Sincopa.

Moartea subit! cardiac!

Dr. Radu V!t!"escu
Pacing and Clinical Electrophysiology Lab., Cardiology Department
Clinic Emergency Hospital Bucharest
Sincopa
Defini"ie: piedere tranzitorie, de scurt! durat! "i
autolimitat! a st!rii de con"tien#! (urmat! de
pierderea tonusului postural), determinat! de o
sc!dere brusc!, sever! (cu $30%) "i tranzitorie a
perfuziei cerebrale
Recuperarea este complet!, rapid! "i spontan!
NB!
>1/3 asociat! cu traumatisme
!! la cei cu sincop! cardiac! (%1/3 MSC n 5 ani!)
RV - Sincopa. MSC 2012 2
RV - Sincopa. MSC 2012 3
Epidemiologie
RV - Sincopa. MSC 2012 4
Sorteriades ES, et al. N Engl J Med 2002 Freed LA,, et al. Am J Cardiol 1997
- un vrf de inciden#! n jurul vrstei de 15 ani, apoi inciden#a cre"te >55 ani (m.a. >70)
- riscul ,,lifetime 1/3 !!!
Clinic
context
n timpul efortului
dup! efort
n repaus
postmic#ional
durere
ortostatism prelungit
deshidratare
prodrome
palpita#ii
durere toracic!
vertij
& vedere
astenie marcat!
simptome de ! simpatic!:
transpira#ii, paloare, grea#!
pierderea con"tien#ei "i a
tonusului postural
paloare
puls absent / slab perceptibil
respira#ie superficial!
mi"c!ri tonico-clonice (fa#a,
extrem. sup.)
control sfincterian
pupile midriatice
f!r! reflexe conjunctivale
RV - Sincopa. MSC 2012 5
Etiologie
RV - Sincopa. MSC 2012 6
Prevalence, percent
Men Women

Cardiac 13.2 6.7

Stroke or transient ischemic attack 4.3 4.0

Seizure disorder 7.2 3.2

Vasovagal 19.8 22.2

Orthostatic hypotension 8.6 9.9

Medication 6.3 7.2

Other 9.5 6.1

Unknown 31.0 40.7
Etiologie
RV - Sincopa. MSC 2012 7
Reflex! (mediat! neural)
-Vasovagal!:
Stress emotional: team!, durere, fobii (snge)
Stress ortostatic
-Situa"ional!:
Stimulare respiratorie: tuse, str!nut
Stimulare g-i: nghi#it, defecare, durere visceral!
Mic#ional!
Post-exerci#ional!
Postprandial!
Altele (rs, ridicat greut!#i)
-Carotidian!
-Atipice
Prin hTA ortostatic!
-Insuficien"! autonom! primar!:
Insufic. autonom! pur!, atrofii multisistemice,
b. Parkinson, Lewy body dementia
-Insuficien"! autonom! secundar!:
DZ, amiloidoz!, uremie, leziuni spinale
-hTA ortostatic! medicamentoas!:
Alcool, v-d, diuretice, phenotiazine,
antidepresive
-Hipovolemie:
Hemoragie, diaree, emez!, etc
Cerebro-vascular!: sindroame de furt vascular
-boal! ocluziv! trunchi brahiocefalic: ASC, tr.-emb., arterite (Takayasu)
-furt subclavicular
Sincopa cardiac!
RV - Sincopa. MSC 2012 8
Aritmic!:
-Bradicardii:
&fx NSA
BAV (II gr. nalt sau III)
Disfunc#ii dispozitive implantate
-Tahicardii:
Supraventriculare
Ventriculare (idiopatice, b. structural!, canalopatii
-bradi sau tahiaritmii iatrogene
Boli structurale:
-Cardiace:
valvulopatii / disfx proteze valvulare, IMA,
CMHO, mase intracardiace (mixom, tumori, etc),
b. pericardice/tamponada, aN cong. coronariene
-Altele: TEP, disec#ie ac. Ao, HTP
Etiologie vs prognostic
RV - Sincopa. MSC 2012 9
Sorteriades ES, et al. N Engl J Med 2002
Stratificare risc
Mare: boal! cardiac! structural!
Intermediar
Redus
tn!r
f!r! comorbidit!#i
ECG N
sincop!
reflex!
ortostatic!
neexplicat!
RV - Sincopa. MSC 2012 10
Screening ini"ial
Anamneza
Ex. obiectiv
TA clino/orto
neurologic
CSC
ECG

RV - Sincopa. MSC 2012 11
Screening secundar
Ecocardiografia
monitorizare ECG
monitor CG
test de efort ECG
Holter
Test tilt
Biologic: necroz! miocardic!, DVS,
inflama#ie, TEP
RV - Sincopa. MSC 2012 12
Teste specifice
coronarografie
CT
adenozina
ILR: simptome severe, recurente la intervale mari
EPS
&NSA
BR
BCI
CMP: H, ARVD
canalopatii: Brugada
RV - Sincopa. MSC 2012 13
Tratament
Obiective:
Profilaxia recuren"elor
QoL
profilaxia complica"iilor TCC
preven"ia MSC
RV - Sincopa. MSC 2012 14
Tratament
Sincopa reflex!:
Educa"ia pacientului
asigurare
stil de via"!
recunoa#tere prodrome
m!suri de !returului venos
eliminare triggeri
RV - Sincopa. MSC 2012 15
RV - Sincopa. MSC 2012 16
RV - Sincopa. MSC 2012 17
Defini$ie
Moartea subit! cardiac! (MSC)
Deces prin stop circulator, de obicei datorat
aritmiilor cardiace, care survine n mai pu"in
de 1 or! de la debutul simptomelor

Stopul cardiac resuscitat (SCR)
Stop circulator, de obicei datorat aritmiilor
cardiace, care survine n mai pu"in de 1 or!
de la debutul simptomelor #i n care
interven"ia medical! (defibrilarea) mpiedic!
decesul
RV - Sincopa. MSC 2012 18
Ct de subit! este MSC?
Muller D et al Circulation 2006
RV - Sincopa. MSC 2012 19
450,000
1
U.S. Census Bureau, Statistical Abstract of the United States: 2001.
2
American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.
3
2006 Heart and Stroke Statistical Update, American Heart Association.
4
Circulation. 2001;104:2158-2163.
Dimensiunea problemei
SUA
Cancer de sn
2
MSC
4
42,156
40,600
157,400
167,366
SIDA
1
Cancer
pulmonar
2
AVC
3
#1 Killer
n S.U.A.
RV - Sincopa. MSC 2012 20
Cauze majore de deces
SUA 1999
1
1
National Vital Statistics Report, Vol 49 (11), Oct. 12, 2001
2
MMWR. State-specific mortality from sudden cardiac death US 1999.Feb 15, 2002;51:123-126.
MSC
0% 5% 10% 15% 20% 25%
Septicemie
Nefrite
Alzheimer
Grip!/pneumonie
Diabet
Accidente/atac armat
B.P.C.O
Boli cerebrovasculare
Alte cauze cardiace
Toate cancerele
Doar mortalitatea combinat! a
tuturor formelor de cancer
dep!#este MSC.
RV - Sincopa. MSC 2012 21
Supravie$uirea SCR
17-25% din MSC sunt resuscitate


Externa$i:
SUA %i Canada 5%
Europa de Vest 5%
Restul lumii << 1%
RV - Sincopa. MSC 2012 22
Fox CS et al Circulation 2004
Evolu$ia MSC
RV - Sincopa. MSC 2012 23
Evolu$ia supravie$uitorilor SCR
Rea TD et al Circulation 2003
RV - Sincopa. MSC 2012 24
Etiologia MSC
BCI
ASC coronarian!
IM acut sau sechelar
AI
Embolii coronariene
Boli coronariene non-ASC
arterite
disec"ii
Anomalii congenitale
Spasm coronarian
Boli cardiace nonischemice
CM (D, H, ARVD)
Miocardite
Disec"ia de Ao
Valvulopatii
CpCo
Tamponada cardiac!
Ruptura cardiac!
Boli cardiace f!r! afectare
structural!
Boala electric! primitiv! (FV idiopatic!)
Sd. Brugada
Sd. LQT/SQT
Sd. WPW
BAV complet
MSC familial!
Traumatisme toracice (commotio cordis)
Boli noncardiace
TEP
Hemoragii intracraniene
nec
Sd. Pickwick (OSA)
Intoxica"ii medicamentoase
Obstruc"ia CAS
Sd. mor"ii subite a sugarului
RV - Sincopa. MSC 2012 25
Huikuri HV, Castellanos A, Myerburg RJ. N Engl J Med 2001
RV - Sincopa. MSC 2012 26
Myerburg RJ. J Cardiovasc Electrophysiol 2001.
RV - Sincopa. MSC 2012 27
Bays de Luna A. Am Heart J 1989
Bradycardia
17%
VT
62%
Primary VF
8%
TdP
13%
Albert CM. Circulation 2003
12%
Other Cardiac
Cause
88%
Arrhythmic
Cause
MSC
mecanisme
RV - Sincopa. MSC 2012 28
Muller D et al Circulation 2006
asistola 50% 50 minute
disocia'ie electromecanic! 25% 20 minute
TV/FV 25% 30 minute
Supravie'uirea
10% ! 0-2%
23% ! 6%
40% ! 34%
RV - Sincopa. MSC 2012 29
Cummins RO. Annals Emerg Med. 1989;18:1269-1275.
MSC: succesul resuscit!rii vs. timp*
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9
%

S
u
c
c
e
s

(
*
N
o
n
l
i
n
e
a
r

)
Timp (minute)
Rata succesului scade cu 7 - 10% n fiecare minut
RV - Sincopa. MSC 2012 30
Stratificarea riscului
De ce este necesar!?
RV - Sincopa. MSC 2012 31
Risc coronarian nalt
Eveniment coronarian
n antecedente
FE <35%, ICC
APP de stop cardiac
resuscitat
APP de IM, FEvs", TV
Popula"ia general!
MSC n diferite subgrupuri
Inciden$a %i contribu$ia anual!
Myerburg RJ. Circulation 1998.
300,000 200,000 100,000 0
No. of Sudden Deaths
Per Year
30 25 20 10 5 0
Incidence of Sudden Death
(% of group)
SCD-HeFT
AVID, CIDS, CASH
MADIT I - MUSTT
MADIT-II
RV - Sincopa. MSC 2012 32
Myerburg RJ. J Cardiovasc Electrophysiol 2001.
RV - Sincopa. MSC 2012 33
Stratificarea riscului
AHC
Vrsta
Sex
SCR
BCI (IM, AI)
Personalitate

Indicatori ai func"iei VS
Simptome
Sincopa
ICC
FEvs
Masa VS
Hormonii natriuretici
Indicatori electrofiziologici
Dezechilibru autonomic
HR de repaus/efort
HRV
HRT
BRS
Alter!ri ale conducerii
miocardice
QRSd
SAECG
EPS
Dispersia repolariz!rii
Dispersia QT
MTWA
Substrat Trigger
RV - Sincopa. MSC 2012 34
Kannel WB et al, Am Hear J 1998
ICC
RV - Sincopa. MSC 2012 35
Clasa func'ional! (i modalitatea de
deces n ICC
MERIT-HF Study Group Lancet 1999
NYHA II
12%
64%
24%
NYHA IV
56%
11%
33%
NYHA III
26%
15%
59%
CHF
Other
Sudden Death
N = 103 N = 27 N = 103
RV - Sincopa. MSC 2012 36
Inciden"a MSC #i FEvs la pacien"ii
cu ICC
0
1
2
3
4
5
6
7
8
0-30% 31-40% 41-50% >50%
Gorgels APM Eur Heart J 2003
LVEF
%

S
C
A

V
i
c
t
i
m
s

7.5%
5.1%
2.8%
1.4%
RV - Sincopa. MSC 2012 37
MSC si FEvs la pacien$ii
asimptomatici
Wang TJ et al. Circulation 2003
RV - Sincopa. MSC 2012 38
Whang W et al TOVA, Circulation 2005
RV - Sincopa. MSC 2012 39
MSC %i HVS
Haider AW et al. J Am Coll Cardiol 1998
RV - Sincopa. MSC 2012 40
MSC %i hormonii natriuretici
Tapanainen JN et al. J Am Coll Cardiol 2004
RV - Sincopa. MSC 2012 41
HR %i riscul MSC
Jouven X et al. N Engl J Med 2002
RV - Sincopa. MSC 2012 42
Baldasseroni S et al, Am Hear J 2002
QRSd %i MSC
RV - Sincopa. MSC 2012 43
Moss AJ, Circulation 2005
dQRS$120 msec
dQRS<120 msec
RV - Sincopa. MSC 2012 44
Profilaxia MSC
Corectarea ischemiei
Revascularizare
$B
Reducerea inflam"iei #i/sau prevenirea
rupturii pl!cii
Statine
IEC
Aspirin!
Stabilizarea balan"ei autonomice
Beta-blocker
IEC
Ameliorarea func"iei de pomp!
IEC
$B
Profilaxia remodel!rii ventriculare #i a
form!rii de colagen
blocarea receptorilor de aldosteron
IEC
Prevenirea aritmiilor
$B
Amiodarona
a.g. polinesatura"i (ulei de pe#te)?
Terapia ablativ!
Interven"ional
chirurgical
Terminarea aritmiilor
ICDs
AEDs
RV - Sincopa. MSC 2012 45
Trial ACE-I Controls RR (95% CI)
CONSENSUS I
SOLVD (Treatment)
SOLVD (Prevention)
Chronic CHF
Post- MI
SAVE
TRACE
AIRE
39% 54% 0.56 (0.34 - 0.91)
40% 35% 0.82 (0.70 - 0.97)
15% 16% 0.92 (0.79 - 1.08)
25% 20% 0.81 (0.68 - 0.97)
17% 23% 0.73 (0.60 - 0.89)
SMILE 6.5% 8.3% 0.78 (0.52 - 1.12)
Mean
0.78 (0.67 - 0.91) 35% 42%
21% 25%
Mortality
RV - Sincopa. MSC 2012 46
Automated External Defibrillator
AED
Analiz! automat! a
ritmului
Apreciaz!
necesitatea SEE
Avertiz!ri sonore %i
vizuale ce ghideaz!
resuscitatorul
RV - Sincopa. MSC 2012 47
Supravie$uirea dup! introducerea
AEDs
Ornato JP. Community experience in treating out-of-hospital cardiac arrest. In: Akhtar M.
Sudden Cardiac Death. Baltimore, Md: Williams & Wilkins; 1994.
0
5
10
15
20
25
30
King County,
WA
Iowa SE Minnesota NE Minnesota Wisconsin
Before Early DF
After Early DF
V
F

S
u
r
v
i
v
a
l

26%
19%
17%
10%
11%
7%
3%
4%
3%
4%
RV - Sincopa. MSC 2012 48
Defibrilatorul implantabil - ICD
" Defibrilare
" Cardioversie
" Pacing antitahicardic
Ventricul
Atriu & Ventricul
" Detec'ia bradicardiei
" Pacing antibradicardic
RV - Sincopa. MSC 2012 49
0
10
20
30
40
Control
ICD
73%
Preven"ie secundar! Preven"ie primar!
39%
20%
38%
0
54%
51%
ICD reduc mortalitatea cu ~ 40%
31%
att in preven'ia primar! ct (i n cea secundar!
41% 0
23%
36%
0
RV - Sincopa. MSC 2012 50
Al-Khatib SM et al, Am Heart J 2005
RV - Sincopa. MSC 2012 51
&i totu%i...
2/3 din cei cu MSC au boal! cardiac! organic! dovedit!/
suspectat!

3/4 din MSC la domiciliu

#100% sunt n prezen'a martorilor
$90% au simptome cu cel pu'in 10 anterior evenimentului (n
medie 1h)
Martorii ncearc! manevre de resuscitare 8-23%
Supravie'uirea:
25% dac! martorii efectueaz! BLS
) 4% dac! se a(teapt! ambulan'a
Educa$ia popula$iei