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Based on an original paper from Dr Sanjiv Petkar, Manchester Heart Centre, Manchester Royal Infirmary, Manchester UK

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REVISE (Reveal in the Investigation of Syncope and Epilepsy) Study presented

Up to 1 in 4 patients thought to be suffering from epilepsy do not actually have this condition. Now an implantable ECG monitor allows detection of abnormal heart rate causing syncope, according to a presentation during the European Society of Cardiology recent congress in Barcelona.

The REVISE Study (Reveal in the Investigation of Syncope and Epilepsy) found that 1 in 8 adult patients in the United Kingdom, previously thought to be suffering from epilepsy or in whom this diagnosis was in doubt, in fact had symptoms as a result of an abnormal rhythm, commonly found in patients with syncope.

REVISE is the first study to show that, by means of an implantable ECG recorder, 1 in 8 patients who were previously thought to have epilepsy or in whom this diagnosis was in doubt, have an abnormality in their heart rhythm as a cause of their symptoms. Eighty percent of those who underwent a pacemaker insertion based on the results of the ECG loop recorder were subsequently found to be free of their symptoms.

Four of the 5 patients who underwent a pacemaker as part of this study were subsequently free of symptoms. The average duration of follow-up was 9 months.  This study was carried out at the Manchester Heart Centre, Manchester Royal Infirmary, Manchester, UK in collaboration with the Greater Manchester Centre for Neurosciences, Hope Hospital, Salford, UK. A small device about the size of a memory stick was used to record the heart rhythm of patients in this study. This device was inserted underneath the skin, on the left side of the chest as a simple 20 minute procedure. Study patients also underwent a number of other brain and cardiac tests.

Previous scientific studies, mainly from the United Kingdom, have shown that up to 1 in 4 patients thought to be suffering from epilepsy do not actually have this condition. This conclusion was based on reviewing medical records of patients known to have epilepsy and on the results of the tilt table testing. Moreover, the All Party Parliamentary Group on Epilepsy, in their report published in June 2007, found that 74,000 patients in the United Kingdom were taking drugs for epilepsy, which they did not need. Patients with syncope as well as epilepsy present with transient loss of consciousness (T-LOC) or ‘blackouts’. In some patients syncope can mimic epilepsy. In the general population, syncope is much more common than epilepsy, affecting 25% of the population at any given time, more so in the elderly.

Patients symptomatic with T-LOC/‘blackouts’ were considered for inclusion in this study if on review by the neurologists there was a suspicion of misdiagnosis of epilepsy or there was a doubt regarding the diagnosis. Patients had to have suffered at least 3 blackouts in the year before enrollment. In addition, they had to have had a normal or equivocal recording of their heart rhythm (standard ECG and an external recording for at least 24 hours), EEG, echocardiogram, CT or MRI brain scan. Once included, all patients underwent a Reveal® Plus/Reveal® DX implant for monitoring their heart rhythm and tilt table testing. The study protocol allowed for treatment, based on the results of the implantable ECG monitor. The main aim of the study was to record the heart rhythm at the time of the patients symptoms of T-LOC/blackouts by means of the implantable ECG monitor. This study also aimed to determine the value of the tilt table test, in this group of patients.

Of the 119 patients screened, 40 were found suitable for inclusion in the study. Two thirds of patients were females and the average age was 39 years. The oldest patient in the study was 80 years of age. The implantable ECG monitor recorded a heart rhythm at the time of symptoms in two thirds of patients. Six patients were found to have an abnormal cardiac rhythm (severe bradycardia), to the point of an absent heart rhythm, for a few seconds. In four other patients, the heart rhythm was found to slow but not as severely as the previous group. In 4 others, the implantable ECG monitor recorded signals due to muscle shaking in a pattern commonly seen in patients with epilepsy. All but one of the six patients with severe bradycardia underwent a pacemaker. Four of the five (80%) who had pacemakers were subsequently free of symptoms over the following 9 months. Tilt table testing was positive in 5 of 40 patients. None of the patients with a positive tilt table test showed severe slowing of the heart on the implantable ECG monitor.

Conclusion

REVISE is the first study to show, that by means of an implantable ECG recorder, 1 in 8 patients who were previously thought to have epilepsy or in whom this diagnosis was in doubt, have an abnormality in their heart rhythm as a cause of their symptoms. Eighty percent of those who underwent a pacemaker insertion based on the results of the ECG loop recorder were subsequently found to be free of their symptoms. The implantable ECG loop recorder was also helpful in pointing towards a diagnosis of epilepsy. The findings of this small study will need confirmation in a larger group of patients.

Note

This study was carried out by Dr Sanjiv Petkar, Clinical Research Fellow, Manchester Heart Centre, Manchester Royal Infirmary, under the supervision of Dr Adam Fitzpatrick (Principal Investigator), Consultant Cardiologist, Manchester Heart Centre,Manchester Royal Infirmary and Dr Paul Cooper (Co-Principal Investigator), Consultant Neurologist, Greater Manchester Centre for Neurosciences, Hope Hospital, Salford.

This study was possible due to a research grant by Medtronic Inc. to the University of Manchester.  


This news item includes  both a presentation and an ESC press conference given at the ESC Congress 2009 in Barcelona. It does not necessarily reflect the opinion of the European Society of Cardiology.

Published on: September 22, 2009

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