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Pacing therapy in the management of unexplained syncope : A tertiary care centre prospective study

Yasa, Ekrem LU ; Ricci, Fabrizio LU ; Holm, Hannes LU ; Persson, Torbjörn; Melander, Olle LU ; Sutton, Richard; Hamrefors, Viktor LU and Fedorowski, Artur LU (2019) In Open Heart 6(1).
Abstract

Objective Pacemaker (PM) therapy is effective when syncope is associated with bradycardia, but syncope recurrences and fall injuries after PM implantation may occur. We aimed to survey indications and outcomes of PM implantation, following evaluation of unexplained syncope. Methods Among 1666 consecutive unpaced patients investigated in a tertiary syncope unit by carotid-sinus massage (CSM), head-up tilt test (HUT) and ECG monitoring, 106 (6.4%; age, 65 ± 17 years) received a PM. We assessed bradycardia detection methods, PM implantation indications, and explored incidence of recurrent syncope, fall-related fractures and mortality. Results Indications for PM therapy were met in 32/106 patients (30%) by CSM, in 41/106 (39%) by HUT, in... (More)

Objective Pacemaker (PM) therapy is effective when syncope is associated with bradycardia, but syncope recurrences and fall injuries after PM implantation may occur. We aimed to survey indications and outcomes of PM implantation, following evaluation of unexplained syncope. Methods Among 1666 consecutive unpaced patients investigated in a tertiary syncope unit by carotid-sinus massage (CSM), head-up tilt test (HUT) and ECG monitoring, 106 (6.4%; age, 65 ± 17 years) received a PM. We assessed bradycardia detection methods, PM implantation indications, and explored incidence of recurrent syncope, fall-related fractures and mortality. Results Indications for PM therapy were met in 32/106 patients (30%) by CSM, in 41/106 (39%) by HUT, in 14/106 patients (13%) by implantable loop-recorder (ILR) and in 19/106 (18%) by standard ECG. Sinus arrest with asystole was the predominant PM indication during CSM/HUT and external ECG monitoring, whereas ILR detected proportionally the same numbers o f asystole due to sinus arrest and atrioventricular block. During follow-up (median, 4.3 years), 15 patients (14%) had syncope recurrence, 15 suffered fall-related fractures and 9 died. Neither syncope recurrence nor fall-related fractures were dependent on initial PM indication. The composite endpoint of recurrent syncope/fall-related fracture was associated with treated hypertension (OR 2.45; 95% CI 1.00 to 6.0), reduced glomerular filtration rate (OR 1.63 per 10 mL/minâ †"; 95% CI 1.22 to 2.19) and atrial fibrillation (OR 3.98; 95% CI 1.11 to 14.3). Recurrent syncope predicted increased mortality (OR 9.20; 95% CI 1.89 to 44.8). Conclusions Cardiovascular autonomic testing and ECG monitoring effectively identify pacing indications in patients with unexplained syncope. After PM implantation, treated hypertension, renal failure and atrial fibrillation predict syncope recurrence and fall-related injury. Recurrent syncope predicts increased mortality.

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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
autonomic disease, fractures, orthostatic hypotension, pacemaker, syncope
in
Open Heart
volume
6
issue
1
publisher
BMJ Publishing Group
external identifiers
  • scopus:85063539640
ISSN
2053-3624
DOI
10.1136/openhrt-2019-001015
language
English
LU publication?
yes
id
16ac0d16-8254-4197-8fbc-03f692328c08
date added to LUP
2019-04-08 10:55:32
date last changed
2019-04-30 04:10:28
@article{16ac0d16-8254-4197-8fbc-03f692328c08,
  abstract     = {<p>Objective Pacemaker (PM) therapy is effective when syncope is associated with bradycardia, but syncope recurrences and fall injuries after PM implantation may occur. We aimed to survey indications and outcomes of PM implantation, following evaluation of unexplained syncope. Methods Among 1666 consecutive unpaced patients investigated in a tertiary syncope unit by carotid-sinus massage (CSM), head-up tilt test (HUT) and ECG monitoring, 106 (6.4%; age, 65 ± 17 years) received a PM. We assessed bradycardia detection methods, PM implantation indications, and explored incidence of recurrent syncope, fall-related fractures and mortality. Results Indications for PM therapy were met in 32/106 patients (30%) by CSM, in 41/106 (39%) by HUT, in 14/106 patients (13%) by implantable loop-recorder (ILR) and in 19/106 (18%) by standard ECG. Sinus arrest with asystole was the predominant PM indication during CSM/HUT and external ECG monitoring, whereas ILR detected proportionally the same numbers o f asystole due to sinus arrest and atrioventricular block. During follow-up (median, 4.3 years), 15 patients (14%) had syncope recurrence, 15 suffered fall-related fractures and 9 died. Neither syncope recurrence nor fall-related fractures were dependent on initial PM indication. The composite endpoint of recurrent syncope/fall-related fracture was associated with treated hypertension (OR 2.45; 95% CI 1.00 to 6.0), reduced glomerular filtration rate (OR 1.63 per 10 mL/minâ †"; 95% CI 1.22 to 2.19) and atrial fibrillation (OR 3.98; 95% CI 1.11 to 14.3). Recurrent syncope predicted increased mortality (OR 9.20; 95% CI 1.89 to 44.8). Conclusions Cardiovascular autonomic testing and ECG monitoring effectively identify pacing indications in patients with unexplained syncope. After PM implantation, treated hypertension, renal failure and atrial fibrillation predict syncope recurrence and fall-related injury. Recurrent syncope predicts increased mortality.</p>},
  articleno    = {e001015},
  author       = {Yasa, Ekrem and Ricci, Fabrizio and Holm, Hannes and Persson, Torbjörn and Melander, Olle and Sutton, Richard and Hamrefors, Viktor and Fedorowski, Artur},
  issn         = {2053-3624},
  keyword      = {autonomic disease,fractures,orthostatic hypotension,pacemaker,syncope},
  language     = {eng},
  number       = {1},
  publisher    = {BMJ Publishing Group},
  series       = {Open Heart},
  title        = {Pacing therapy in the management of unexplained syncope : A tertiary care centre prospective study},
  url          = {http://dx.doi.org/10.1136/openhrt-2019-001015},
  volume       = {6},
  year         = {2019},
}