August 28, 2006

2006 AHA/ACCF Syncope Statement stirs debate

Dr Carlos A Morillo, ModeratorProfessor, Department of MedicineDirector, Arrhythmia Service, Cardiology DivisionMcMaster University, Population Health Research Institute, Hamilton, ON

Dr David G BendittProfessor of Medicine, Cardiovascular DivisionCardiac Arrhythmia CenterUniversity of MinnesotaMedical School,Minneapolis, MN

Dr Adam StrickbergerDirector, Arrhythmia ResearchWashington Hospital CenterProfessor of MedicineGeorgetown University Schoolof MedicineWashington, DC

August 28, 2006

Syncope Statement: Background

• ACCF/AHA statement on evaluation of syncope published earlier this year

• "Long needed": Syncope undervalued, given it causes about ~1% of ED visits

• Occasionally a marker of high risk of bad outcome

• Several features from statement need to be reconsidered

- Benditt

August 28, 2006

Syncope Statement: Points for reconsideration

• Definition of syncope—Important for physicians to distinguish syncope from other forms of transient loss of consciousness

• All patients deserve thorough evaluation, not just high-risk patients with suspected malignant syncope

- Benditt

August 28, 2006

Syncope Statement: The goal

"The goal ought to be . . . discerning what the underlying cause is so that one can predict prognosis and hopefully find an effective treatment strategy."

- Benditt

August 28, 2006

Syncope Statement: Up for debate

• Difficult to divorce evaluation and treatment in terms of clinical data

• All relevant clinical trials should have been included

• Large professional organizations as well as non-CV organizations should be involved

• Long-term goal should be to develop true, multidisciplinary practice guidelines

- Benditt

August 28, 2006

Syncope Statement: Rebuttal

• Task set by AHA was evaluation and treatment of syncope, not management

• Focus was on patient with single episode • Multiple organizations, >50 people

reviewed or contributed to document

- Strickberger

August 28, 2006

Syncope Statement: Rebuttal

• No gold standard/consensus on definition

• Main goal of evaluation in first-time syncope is to rule out dangerous causes

• Some treatment options addressed; primarily defibrillators for people with structural heart disease

- Strickberger

August 28, 2006

Syncope Statement: Evaluation, not treatment

"Most people would say for one episode or even three episodes over 20 years, that you're probably not going to treat that patient, but you will provide them with education, pay attention to symptoms, increase your volume status, pay attention to situations where you could . . . precipitate an episode."

- Strickberger

August 28, 2006

Syncope Statement: Rebuttal, cont'd

• Studies omitted if they dealt primarily with multiple episodes of neurocardiogenic syncope/syndrome

No one is opposed to multidisciplinary guidelines

- Strickberger

August 28, 2006

Syncope Statement: Unpublished concerns

• The context: Scientific statement published in Circulation and the Journal of the American College of Cardiology (JACC); in response, Benditt et al sent an extensive letter, but it was never published

"When should a letter to the editor really be published? . . . Some of the issues that have been raised may be very important but will never really go to press."

- Morillo

August 28, 2006

• Physicians rely heavily on professional organizations to publish guidance documents

• There will always be differences of opinion, but concerns should be aired

• In the case of syncope letter: Circulation refused to publish; JACC has accepted an abbreviated letter

- Benditt

Syncope Statement: Unpublished concerns

August 28, 2006

Syncope Statement: Persistent issues

"It's not easy to get differences of opinion published, even when they're reasoned."

Statement does not clearly state at outset that focus is on single episode.

We agree: primary purpose of an evaluation ought to be for assessing prognosis

Beyond syncope statement: if there are differences of opinion with this, there may be differences of opinion never aired for other documents

- Benditt

August 28, 2006

In defense of the statement

• There's room for a reasoned response; but it's up to organizations to set policies

• We all agree, we need to figure out what's wrong with patients

• If heart tests are normal, we know what diagnosis is going to be

- Strickberger

August 28, 2006

"The issue for me is not perhaps what was written but what was missing."

• Definition of syncope should be up front

• Need to differentiate between syncope and transient loss of consciousness as a starting point, otherwise diagnoses get missed

- Benditt

Syncope Statement: Persistent issues

August 28, 2006

Syncope Statement: A philosophic change

"This might seem semantic, but I think it's more than that. I think it's a fundamental philosophic change in diagnostic attitude. . . . I want doctors seeing a patient who's had a fall or apparent blackout to really move to a broader picture."

- Benditt

August 28, 2006

Syncope diagnosis: Start broad

• Single vs multiple episodes can be difficult to prove, so strategies need to be addressed: loop recorders may be undervalued

• Start with a "broad radar"

• ESC syncope guidelines useful and should have been referenced in statement

- Benditt

August 28, 2006

In defense of the statement

• Exclusion of ESC syncope guidelines an oversight

• Statement does discuss strategies in patients with multiple episodes

• Differential diagnoses discussed, including seizures, psychiatric problems, etc

- Strickberger

August 28, 2006

Syncope Statement: Utility disputed

"The paper . . . has the basic problem of not going through the evaluation in terms of what are the most likely events, what are the concerning events that we need to eliminate up front. At the end of the day, it doesn't provide the reader with something that they can actually use at home and improve the efficiency of the diagnosis. But what it does do, fortunately, is bring loss-of-consciousness events up higher on our radar screen."

- Benditt

August 28, 2006

Syncope Statement: Utility disputed

"There's a lot of people—people I haven't seen for 15 years—who have called me up and said, this is really helpful."

• May need to agree to disagree over helpfulness, efficiency of the statement

- Strickberger

August 28, 2006

Syncope Statement: A role for tilt table testing?

• TTT is a subsidiary test with diagnostic value in patients with suspected but uncertain vasovagal syncope

• Problems of false negatives and false positives: test not perfect, but may be of some help

• Possible role in treatment as a "training" tool

- Benditt

August 28, 2006

Syncope: More general guidance needed?

• Should we be looking into developing more general, multidisciplinary guidelines?

• Readership may not distinguish between statements and guidelines

• Physicians can tweak statements in practice, but legal community sees them as definitive

- Benditt

- Morillo

August 28, 2006

Syncope Statement: Conclusions

"Discourse, and controversy, and disagreements are good. . . . I'm glad that you brought it up."

- Strickberger

August 28, 2006

Syncope Statement: Conclusions

"It's easy to take potshots at things that are on the table. If everybody sort of stood back and never stuck their necks out to put a written document out for us, it would be very unfortunate. . . . Even if we disagree with part or all or whatever, it takes time, effort, courage, and dedication to do that, and that is a crucial part of advancement of medical care."

- Benditt