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Clinical predictors of cardiac syncope in patients with unexplained syncope after the implantation of an insertable cardiac monitor

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Abstract

Syncope prognosis is related to both its etiology and comorbidities, with cardiac syncope (CS) having higher risks for mortality and cardiovascular events than syncope of non-cardiac causes. Although a novel insertable cardiac monitor (ICM) is an effective diagnostic tool for unexplained syncope, decision regarding ICM implantation with a high pre-test likelihood of CS should contribute to economic cost reduction and avoidance of unnecessary complications. This study aimed to investigate clinical factors associated with CS after ICM implantation in patients with unexplained syncope. This retrospective observational study included 31 consecutive patients with ICM implantation for syncope between September 2016 and August 2021. The initial examinations for syncope included a detailed history, physical examination, blood tests, 12-lead electrocardiograms, and transthoracic echocardiography. Of the 31 patients, 13 (41.9%) experienced recurrent CS during follow-up (676 ± 469 days). Among several clinical factors, syncope-related minor injuries (p = 0.017) and higher brain natriuretic peptide (BNP; p = 0.043) levels were significantly associated with CS. Moreover, multivariable analysis showed that both syncope-related minor injuries (odds ratio, 11.2; 95% confidence interval, 1.4–88.4; p = 0.022) and BNP higher than 64.0 pg/mL (odds ratio, 7.0; 95% confidence interval, 1.1–44.2; p = 0.038) were independent predictors of CS after ICM implantation. In conclusion, a history of minor injury secondary to syncope and higher BNP levels were independent CS predictors in patients receiving ICM for syncope. These results emphasized the utility of ICM implantation early in the diagnostic journey of patients presenting with CS predictors requiring specific treatments.

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Data availability statement

The data that support the findings of the current study are available from the corresponding author on reasonable request.

Abbreviations

CS:

Cardiac syncope

ILR:

Implantable loop recorder

ICM:

Insertable cardiac monitor

ISSUE:

International Study on Syncope of Uncertain Etiology

ROC:

Receiver operating characteristic

BNP:

Brain natriuretic peptide

OR:

Odds ratio

CI:

Confidence interval

NT-proBNP:

N-terminal pro-brain natriuretic peptide

References

  1. Cheung CC, Krahn AD (2016) Loop recorders for syncope evaluation: what is the evidence? Expert Rev Med Devices 13:1021–1027

    Article  CAS  PubMed  Google Scholar 

  2. Burkowitz J, Merzenich C, Grassme K, Brüggenjürgen B (2016) Insertable cardiac monitors in the diagnosis of syncope and the detection of atrial fibrillation: a systematic review and meta-analysis. Eur J Prev Cardiol 23:1261–1272

    Article  PubMed  Google Scholar 

  3. Kenny RA, Bhangu J, King-Kallimanis BL (2013) Epidemiology of syncope/collapse in younger and older Western patient populations. Prog Cardiovasc Dis 55:357–363

    Article  PubMed  Google Scholar 

  4. Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D (2002) Incidence and prognosis of syncope. N Engl J Med 347:878–885

    Article  PubMed  Google Scholar 

  5. Sandgren E, Rorsman C, Edvardsson N, Engdahl J (2019) Role of baseline 12-lead ECG in predicting syncope caused by arrhythmia in patients investigated using an implantable loop recorder. Int J Cardiol Heart Vasc 24:100386

    PubMed  PubMed Central  Google Scholar 

  6. Sato N, Minami Y, Ako J, Maeda A, Akashi Y, Ikari Y, Ebina T, Tamura K, Namiki A, Fukui K, Michishita I, Kimura K, Suzuki H (2021) Clinical significance of prehospital 12-lead electrocardiography in patients with ST-segment elevation myocardial infarction presenting with syncope: from a multicenter observational registry (K-ACTIVE study). Heart Vessels 36:1466–1473

    Article  PubMed  Google Scholar 

  7. Huemer M, Becker AK, Wutzler A, Attanasio P, Parwani AS, Lacour P, Boldt LH, Pieske B, Haverkamp W, Blaschke F (2019) Implantable loop recorders in patients with unexplained syncope: clinical predictors of pacemaker implantation. Cardiol J 26:36–46

    Article  PubMed  PubMed Central  Google Scholar 

  8. Farwell DJ, Freemantle N, Sulke N (2006) The clinical impact of implantable loop recorders in patients with syncope. Eur Heart J 27:351–356

    Article  PubMed  Google Scholar 

  9. Furukawa T, Maggi R, Bertolone C, Fontana D, Brignole M (2012) Additional diagnostic value of very prolonged observation by implantable loop recorder in patients with unexplained syncope. J Cardiovasc Electrophysiol 23:67–71

    Article  PubMed  Google Scholar 

  10. Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H, JCS/JHRS Joint Working Group (2021) JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 37:709–870

    Article  PubMed  PubMed Central  Google Scholar 

  11. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG, ESC Scientific Document Group (2018) 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 39:1883–1948

    Article  PubMed  Google Scholar 

  12. Vitale E, Ungar A, Maggi R, Francese M, Lunati M, Colaceci R, Del Rosso A, Castro A, Santini M, Giuli S, Belgini L, Casagranda I, Brignole M (2010) Discrepancy between clinical practice and standardized indications for an implantable loop recorder in patients with unexplained syncope. Europace 12:1475–1479

    Article  PubMed  PubMed Central  Google Scholar 

  13. Brignole M, Menozzi C, Bartoletti A, Giada F, Lagi A, Ungar A, Ponassi I, Mussi C, Maggi R, Re G, Furlan R, Rovelli G, Ponzi P, Scivales A (2006) A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J 27:76–82

    Article  PubMed  Google Scholar 

  14. Gunda S, Reddy YM, Pillarisetti J, Koripalli S, Jeffery C, Swope J, Atkins D, Bommana S, Emert MP, Pimentel R, Dendi R, Berenbom LD, DiBiase L, Natale A, Lakkireddy D (2015) Initial real world experience with a novel insertable (Reveal LinQ(@Medtronic)) compared to the conventional (Reveal XT(@Medtronic)) implantable loop recorder at a tertiary care center—points to ponder! Int J Cardiol 191:58–63

    Article  PubMed  Google Scholar 

  15. Krahn AD, Klein GJ, Yee R, Hoch JS, Skanes AC (2003) Cost implications of testing strategy in patients with syncope: randomized assessment of syncope trial. J Am Coll Cardiol 42:495–501

    Article  PubMed  Google Scholar 

  16. Task Force members, Brignole M, Vardas P, Hoffman E, Huikuri H, Moya A, Ricci R, Sulke N, Wieling W, Scientific Documents Committee EHRA, Auricchio A, Lip GY, Almendral J, Kirchhof P, Aliot E, Gasparini M, Braunschweig F, Reviewers D, Lip GY, Almendral J, Kirchhof P, Botto GL, EHRA Scientific Documents Committee (2009) Indications for the use of diagnostic implantable and external ECG loop recorders. Europace 11:671–687

    Article  Google Scholar 

  17. Ahmed N, Frontera A, Carpenter A, Cataldo S, Connolly GM, Fasiolo M, Cripps T, Thomas G, Diab I, Duncan ER (2015) Clinical predictors of pacemaker implantation in patients with syncope receiving implantable loop recorder with or without ECG conduction abnormalities. Pacing Clin Electrophysiol 38:934–941

    Article  PubMed  Google Scholar 

  18. Palmisano P, Accogli M, Zaccaria M, Luzzi G, Nacci F, Anaclerio M, Favale S (2013) Predictive factors for pacemaker implantation in patients receiving an implantable loop recorder for syncope remained unexplained after an extensive cardiac and neurological workup. Int J Cardiol 168:3450–3457

    Article  PubMed  Google Scholar 

  19. Lee SH, Kim TH, Oh YS, Oh S, Choi JI, Kim JB, Nah JC, Im SI, Kang KW, Han S, Kim JS (2020) Usefulness of an implantable loop recorder in diagnosing unexplained syncope and predictors for pacemaker implantation. J Korean Med Sci 35:e11

    Article  CAS  PubMed  Google Scholar 

  20. Onuki T, Shoji M, Sugiyama H, Arai S, Yoshikawa K, Mase H, Kurata M, Kikuchi M, Wakatsuki D, Asano T, Suzuki H, Tanno K, Kobayashi Y, Shinke T (2021) Clinical predictors for bradycardia and supraventricular tachycardia necessitating therapy in patients with unexplained syncope monitored by insertable cardiac monitor. Clin Cardiol 44:683–691

    Article  PubMed  PubMed Central  Google Scholar 

  21. Brignole M, Ammirati F, Arabia F, Quartieri F, Tomaino M, Ungar A, Lunati M, Russo V, Del Rosso A, Gaggioli G, Syncope Unit Project (SUP) Two Investigators (2015) Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes. Eur Heart J 36:1529–1535

    Article  PubMed  Google Scholar 

  22. Goland S, Czer LS, Kass RM, Siegel RJ, Mirocha J, De Robertis MA, Lee J, Raissi S, Cheng W, Fontana G, Trento A (2008) Use of cardiac allografts with mild and moderate left ventricular hypertrophy can be safely used in heart transplantation to expand the donor pool. J Am Coll Cardiol 51:1214–1220

    Article  PubMed  Google Scholar 

  23. Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M, Sandoval E, Calvo N, Brugada J, Kelder J, Wijffels M, Mont L (2012) Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation 125:23–30

    Article  PubMed  Google Scholar 

  24. Brignole M, Menozzi C, Maggi R, Solano A, Donateo P, Bottoni N, Lolli G, Quartieri F, Croci F, Oddone D, Puggioni E (2005) The usage and diagnostic yield of the implantable loop-recorder in detection of the mechanism of syncope and in guiding effective antiarrhythmic therapy in older people. Europace 7:273–279

    Article  PubMed  Google Scholar 

  25. Moya A, Brignole M, Menozzi C, Garcia-Civera R, Tognarini S, Mont L, Botto G, Giada F, Cornacchia D, International Study on Syncope of Uncertain Etiology (ISSUE) Investigators (2001) Mechanism of syncope in patients with isolated syncope and in patients with tilt-positive syncope. Circulation 104:1261–1267

    Article  CAS  PubMed  Google Scholar 

  26. Wieling W, Thijs RD, van Dijk N, Wilde AA, Benditt DG, van Dijk JG (2009) Symptoms and signs of syncope: a review of the link between physiology and clinical clues. Brain 132:2630–2642

    Article  PubMed  Google Scholar 

  27. Parry SW, Kenny RA (2005) Drop attacks in older adults: systematic assessment has a high diagnostic yield. J Am Geriatr Soc 53:74–78

    Article  PubMed  Google Scholar 

  28. Bhangu J, McMahon CG, Hall P, Bennett K, Rice C, Crean P, Sutton R, Kenny RA (2016) Long-term cardiac monitoring in older adults with unexplained falls and syncope. Heart 102:681–686

    Article  CAS  PubMed  Google Scholar 

  29. Jorge JG, Pournazari P, Raj SR, Maxey C, Sheldon RS (2020) Frequency of injuries associated with syncope in the prevention of syncope trials. Europace 22:1896–1903

    Article  PubMed  PubMed Central  Google Scholar 

  30. Wu Y, Zhang W, Zhang L, Schwebel DC, Ning P, Cheng X, Deng X, Li L, Deng J, Hu G (2017) Non-fatal injuries treated outside a hospital in Hunan, China: results from a household interview survey. Eur J Public Health 27:331–334

    PubMed  Google Scholar 

  31. du Fay de Lavallaz J, Badertscher P, Nestelberger T, Zimmermann T, Miró Ò, Salgado E, Christ M, Geigy N, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Morawiec B, Walter J, Twerenbold R, Puelacher C, Wussler D, Boeddinghaus J, Koechlin L, Strebel I, Keller DI, Lohrmann J, Michou E, Kühne M, Reichlin T, Mueller C (2019) B-type natriuretic peptides and cardiac troponins for diagnosis and risk-stratification of syncope. Circulation 139:2403–2418

    Article  CAS  Google Scholar 

  32. Maisel A, Mueller C, Adams K Jr, Anker SD, Aspromonte N, Cleland JG, Cohen-Solal A, Dahlstrom U, DeMaria A, Di Somma S, Filippatos GS, Fonarow GC, Jourdain P, Komajda M, Liu PP, McDonagh T, McDonald K, Mebazaa A, Nieminen MS, Peacock WF, Tubaro M, Valle R, Vanderhyden M, Yancy CW, Zannad F, Braunwald E (2008) State of the art: using natriuretic peptide levels in clinical practice. Eur J Heart Fail 10:824–839

    Article  CAS  PubMed  Google Scholar 

  33. Horio T, Ito S, Fujimoto K, Izumiya Y, Yoshiyama M, Iwashima Y, Nakamura S, Yoshihara F (2022) Kinetics of atrial and brain natriuretic peptides during hemodialysis are regulated in association with different cardiac functional changes. Heart Vessels 37:1146–1152

    Article  PubMed  Google Scholar 

  34. Pfister R, Hagemeister J, Esser S, Hellmich M, Erdmann E, Schneider CA (2012) NT-pro-BNP for diagnostic and prognostic evaluation in patients hospitalized for syncope. Int J Cardiol 155:268–272

    Article  PubMed  Google Scholar 

  35. Geyik B, Ozdemir O, Osmonov D, Soylu MO (2012) N-terminal pro-brain natriuretic peptide and electrocardiographic variables associated with increased risk of complete atrioventricular block and mortality in patients with acute inferior myocardial infarction. Cardiol J 19:479–486

    Article  PubMed  Google Scholar 

  36. Pan W, Su Y, Hu K, Shu X, Ge J (2009) Effect of bradyarrhythmia on the plasma levels of N-terminal pro-brain natriuretic peptide. Int J Cardiol 136:105–107

    Article  PubMed  Google Scholar 

  37. Zhang K, Kamtchum-Tatuene J, Li M, Jickling GC (2021) Cardiac natriuretic peptides for diagnosis of covert atrial fibrillation after acute ischaemic stroke: a meta-analysis of diagnostic accuracy studies. Stroke Vasc Neurol 6:128–132

    Article  PubMed  Google Scholar 

  38. Shibazaki K, Kimura K, Fujii S, Sakai K, Iguchi Y (2012) Brain natriuretic peptide levels as a predictor for new atrial fibrillation during hospitalization in patients with acute ischemic stroke. Am J Cardiol 109:1303–1307

    Article  CAS  PubMed  Google Scholar 

  39. Edvardsson N, Wolff C, Tsintzos S, Rieger G, Linker NJ (2015) Costs of unstructured investigation of unexplained syncope: insights from a micro-costing analysis of the observational PICTURE registry. Europace 17:1141–1148

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

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Authors and Affiliations

  1. Department of Cardiology, Izumi City General Hospital, 4-5-1 Wake-Cho, Izumi, 594-0073, Japan

    Kenji Matsumoto, Yuka Kodama, Shinji Ito, Yuka Nakamura, Ryosuke Fujiwara, Keiko Kajio, Keiko Kasamatsu, Eriko Murata, Yasuhiro Nakamura & Yoshio Kawase

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  1. Kenji Matsumoto
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  2. Yuka Kodama
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Correspondence to Kenji Matsumoto.

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All procedures performed in this study were conducted with the patients’ informed consent and complied with the national ethical guidelines for medical and health research involving human subjects and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Matsumoto, K., Kodama, Y., Ito, S. et al. Clinical predictors of cardiac syncope in patients with unexplained syncope after the implantation of an insertable cardiac monitor. Heart Vessels 38, 731–739 (2023). https://doi.org/10.1007/s00380-022-02212-x

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