Diagnosis, management, and outcomes of patients with syncope and bundle branch block
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AIMS: Although patients with syncope and bundle branch block (BBB) are at high risk of developing atrio-ventricular block, syncope may be due to other aetiologies. We performed a prospective, observational study of the clinical outcomes of patients with syncope and BBB following a systematic diagnostic approach. METHODS AND RESULTS: Patients with ≥1 syncope in the last 6 months, with QRS duration ≥120 ms, were prospectively studied following a three-phase diagnostic strategy: Phase I, initial evaluation; Phase II, electrophysiological study (EPS); and Phase III, insertion of an implantable loop recorder (ILR). Overall, 323 patients (left ventricular ejection fraction 56 ± 12%) were studied. The aetiological diagnosis was established in 267 (82.7%) patients (102 at initial evaluation, 113 upon EPS, and 52 upon ILR) with the following aetiologies: bradyarrhythmia (202), carotid sinus syndrome (20), ventricular tachycardia (18), neurally mediated (9), orthostatic hypotension (4), drug-induced (3), secondary to cardiopulmonary disease (2), supraventricular tachycardia (1), bradycardia-tachycardia (1), and non-arrhythmic (7). A pacemaker was implanted in 220 (68.1%), an implantable cardioverter defibrillator in 19 (5.8%), and radiofrequency catheter ablation was performed in 3 patients. Twenty patients (6%) had died at an average follow-up of 19.2 ± 8.2 months. CONCLUSION: In patients with syncope, BBB, and mean left ventricular ejection fraction of 56 ± 12%, a systematic diagnostic approach achieves a high rate of aetiological diagnosis and allows to select specific treatment.
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In patients with bundle branch block in whom paroxysmal AV block is likely despite negative complete EPS, an arrhythmia was observed in 41% under ILR observation, being paroxysmal AV block in 70%.
“Patients with bundle branch block (BBB) in whom paroxysmal atrioventricular (AV) block is likely despite negative complete EPS: an arrhythmia was observed in 41% of these patients (being paroxysmal AV block in 70%) under ILR observation, based on pooled data from three studies 174,187,188”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [188]
The Discussion reports that ILR documented an arrhythmia in 45% of patients with a negative EPS, and the Results (Endpoints) record AV block in 36 patients. This supports the clinical pattern, but this single study does not report the cited pooled estimates of 41% and 70%; its recorded arrhythmias total 45, of which 36 (80%) were AV block. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThis finding has been indirectly confirmed by recent studies that showed a significant reduction in syncopal recurrences in patients with prolonged HV implanted with a pacemaker compared with a control group of untreated patients with a negative EPS, or with a control group who received an empiric pacemaker.
“This finding has been indirectly confirmed by recent studies that showed a significant reduction in syncopal recurrences in patients with prolonged HV implanted with a pacemaker compared with a control group of untreated patients with a negative EPS 188 , or with a control group who received an empiric pacemaker. 217”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [188]
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Experimental — accuracy not yet measuredThere is strong consensus based on evidence from several controlled trials that a correlation between symptoms and a documented arrhythmia, or the presence of some asymptomatic significant arrhythmias, is diagnostic of the cause of syncope and specific treatment must be prescribed.
“Even if the quality of evidence is moderate, there is strong consensus based on evidence from several controlled trials that a correlation between symptoms and a documented arrhythmia, or the presence of some asymptomatic significant arrhythmias (defined above), is diagnostic of the cause of syncope and specific treatment must be prescribed.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [188]
The Methods (Diagnostic criteria; page unavailable) treat documented significant arrhythmias as diagnostic of arrhythmic syncope, with or without a syncopal episode. The Discussion (page unavailable) says diagnosis allows clinicians to select specific treatment. But this observational study does not establish the claimed strong consensus or evidence from several controlled trials, and it does not say treatment must be prescribed. (LLM, conf=0.86)
Experimental — accuracy not yet measuredMost evidence in support of the above diagnostic criteria is indirectly based on the benefit of specific therapies guided by ECG monitoring in preventing syncopal recurrences.
“Most evidence in support of the above diagnostic criteria is indirectly based on the benefit of specific therapies guided by ECG monitoring in preventing syncopal recurrences. 172,184-186,188,200”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [188]
The Results (Endpoints; page not available) report fewer syncopal recurrences among patients diagnosed and treated after the initial evaluation or electrophysiological study than among those given an implantable loop recorder after a negative work-up. This supports an indirect link between diagnosis-guided treatment and fewer recurrences, but the paper does not establish that most evidence for the criteria comes from ECG-monitoring-guided therapies; its diagnostic strategy also includes evaluations other than ECG monitoring. (LLM, conf=0.84)
Experimental — accuracy not yet measuredWith a strategy of EPS followed by ILR if EPS findings are unremarkable, a pacemaker was implanted in approximately half of patients and these patients had syncope recurrence after pacemaker implantation in 0-7% of cases.
“With this strategy, a pacemaker was implanted in approximately half of the patients and these patients had syncope recurrence after pacemaker implantation in 0-7% of cases 188,217 .”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [188]
The Results (Treatments) report pacemaker implantation in 220 of 323 patients (68.1%), rather than approximately half. The Results (Endpoints) report 7% syncope recurrence among patients diagnosed and treated in phases I or II, not specifically among pacemaker recipients; they do not establish a 0–7% post-pacemaker recurrence rate. (LLM, conf=0.90)
Experimental — accuracy not yet measured
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- Authors
- Moya, A., Garcia-Civera, R., Croci, F., Menozzi, C., Brugada, J., Ammirati, F., Del Rosso, A., Bellver-Navarro, A., Garcia-Sacristan, J., Bortnik, M., Mont, L., Ruiz-Granell, R., Navarro, X., & study, O. B. O. T. B. D. I. B. B. B. (.
- Affiliations
- Presidio Ospedaliero (IT)
- Santa Maria Nuova Hospital (IT)
- Hospital Clínic de Barcelona (ES)
- Hospital General Universitari de Castelló (ES)
- Azienda Ospedaliero Universitaria Maggiore della Carita (IT)
- Medtronic (Spain) (ES)
- Venue
- European Heart Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2011-03-28
- Volume
- 32
- Issue
- 12
- Pages
- 1535-1541
- ISSN
- 0195-668X (ISSN-L)
- 1522-9645
- PMC
- PMC3114095
- OpenAlex
- W2130359882
- Cited by
- 124
- References
- 31
- Citations by year
- 2026: 2 · 2025: 1 · 2024: 5 · 2023: 10 · 2022: 15 · 2021: 9 · 2020: 6 · 2019: 8 · 2018: 16 · 2017: 6 · 2016: 5 · 2015: 3 · 2014: 14 · 2013: 9 · 2012: 13
- FWCI
- 12.43
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- other-oa
- Locations
- European Heart Journal (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Dipòsit Digital de Documents de la UAB (Universitat Autònoma de Barcelona) (submittedVersion, cc-by-nc)
- LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (submittedVersion, cc-by-nc)
- Funders
- Sociedad Española de Cardiología
- Medtronic Europe
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- syncope, bundle branch block, bradycardia, carotid sinus syndrome, ventricular tachycardia, neurally mediated syncope, orthostatic hypotension, implantable loop recorder, electrophysiological study, pacemaker implantation, implantable cardioverter-defibrillator, radiofrequency catheter ablation
- MeSH terms
- Aged, Aged, 80 and over, Bundle-Branch Block, Female, Humans, Male, Middle Aged, Pacemaker, Artificial, Prospective Studies, Recurrence, Syncope, Ventricular Outflow Obstruction, Treatment Outcome, Ventricular Dysfunction, Left, Kaplan-Meier Estimate
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