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William J, Nanayakkara S, Chieng D, Sugumar H, Ling LH, Patel H, Mariani J, Prabhu S, Kistler PM, Voskoboinik A. Predictors of pacemaker requirement in patients receiving implantable loop recorders for unexplained syncope: A systematic review and meta-analysis. Heart Rhythm 2024:S1547-5271(24)00284-4. [PMID: 38508296 DOI: 10.1016/j.hrthm.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Implantable loop recorders (ILRs) are increasingly used to evaluate patients with unexplained syncope. Identification of all predictors of bradycardic syncope and consequent permanent pacemaker (PPM) insertion is of substantial clinical interest as patients in the highest risk category may benefit from upfront pacemaker insertion. OBJECTIVE We performed a systematic review and meta-analysis to identify risk predictors for PPM insertion in ILR recipients with unexplained syncope. METHODS An electronic database search (MEDLINE, Embase, Scopus, Cochrane) was performed in June 2023. Studies evaluating ILR recipients with unexplained syncope and recording risk factors for eventual PPM insertion were included. A random effects model was used to calculate the pooled odds ratio (OR) for clinical and electrocardiographic characteristics with respect to future PPM requirement. RESULTS Eight studies evaluating 1007 ILR recipients were included; 268 patients (26.6%) underwent PPM insertion during study follow-up. PPM recipients were older (mean age, 70.2 ± 15.4 years vs 61.6 ± 19.7 years; P < .001). PR prolongation on baseline electrocardiography was a significant predictor of PPM requirement (pooled OR, 2.91; 95% confidence interval, 1.63-5.20). The presence of distal conduction system disease, encompassing any bundle branch or fascicular block, yielded a pooled OR of 2.88 for PPM insertion (95% confidence interval, 1.53-5.41). Injurious syncope and lack of syncopal prodrome were not significant predictors of PPM insertion. Sinus node dysfunction accounted for 62% of PPM insertions, whereas atrioventricular block accounted for 26%. CONCLUSION Approximately one-quarter of ILR recipients for unexplained syncope require eventual PPM insertion. Advancing age, PR prolongation, and distal conduction disease are the strongest predictors for PPM requirement.
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Affiliation(s)
- Jeremy William
- The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - David Chieng
- The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Hariharan Sugumar
- The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Hitesh Patel
- The Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia
| | - Peter M Kistler
- The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia.
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Doundoulakis I, Tsiachris D, Kordalis A, Koliastasis L, Soulaidopoulos S, Arsenos P, Xintarakou A, Bartsioka LI, Dilaveris P, Vlachopoulos C, Sideris S, Tsioufis K, Gatzoulis KA. Management of Patients With Unexplained Syncope: Derivation and Validation of a Simplified 2-Step Diagnostic Approach. J Am Heart Assoc 2023; 12:e031659. [PMID: 37982260 PMCID: PMC10727290 DOI: 10.1161/jaha.123.031659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/19/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The aim of this study was to develop a structured 2-step approach, based on noninvasive diagnostic criteria, that led to an electrophysiology study in patients with unexplained syncope. METHODS AND RESULTS Two independent cohorts were used: the derivation cohort with 665 patients based on electronic health record data to develop our 2-step diagnostic approach, and the validation cohort based on 160 prospectively screened patients, presenting with unexplained syncope episodes. Noninvasive electrocardiographic and imaging markers and an electrophysiology study-based invasive assessment were combined. A positive diagnostic approach according to our study's prespecified criteria resulted in a decision to proceed with a permanent pacemaker/implantable cardioverter-defibrillator. The primary end point was the time until the event of recurrent syncope (syncope-free survival). Number needed to treat was calculated for patients with a positive diagnostic approach. The number of patients with unexplained syncope and borderline sinus bradycardia needed to treat was 5, and the number of patients with unexplained syncope and bundle branch block needed to treat was 3 over a mean follow-up of ≈4 years. After the structured 2-step approach, the primary outcome occurred in 14 of 82 (17.1%) with a pacemaker/implantable cardioverter-defibrillator and 19 of 57 (33%) with a negative approach, with a mean follow-up of ≈2.5 years (29.29±12.58 months, P=0.03). CONCLUSIONS The low number needed to treat in the derivation cohort and the low percentage of syncope recurrence in the validation cohort supports the proposed 2-step electrophysiology-inclusive algorithm as a potentially low-cost, 1-day, structured tool for these patients.
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Affiliation(s)
- Ioannis Doundoulakis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Dimitris Tsiachris
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Athanasios Kordalis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Leonidas Koliastasis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Stergios Soulaidopoulos
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Petros Arsenos
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Anastasia Xintarakou
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Lamprini Iro Bartsioka
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Polychronis Dilaveris
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Charalambos Vlachopoulos
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Skevos Sideris
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Konstantinos Tsioufis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Konstantinos A. Gatzoulis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
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