Syncope expert and additional members

Michele Brignole

Faint & Fall programmeIRCCS Istituto Auxologico, Milano

Syncope expert and additional members

Michele BrignoleIRCCS, Istituto Auxologico

Founder & board member of GIMSI

www.gimsi.it

Syncopeexpert

The 3 concentric circles of an efficient syncope evaluation

• Neurally mediated / reflex

• Orthostatic

• Arrhythmia

• Structural cardiac disease

1

3

2 • Other real TLC / epilepsy

• Apparent TLC

Neurology

Cardiology

Emergency Internal Med Geriatrics

Psychiatry

Who should manage syncope patients?

'By subject' approach

4 • …and when the cause is unclear ?

SINCOPE2 0 1 9

www.gimsi.it

56

38

23

29

2

0 10 20 30 40 50 60

Cardiologia - Aritmologia

Geriatria

Medicina d'Urgenza

Medicina Interna

Neurologia

GIMSI members per discipline (tot=148)

Who should manage syncope patients?

No cooperation = no sense

www.gimsi.it

Who must manage syncope patients?

The Syncope ExpertThe syncope expert is a single physician or the team of

physicians who lead the process of a comprehensive

management of the patient from risk stratification to diagnosis,

therapy and follow-up. They usually perform directly the core

laboratory tests and have preferential access to hospitalization

and any other diagnostic test and eventual therapy.

Syncope management facilities:

ESC standards

ESC Guidelines on Management of Syncope

www.gimsi.it

Syncopeexpert

Syncope & Fall Unit

The 3 concentric circles of an efficient syncope evaluation

www.gimsi.it

Scopi del GIMSI sono:

1. Migliorare il governo clinico del problema sincope (e più in generale delle perdite transitorie di coscienza) attraverso organizzazione di congressi, formazione e divulgazione delle conoscenze scientifiche.

2. Promuovere la costituzione di unità funzionali per lo studio della sincope negli ospedali italiani (cosìdette “Unità Sincope” o “Syncope Unit”) che rispettino i requisiti di qualità stabiliti dalle lineeguida europee e recepiti dal GIMSI.

3. Promuovere attività scientifica e di ricerca attraverso organizzazione di studi clinici.

4. Attuare programmi scientifici in collaborazione con centri ospedalieri nazionali ed internazionali;

5. Promuovere la formazione, la qualificazione e l’aggiornamento nel campo della sincope e delle Perdite Transitorie di Coscienza.

Established in 2003

www.gimsi.it

Established in 2003

GIMSI certified Syncope Unit

2015

Syncope Unit: 69

20092011

2013

www.gimsi.it

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

SINCOPE2 0 1 9

www.gimsi.it

Abruzzo = 1

Basilicata = 1

Calabria = 2

Campania = 6

Emilia-Romagna = 8

Friuli-Venezia-Giulia = 1

Lazio = 5

Liguria = 4

Lombardia = 13

Marche = 1

Piemonte = 7

Puglia = 4

Sardegna = 2

Sicilia = 3

Toscana = 5

Trentino - Alto Adige = 2

Umbria = 1

Valle d’Aosta = 1

Veneto = 5

Le 72 Syncope Unit certificate

GIMSI 2019

SUP data in perspectivesSyncope Unit Project

(SUP)

How many SU ?

70 GIMSI SU in Italy, year 2017

Optimal

One SU every

150-300.000 inhabitants

(one each ASL/USL/ASST)

Total (in Italy): 200-400 SU

www.escardio.org/EHRA 17

Europace 2015; 17: 1325-40

ESC GUIDELINES

European Heart Journal (2018) 39, 1883–1948

2018 ESC Guidelinesfor the diagnosis and managementof syncope

www.escardio.org/EHRA 19

Europace 2015; 17: 1325-40

Expected benefits of syncope unit:

• SU reduces underdiagnosis and

misdiagnosis of syncope

• SU reduces hospitalization

• SU reduces costs

EHRA Syncope Unit Europace 2015; 17: 1325-40

Organisational aspects: Syncope Unit

EHRA Syncope Unit Europace 2015; 17: 1325-40

Organisational aspects: Syncope Unit

15/16 studies showed that SU

improve diagnoses and reduce

admissions and costs

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.

Organizational aspects: Structure of the SU

22

2. Established procedures for:

– Echocardiography

– Electrophysiological studies

– Stress test

– Neuroimaging tests

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

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

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

Test and assessments available in a SU

EHRA Syncope Unit www.escardio.org/EHRA Europace 2015; 17: 1325-40

EHRA Syncope Unit www.escardio.org/EHRA

Procedure or test SUPhysician

SU Staff Non-SUpersonnel

History taking xStructured history taking (e.g., application of software technologies)

x

12-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 x

Implantable loop recorder x (x) Remote monitoring xOthers: stress test, electrophysiological study, angiograms

x

Neurological tests (CT, MRI, EEG, video-EEG) x

Pacemaker and ICD implantation, catheter ablation x

Patient’s education, biofeedback training. and instructions

x x

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

Follow-up x x

The role of physician and staff in performing procedures and tests

Europace 2015; 17: 1325-40

Beyond Syncope Unit: the Faint & Fall Centres

Programma Svenimenti e Cadute (Faint & Fall Clinic)

Programma Svenimenti e Cadute (Faint & Fall Clinic)

Pioneering experiences:

• RA Kenny: Day Case Syncope Evaluation Unit,

Newcastle - UK

• RA Kenny: Fall & Syncope Unit (FASU), Dublin, Ireland

• A. Ungar: Syncope and Fall Unit, Florence, Italy

• M. Hamdan: Faint & Fall Clinic, University of Utah and

University of Wisconsin, USA

Non-accidental Accidental

“slip or trip”

Unexplained Fall,“syncope likely”

Explainedi.e., impaired gait/balance,

lower limb joint abnormalities

cognitive status,

visual status

enviroment hazard

drug interaction

Fall

Same evaluation as for

unexplained syncope

Faint(TLOC)

Faint prevention therapy and FU Fall prevention therapy and FU

Neurological consult

Initial presentation

• Syncope(reflex, OI, cardiac)

• Non-syncopal faint(epilepsy, PPS, others)

Programma Svenimenti e Cadute (Faint & Fall Clinic)

Programma Svenimenti e Cadute (Faint & Fall Clinic)

Prospective observational study:

Inclusion: pts >40 yrs with syncope or fall

Aim: Comparison of 100 unexplained fallsand 100 unexplained syncope

Method:Standardized assessment

www.gimsi.it

Syncopeexpert

Syncope & Fall Unit

Referrals & education

The 3 concentric circles of an efficient syncope evaluation

Europace 2015; 17: 1325-40

Which patients ?

Organizing the Management of Syncope

Initial evaluation

Syncope facility

(“Syncope Unit”)

Diagnosis

certain

Dischargeor

Treatment

Syncope-like

condition

Refer to

Neurology/

Psychiatry

as appropriate

Diagnosis

suspected or unexplained

Full access to cardiological and

autonomic tests

and specialists’consultancies

(Emergency dept., In- and out-hospital service, General practitioner)

ESC Guidelines on Syncope

The “Careggi” model

Ungar A et al. Europace, in press

29% 20%

20%

31%

www.escardio.org/guidelines

Should not be dischargedfrom the ED

Any high-riskfeatures require intensive

diagnostic approachShould 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

Ifrecurrent

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

Referral source

Syncope Unit Project (SUP)

Emergencyroom

Out-hospital

In-hospital

13%60%

11%

16%

Protected discharge

Management

Brignole et al. Europace 2010; 12: 109–118

Setting Incidence

(per 1000

subject-years)

Relative

frequency

(compared to 100

patients with

syncope)

General population 18−40 100

Seeking any medical

evaluation 9.3–9.5 25−50

Referred for specialty

evaluation3.6 10−20

Referred to emergency

department 0.7–1.8 2−10

Syncope frequency depends on the setting in which

the measurement is made

ESC Guidelines on Syncope – Version 2018

Epidemiology

Who should manage syncope patients?

'By process' approach

Who makes the decisions now?

... but when it is unclear?

• General practioner?

• Ambulance staff? Triage nurses? ER physicians?• Referral easy when cause is evident

o Epilepsy neurologyoArrhythmia cardiologyoPseudo-unconsciousness psychiatryoSyncope in Parkinson or MSA neurology

Education

Education

Education

www.gimsi.it

Basic Competence on Syncope Course

The role of GIMSI …

… organize training activities, such as continuing educational courses, dedicated to physicians and health-care professionals working in the field of

syncope

Certified physicians

Since September 2014

29 training course to date

620 GIMSI certified physicians

www.gimsi.it

1- The tilt testing laboratory

2- The VVS clinic

3- The disautomia laboratory

4- The epilepsy clinic

5- etc, etc…..

What is not SU ?

www.gimsi.it

1- the right physician: syncope specialist

2- the right place: adequate equipment, including

on-line prompting tool, and logistic

3- the right time: optimal organization (fast track,

on-site preferential access to specialized tests)

What is SU ?