Synkopeneinheiten

ZUSAMMENFASSUNG

Die Synkopenversorgung bei geriatrischen Patienten ist häufig aufgrund der höheren Wahrscheinlichkeit für schwerwiegende Grunderkrankungen sowie dem Vorliegen von Begleiterkrankungen und Polypharmazie anspruchsvoll. Häufig erfolgt eine stationäre Aufnahme zur weiteren Abklärung mit konsekutiv hohen Kosten für das Gesundheitssystem und ohne verbessertem Outcome für die Patienten. Zur spezifischen diagnostischen Abklärung, Risikostratifizierung und raschen Therapieinitiierung haben sich insbesondere für Intermediär- und Hochrisikosynkopen interdisziplinäre Synkopeneinheiten bewährt. Diese bestehen aus ärztlichen und pflegerischen Synkopenspezialisten sowie einem multidisziplinären Team und können anhand standardisierter Behandlungsalgorithmen eine rasche Diagnostik und ein optimiertes Management gewährleisten. Stationäre Aufnahmen, Aufenthaltsdauer sowie Behandlungskosten konnten hierdurch um 77 %, 50 % bzw. 29 % reduziert werden. Trotz einer klaren Empfehlung der European Society of Cardiology (ESC), haben 88 % der europäischen Krankenhäuser heute weiterhin keinen Zugriff auf eine Synkopeneinheit.

ABSTRACT

The investigation and management of loss of consciousness in older patients is challenging due to the higher rate of co-morbidity and polypharmacy and the greater likelihood of underlying serious pathology. As a result, further assessment is commonly undertaken on an in-patient basis, which increases overall costs whilst not clearly improving patient-orientated outcomes. Multi-disciplinary syncope units consisting of a team including a physician, nurse, and other key allied health professionals with experience in syncope, working according to an approved and evidence-based protocol, have been shown to achieve a diagnosis, risk stratify and initiate therapy more rapidly in patients at intermediate and higher risk. Such units can achieve reductions in hospitalizations, length of stay and costs by 77 %, 50 %, 29 %, respectively. Despite clear recommendations from European Society of Cardiology (ESC), 88 % of European hospitals nowadays still do not have access to a syncope unit.

Schlüsselwörter

Geriatrie - Synkopeneinheit - Risikostratifizierung

Key words

Geriatric - syncope unit - risk stratification

Publication History

Article published online:
28 July 2022

• Literatur

• 1 Elesber AA, Decker WW, Smars PA. et al Impact of the application of the American College of Emergency Physicians recommendations for the admission of patients with syncope on a retrospectively studied population presenting to the emergency department. Am Heart J 2005; 149: 826-831 DOI: 10.1016/j.ahj.2004.07.024.
• 2 Shen WK, Decker WW, Smars PA. et al Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management. Circulation 2004; 110: 3636-3645 DOI: 10.1161/01.CIR.0000149236.92822.07.
• 3 Shen WK, Traub SJ, Decker WW. Syncope management unit: evolution of the concept and practice implementation. Prog Cardiovasc Dis 2013; 55: 382-389 DOI: 10.1016/j.pcad.2012.11.001.
• 4 Canzoniero JV, Afshar E, Hedian H. et al Unnecessary hospitalization and related harm for patients with low-risk syncope. JAMA Intern Med 2015; 175: 1065-1067 DOI: 10.1001/jamainternmed.2015.0945.
• 5 Ungar A, Mussi C, Del Rosso A. et al Diagnosis and characteristics of syncope in older patients referred to geriatric departments. J Am Geriatr Soc 2006; 54: 1531-1536 DOI: 10.1111/j.1532-5415.2006.00891.x.
• 6 Koene RJ, Adkisson WO, Benditt DG. Syncope and the risk of sudden cardiac death: Evaluation, management, and prevention. J Arrhythm 2017; 33: 533-544 DOI: 10.1016/j.joa.2017.07.005.
• 7 Goyal P, Maurer MS. Syncope in older adults. J Geriatr Cardiol 2016; 13: 380-386 DOI: 10.11909/j.issn.1671-5411.2016.05.002.
• 8 van der Velde N, van den Meiracker AH, Pols HA. et al Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes. J Am Geriatr Soc 2007; 55: 734-739 DOI: 10.1111/j.1532-5415.2007.01137.x.
• 9 Solari D, Tesi F, Unterhuber M. et al Stop vasodepressor drugs in reflex syncope: a randomised controlled trial. Heart 2017; 103: 449-455 DOI: 10.1136/heartjnl-2016-309865.
• 10 Kwok CS, Ong AC, Potter JF. et al TIA, stroke and orthostatic hypotension: a disease spectrum related to ageing vasculature?. Int J Clin Pract 2014; 68: 705-713 DOI: 10.1111/ijcp.12373.
• 11 Mankoo AS, Minhas JS, Coles B. et al Clinical Relevance of Orthostatic Hypotension in Patients with Atrial Fibrillation and Suspected Transient Ischemic Attack. High Blood Press Cardiovasc Prev 2020; 27: 93-101 DOI: 10.1007/s40292-020-00363-4.
• 12 Sardu C, Paolisso P, Santamaria M. et al Cardiac syncope recurrence in type 2 diabetes mellitus patients vs. normoglycemics patients: The CARVAS study. Diabetes Res Clin Pract 2019; 151: 152-162 DOI: 10.1016/j.diabres.2019.04.015.
• 13 Shaw FE, Bond J, Richardson DA. et al Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ 2003; 326: 73 DOI: 10.1136/bmj.326.7380.73.
• 14 Frewen J, King-Kallimanis B, Boyle G. et al Recent syncope and unexplained falls are associated with poor cognitive performance. Age Ageing 2015; 44: 282-286 DOI: 10.1093/ageing/afu191.
• 15 Marrison VK, Fletcher A, Parry SW. The older patient with syncope: practicalities and controversies. Int J Cardiol 2012; 155: 9-13 DOI: 10.1016/j.ijcard.2010.10.055.
• 16 Colivicchi F, Ammirati F, Melina D. et al Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J 2003; 24: 811-819 DOI: 10.1016/s0195-668x(02)00827-8.
• 17 Sheldon R, Rose S, Connolly S. et al Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur Heart J 2006; 27: 344-350 DOI: 10.1093/eurheartj/ehi584.
• 18 Dermksian G, Lamb LE. Syncope in a population of healthy young adults; incidence, mechanisms, and significance. J Am Med Assoc 1958; 168: 1200-1207 DOI: 10.1001/jama.1958.03000090030007.
• 19 Quinn JV, Stiell IG, McDermott DA. et al Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med 2004; 43: 224-232 DOI: 10.1016/s0196-0644(03)00823-0.
• 20 Thiruganasambandamoorthy V, Sivilotti MLA, Le Sage N. et al Multicenter Emergency Department Validation of the Canadian Syncope Risk Score. JAMA Intern Med 2020; 180: 737-744 DOI: 10.1001/jamainternmed.2020.0288.
• 21 Brignole M, Moya A, de Lange FJ. et al 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39: 1883-1948 DOI: 10.1093/eurheartj/ehy037.
• 22 Sarasin FP, Hanusa BH, Perneger T. et al A risk score to predict arrhythmias in patients with unexplained syncope. Acad Emerg Med 2003; 10: 1312-1317 DOI: 10.1111/j.1553-2712.2003.tb00003.x.
• 23 Middlekauff HR, Stevenson WG, Stevenson LW. et al Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. J Am Coll Cardiol 1993; 21: 110-116 DOI: 10.1016/0735-1097(93)90724-f.
• 24 Puppala VK, Dickinson O, Benditt DG. Syncope: classification and risk stratification. J Cardiol 2014; 63: 171-177 DOI: 10.1016/j.jjcc.2013.03.019.
• 25 Barold SS. Indications for permanent cardiac pacing in first-degree AV block: class I, II, or III?. Pacing Clin Electrophysiol 1996; 19: 747-751 DOI: 10.1111/j.1540-8159.1996.tb03355.x.
• 26 Costantino G, Sun BC, Barbic F. et al Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department. Eur Heart J 2016; 37: 1493-1498 DOI: 10.1093/eurheartj/ehv378.
• 27 Thiruganasambandamoorthy V, Stiell IG, Wells GA. et al Outcomes in presyncope patients: a prospective cohort study. Ann Emerg Med 2015; 65: 268-276 e266 DOI: 10.1016/j.annemergmed.2014.07.452.
• 28 Krahn AD, Klein GJ, Yee R. et al Predictive value of presyncope in patients monitored for assessment of syncope. Am Heart J 2001; 141: 817-821 DOI: 10.1067/mhj.2001.114196.
• 29 Thiruganasambandamoorthy V, Hess EP, Alreesi A. et al External validation of the San Francisco Syncope Rule in the Canadian setting. Ann Emerg Med 2010; 55: 464-472 DOI: 10.1016/j.annemergmed.2009.10.001.
• 30 Serrano LA, Hess EP, Bellolio MF. et al Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Med 2010; 56: 362-373 e361 DOI: 10.1016/j.annemergmed.2010.05.013.
• 31 Perego F, Costantino G, Dipaola F. et al Predictors of hospital admission after syncope: relationships with clinical risk scores. Int J Cardiol 2012; 161: 182-183 DOI: 10.1016/j.ijcard.2012.06.061.
• 32 Kenny RA, O’Shea D, Walker HF. Impact of a dedicated syncope and falls facility for older adults on emergency beds. Age Ageing 2002; 31: 272-275 DOI: 10.1093/ageing/31.4.272.
• 33 Sun BC, McCreath H, Liang LJ. et al Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission. Ann Emerg Med 2014; 64: 167-175 DOI: 10.1016/j.annemergmed.2013.10.029.
• 34 Brignole M, Ungar A, Bartoletti A. et al Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace 2006; 08: 644-650 DOI: 10.1093/europace/eul071.
• 35 Dan GA, Scherr D, Jubele K. et al Contemporary management of patients with syncope in clinical practice: an EHRA physician-based survey. Europace 2020; 22: 980-987 DOI: 10.1093/europace/euaa085.
• 36 Kenny RA, Brignole M, Dan GA. et al Syncope Unit: rationale and requirement – the European Heart Rhythm Association position statement endorsed by the Heart Rhythm Society. Europace 2015; 17: 1325-1340 DOI: 10.1093/europace/euv115.
• 37 Brignole M, Disertori M, Menozzi C. et al Management of syncope referred urgently to general hospitals with and without syncope units. Europace 2003; 05: 293-298 DOI: 10.1016/s1099-5129(03)00047-3.
• 38 Petkar S, Bell W, Rice N. et al Initial experience with a rapid access blackouts triage clinic. Clin Med 2011; 11: 11-16 DOI: 10.7861/clinmedicine.11-1-11.
• 39 van Dijk N, Boer KR, Colman N. et al High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment study. J Cardiovasc Electrophysiol 2008; 19: 48-55 DOI: 10.1111/j.1540-8167.2007.00984.x.
• 40 Firouzbakht T, Shen ML, Groppelli A. et al Step-by-step guide to creating the best syncope units: From combined United States and European experiences. Auton Neurosci 2022; 239: 102950 DOI: 10.1016/j.autneu.2022.102950.