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Cited by 119Cardiovascular Syncope and Autonomic DisordersHeart Failure Treatment and ManagementCardiac pacing and defibrillation studies

Syncope Predicts the Outcome of Cardiomyopathy Patients

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Olshansky, Brian, Poole, Jeanne E., Johnson, George, Anderson, Jill, Hellkamp, Anne S., Packer, Douglas, Mark, Daniel B., Lee, Kerry L. +1 more·2008·Journal of the American College of Cardiology
DOI 10.1016/j.jacc.2007.11.065
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Abstract

Objectives The outcome of congestive heart failure (CHF) patients with syncope is understood incompletely.Background We analyzed data from patients enrolled in the SCD-HeFT (Sudden Cardiac Death Heart Failure Trial) to determine whether syncope predicted outcomes in patients with CHF.Methods We compared outcomes (and associated clinical characteristics) in patients with and without syncope enrolled in SCD-HeFT.Results In SCD-HeFT, 162 (6%) patients had syncope before randomization, 356 (14%) had syncope after randomization (similar incidence in each randomized arm), and 46 (2%) had syncope before and after randomization. A QRS duration >or=120 ms and absence of beta-blocker use predicted syncope during follow-up (hazard ratio [HR] 1.30 and 95% confidence interval [CI] 1.06 to 1.61, p = 0.014 and HR 1.25, 95% CI 1.01 to 1.56, p = 0.048, respectively). Syncope recurrence did not differ by randomization arm. However, in the implantable cardioverter-defibrillator (ICD) arm, syncope, before and after randomization, was associated with appropriate ICD discharges (HR 1.75, 95% CI 1.10 to 2.80, p = 0.019 and HR 2.91, 95% CI 1.89 to 4.47, p = 0.001, respectively). Post-randomization syncope predicted total and cardiovascular death (HR 1.41, 95% CI 1.13 to 1.76, p = 0.002 and HR 1.55, 95% CI 1.19 to 2.02, p = 0.001, respectively). The elevated relative risk of mortality for syncope versus non-syncope patients did not vary significantly across treatment arms (ICD, HR 1.54, 95% CI 1.04 to 2.27; amiodarone, HR 1.33, 95% CI 0.91 to 1.93; and placebo, HR 1.39, 95% CI 0.96 to 2.02, test for difference p = 0.86).Conclusions For CHF patients with ICDs, syncope was associated with appropriate ICD activations. Syncope was associated with increased mortality risk in SCD-HeFT regardless of treatment arm (placebo, amiodarone, or ICD).

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Crossref · 10.1016/j.jacc.2007.11.065

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  • ICD may not prevent syncope recurrence in patients with syncope and depressed cardiac function and ventricular tachycardia or ventricular fibrillation without correctable cause.

    “Although ICD may not prevent syncope recurrence in these patients, 31,348 it is indicated to reduce the risk of SCD”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [31]

    The Results (Syncope recurrence; page unavailable) report no difference in recurrent syncope between the ICD, placebo, and amiodarone arms, and the Discussion says the ICD did not protect against syncope. The study concerns patients with heart failure and cardiomyopathy; these passages do not establish the claim specifically for patients with ventricular tachycardia or fibrillation without a correctable cause. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • When indicated, ICD prevents sudden cardiac death but may be unable to prevent syncope due to ventricular tachycardia recurrence.

    “When indicated, ICD prevents SCD but it may be unable to prevent syncope due to VT recurrence. 31,348”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [31]

    The Discussion (page unavailable) reports that a single-chamber ICD did not protect SCD-HeFT patients against syncope, and the Results report similar syncope-recurrence rates across treatment arms. But the paper does not establish that the syncope was due to recurrent ventricular tachycardia; it says the mechanism was uncertain. It also does not establish the claim’s broad statement that an ICD prevents sudden cardiac death when indicated, noting sudden cardiac death despite ICD assignment in this population. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • 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 [46]

    The Results (page unavailable) report syncope after randomization in 14% of SCD-HeFT patients, supporting one endpoint of the stated range. But the Methods (page unavailable) identify the study population as NYHA classes II and III, not III and IV, and the paper does not establish a 12%–14% prevalence for the claimed population. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • 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 [31]

  • 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 [31]

    The Results (page unavailable) discuss predictors of syncope in cardiomyopathy patients, including QRS duration, but do not give the claimed ECG criteria for highly probable arrhythmic syncope. Searches for the specified bradycardia and pause thresholds, Mobitz II block, alternating bundle branch block, and rapid SVT found no matching passage in our copy. (LLM, conf=0.78)

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Research works printed but not linked: 1

  1. [23]23. Poole J.E., Johnson G., Callans D.J. et al: Analysis of implantable defibrillator shock electrograms in the Sudden Cardiac Death-Heart Failure Trial. (abstr) Heart Rhythm 2004; 1: S178. Google Scholar

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Authors
Olshansky, B., Poole, J. E., Johnson, G., Anderson, J., Hellkamp, A. S., Packer, D., Mark, D. B., Lee, K. L., & Bardy, G. H.
Affiliations
  • University of Iowa (US)
  • University of Washington (US)
  • The Seattle Institute for Cardiac Research (US)
  • Duke University (US)
  • Mayo Clinic (US)
Corresponding author
Olshansky, Brian
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
2008-04
Volume
51
Issue
13
Pages
1277-1282
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/j.jacc.2007.11.065
OpenAlex
W2135351378
Cited by
119
References
32
Citations by year
2026: 2 · 2025: 2 · 2024: 1 · 2023: 3 · 2022: 2 · 2021: 3 · 2020: 5 · 2019: 1 · 2018: 11 · 2017: 20 · 2016: 2 · 2015: 9 · 2014: 7 · 2013: 14 · 2012: 8
FWCI
10.19
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • National Institutes of Health
  • Medtronic
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 pacing and defibrillation studies
Keywords
syncope, congestive heart failure, cardiomyopathy, SCD-HeFT trial, implantable cardioverter-defibrillator, mortality prediction, QRS duration, beta-blocker therapy, amiodarone, sudden cardiac death, syncope recurrence, prognostic factors, cardiovascular mortality, arrhythmic risk stratification, heart failure with reduced ejection fraction
MeSH terms
Adult, Amiodarone, Anti-Arrhythmia Agents, Female, Health Status, Heart Failure, Humans, Male, Middle Aged, Cardiomyopathies, Predictive Value of Tests, Prognosis, Recurrence, Risk, Risk Factors, Stroke Volume, Syncope, Time Factors, Death, Sudden, Cardiac, Treatment Outcome, Defibrillators, Implantable, Myocardial Ischemia

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