1. Consultant Cardiologist
"Blackouts”
Dr Paul Venables
Consultant Cardiologist

2. Blackouts Introduction NICE Clinical Guideline Red Flags Epidemiology
Historic standard of care
Key recommendations
Practice points
Red Flags
Background on syncope
NICE: Important cardiovascular documnt we ought to have a working knowledge of, aim to summarise the main points

3. Blackout: Definition Loss of consciousness Rapid onset
Character:
Loss of consciousness
Rapid onset
Transient/Short duration
Spontaneous recovery
TLoC (blackout) is a spontaneous loss of consciousness with complete recovery
Syncope is a T-LOC due to transient global cerebral hypoperfusion
TLOC: Most frequently cardiovascular, epilepsy, or more rarely Psychogenic or rare cause such as metabolic
Syncope: characterized by rapid onset, short duration, and spontaneous
complete recovery. Excludes TLOC caused by other mechanisms ie epilepsy/hypoglcaemia
Important to consider these as part of a wider framework, because the history may not be claer cut for ex possible syncope in an elderly patient.

4. Epidemiology Increase with old age Peak in teenage²
Incidence /1000¹
Often unreported
Affects half population during lifetime
Incidence according to
age and sex
Graphic data based on Framingham
Approximate around 1% of population annually
Soteriades et al. NEJM 2002
Ganzeboom et al. J Cardiovasc Electrophysiol 2006

5. Blackout in the UK: Scale
4% ED attendances
550,000 per annum
Primary care
6% Acute admissions
>100,000 per annum¹
Average Length of stay 3.9 days
Falls not included
Finished consultant episodes: Syncope /collapse
Staggering numbers
Additionally many present to primary care- number difficult to dtermine
Graph shows over 100K admission purely for syncope
Hospital episode statistics : , 000 admissions PA, Massive bed use
Not specified admission speciality
1 .NHS Health and Social care information centre (2009): Hospital episode statistics

6. Blackout: Causes Reflex syncope 56-73% Orthostatic Hypotension 1-10%
Cardiac %
Neurological %
Unexplained %
Psychogenic
Rare

7. Survival after presentation
Framingham data: Survival after presentation
Underlines that The underlying cause of Syncope determines survival
The 10% with Cardiac cause has significant mortality, over 10% even afetr a single year
Green line is unknow: Hybrid of vasovagal and more malignant conditions
Soteriades et al. NEJM 2002

8. Both Comprehensive systematic reviews of available evidence
Expert Panel recommendations where evidence is poor
NICE: Bottom-up approach: Algorithm designed to define appropriate pathways. Where necessary relate to the other available guidance
Looking at the point of presentation
ESC: Comprehensive document: Designed to give clarity about Classification of syncope, recommend strategies for diagnosis and management and risk stratification
No going on to talk aboutthe NICE guideline over the next 10 minutes

9. NICE Clinical Guideline 109: Historic standard of care
Range of clinicians
Non-Standardised investigation:
Underuse of ECG
Overuse of EEG
Poor Referral:
Wrong speciality or unnecessary
Delayed diagnosis: Dangerous conditions missed
Inaccurrate: 20-30% “epilepsy” had cardiac cause¹
Inefficient: Resource implications
Next 10 mins I’ll go on to talk about the NICE guidance
We have seen that syncope is frequent cause of presentation to the NHS. This is a summary of how NICE felt Tloc was currently being managed
Range of clinicians
Data from neuro literature>74,000 people in UK treated for epilepsy without the condition£189 million economic cost
Dangerous conditions: Overall mortality rates high: High Risk patient not identified eg ischaemic cardiomyopathyNICE Expert panel
Innappropriate testing: Holter monitors used in low Fz setting of low yield of only 1-2%
1. NICE CG20 Epilepsy in adults and children 2004

10. NICE Clinical Guideline: Key priorities
Define pathways:
Algorithm
Initial assessment:
History
ECG
Risk stratification
Appropriate referral for specialist assessment
Importance of obtaining accurrate history and collateral history. Witness. Important for Primary care, Emergency settings.
And of ECG: Recognition that abnormal ECG is an important maker of SCD

11. Initial assessment: History and examination
Exact history of event:
Personal and collateral history
Posture, prodrome etc
Previous blackout?
Medical history and family history
Medication
Examination
Vital signs
Other cardiovascular and neurological signs
+/- Lying and standing blood pressure

12. 1.1.4.2 Red flags: Urgent assessment and treatment
Refer for specialist cardiovascular assessment
within 24 hours, patients with:
ECG abnormality
Heart failure
TLoC during exertion
Family history of SCD <40 or ICC
New or unexplained breathlessness
Heart murmur
Consider referring >65 years and TLoC without prodromal symptoms
Once TLOc confirmed the algorithm invilved a checklist of Red Flags
There is evidence suggesting % major adverse events in allcomers presenting to ED with syncope
Should have high sensitivity for picking up high risk patients, at the expense of being overly inclusive
The GDG therefore decided to also take into account the significant univariate and multivariable predictors which they predicted poor short term outcomes.
FH included as rare but serious
>65 is predictor of poor outcome longer term, but included due to opinion of GDG

13. 1.1.2.3 ECG “Red Flags" Use automated interpretation......
if not possible obtain expert opinion!
Conduction abnormality
Inappropriate persistent bradycardia
Any ventricular arrhythmia (including ventricular ectopic beats)
Long QT (corrected QT > 450 ms) and short QT (corrected QT < 350 ms)
Brugada syndrome
Ventricular pre-excitation
Left or right ventricular hypertrophy
Abnormal T wave inversion
Pathological Q waves
Atrial arrhythmia (sustained)
Paced rhythm
Inclusive list, to avoid missing high risk patients

14. Diagnosis based on the initial assessment:
Diagnose uncomplicated faint when:
There are features suggestive of uncomplicated faint such as:
Posture
Provoking factors (such as pain or a medical procedure)
Prodromal symptoms
Diagnose situational syncope when:
Syncope is clearly and consistently provoked by straining during micturition or by coughing or swallowing
Diagnose orthostatic hypotension when:
The history is typical
and Lying and standing blood pressure confirms postural drop
There are no features that suggest an alternative diagnosis or red flag
If Hx suggestive
Provoking
OH if typical Hx and postural drop is noted
Appropriate advice and education in the first instance and review of medication

15. 1.2.3 Referral for specialist cardiovascular assessment
Refer all people with TLoC for a specialist cardiovascular assessment except:
Uncomplicated faint
Situational syncope
Orthostatic hypotension
Presentation is strongly suggestive of epileptic seizures
Everyone other than this should be referred for specialist opinion: most to Cardiology, but Neuro in case of....

17. 1.3.2 Diagnostic tests for different types of syncope
Ambulatory ECG:
Arrhythmic cause
Unexplained cause (after CSM where appropriate)
Exertional syncope: Initial investigations negative
CSM If history suggestive or unexplained and >60yrs

18. Criteria to determine type of ambulatory ECG:
TLoC at least several times a week:
Holter monitoring
If no TLoC occurs during monitor, offer external event recorder
TLoC every 1–2 weeks:
External event recorder
Further TLoC outside the period of external event recording, offer an ILR
TLoC less than once every 2 weeks:
Offer an ILR
Holter monitor should not usually be offered unless there is evidence of a conduction abnormality on the 12-lead ECG
Effective

19. Implantable loop recorders
Subcutaneous
Patient and automatic activation
Stores EGM
Lasts 2 years
Home monitoring

20. NICE: ILR vs “Conventional testing”
Low diagnostic yield with external recorders
Much better symptom–ECG correlation with ILR
High initial cost
May be more cost-effective
44 vs 10% Medtronic Farwell DJ, Freemantle N, and Sulke AN (2004) Use of implantable loop recorders in the diagnosis and management of syncope, European Heart Journal, 25(14): Medtronic
Krahn AD, Klein GJ, Yee R, Skanes AC, and REVEAL Investigators (2001) Predictive value of presyncope in patients monitored for assessment of syncope, American Heart Journal, 141(5): american
Extrapolated
Note: Possibly lower hospitalisation

21. Tilt Test Vasovagal syncope: Consider a tilt test only if: Recurrent
and affecting their quality of life,
or high risk of injury
Pacing considered
In patients with normal hearts and a suggestive history the pre-test probability is high and contribute little to diagnosis
And in this group where the test is negative the most likely diagnosis is still VVS

22. Advice for patients: Condition appropriate advice Driving
Safety at work

23. Summary: Practice points
History and ECG:
Red flags: Refer “urgently”
Epilepsy: Refer to Neurology
Unclear Cause: Refer to Cardiology
Reflex syncope, Situational syncope and Orthostatic hypotension:
Advise and Reassure
Separate the wheat from the chaff

24. Summary: Loads more ECG’s: Robust diagnosis: ECG red flags
Diagnose and treat severe cardiac conditions
Avoid misdiagnosis, especially epilepsy

25. Blackouts: Clinical ECG’s not to be missed Sudden cardiac death
Inherited cardiac conditions

26. 80F unwitnessed fall ? blackout
Reassure? b) Emergency admission? c) Refer to Specialist?

27. Complete Heart Block
Class 1 indication for pacemaker

28. 73M brief blackout standing in church
Reassure? b) Emergency admission? c) Refer to Specialist?

29. Conduction system disease RBBB, left axis deviation
2a indication for pacemaker if other causes excluded

30. 24 male with palpitations and blackout:
Reassure? b) Emergency admission? c) Refer to Specialist?

31. Wolff-Parkinson-White syndrome (WPW)
Common
0.1% prevalence
AVRT
Sudden Cardiac Death:
– 0.25% per year
Pre-excited AF
VF induced by “R on T”
Avoid AV Node blocking drugs
- Short refractory period- Rapid conduction velocity
- Short refractory period- Asymptomatic
- Palpitation
- SCD
- Rapid conduction velocity
AP’s are thin fibres of myocardial cells, permitting electrical communication between the atrium and ventricles extrinsic to the normal AV node. may occur at rates approaching 300bpm, with multiple R-on-T stimuli risking VF. 31

32. Pre-excited AF Fast Broad Irregular
Can occur following adenosine for SVT: where SVT was AVRT as AF is sometimes started by adenosine. This may be distinguished from VT by recognising the characteristic QRS broadening pattern from the delta wave compared to the uniformly broad QRS during VT.

33. 29M blackout playing football
a) 24 hour tape? b) Refer to specialist? c) Admission?

34. Hypertrophic cardiomyopathy
1 in 500 people AD
Three of the
HCM-causing mutant genes predominate in frequency—
i.e., beta-myosin heavy chain (the first identified), myosin binding
protein C and cardiac troponin-T probably comprise
more than one-half of the genotyped patients to date. 34

35. Typical electrocardiographic pattern of Brugada syndrome, with ST segment elevation in the right precordial leads, coved type.
Na channel gene SCN5A
©2011 by BMJ Publishing Group Ltd and British Cardiovascular Society

36. Brugada Syndrome Gene defect of cardiac Sodium Ion-channels (SCN5A)
Associated with SCD
Development of VF
ICD:
Syncope aborted SCD
EPS inducibility
Identification of families

37. ECG with prolonged QT in a patient with long QT syndrome.
©2011 by BMJ Publishing Group Ltd and British Cardiovascular Society

38. Long QT-Syndrome QTc >450ms Genetic Ion-channel defect
Syncope (seizures) and SCD
Drugs

39. Triggered activity Dispersion of refractoriness
After depolarisations in phase 3 or 4
Exceed threshold
Trigger further depolarisation
Torsades de points in LQTS

40. Precordial leads of an ECG from a 44-year-old woman recorded during regular sinus rhythm, with an epsilon wave (arrow) in
leads V1–V. The ECG shows a right bundle branch block pattern.

41. Arrythmogenic Right Ventricular Cardiomyopathy (ARVC)
Multiple gene defects: Desmosomes AD
Syncope
SCD
Palpitation HF

42. Sudden cardiac death CHD Cardiomyopathy: Channelopathies:
80% Coronary Heart Disease
CHD
Cardiomyopathy:
Hypertrophic cardiomyopathy
Channelopathies:
Long QT syndrome
Brugada syndrome
“Electrical” diseases:
Wolff-Parkinson-White
5% Other*
15% Cardiomyopathy
Incidence 0.1% gen pop, 5% prior MI, 15% LVEF <35%, 20% prior SCD. SCD is first and most common presentation of CHD
American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex.: American Heart Association; 2002.
2 Adapted from Heikki et al. N Engl J Med, Vol. 345, No. 20, 2001.
3 Myerberg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. P. 895. 42

43. Prevention of SCD
>95% patient die after out of hospital cardiac arrest
Identify patients at risk before it occurs
ICD is proven to improve survival as a primary preventative treatment in:
Ischaemic/non-ischaemic cardiomyopathy
Inherited cardiac conditions

44. Sudden death syndromes:
Technology
Impact
Diagnostic devices
Pacemakers
Implantable defibrillators
Catheter Ablation
Prevention of SCD
Cure
Stroke prevention
Patient reassurance

45. Thankyou www.guidance.nice.org.uk/CG109 www.arrhythmiaalliance.org.uk