How to Manage Patient with Syncope;

Arrhythmia Perspective

Ardian Rizal
Arrhythmia and Pacing Division
JOHN DOE, MD
Cardiology and Vascular Medicine Departement
Universitas Brawijaya - RSSA
SUBTITLE 32 PT ARIAL BOLD ITALICS
 What you should do in this situation ?

a) Cardiac Resucitation
b) Bring minyak kayu putih
c) Nothing

d)
 What is Syncope ?

• Syncope is defined as TLOC (Transient Loss of Consciousness) due to

cerebral hypoperfusion, characterized by a rapid onset, short duration, and
spontaneous complete recovery
Classification
Pathophysiology
 Epidemiology :
Cause of Syncope
Reflex Syncope

Vasovagal:
• orthostatic VVS: standing, less common sitting
• emotional: fear, pain (somatic or visceral),
instrumentation, blood phobia

Situational:
• micturition
• gastrointestinal stimulation (swallow, defaecation)
• cough, sneeze
• post-exercise
• others (e.g. laughing, brass instrument playing)

Carotid sinus syndrome

Non-classical forms (without prodromes and/or without

apparent triggers and/or atypical presentation
Orthostatic Hypotension

Drug-induced OH (most common cause of OH):

e.g. vasodilators, diuretics, phenothiazine,
antidepressants

Volume depletion:
haemorrhage, diarrhoea, vomiting, etc.

Primary autonomic failure (neurogenic OH):

pure autonomic failure, multiple system atrophy,
Parkinson’s disease, dementia with Lewy bodies

Secondary autonomic failure (neurogenic OH):

diabetes, amyloidosis, spinal cord injuries, auto-
immune autonomic neuropathy, paraneoplastic
autonomic neuropathy, kidney failure
 Clinical Features
that can suggest a diagnosis
Clinical Features
that can suggest a diagnosis
 Cardiac Syncope

Structural Heart
Arrhythmia Others
Disease

• Persistent sinus bradycardia 3 s in awake • atrial myxoma, • Myocardial infarct

state and in absence of physical training; • left atrial ball thrombus,
• Mobitz II second- and third-degree AV • severe aortic stenosis,
block; • pulmonary embolus, or
• Alternating left and right BBB; • acute aortic dissection
• VT or rapid paroxysmal SVT;
• Non-sustained episodes of polymorphic
VT and long or short QT interval;
• • Pacemaker or ICD malfunction with
cardiac pauses.
 RBBB

LAD (LAFB)

1st Degree AVB

Structural Heart Disease
Related to Syncope
How to Manage Syncope in ER ?
 Diagnosis
Test for Autonomic Function Other Test

• Active standing test • ECG

• Valsalva maneuver • Echocardiography

• Carotid sinus massage • Ambulatory ECG Monitoring

• Tilt table testing • EP Study

• Ambulatory blood pressure monitoring (ABPM)

Counter Pressure Maneuver
Tilt Training
PACEMAKER in Vaso-Vagal Syncope ?
Cardio Inhibitory Type

Circulation. 2001;104:903–907
Pacemaker Indication
Symptom – ECG Correlation
 Not only bradycardia

Girl 12 y.o.
Frequent episode of syncope
Diagnosed as epileptic attack

QTC 580 ms
 They are not too rare….

Brugada Syndrome

Long QT Syndrome

Short QT Syndrome

Cholinergic Polymorphic VT
 ICD INDICATION

PRIMARY SECONDARY
PREVENTION PREVENTION
 AVID Registry Study
Syncope and Sudden Cardiac Death

Unexplained syncope
Non -syncopal VT w/symptoms
1.00
VF
Transient correctable VT/VF

Cumulative Survival (%)

Asymptomatic VT
.90 VT w/syncope

.80

.70 P = 0.007

.65
0 1 2 3
Years
Anderson JL, et al. Circulation. 1999;99:1692-1699.
Syncope after MI
Sudden Cardiac Death : ICD ?
 TYPE A : COMPARATION COVERAGE AND THERAPY
PMK 64 Tahun 2016 Type A

Protecta XT VR (ICD)

Consulta CRTP

 For Single
Chamber and
Dual Chamber
therapy hospital
still has positive
Sensia DR (DC) GAP from BPJS

 BPJS Coverage
is not sufficient
Sensia S (SC)
on ICD Therapy
and CRT-P

Class 3 Mild Class 2 Mild Class 1 Mild Class 3 Moderate Class 2 Moderate Class 1 Moderate Class 3 Severe Class 2 Severe Class 1 Severe

Project X Decision Point X| Date| Template v1| Confidential, for internal use only
Catheter Ablation Indication
 Relative efficacy of catheter ablation vs antiarrhythmic
drugs in treating premature ventricular contractions: A
30.000
single-center retrospective study (Zhong Li et al, 2014)
Before After

25.000

36
% 43
%
20.000
73 82
84 % % 93
%
PVC/24 H

%
15.000

10.000
Conclusion
Catheter ablation appears to be more effective than
5.000
AADs in PVC reduction and LVEF normalization Li Zhong, Ying-Hsiang Lee, Xin-Miao
Huang, Samuel J. Asirvatham, Win-
Kuang Shen, Paul A. Friedman, David
O. Hodge, Joshua P. Slusser, Zhi-Yuan
Song, Douglas L. Packer, Yong-Mei
Cha,
Relative efficacy of catheter ablation vs
antiarrhythmic drugs in treating
premature ventricular contractions: A
0 single-center retrospective study,
Heart Rhythm,
BB CCB Amiodarone Propafenone Class 1, 3 AAD RFA Volume 11, Issue 2,
2014,
Take Home Messages

Syncope could be the sign of fatal cardiac event in the future

Syncope management should be treated according to its basic

pathophysiology

Sometimes, it doesn’t need further evaluation

THANK YOU