissection	Historical findings - Family history of unexplained sudden death at young age - Presence of structural heart disease or coronary artery disease

Improving the approach to non-cardiac syncope in the emergency department observation unit

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Main eductional points
- Only patients with APDs underlying syncope or syncope due to a proven or highly suspected acute cardiac diseases, namely the “causal risk”, warrant admission
- Syncope severity is affected by recurrences, shortness of prodromes, impact on a patient’s life (injuries, disruption of school and work activity, driving), namely the “consequential risk”
- After a non-cardiac syncope, risk for traumatic recurrences is affected by age, personal characteristics (frailty, motor difficulties, comorbidities), and pharmacologic treatment
- A thorough blood pressure assessment should comprehend active and passive standing challenge test as well as a more extensive execution of ABPM
- BP targets in hypertensive patients with syncope should be tailored on cardiovascular and hypotensive (syncope and fall) risk
- Drug-related hypotension may result from non-cardiovascular drugs (antipsychotics,TCAs, trazodone, BDZ) to be considered as a risk factors for a hypotensive susceptibility, particularly at old age
- Carotid sinus massage is a safe maneveur, to be extensively applied in ED to all patients aged over 40 years and syncope compatible with a reflex mechanism
- To optimize management of patients with non-cardiac syncope, especially at old age, there is the need of close connections between EDOU, geriatrics and outpatient syncope unit
- New technologies (e.g. smartwatch, home videorecording, etc.) can have a role for identifying the prevalent mechanism of syncope, between hypotensive and bradycardic phenotype