LagestioneclinicadellasincopenelDipartimentodiEmergenzaedilruolo

dellaSyncope UnitGiorgioCostantinoMedicinaInterna

IRCCSFondazioneCa’Granda,OspedaleMaggiorePoliclinico

Milano

Pazientedi78anni

• Nulladirilevanteinanamnesi• Datregiorninausea• Vieneperepisodiosincopalealpassaggiodalclino all’ortostatismo,precedutodabreviprodromi(iniziatiinposizioneseduta),nonangor,dispneaopalpitazioni

• All’arrivoinPSPA105/60,FC56r,obiettivitàneilimiti.

• PAinclino 105/70,inorto90/60conlievisintomi• All’ECGRS,60bpm,PQ0.16,lievialterazionidellaripolarizzazione,QTlungo(QTc 0.48)

STRATIFICAREILRISCHIO

Stratificareilrischio

72of theadmissions (34%)wereforlow-risk(SFSRscore,0).Thesepatientshasamean1.73-daylengthofstayand10.8tests.Clinicaldataarereported in(Table1).Elevenadverseeventswereidentifiedin9admissions forlow-risksyncope(13%[95%CI,0.06-0.23]).Fouroftheseadverseeventswereclassifiedasseriousandincludeddelirium,transfusionerror,hypoglycemia,andfall.Otheradverseeventsincludedmissedmedicationerrorsandcomplicationsfromintravenousandurinarycatheterplacement

Stratificazione del rischio della sincope:Scores Prognostici (prevalentemente medicina d’urgenza)

Stratificazione del rischio della sincope:Scores Prognostici (prevalentemente medicina d’urgenza)

Rose RuleRose Rule(Reed M et al. JACC 2010;55:713-21)

üB BNP>300 orBradicardia<50 bpm

üR Rectal examination showing fecal occult blood if suspectedüA Anemia (Hb<9g/dl)üC Chest pain associated with syncopeüE ECG showing Q wave not in lead IIIüS Saturation <94% in room air

ricovero se presenza di almeno 1 fattore

San Francisco Syncope RuleSan Francisco Syncope Rule(Quinn JV et al. Ann Emerg Med 2006;47:448-454)

üC Congestive heart failureüH Haematocrit <30%üE ECG abnormalüS Shortness of breathüS Systolic blood pressure < 90 mm Hg

ricovero se presenza di almeno 1 fattore

Stratificazione del rischio della sincope:Scores Prognostici (prevalentemente cardiologici)

Stratificazione del rischio della sincope:Scores Prognostici (prevalentemente cardiologici)

OESIL RISK SCOREOESIL RISK SCORE(Colivicchi F et al. Eur Heart J 2003;24:811-819)

üetà > 65 anni = 1 puntoüstoria di malattie cardiovascolari = 1 puntoüsincope senza prodromi = 1 puntoüelettrocardiogramma anomalo = 1 punto

ricovero consigliato per score ≥ 2

EGSYS ScoreEGSYS Score(Del Rosso A, et al. Heart 2008;94:1620-26)

üPalpitations before syncope (+4)üAbnormal ECG or heart disease (+3)üSyncope during effort (+3)üSyncope while supine (+2)üAutonomic prodrome (-1)üPredisposing or precipitating factor (-1)

ricovero se score ≥ 3

Gigerenzereiltacchino

SyncopeclinicalmanagementintheEmergencyDepartment:aconsensusfromthefirstinternationalworkshoponsyncoperiskstratificationintheED

SyncopeclinicalmanagementintheEmergencyDepartment:aconsensusfromthefirstinternationalworkshoponsyncoperiskstratificationintheED

Thefirstpatient’sassessmentshouldincludehistory,physicalexamination,ECG,supineandstandingbloodpressuremeasurementandsubsequenttests(suchasbloodsampling,carotidsinusmassage,echocardiogram,chestx-ray,bloodgasanalysis)accordingtothepatient’scharacteristicsandphysician’sjudgment.IftheetiologyofsyncopeisidentifiedduringEDstay,thepatientwillbemanagedaccordingtothecausalcondition.

Causedisincopeapotenzialerapidaevolutività

Embolia polmonare Pneumotorace iperteso

Dissecazione aortica Aritmia cardiaca maligna

Emorragia interna Gravidanza ectopica

Aneurisma dell’aorta addominale in rottura

Emorragia subaracnoidea

Infarto miocardico acuto Dissecazione carotidea o vertebrale

Tamponamento cardiaco Embolia grassosa

Latriade(sintomiosegniunificanti)DDDt

• Dolore• Dispnea• Disability(segniosintomineurologici)• Tachicardiapersistente

Lapresenzadialmenounodiquestisegni/sintomipuòfaresospettareunapatologiaarapidaevolutivitàcomecausadisincopeedeveportareadescluderla,conanamnesi/esameobiettivomiratioulterioriapprofondimentidiagnostici

Low risk factors High risk factors

Characteristics of the patients

Young age (<40 years)

Characteristics of syncope

Only while in standing position During exertion

Standing from supine/sitting position In supine position

Nausea/vomiting before syncope New onset of chest discomfort

Feeling of warmth before syncope Palpitations before syncope

Triggered by painful/emotionally distressing stimulus

Triggered by cough/defecation/micturition

Low risk factors High risk factors

Factors present in the history of the patient

Prolonged history (years) of syncope with the same characteristics of the current episode

Family history of sudden death

Congestive heart failure

Aortic stenosis

Left ventricular outflow tract disease

Dilated cardiomyopathy

Hypertrophic cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy

Left ventricular ejection fraction <35%

Previously documented arrhythmia (ventricular)

Coronary artery disease

Congenital heart disease

Previous myocardial infarction

Pulmonary hypertension

Previous ICD implantation

Low risk factors High risk factors

Symptoms, signs or variables associated with the syncopal episode

Anemia (Hb <9 g/dl)

Lowest systolic blood pressure in the ED <90 mmHg

Sinus bradycardia (<40 bpm)

ECG features

New (or previously unknown) left bundle branch block

Bifascicular block + first degree AV block

Brugada ECG pattern

ECG changes consistent with acute ischemia

Non sinus rhythm (new)

Bifascicular block

Prolonged QTc (>450 msec)

• Lowrisk:patientswithoneormorelowriskcharacteristicsandwithoutanyhighriskcharacteristics;

• Highrisk:patientswithatleastonehighriskcharacteristic;

• Patientneitherathigh,noratlowrisk.Namely,patientswithanyofthefollowing:– patientswithcomorbiditieswhowouldotherwisebeatlowrisk;

– patientswithoutanycomorbiditywhosesyncopehassomeworrisomecharacteristicsitself;

– patientswithoutanyloworhighriskcharacteristics”.

SyncopeclinicalmanagementintheEmergencyDepartment:aconsensusfromthefirstinternationalworkshoponsyncoperiskstratificationintheED

SyncopeclinicalmanagementintheEmergencyDepartment:aconsensusfromthefirstinternationalworkshoponsyncoperiskstratificationintheED

PScosedafare:

• SempreECG• PAinclino eortostatismo• Ricercareunacausasepossibile• Escluderelepatologiearischioimmediato• Monitorare• Eventualecontattoeinvioallasyncope unit

PScosedanonfare

• D-dimeroetroponina• TACencefalo• Chiamareilneurologo• Ricoverareinrepartosenzatelemetria(inassenzadidiagnosieconrischiononbasso)

• Ricoveraresenzaunobiettivo

La sacra Sincope