Diagnosis, management, and outcomes of patients with syncope and bundle branch block

Angel Moya, Roberto García-Civera, Francesco Croci, Carlo Menozzi, Josep Brugada, Fabrizio Ammirati, Attilio Del Rosso, Alejandro Bellver-Navarro, Jesús Garcia-Sacristán, Miriam Bortnik, Lluis Mont, Ricardo Ruiz-Granell, Xavier Navarro, Bradycardia detection in Bundle Branch Block (B4) study, J Benezet, J Lacunza, A García-Alberola, M Brignole, Francesco Croci, N Rivas, Angel Moya, Carlo Menozzi, Fabrizio Ammirati, M Santini, F Planas, M Alvarez, L Tercedor, A Asso, X Beiras, E García, F Giada, A Raviele, M Rodriguez, R Barba, L Pandolfo, A Porzio, S Orazi, I Fernandez-Lozano, J Toquero, G Barón, F Errázquin, A Pedrote, J Tomás, G Buja, A Folino, S De Ceglia, A Vicenti, J Villacastín, A Ungar, J Roda, V Palanca, J L Merino, R Peinado, A H Madrid, C Moro, J Marti, Roberto García-Civera, Angel Moya, Fabrizio Ammirati, M Brignole, Josep Brugada, Carlo Menozzi, Xavier Navarro, M P López, G Monzón, N Grovale, M Martín, T de Santo, Attilio Del Rosso, Josep Brugada, Lluis Mont, I Molina, Alejandro Bellver-Navarro, Jesús Garcia-Sacristán, Roberto García-Civera, Ricardo Ruiz-Granell, Miriam Bortnik, E Occhetta, Angel Moya, Roberto García-Civera, Francesco Croci, Carlo Menozzi, Josep Brugada, Fabrizio Ammirati, Attilio Del Rosso, Alejandro Bellver-Navarro, Jesús Garcia-Sacristán, Miriam Bortnik, Lluis Mont, Ricardo Ruiz-Granell, Xavier Navarro, Bradycardia detection in Bundle Branch Block (B4) study, J Benezet, J Lacunza, A García-Alberola, M Brignole, Francesco Croci, N Rivas, Angel Moya, Carlo Menozzi, Fabrizio Ammirati, M Santini, F Planas, M Alvarez, L Tercedor, A Asso, X Beiras, E García, F Giada, A Raviele, M Rodriguez, R Barba, L Pandolfo, A Porzio, S Orazi, I Fernandez-Lozano, J Toquero, G Barón, F Errázquin, A Pedrote, J Tomás, G Buja, A Folino, S De Ceglia, A Vicenti, J Villacastín, A Ungar, J Roda, V Palanca, J L Merino, R Peinado, A H Madrid, C Moro, J Marti, Roberto García-Civera, Angel Moya, Fabrizio Ammirati, M Brignole, Josep Brugada, Carlo Menozzi, Xavier Navarro, M P López, G Monzón, N Grovale, M Martín, T de Santo, Attilio Del Rosso, Josep Brugada, Lluis Mont, I Molina, Alejandro Bellver-Navarro, Jesús Garcia-Sacristán, Roberto García-Civera, Ricardo Ruiz-Granell, Miriam Bortnik, E Occhetta

Abstract

Aims: Although patients with syncope and bundle branch block (BBB) are at high risk of developing atrio-ventricular block, syncope may be due to other aetiologies. We performed a prospective, observational study of the clinical outcomes of patients with syncope and BBB following a systematic diagnostic approach.

Methods and results: Patients with ≥1 syncope in the last 6 months, with QRS duration ≥120 ms, were prospectively studied following a three-phase diagnostic strategy: Phase I, initial evaluation; Phase II, electrophysiological study (EPS); and Phase III, insertion of an implantable loop recorder (ILR). Overall, 323 patients (left ventricular ejection fraction 56 ± 12%) were studied. The aetiological diagnosis was established in 267 (82.7%) patients (102 at initial evaluation, 113 upon EPS, and 52 upon ILR) with the following aetiologies: bradyarrhythmia (202), carotid sinus syndrome (20), ventricular tachycardia (18), neurally mediated (9), orthostatic hypotension (4), drug-induced (3), secondary to cardiopulmonary disease (2), supraventricular tachycardia (1), bradycardia-tachycardia (1), and non-arrhythmic (7). A pacemaker was implanted in 220 (68.1%), an implantable cardioverter defibrillator in 19 (5.8%), and radiofrequency catheter ablation was performed in 3 patients. Twenty patients (6%) had died at an average follow-up of 19.2 ± 8.2 months.

Conclusion: In patients with syncope, BBB, and mean left ventricular ejection fraction of 56 ± 12%, a systematic diagnostic approach achieves a high rate of aetiological diagnosis and allows to select specific treatment.

Figures

Figure 1
Figure 1
Proposed diagnostic strategy. Initial evaluation was performed in all patients. Those in whom initial evaluation achieved the diagnosed were treated accordingly. If initial evaluation was not diagnostic, an electrophysiological study (EPS) was performed: If it was diagnostic, patients were treated according to the findings, and if it was negative, an implantable loop recorder (ILR) was implanted.
Figure 2
Figure 2
Flowchart of included patients. From 423 patients initially eligible, only 323 (represented in red) entered in the study. The reasons for exclusion were incomplete data at baseline (7), lost of follow-up (LFU): 6 after initial diagnosis, 6 after electrophysiological study (EPS), and 7 after implantable loop recorder (ILR) or lack of adherence to protocol (20 without diagnosis at initial evaluation in whom an EPS was not performed and with negative EPS in whom ILR was not implanted).
Figure 3
Figure 3
The Kaplan–Meier survival curve of syncopal recurrences in patients in which the diagnosis was achieved at Phase I or II and were treated according to the diagnosis (black line) and those in which an ILR was implanted after a negative work-up in Phase I or II. Patients diagnosed and treated had a significant reduction or syncopal recurrence when compared with those with an ILR implanted.

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