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Cited by 311Cardiovascular Syncope and Autonomic DisordersHeart Failure Treatment and ManagementCardiac electrophysiology and arrhythmias

Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope

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Middlekauff, Holly R., Stevenson, William G., Stevenson, Lynne Warner, Saxon, Leslie A.·1993·Journal of the American College of Cardiology
DOI 10.1016/0735-1097(93)90724-f
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Abstract

Objectives The purpose of this study was to assess the importance of syncope as a warning sign for sudden death in advanced heart failure and to determine the relative importance of cardiac syncope and syncope from other causes.Background Despite remarkable advances in the pharmacologic approach to advanced heart failure, 20% to 40% of patients with advanced heart failure will die each year. In such patients, the relation between sudden death and the etiology of syncope has not been evaluated.Methods The relation of syncope to sudden death was evaluated in 491 consecutive patients with advanced heart failure (New York Heart Association functional class III or IV), no history of cardiac arrest and a mean left ventricular ejection fraction of 0.20 +/- 0.07. Patients were evaluated for the presence and origin of syncope. The severity of heart failure was assessed from serum sodium levels, ejection fraction, functional class and echocardiographic and hemodynamic variables.Results Sixty patients (12%) had a history of syncope; the condition had a cardiac origin in 29 (48%) and was due to other causes in 31 (52%). The origin of heart failure was coronary artery disease in 234 patients (48%) and dilated cardiomyopathy in 253 (51%) and its severity was similar in patients with and without syncope. During a mean follow-up interval of 365 +/- 419 days, 69 patients (14%) died suddenly and 66 patients (13%) died of progressive heart failure. The actuarial incidence of sudden death by 1 year was significantly greater in patients with (45%) than in those without (12%, p < 0.00001) syncope. In the Cox proportional hazards model, syncope predicted sudden death independent of atrial fibrillation, serum sodium, cardiac index, angiotensin-converting enzyme inhibition and patient age. The actuarial risk of sudden death by 1 year was similarly high in patients with either cardiac syncope or syncope from other causes (49% vs. 39%, p = NS).Conclusions Patients with advanced heart failure are at especially high risk for sudden death regardless of the etiology of syncope.

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  • Arrhythmic syncope is highly probable when the ECG shows persistent sinus bradycardia <40 b.p.m. or sinus pauses >3 s in awake state and in absence of physical training; Mobitz II second- and third-degree AV block; alternating left and right BBB; VT or rapid paroxysmal SVT.

    “Arrhythmic syncope is highly probable when the ECG shows 25-39 : • Persistent sinus bradycardia <40 b.p.m. or sinus pauses >3 s in awake state and in absence of physical training; • Mobitz II second- and third-degree AV block; • Alternating left and right BBB; • VT or rapid paroxysmal SVT;”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [27]

    The Methods section identifies ventricular tachycardia, supraventricular tachycardia, high-degree heart block, and sinus bradycardia as possible causes of syncope. It does not give the claimed ECG thresholds or conditions (<40 b.p.m., pauses >3 s while awake and untrained), or specify Mobitz II and alternating bundle branch block as criteria for highly probable arrhythmic syncope. Page numbers are unavailable in our copy. (LLM, conf=0.82)

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  • Cardiac ischaemia-related syncope is confirmed when syncope presents with evidence of acute myocardial ischaemia with or without myocardial infarction.

    “Cardiac ischaemia-related syncope is confirmed when syncope presents with evidence of acute myocardial ischaemia with or without myocardial infarction. 25-39”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [27]

    The Methods (page unavailable) classify acute cardiac ischaemia as a cause of syncope when chest pain occurs at the time of syncope, subsequent angiography shows significant coronary obstruction, and no other cause is identified. This supports the link between syncope and acute cardiac ischaemia, but the paper does not give the claimed general confirmation rule or specify that it applies with or without myocardial infarction. (LLM, conf=0.84)

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  • Structural heart disease and primary electrical disease are major risk factors for sudden cardiac death and overall mortality in patients with syncope.

    “Structural heart disease 25-27,31,35,36,45 and primary electrical disease 46 are major risk factors for sudden cardiac death (SCD) and overall mortality in patients with syncope.”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [27]

    The Results (page unavailable) report high one-year sudden-death and all-cause mortality among patients with syncope and advanced heart failure. The study supports elevated risk in that specific group, but does not establish structural heart disease generally as a risk factor across patients with syncope. The primary-electrical-disease portion is attached to a different citation. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Data from observational studies in selected cohorts show a high rate of occurrence of ventricular arrhythmias, ICD discharge, and death in patients with a history of unexplained syncope, but owing to a lack of control groups are unable to show the benefit of an ICD.

    “Data from observational studies in selected cohorts show a high rate of occurrence of ventricular arrhythmias, ICD discharge, and death in patients with a history of unexplained syncope but, owing to a lack of control groups, are unable to show the benefit of an ICD. 27,28,359,360”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [27]

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  • In patients with New York Heart Association class III-IV heart failure, syncope is present in 12% to 14% of patients.

    “In patients with New York Heart Association class III–IV HF, syncope is present in 12% to 14% of patients (46,47).”

    From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [47]

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Authors
Middlekauff, H. R., Stevenson, W. G., Stevenson, L. W., & Saxon, L. A.
Affiliations
University of California, Los Angeles (US)
Corresponding author
Middlekauff, Holly R.
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
1993-01
Volume
21
Issue
1
Pages
110-116
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/0735-1097(93)90724-f
OpenAlex
W1994239059
Cited by
311
References
37
Citations by year
2026: 1 · 2025: 3 · 2024: 1 · 2023: 5 · 2022: 8 · 2021: 5 · 2020: 7 · 2019: 9 · 2018: 15 · 2017: 15 · 2016: 8 · 2015: 8 · 2014: 14 · 2013: 12 · 2012: 7
FWCI
8.08
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
Keywords
syncope, sudden death, advanced heart failure, cardiac syncope, dilated cardiomyopathy, coronary artery disease, mortality risk, prognostic factors, left ventricular ejection fraction
MeSH terms
Adult, Cardiac Pacing, Artificial, Female, Heart Failure, Humans, Male, Middle Aged, Risk Factors, Syncope, Los Angeles, Incidence, Chi-Square Distribution, Logistic Models, Proportional Hazards Models, Survival Analysis, Death, Sudden, Cardiac

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