Follow‐Up of Patients with Unexplained Syncope and Inducible Ventricular Tachyarrhythmias: Analysis of the AVID Registry and an AVID Substudy
Abstract
INTRODUCTION: A prospective registry and substudy were conducted in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study to clarify the prognosis and recurrent event rate, risk factors, and impact of implantable cardioverter defibrillator (ICD) therapy in patients with unexplained syncope, structural heart disease, and inducible ventricular tachyarrhythmias. METHODS AND RESULTS: Included in the AVID registry were patients from all participating sites who had "out of hospital syncope with structural heart disease and EP-inducible VT/VF with symptoms." In addition, 13 collaborating sites provided more in-depth clinical and electrophysiologic data as part of a formal prospective substudy. Patients in the substudy were followed by local investigators for recurrent arrhythmic events and mortality. Registry patients were tracked for fatal outcomes by the National Death Index. A total of 429 patients with syncope were entered in the AVID registry, of whom 80 participated in the substudy. Of the substudy patients, 21 patients (26%) had inducible polymorphic ventricular tachycardia/ventricular fibrillation (VT/VF), 11 patients (14%) had sustained monomorphic VT <200 beats/min, and 48 patients (60%) had sustained monomorphic VT > or = 200 beats/min. The ICD was used as sole therapy in 75% of the syncope substudy patients (and with antiarrhythmic drug in an additional 9%) and in 59% of the syncope registry patients. Survival rates at 1 and 3 years were 93% and 74% for the substudy patients and 90% and 74% for the registry patients, respectively. Survival of the syncope substudy patients (predominantly treated by ICD) was similar to the VT patients treated by ICD and superior to the VT patients treated by an antiarrhythmic drug (P = 0.05) in the randomized main trial. Mortality events in the substudy were marginally predicted by ejection fraction (P = 0.06) but not by electrophysiologic study-induced arrhythmia. The significant predictor of increased mortality in the registry was age (P = 0.003) and of reduced mortality was treatment with ICD (P = 0.006). CONCLUSION: The results of these analyses support the role of the ICD as primary antiarrhythmic therapy in patients with unexplained syncope, structural heart disease, and inducible VT/VF at electrophysiologic study.
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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 [29]
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 [29]
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 [195]
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- Authors
- STEINBERG, J. S., BECKMAN, K., GREENE, H. L., MARINCHAK, R., KLEIN, R. C., GREER, S. G., EHLERT, F., FOSTER, P., MENCHAVEZ, E., RAITT, M., WATHEN, M. S., MORRIS, M., & HALLSTROM, A.
- Affiliations
- St. Luke's-Roosevelt Hospital Center (US)
- University of Oklahoma Health Sciences Center (US)
- University of Washington (US)
- Lankenau Medical Center (US)
- University of Utah (US)
- Methodist Hospital (US)
- Oregon Health & Science University (US)
- Vanderbilt University (US)
- Corresponding author
- STEINBERG, JONATHAN S.
- GREENE, H. LEON
- Venue
- Journal of Cardiovascular Electrophysiology
- Publisher
- Wiley
- Published
- 2001-09
- Volume
- 12
- Issue
- 9
- Pages
- 996-1001
- ISSN
- 1045-3873 (ISSN-L)
- 1540-8167
- OpenAlex
- W2034489345
- Cited by
- 51
- References
- 0
- Citations by year
- 2023: 2 · 2020: 1 · 2018: 4 · 2017: 5 · 2015: 2 · 2014: 2 · 2013: 4 · 2012: 1
- FWCI
- 2.31
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Cardiovascular Electrophysiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (n01hc025117-014)
- National Heart, Lung, and Blood Institute (N01-HC-25117)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- unexplained syncope, implantable cardioverter-defibrillator, antiarrhythmic drugs, structural heart disease, ventricular fibrillation, polymorphic ventricular tachycardia, monomorphic ventricular tachycardia, survival, mortality risk factors, ejection fraction
- MeSH terms
- Anti-Arrhythmia Agents, Female, Humans, Male, Middle Aged, Prognosis, Prospective Studies, Recurrence, Registries, Syncope, Ventricular Fibrillation, Survival Rate, Multivariate Analysis, Proportional Hazards Models, Randomized Controlled Trials as Topic, Defibrillators, Implantable, Tachycardia, Ventricular
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