Unexplained syncope in patients with structural heart disease and no documented ventricular arrhythmias: value of electrophysiologically guided implantablecardioverter defibrillator therapy
Open accessAbstract
AIMS: To evaluate electrophysiologically guided implantable cardioverter defibrillator (ICD) therapy in patients with syncope, structural heart disease and no documented sustained ventricular tachycardia (sVT). METHODS AND RESULTS: Programmed ventricular stimulation (PVS) was performed in 52 patients (age 62+/-10 years): 40 patients had ischaemic and 12 patients had idiopathic dilated cardiomyopathy. On PVS sVT and ventricular fibrillation were induced in seven and four patients, respectively, and two patients spontaneously experienced symptomatic sVT. These patients received an ICD (ICD group, n=13). Non-inducible patients were left on conventional therapy (non-ICD group, n=39). During 5+/-2.8 years five ICD patients received therapies, all appropriate. There were seven non-sudden deaths and overall survival analysis revealed no significant difference. Recurrent syncope occurred in five ICD and four non-ICD patients and did not correlate well with sVT. The positive and negative predictive values of PVS for tachyarrhythmias or sudden death were 36 and 98%, respectively. CONCLUSION: Syncope per se does not necessarily herald a bad prognosis. PVS identifies high-risk patients. Induction of ventricular fibrillation with double or triple extrastimuli is of limited value. Patients with poor left ventricular function and bad clinical condition benefit most from an ICD. Syncope and sVT are not necessarily correlated during follow-up, which may merit consideration.
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The role of EPS in patients with syncope suspected to be due to VA and acquired nonischemic heart disease is unproven.
“The role of EPS in patients with syncope suspected to be due to VA and acquired nonischemic heart disease is unproven (193–198).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [194]
The Introduction (page unavailable) says the value of electrophysiological testing is “not precisely defined” for patients with unexplained syncope, structural heart disease, and no documented ventricular arrhythmias. It does not make that assessment specifically for acquired nonischemic heart disease; the study included both ischemic and dilated-cardiomyopathy patients. The Conclusions also state that programmed ventricular stimulation reliably stratifies risk in the study population. (LLM, conf=0.82)
Experimental — accuracy not yet measuredCardiac 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 [30]
The Definitions section defines syncope and mentions prior myocardial infarction only as part of the definition of structural heart disease. The Introduction and Conclusions address unexplained syncope and arrhythmia risk. Searches for acute myocardial ischaemia and ischaemia-related syncope found no diagnostic criterion linking syncope with evidence of acute ischaemia, with or without infarction. (LLM, conf=0.76)
Experimental — accuracy not yet measuredArrhythmic 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 [30]
The Study population section concerns patients with unexplained syncope and no documented ventricular tachyarrhythmias. The Definitions and Conclusions sections do not give the claimed ECG criteria for highly probable arrhythmic syncope. Searches for the bradycardia and sinus-pause thresholds, Mobitz II block, alternating bundle branch block, and rapid paroxysmal SVT found no passage stating the claim. (LLM, conf=0.75)
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Developed in collaboration with, European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS), societies, E. B. T. F., European Society of Emergency Medicine (EuSEM), European Federation of Internal Medicine (EFIM), European Union Geriatric Medicine Society (EUGMS), American Geriatrics Society (AGS), European Neurological Society (ENS), et al. (2009) · European Heart Journal · doi:10.1093/eurheartj/ehp298 · Cited by 2,040 · see citing works
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- Authors
- Pezawas, T.
- Affiliations
- University of Vienna (AT)
- Corresponding author
- Pezawas, T
- ORCID
- Pezawas, T
- Venue
- Europace
- Publisher
- Oxford University Press (OUP)
- Published
- 2003-07
- Volume
- 5
- Issue
- 3
- Pages
- 305-312
- ISSN
- 1099-5129 (ISSN-L)
- OpenAlex
- W2153563452
- Cited by
- 52
- References
- 34
- Citations by year
- 2026: 1 · 2024: 2 · 2023: 2 · 2022: 1 · 2021: 2 · 2020: 3 · 2019: 1 · 2018: 5 · 2017: 5 · 2015: 2 · 2014: 3 · 2013: 3 · 2012: 4
- FWCI
- 0.88
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- EP Europace (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- syncope, implantable cardioverter-defibrillator, structural heart disease, ventricular tachycardia, programmed ventricular stimulation, ventricular fibrillation, sudden cardiac death, idiopathic dilated cardiomyopathy, ischemic heart disease, left ventricular function, risk stratification, recurrent syncope
- MeSH terms
- Aged, Electrocardiography, Female, Follow-Up Studies, Humans, Male, Middle Aged, Cardiomyopathies, Retrospective Studies, Syncope, Ventricular Fibrillation, Reproducibility of Results, Survival Rate, Outcome Assessment, Health Care, Defibrillators, Implantable
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