Andrea Ungar, MD, PhD, FESC

Syncope Unit, Hypertension CentreGeriatric and Intensive care Medicine

University of Florence, Italy

Le linee guida Sincope 2018 della Società Europea di Cardiologia

La Syncope Unit Multidisciplinare

www.escardio.org/guidelines2

NEW / REVISED CLINICAL SETTINGS AND TESTS:• Tilt testing: concepts of hypotensive

susceptibility• Increased role of prolonged ECG monitoring• Video recording in suspected syncope• “Syncope without prodrome, normal ECG and

normal heart” (adenosine sensitive syncope)• Neurological causes: “ictal asystole”

NEW / REVISED INDICATIONS FOR TREATMENT:• Reflex syncope: algorithms for selection of

appropriate therapy based on age, severity of syncope and clinical forms• Reflex syncope: algorithms for selection of

best candidates for pacemaker therapy• Patients at risk of SCD: definition of

unexplained syncope and indication for ICD• Implantable loop recorder as alternative to

ICD, in selected cases

(OUT-PATIENT) SYNCOPE MANAGEMENT UNIT:• Structure: staff, equipment, and procedures• Tests and assessments• Access and referrals• Role of the Clinical Nurse Specialist• Outcome and quality indicators

MANAGEMENT IN EMERGENCY DEPARTMENT:• List of low-risk and high-risk features• Risk stratification flowchart• Management in ED Observation Unit and/or fast-track to Syncope Unit • Restricted admission criteria• Limited usefulness of risk stratification scores

2018NEW/REVISED

CONCEPTSin management

of syncope

www.escardio.org/guidelines

Organizational aspects: Syncope Unit

�The syncope unit should take the lead in service delivery for syncope, and in education and training of healthcare professionals who encounter syncope.

�The syncope unit should be led by a clinician with specific knowledge of TLOC and additional necessary team members (i.e. clinical nurse specialist) depending on the local model of service delivery.

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Key components - 1

2018 ESC Guidelines on Syncope – Michele brignole & Angel MoyaEHJ Doi:10.1093/eurheartj/ehy037

www.escardio.org/guidelines

Organizational aspects: Syncope Unit

� The syncope unit should provide minimum core treatments for reflex syncope and OH, and treatments or preferential access for cardiac syncope, falls, psychogenic pseudosyncope, and epilepsy.

� Referrals should be directly from family practitioners, EDs, in-hospital and out-hospital services, or self-referral depending on the risk stratification of referrals. Fast-track access, with a separate waiting list and scheduled follow-up visits, should be recommended.

� Syncope units should employ quality indicators, process indicators, and desirable outcome targets.

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Key components - 2

2018 ESC Guidelines on Syncope – Michele brignole & Angel MoyaEHJ Doi:10.1093/eurheartj/ehy037

www.escardio.org/guidelines

Staffing of an SU is composed of:1. One or more physicians of any specialty who are syncope specialists.2. A team comprised of professionals who will advance the care of

syncope patients.Equipment:

1. Essential Equipment/tests:– 12-lead ECG and 3-lead ECG monitoring,– non-invasive beat-to-beat blood pressure monitor,– tilt-table,– Holter monitors,– external loop recorders,– follow-up of implantable loop recorders (*),– 24-hour blood pressure monitoring,– Basic autonomic function tests.

2018 ESC Guidelines on Syncope – Michele brignole & Angel MoyaEHJ Doi:10.1093/eurheartj/ehy037

Organizational aspects: Structure of the SU

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2. Established procedures for:– Echocardiography– Electrophysiological

studies– Stress test– Neuroimaging tests

3. Specialists’ consultancies (cardiology, neurology, internal medicine, geriatric,psychology), when needed

www.escardio.org/guidelines

Initial assessment

History & physical evaluation 12-lead standard ECG

Subsequent tests and assessments (only when indicated)

Blood tests Electrolytes, Haemoglobin, troponin, BNP, glucose, D-dimer, Hemogasanalysis/O2 saturation.

Provocative tests Carotid sinus massage, Tilt table test.

Monitoring External loop recording, Implantable loop recording, Ambulatory 1-7 days ECG monitoring, 24-48 hour BP monitoring.

Autonomic function tests Standing test, Valsalva manoeuvre, deep breathing test.Cardiac evaluation Established procedures for access to echocardiogram, stress test, electrophysiological

study, coronary angiography.

Neurological evaluation Established procedures for access to neurological tests (CT, MRI, EEG, video-EEG).

Geriatric evaluation Established procedures for access to fall risk assessment (cognitive, gait and balance, visual, environmental).

Psychological or psychiatric evaluation

Established procedures for access to psychological or psychiatric consultancy.

Organizational aspects: Test and assessments in a Syncope Unit

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www.escardio.org/guidelines9

Procedure or test SUPhysician

SU Staff Non-SU personnel

History taking xStructured history taking (e.g., application of software technologies) x12-lead ECG xBlood tests xEchocardiogram and imaging xCarotid sinus massage xActive standing test xTilt table test (x) xBasic autonomic function test xECG monitoring (Holter, ELR): administration and interpretation x xImplantable loop recorder x (x)Remote monitoring xOthers: stress test, electrophysiological study, angiograms xNeurological tests (CT, MRI, EEG, video-EEG) xPacemaker and ICD implantation, catheter ablation xPatient’s education, biofeedback training. and instructions x x

Final report and clinic note xCommunication with patients, referring physicians x xFollow-up x x

Organizational aspects: Role of physician and staff in a SU

Ungar a. et al, Europace 2015

Assessment of a novel management pathway for patients referred to the Emergency Department for

syncope: results in a Tertiary Hospital

(Careggi Hospital - Florence, Italy)

Ungar a et al, 2015

ED295 patients

Admitted85 pz(29%)

Short stay60 pt(20%)

Syncope UnitFast Track

58 pt(21%)

Discharded92 pt(31%)

Ungar a et al, 2015

Destination related to ED “suspected” diagnosis

SYNCOPE Admission

n=85

Short – stay observation

n=60

SyncopeUnit

n=58

Discharge

n=80

Refusal

n=12

Cardiac 17 (60.7*) 5 (17.9*) 3 (10.7*) 0 3 (10.7*)

Neurally-mediate 13 (10,1*) 26 (20.2*) 20 (15.5*) 67 (51.9*) 3 (2.3*)

Pseudosyncope 11 (39.3*) 9 (32.1*) 2 (7.1*) 3 (10.7*) 3(10.7*)

Unexplained 44 (40.0*) 20 (18.2*) 33 (30.0*) 10 (9.1*) 3 (2.7*)

* % destination related to the diagnosis Ungar a et al, 2015

0.1

.2.3

.4.5

0 5 10 15Months of follow-up

Ricovero OBIFast Track NienteRifiuta

Estimated hospital re-admission according to multivariable Cox model-destino

New admissions related to ED destination

1 month

12 months

Ungar a et al, 2015

Admitted

Refusal

Discharged

Short stay obs

Syncope Unit

Ungar a et al, 2015

No patients sent to Syncope Unit

was dead within one year

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Should not be discharged

from the ED

Any high-risk

features require intensive

diagnostic approach

Should not be discharged

from the ED

Low-riskfeatures only

Can be dischargeddirectly from the ED

Neitherhigh nor low-risk

Syncope out-patientclinic (SU) (if available)

ED or Hospital SyncopeObservational Unit

(if available)

Any high-riskFeature

Admission for diagnosisor treatment

Syncope(after initial evaluation in ED)

Likely reflex,

situational or orthostatic

If

recurrent

2018 ESC Guidelines on Syncope – Michele brignole & Angel Moya

EHJ Doi:10.1093/eurheartj/ehy037

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2015

Syncope Unit: 69

20092011

2013

GIMSI - Syncope Unit Ceritication

www.gimsi.it

Syncope Unit: 21 Syncope Unit: 47 Syncope Unit: 71

2017

Syncope Unit: 73

57

67

21

Geriatrics

Internal Medicine

Emergency dptNeurology

Cardiology

GIMSI 2017 Certificated Syncope Unit(Total = 73)

www.gimsi.it

Grazie per l’attenzione

Le linee guida Sincope 2018 della Società Europea di Cardiologia

La Syncope Unit Multidisciplinare