医学英文课件 2017 acc、aha、hrs guideline for the evaluation and management of patients with syncope

1、2021 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With SyncopeDeveloped in Collaboration with the American College of Emergency Physicians and Society for Academic Emergency MedicineEndorsed by the Pediatric and Congenital Electrophysiology Society American College of Cardiolo

2、gy Foundation, American Heart Association, and the Heart Rhythm SocietyCitationThis slide set is adapted from the 2021 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope. Published on March 8, 2021, available at: Journal of the American College of Cardiology ) and Circu

3、lation (). The full-text guidelines are also available on the following Web sites: ACC (), AHA (), and the Heart Rhythm Society ().2021 Syncope Guideline Writing CommitteeACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Repre

4、sentative. ACC/AHA Task Force on Performance Measures Liaison.David G. Benditt, MD, FACC, FHRS*Mark S. Link, MD, FACCMitchell I. Cohen, MD, FACC, FHRSBrian Olshansky, MD, FACC, FAHA, FHRS*Daniel E. Forman, MD, FACC, FAHASatish R. Raj, MD, MSc, FACC, FHRS*Zachary D. Goldberger, MD, MS, FACC, FAHA, FH

5、RSRoopinder Kaur Sandhu, MD, MPHBlair P. Grubb, MD, FACCDan Sorajja, MDMohamed H. Hamdan, MD, MBA, FACC, FHRS*Benjamin C. Sun, MD, MPP, FACEP Andrew D. Krahn, MD, FHRS*Clyde W. Yancy, MD, MSc, FACC, FAHAWin-Kuang Shen, MD, FACC, FAHA, FHRS, ChairRobert S. Sheldon, MD, PhD, FHRS, Vice ChairTable 1. A

6、pplying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2021)General Principles 2021 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With SyncopeGeneral Principles Syncope Init

7、ial Evaluation*See relevant terms and definitions in Table 3.Colors correspond to Class of Recommendation in Table 1. This figure shows the general principles for initial evaluation of all patients after an episode of syncope. ECG indicates electrocardiogram.History and Physical ExaminationCORLOERec

8、ommendationIB-NRA detailed history and physical examination should be performed in patients with syncope.ElectrocardiographyCORLOERecommendationIB-NRIn the initial evaluation of patients with syncope, a resting 12-lead ECG is useful.Risk AssessmentCORLOERecommendationsIB-NREvaluation of the cause an

9、d assessment for the short- and long-term morbidity and mortality risk of syncope are recommended.IIbB-NRUse of risk stratification scores may be reasonable in the management of patients with syncope.Disposition After Initial EvaluationCORLOERecommendationsIB-NR Hospital evaluation and treatment are

10、 recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. IIaC-LDIt is reasonable to manage patients with presumptive reflex-mediated syncope in the outpatient setting in the absence of se

11、rious medical conditions.IIaB-RIn intermediate-risk patients with an unclear cause of syncope, use of a structured ED observation protocol can be effective in reducing hospital admission.IIbC-LDIt may be reasonable to manage selected patients with suspected cardiac syncope in the outpatient setting

12、in the absence of serious medical condition.Patient Disposition After Initial Evaluation for SyncopeColors correspond to Class of Recommendation in Table 1.ED indicates emergency department; pts, patients. Additional Evaluation and Diagnosis 2021 ACC/AHA/HRS Guideline for the Evaluation and Manageme

13、nt of Patients With SyncopeAdditional Evaluation and Diagnosis Colors correspond to Class of Recommendation in Table 1.*Applies to patients after a normal initial evaluation without significant injury or cardiovascular morbidities; patients followed up by primary care physician as needed.In selected

14、 patients (see Section 1.4).CT indicates computed tomography; CV, cardiovascular; ECG, electrocardiogram; EPS, electrophysiological study; MRI, magnetic resonance imaging; OH, orthostatic hypotension; and TTE, transthoracic echocardiography.CORLOERecommendationsIIaB-NR Targeted blood tests are reaso

15、nable in the evaluation of selected patients with syncope identified on the basis of clinical assessment from history, physical examination, and ECG.IIbC-LDUsefulness of brain natriuretic peptide and high-sensitivity troponin measurement is uncertain in patients for whom a cardiac cause of syncope i

16、s suspected.III: No BenefitB-RRoutine and comprehensive laboratory testing is not useful in the evaluation of patients with syncope.Blood TestingCardiac ImagingCORLOERecommendationsIIaB-NR Transthoracic echocardiography can be useful in selected patients presenting with syncope if structural heart d

17、isease is suspected.IIbB-NRCT or MRI may be useful in selected patients presenting with syncope of suspected cardiac etiology.III: No BenefitB-RRoutine cardiac imaging is not useful in the evaluation of patients with syncope unless cardiac etiology is suspected on the basis of an initial evaluation,

18、 including history, physical examination, or ECG.Cardiovascular TestingStress TestingCORLOERecommendationIIaC-LDExercise stress testing can be useful to establish the cause of syncope in selected patients who experience syncope or presyncope during exertion.Cardiac MonitoringCORLOERecommendationsIC-

19、EOThe choice of a specific cardiac monitor should be determined on the basis of the frequency and nature of syncope events.IIaB-NRTo evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, the following external cardiac monitoring approaches can be useful:1. Holter monit

20、or 2. Transtelephonic monitor3. External loop recorder 4. Patch recorder5. Mobile cardiac outpatient telemetry.IIaB-RTo evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, an ICM can be useful.In-Hospital TelemetryCORLOERecommendationIB-NRContinuous ECG monitoring is

21、 useful for hospitalized patients admitted for syncope evaluation with suspected cardiac etiology.Electrophysiological StudyCORLOERecommendationsIIaB-NREPS can be useful for evaluation of selected patients with syncope of suspected arrhythmic etiology.III: No BenefitB-NREPS is not recommended for sy

22、ncope evaluation in patients with a normal ECG and normal cardiac structure and function, unless an arrhythmic etiology is suspected.Tilt-Table TestingCORLOERecommendationsIIaB-RIf the diagnosis is unclear after initial evaluation, tilt-table testing can be useful for patients with suspected VVS.IIa

23、B-NRTilt-table testing can be useful for patients with syncope and suspected delayed OH when initial evaluation is not diagnostic.IIaB-NRTilt-table testing is reasonable to distinguish convulsive syncope from epilepsy in selected patients.IIaB-NRTilt-table testing is reasonable to establish a diagno

24、sis of pseudosyncope.III: No BenefitB-RTilt-table testing is not recommended to predict a response to medical treatments for VVS.Autonomic EvaluationCORLOERecommendationIIaC-LDReferral for autonomic evaluation can be useful to improve diagnostic and prognostic accuracy in selected patients with sync

25、ope and known or suspected neurodegenerative disease.Neurological TestingNeurological and Imaging DiagnosticsCORLOERecommendationsIIaC-LDSimultaneous monitoring of an EEG and hemodynamic parameters during tilt-table testing can be useful to distinguish among syncope, pseudosyncope, and epilepsy.III:

26、 No BenefitB-NRMRI and CT of the head are not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings or head injury that support further evaluation.III: No BenefitB-NRCarotid artery imaging is not recommended in the routine evaluation of patients

27、 with syncope in the absence of focal neurological findings that support further evaluation.III: No BenefitB-NRRoutine recording of an EEG is not recommended in the evaluation of patients with syncope in the absence of specific neurological features suggestive of a seizure.Management of Cardiovascul

28、ar Conditions2021 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With SyncopeCORLOERecommendationsBradycardiaIC-EOIn patients with syncope associated with bradycardia, GDMT is recommended.Supraventricular TachycardiaIC-EOIn patients with syncope and SVT, GDMT is recommended.IC-E

29、OIn patients with AF, GDMT is recommended.Ventricular ArrhythmiaIC-EOIn patients with syncope and VA, GDMT is recommended.Arrhythmic ConditionsCORLOERecommendationsIschemic and Nonischemic CardiomyopathyIC-EOIn patients with syncope associated with ischemic and nonischemic cardiomyopathy, GDMT is re

30、commended.Valvular Heart DiseaseIC-EOIn patients with syncope associated with valvular heart disease, GDMT is recommended.Hypertrophic CardiomyopathyIC-EOIn patients with syncope associated with HCM, GDMT is recommended.Structural ConditionsArrhythmogenic Right Ventricular CardiomyopathyCORLOERecomm

31、endationsIB-NRICD implantation is recommended in patients with ARVC who present with syncope and have a documented sustained VA.IIaB-NRICD implantation is reasonable in patients with ARVC who present with syncope of suspected arrhythmic etiology.Cardiac SarcoidosisCORLOERecommendationsIB-NRICD impla

32、ntation is recommended in patients with cardiac sarcoidosis presenting with syncope and documented spontaneous sustained VA.IC-EOIn patients with cardiac sarcoidosis presenting with syncope and conduction abnormalities, GDMT is recommended.IIaB-NRICD implantation is reasonable in patients with cardi

33、ac sarcoidosis and syncope of suspected arrhythmic origin, particularly with LV dysfunction or pacing indication.IIaB-NREPS is reasonable in patients with cardiac sarcoidosis and syncope of suspected arrhythmic etiology.Brugada SyndromeCORLOERecommendationsIIaB-NRICD implantation is reasonable in pa

34、tients with Brugada ECG pattern and syncope of suspected arrhythmic etiology.IIbB-NRInvasive EPS may be considered in patients with Brugada ECG pattern and syncope of suspected arrhythmic etiology.III: No BenefitB-NRICD implantation is not recommended in patients with Brugada ECG pattern and reflex-

35、mediated syncope in the absence of other risk factors.Inheritable Arrhythmic ConditionsShort-QT SyndromeCORLOERecommendationIIbC-EOICD implantation may be considered in patients with short-QT pattern and syncope of suspected arrhythmic etiology. Long-QT SyndromeCORLOERecommendationsIB-NRBeta-blocker

36、 therapy, in the absence of contraindications, is indicated as a first-line therapy in patients with LQTS and suspected arrhythmic syncope.IIaB-NRICD implantation is reasonable in patients with LQTS and suspected arrhythmic syncope who are on beta-blocker therapy or are intolerant to beta-blocker th

37、erapy.IIaC-LDLeft cardiac sympathetic denervation (LCSD) is reasonable in patients with LQTS and recurrent syncope of suspected arrhythmic mechanism who are intolerant to beta-blocker therapy or for whom beta-blocker therapy has failed.CORLOERecommendationsIC-LDExercise restriction is recommended in

38、 patients with CPVT presenting with syncope of suspected arrhythmic etiology.IC-LDBeta blockers lacking intrinsic sympathomimetic activity are recommended in patients with CPVT and stress-induced syncope.IIaC-LDFlecainide is reasonable in patients with CPVT who continue to have syncope of suspected

39、VA despite beta-blocker therapy.IIaB-NRICD therapy is reasonable in patients with CPVT and a history of exercise- or stress-induced syncope despite use of optimal medical therapy or LCSD.IIbC-LDIn patients with CPVT who continue to experience syncope or VA, verapamil with or without beta-blocker the

40、rapy may be considered.IIbC-LDLCSD may be reasonable in patients with CPVT, syncope, and symptomatic VA despite optimal medical therapy.Catecholaminergic Polymorphic Ventricular TachycardiaEarly Repolarization PatternCORLOERecommendationsIIbC-EOICD implantation may be considered in patients with ear

41、ly repolarization pattern and suspected arrhythmic syncope in the presence of a family history of early repolarization pattern with cardiac arrest.III: HarmB-NREPS should not be performed in patients with early repolarization pattern and history of syncope in the absence of other indications.Reflex

42、Conditions2021 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With SyncopeCORLOERecommendationsIC-EOPatient education on the diagnosis and prognosis of VVS is recommended.IIaB-RPhysical counter-pressure maneuvers can be useful in patients with VVS who have a sufficiently long pr

43、odromal period.IIaB-RMidodrine is reasonable in patients with recurrent VVS with no history of hypertension, HF, or urinary retention.IIbB-RThe usefulness of orthostatic training is uncertain in patients with frequent VVS.IIbB-RFludrocortisone might be reasonable for patients with recurrent VVS and

44、inadequate response to salt and fluid intake, unless contraindicated.Reflex ConditionsVasovagal SyncopeIIbB-NRBeta blockers might be reasonable in patients 42 years of age or older with recurrent VVS.IIbC-LDEncouraging increased salt and fluid intake may be reasonable in selected patients with VVS,

45、unless contraindicated.IIbC-LDIn selected patients with VVS, it may be reasonable to reduce or withdraw medications that cause hypotension when appropriate.IIbC-LDIn patients with recurrent VVS, a selective serotonin reuptake inhibitor might be considered.Vasovagal Syncope (cont.)Vasovagal SyncopeCo

46、lors correspond to Class of Recommendation in Table 1.VVS indicates vasovagal syncope.Pacemakers in Vasovagal SyncopeCORLOERecommendationIIbB-R SRDual-chamber pacing might be reasonable in a select population of patients 40 years of age or older with recurrent VVS and prolonged spontaneous pauses.SR

47、 indicated systematic review. Carotid Sinus SyndromeCORLOERecommendationsIIaB-RPermanent cardiac pacing is reasonable in patients with carotid sinus syndrome that is cardioinhibitory or mixed.IIbB-RIt may be reasonable to implant a dual-chamber pacemaker in patients with carotid sinus syndrome who r

48、equire permanent pacing.Orthostatic Hypotension2021 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With SyncopeCORLOERecommendationsIB-RAcute water ingestion is recommended in patients with syncope caused by neurogenic OH for occasional, temporary relief. IIaC-LDPhysical counter

49、-pressure maneuvers can be beneficial in patients with neurogenic OH with syncope. IIaC-LDCompression garments can be beneficial in patients with syncope and OH. IIaB-RMidodrine can be beneficial in patients with syncope due to neurogenic OH. IIaB-RDroxidopa can be beneficial in patients with syncop

50、e due to neurogenic OH.Orthostatic HypotensionNeurogenic Orthostatic HypotensionIIaC-LDFludrocortisone can be beneficial in patients with syncope due to neurogenic OH. IIbC-LDEncouraging increased salt and fluid intake may be reasonable in selected patients with neurogenic OH. IIbC-LDPyridostigmine

51、may be beneficial in patients with syncope due to neurogenic OH who are refractory to other treatments. IIbC-LDOctreotide may be beneficial in patients with syncope and refractory recurrent postprandial or neurogenic OH. Neurogenic Orthostatic Hypotension (cont.)Dehydration and DrugsCORLOERecommenda

52、tionsIC-LDFluid resuscitation via oral or intravenous bolus is recommended in patients with syncope due to acute dehydration.IIaB-NRReducing or withdrawing medications that may cause hypotension can be beneficial in selected patients with syncope.IIaC-LDIn selected patients with syncope due to dehyd

53、ration, it is reasonable to encourage increased salt and fluid intake.Orthostatic HypotensionColors correspond to Class of Recommendation in Table 1.BP indicates blood pressure; OH, orthostatic hypotension.Pseudosyncope2021 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syn

54、copeIIbC-LDIn patients with suspected pseudosyncope, a candid discussion with the patient about the diagnosis may be reasonable. IIbC-LDCognitive behavioral therapy may be beneficial in patients with pseudosyncope.CORLOERecommendationsTreatment of PseudosyncopeAge, Lifestyle, and Special Populations

55、 2021 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With SyncopePediatric SyncopeCORLOERecommendationsIC-LDVVS evaluation, including a detailed medical history, physical examination, family history, and a 12-lead ECG, should be performed in all pediatric patients presenting wit

56、h syncope. IC-LDNoninvasive diagnostic testing should be performed in pediatric patients presenting with syncope and suspected CHD, cardiomyopathy, or primary rhythm disorder.IC-EOEducation on symptom awareness of prodromes and reassurance are indicated in pediatric patients with VVS. IIaC-LDTilt-table testing can be useful for pediatric patients with suspected VVS when the diagnosis is unclear.IIaB-RIn pediatric patients with VVS not responding to lifestyle measures, it is reasonable to prescribe midodrine.Age, Lifestyle, and Spec