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Syncope – improving approaches to diagnosis and treatment

A new, position paper1 on syncope, from the European Heart Rhythm Association (EHRA) offers a pragmatic approach to the rationale and requirement for establishing syncope Units (SU) based on specialist consensus, existing practice and scientific evidence.

Syncope is a common medical problem that can be debilitating and is associated with high healthcare costs. There is wide variation in practice of syncope evaluation, and wide variation in adoption of recommendations from published guidelines. The absence of a systematic approach to transient loss of consciousness(T-LOC) incurs higher health and social care costs, unnecessary hospitalisations, and diagnostic procedures, as well as prolongation of hospital stays, lower diagnostic rates, and higher rates of symptom recurrences, according to the new document.

Therefore, a systematic approach, set out in this new document, by a dedicated service (an SU), equipped to evaluate and manage this common problem may ensure better management of T-LOC, from risk stratification to diagnosis, therapy and follow-up

Professor Michele Brignole (Ospedali del Tigullio, Italy)

Professor Michele Brignole (Ospedali del Tigullio, Italy)

Patients with syncope may often present in primary as well as secondary care. There are many causes of syncope, some common and some rare. Reflex Syncope is the most common cause of blackouts. However, many people, including medical professionals, are unaware that some everyday activities can be the cause of many reported fainting attacks (see: http://www.stars.org.uk/patient-info/conditions/syncope).

Despite the recommendation from the ESC, SUs are not widely established in clinical practice in the UK and other European countries. Possible reasons for this include:

- Lack of awareness of the benefits of an SU due to inadequate research trials comparing SUs to normal practice

- Underestimation of consequences of syncope

- Lack of awareness of benefit of an SU on quality-of-life

- Low numbers of syncope specialists

- Lack of formal syncope training programmes

Professor Rose Anne Kenny (Trinity College, Dublin)

Professor Rose Anne Kenny (Trinity College, Dublin)

BJC Arrhythmia Watch interviewed, Professor Michele Brignole, Head of Department, 
Arrhythmology Centre, Department of Cardiology,
 Ospedali del Tigullio, Lavagna, Italy, and Professor Rose Anne Kenny, Professor of Medical Gerontology, Trinity College, Dublin, the co-chairpersons of the Position Paper  about the concept of an SU and why barriers exist to their wider adoption.

A number of barriers to establishing a SU have been identified. Why do you think there are so few specialists, is this possibly due to some ‘political rivalry’ between care of the elderly, neurologists, cardiologists, cardiac electrophysiologists, or mainly that it is not a recognised sub-specialty, and what is being done to address this?

“Syncope is not a recognised sub-speciality by most. The EHRA consensus document is aimed at achieving that”

Who ‘owns’ these patients i.e. who should primarily care for the syncopal patient?

“Syncope is a symptom, not a disease. Depending on the different aetiology of syncope, cardiologists, neurologists, internists, geriatricians, should take care of these patients. Most syncope has unexplained aetiology. The final results are that nobody ‘owns’ syncope patients.”

Professor Kenny commented:

The consensus was that there was no evidence for superiority of one specialty over another for managing syncope – the leadership could come from any interested specialty provided that the SU could deliver the multidisciplinary approach recommended”.

Are investigations such as tilt testing available in many general cardiology units in the UK or other European countries or is it under-provided and only seen in highly specialist centres?

“I believe that tilt testing is performed in many general hospitals in the UK and Europe, not necessarily in cardiology departments. However, specialised, structured units, i.e. syncope units, are rare”.

How many units are there in Italy, for example?

“There are 72 Gruppo Italiano Multidisciplinare per lo Studio della Sincope [GIMSI] certified units in Italy”.

Professor Kenny added:

In order to deliver a structured training program the Royal College of Physicians in Ireland has developed a diploma course in ‘Syncope and related disorders’. This is a year long course of lectures/workshops, digital curriculum and practical sessions. This is its second year. Participants are predominantly from British and Irish Isles and to a lesser extent to date, other European centres. https://www.rcpi.ie/course

Syncope – Arrhythmia Alliance UK 2016 Cardiac Update Meetings

‘Setting up a T-LOC/syncope clinic’ will be one of the topics covered in the series of Regional Cardiac Update meetings organised by the Arrhythmia Alliance throughout 2016: http://www.heartrhythmcharity.org.uk/www/507/0/Cardiac_update_meetings/

The meetings are intended for healthcare professionals involved in the management and treatment of arrhythmias. The meetings also provide a platform for education and networking and sharing best practice on related topics, such as syncope.

Further information is available from: n.bennett@heartrhythmalliance.org

Reference

1. Kenny RA, et al. Syncope Unit: rationale and requirement – the European Heart Rhythm Association position statement endorsed by the Heart Rhythm Society. Europace 2015;17:1325–40. http://dx.doi.org/10.1093/europace/euv115

Published on: January 14, 2016

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