Is Left Ventricular Diastolic Dysfunction a clinical predictor of Syncope?

(1)

Is

Left

Ventricular

Diastolic

Dysfunction

a

clinical

predictor

of

Syncope?

Abdul

Jawwad Samdani,

MBBS

Mentor:

Mrinalini Meesala,

MD

Yuji

Saito,

MD

(2)

Introduction

•

What

is

Syncope?

•

Why

it

is

important?

•

Common

clinical

problem

–

1

‐

3.5

%

of

all

emergency

room

visits

–

1

‐

6

%

of

hospital

admissions

annually

in

the

US

–

Incidence

increasing

with

age

•

Maybe

disabling

•

Trivial

to

Life

threatening

causes.

•

Challenging

differential

diagnoses

(3)

Introduction

‐

Causes

Of

Syncope

Orthostatic

Cardiac

Arrhythmia

Structural

Cardio-Pulmonary

1

• Vasovagal

Syncope

• Carotid sinus

syndrome

• Situational

Cough  Post-Micturition

2

• Drug-Induced

• Dehydration/

Hypovolemia

• ANS Failure

Primary Secondary

3

• Brady

SN Dysfunction AV Block

•

Tachy

VT SVT

• Long QT

Syndrome

4

• Acute MI

• AS or MS

• HCM

• Pulm HTN/

PE

• Aortic

Dissection

• Cardiac

tumor/

thrombus

Reflex/

Neurally-Mediated

Unexplained Causes = Approximately 1/3

(4)

Introduction

•

What

is

the

utility

of

echocardiogram

in

evaluation

of

syncope?

•

An

echocardiogram

has

been

described

as

an

important

tool

with

variable

utility

in

the

workup

of

syncope.

•

Traditionally

mainly

used

for

identifying

and

quantifying

an

underlying

structural

heart

disease

(LVOT

obstruction,

valvular heart

disease

and

(5)

Introduction

•

Echocardiography

can

provide

additional

information

for

diagnostic

and

risk

stratification

purposes.

•

Certain

recent

studies

suggest

that

a

small

left

atrial

volume

and

lower

mitral

A

velocity

(a

measure

of

atrial

kick

in

LV

filling)

can

predict

positive

Head

‐

up

Tilt

Test

seen

in

neurocardiogenic syncope.

•

Other

studies

suggest

that

LVDD

may

have

a

PARTIAL

role

in

pathogenesis

of

syncope

in

patients

with

HOCM

and

(6)

Introduction

•

No

direct

studies

to

date

to

evaluate

possible

role

of

LVDD

in

pathophysiology

of

syncope

•

There

is

an

overlap

in

risk

factor

associated

with

syncope

and

LVDD

(Age,

obesity,

HTN,

DM)

•

Pathophysiologically,

we

know

that

LVDD

results

in

a

smaller

stroke

volume

and

hence

a

lower

cardiac

(7)

Objectives

To

elucidate

•

If

Left

Ventricular

Diastolic

Dysfunction

(LVDD)

is

a

clinical

predictor

of

Syncope

•

If

Echocardiography

plays

a

role

in

risk

stratifying

patients

presenting

with

syncope

in

the

absence

of

underlying

structural

heart

(8)

(9)

Methodology

•

Retrospective

Chart

Review

•

Single

center:

SOCH

•

Duration:

January

2011

to

Dec

2012

•

Adult

patients

≥

18

years

•

2

groups;

Syncope

and

Comparison

group

(Control)

•

IRB

Approval

obtained

(10)

Methodology:

Sample

Selection

Echocardiography database searched by “Syncope” N = 421 Syncope Cases:

N = 197

Diagnoses of Seizure, TIA, Fall, Presyncope Exclusion

Echocardiography database searched by

“Routine” “Pre‐op” and

“Evaluate Cardiac/ LV function”

N = 463

Control Group:

N = 170

EF < 50%

Severe Aortic (AS) and

Mitral Valve disease HOCM

AFib/ Flutter

Acute coronary syndrome CHF exacerbation Limited Echo Incomplete data Exclusion Diagnosis of Syncope. Exclusion

(11)

Methodology:

Data

Collection

•

Performa

–

Demographics

–

Co

‐

morbids and

medications

–

2

‐

D

Echocardiographic

parameters

(12)

Methodology:

Data

Collection

•

Echocardiographic

measurements

and

grading

of

LVDD

per

American

Society

of

Echocardiography

(13)

(14)

(15)

Methodology

•

Statistical

Analysis:

SPSS

version

20

–

Chi

square

–

2

‐

sample

independent

t

‐

test

–

One

‐

way

ANOVA

(16)

(17)

Results

‐

Demographics

66.5 27.8 35.5 64.5 56.3 36.5 65.5 29.7 37.1 62.9 57.1 37.1

0

10

20

30

40

50

60

70

Cases

Controls

p = 0.021

(18)

Results

‐

Co

‐

morbids

75.1 26.4 19.3 5.1 4.6 18.8 46.2 21.3 12.7 75.3 32.9 17.6 4.1 6.5 22.9 49.4 22.9 12.9

0

10

20

30

40

50

60

70

80

P

e

rc

e

nta

ge

s

Cases

Controls

(19)

Results

‐

Medications

Drugs Syncope (n=197) Control (n=170) p‐value

Beta Blockers % 27.9 28.2 0.946 CCBs % 27.4 32.4 0.302 Diuretics % 29.9 29.4 0.911 ACEI/ARB % 38.6 38.8 0.962 Nitrates % 5.1 4.7 0.870 Hydralazine % 3.6 3.5 0.990 Clonidine % 5.6 5.3 0.903

(20)

Results

– LVDD

Frequency

73.6

58.9

13.7

1

57.1

45.9

10.6

0.6

0

10

20

30

40

50

60

70

80

LVDD

Grade 1

Grade 2

Grade 3

P

e

rc

e

nta

ge

s

Cases

Controls

p < 0.001** _{p =}_0.004**

(21)

Results

– Other

Cardiac

Parameters

0.77 0.84 1 0.12 6.8 0.82 0.83 1.1 0.13 6.6

0

1

2

3

4

5

6

7

8

E Velocity

(m/s)

A Velocity

(m/s)

E/A

E' Velocity

(m/s)

E/E'

Means

Syncope Control p = 0.03 p = 0.003

(22)

Results

– Other

Cardiac

Parameters

Cardiac Parameters Syncope (n=197) Control (n=170) p‐value

HR (Mean ± SD) 70.9 ± 14 71.9 ± 14 0.484 LVEF (Mean ± SD) 62.8 ± 7 61.5 ± 6 0.061 LVIDd (Mean ± SD) 4.5 ± 0.7 4.5 ± 0.6 0.454 LVM index (Mean ± SD) 87.8 ± 27 90.9 ± 27 0.214 LVH % 33.5 40.0 0.197 LA size (Mean ± SD) 3.5 ± 0.6 3.7 ± 0.7 0.005**

LA volume index (Mean ± SD) 24.3 ± 8 25.4 ± 9 0.228

E Velocity (Mean ± SD) 0.77 ± 0.2 0.82 ± 0.2 0.030**

A (Mean ± SD) 0.84 ± 0.3 0.83 ± 0.2 0.496

E/A (Mean ± SD) 1.0 ± 0.4 1.1± 0.4 0.115

DT (Mean ± SD) 245.5 ± 68 232.0 ± 65 0.054

IVRT (Mean ± SD) 88.7 ± 21 86.6 ± 22 0.349

E’ Velocity (Mean ± SD) 0.12 ± 0.04 0.13 ± 0.04 0.003**

E/E’ (Mean ± SD) 6.8 ± 2.5 6.6 ± 2.4 0.279

(23)

Results

‐

Sub

‐

group

Analysis

Undiagnosed

46%

Reflex/Neural

23%

Cardiac

14%

Orthostatic

17%

Causes

of

Syncope

(24)

Subgroup

Analysis

– LVDD

Frequency

0

10

20

30

40

50

60

70

80

90

100

LVDD

Grade 1

Grade 2

Grade 3

P

e

rc

e

nta

ge

Reflex/ Neural

Cardiac

Orthostatic

p = 0.021

(25)

Comparison

between

Causes

of

Syncope

0

10

20

30

40

50

60

70

80

90

100

Age (mean)

HTN (%)

DM (%)

CAD (%)

CHF (%)

Reflex/ Neural

Cardiac

Orthostatic

p < 0.001

p < 0.003

p = 0.034

p = 0.006

(26)

0

20

40

60

80

100

120

LVM index

(gm/kg2)

LVH (%)

LA volume

index cm3/ kg2

A (cm/s)

E/E'

Reflex/ Neural

Cardiac

Orthostatic

p = 0.005

p = 0.006

p < 0.001

p = 0.019

p = 0.031

(27)

Results

‐

Comparison

between

Causes

Variables of Interest Reflex Cardiac Orthostatic p‐value

n=45 n=27 n=34 Age (Mean) 58 76 69 <0.001 BMI (Mean) 28 27 27 0.453 HTN % 53 93 68 <0.003 DM % 9 33 24 0.034 CAD % 9 41 21 0.006 CHF % 0 22 3 <0.001 LVEF (Mean) 63 60 63 0.159 LVIDd (Mean) 4.5 4.5 4.4 0.860 LVM index (Mean) 81 102 85 0.005 LVH % 22 56 24 0.006 LA size (Mean) 3.2 3.9 3.5 <0.001

LA volume index (Mean) 20.3 29.4 22.5 <0.001

E Velocity (Mean) 0.74 0.84 0.73 0.062

A Velocity (Mean) 0.8 0.9 0.8 0.019

E/A (Mean) 1.1 0.9 1.0 0.148

DT (Mean) 253 256 231 0.237

IVRT (Mean) 84 96 86 0.047

E’ Velocity (Mean) 0.13 0.11 0.12 0.201

LA pressure (Mean) 9.5 11.4 10.0 0.031 RVSP (Mean) 32 40 32 0.004 LVDD % 56 93 73 0.021 Normal % 44 7 27 0.001 Grade 1 % 51 56 65 Grade 2 % 4 33 9 Grade 3 % 0 4 0

(28)

Conclusion

•

Our

results

show

that

LVDD

is

more

common

in

patients

with

syncope

than

the

control

group

reaching

statistical

significance

–

Hence

LVDD

is

likely

a

predictor

of

syncope.

•

Also,

presence

of

LVH,

larger

LAV

index,

higher

mitral

A

velocity,

larger

E/E’

and

presence

of

LVDD

are

significant

predictors

of

cardiac

syncope

in

the

absence

of

structural

heart

(29)

Implications/

Future

Considerations

•

Hypothesis

generation

for

future

studies

to

explore

the

link

between

LVDD

and

Syncope

•

Echocardiography

may

have

additional

role

in

the

evaluation

of

syncope

.

•

Parameters

like

LVH,

LAVI,

A

velocity

and

LVDD

can

likely

be

incorporated

in

the

risk

stratification

tools/

score

systems

in

evaluation

of

syncope

– and

can

be

further

(30)

Limitations

•

Retrospective

design

•

Causal

association

can

not

be

definitely

established

(31)

References

1. Manganelli F, Betocchi S, Ciampi Q, Storto G, Losi MA, Violante A, et al. Comparison of hemodynamic

adaptation to orthostatic stress in patients with hypertrophic cardiomyopathy with or without syncope and in

vasovagal syncope. Am J Cardiol 2002;89(12):1405‐10.

2. Folino AF, Russo G, Buja G, Iliceto S. Contribution of decreased atrial function in the pathogenesis of neurally mediated syncope. Am J Cardiol 2006;97(7):1017‐24.

3. Sarasin FP, Junod AF, Carballo D, Slama S, Unger PF, Louis‐Simonet M. Role of echocardiography in the

evaluation of syncope: a prospective study. Heart 2002;88(4):363‐7.

4. Moon J, Shim J, Park JH, Hwang HJ, Joung B, Ha JW, et al. Small left atrial volume is an independent predictor for

fainting during head‐up tilt test: the impact of intracardiac volume reserve in vasovagal syncope. Int J Cardiol 2013;166(1):44‐9.

5. Park SJ, Enriquez‐Sarano M, Chang SA, Choi JO, Lee SC, Park SW, et al. Hemodynamic patterns for symptomatic

presentations of severe aortic stenosis. JACC Cardiovasc Imaging 2013;6(2):137‐46.

6. Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA,

Evangelista A. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J

Am Soc Echocardiogr. 2009 Feb;22(2):107‐33. doi: 10.1016/j.echo.2008.11.023.

7. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J,

Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ; Chamber Quantification Writing Group;

American Society of Echocardiography's Guidelines and Standards Committee; European Association of

Echocardiography. Recommendations for chamber quantification: a report from the American Society of

Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group,

developed in conjunction with the European Association of Echocardiography, a branch of the European Society

of Cardiology. J Am Soc Echocardiogr. 2005 Dec;18(12):1440‐63.

8. Puppala VK, Dickinson O, Benditt DG. Syncope: classification and risk stratification. J Cardiol. 2014

Mar;63(3):171‐7. doi: 10.1016/j.jjcc.2013.03.019. Epub 2014 Jan 7.

9. Puppala VK, Dickinson O, Benditt DG. Syncope: classification and risk stratification. J Cardiol. 2014

Mar;63(3):171‐7. doi: 10.1016/j.jjcc.2013.03.019. Epub 2014 Jan 7.

10. Thiruganasambandamoorthy V, Stiell IG, Sivilotti ML, Murray H, Rowe BH, Lang E, McRae A, Sheldon R, Wells

GA. Risk stratification of adult emergency department syncope patients to predict short‐term serious outcomes

(32)

Thank

you

(33)

(34)

Results

‐

Demographics

Syncope

(n=197)

Control

(n=170)

p

‐

value

Age

(Mean

± SD)

66.5 ± 17.9

65.5 ± 15.7

0.541

Gender

Male

%

35.5

37.1

0.762

Female

%

64.5

62.9

Race

Caucasians

%

56.3

57.1

0.894

African

Americans

%

36.5

37.1

Other

%

7.1

5.9

BMI

(Mean

± SD)

27.8 ± 7.3

29.7 ± 8.3

0.021**

(35)

Results

‐

Comorbids

Syncope

(n=197)

Control

(n=170)

p

‐

value

HTN

%

75.1

75.3

0.970

DM

%

26.4

32.9

0.170

CAD

%

19.3

17.6

0.686

CHF

%

5.1

4.1

0.663

CVA

%

4.6

6.5

0.423

Paroxysmal

Afib

%

3.6

3.5

0.990

COPD/

Asthma

%

18.8

22.9

0.327

DL

%

46.2

49.4

0.538

Active

Tobacco

%

21.3

22.9

0.709

CKD

%

12.7

12.9

0.943

%

10.2

0

(36)

RESULTS

‐

SUBGROUP

ANALYSIS

CAUSE

of

SYNCOPE

Unknown

n (%)

91 (46.2)

Reflex/

Neural

n (%)

45 (22.8)

Cardiac

n (%)

27 (13.7)

Orhtstatic

n (%)

34 (17.3)

(37)

RESULTS

– LVDD

Frequency

Syncope

(n=197)

Control

(n=170)

p

‐

value

LVDD

%

73.6

57.1

0.001**

Adjusted***

<0.001**

Grade

1

%

58.9

45.9

0.011**

Grade

2

%

13.7

10.6

Grade

3

%

1.0

0.6

Adjusted***

0.004**

(38)

Results

‐

Comparison

between

Causes

Unknown Reflex Cardiac Orthostatic p‐value

Age (Mean) 67 58 76 69 <0.001** HTN % 84 53 93 69 <0.001** DM % 34 9 33 24 0.014** CAD % 17 9 41 24 0.008** CHF % 3 0 22 3 <0.001** LVEF (Mean) 64 63 60 63 0.138 LVIDd (Mean) 4.5 4.4 4.5 4.4 0.887 LVM index (Mean) 88 81 102 85 0.009** LVH % 36 22 56 24 0.016** LA size (Mean) 3.6 3.3 3.9 3.5 <0.001**

LA volume index (Mean) 25.4 20.3 29.4 22.5 <0.001** E Velocity (Mean) 0.79 0.74 0.84 0.73 0.098

A (Mean) 0.87 0.75 0.93 0.83 0.029**

E/A (Mean) 1.0 1.1 0.9 1.0 0.399

DT (Mean) 244 253 256 231 0.437

IVRT (Mean) 90 84 96 86 0.091

E’ Velocity (Mean) 0.12 0.13 0.11 0.12 0.291

E/E’ (Mean) 6.9 6.2 7.7 6.6 0.064 LA pressure (Mean) 10.5 9.5 11.5 10.0 0.064 LVDD % 77 56 92 74 0.004** Grade 1 % 62 51 56 65 0.004** Grade 2 % 14 4 33 9 Grade 3 % 1 0 4 0

(39)

Methodology:

Sample

Selection

Echocardiography database searched by “Syncope” N = 421 Syncope Cases:

N

=

197

EF < 50%

AFib/ Flutter

Acute coronary syndrome CHF exacerbation Limited Echo Incomplete data

Exclusion

Diagnoses of Seizure, TIA, Fall, Presyncope

Exclusion

Echocardiography database searched by “Routine” “Pre‐op” and

“Evaluate Cardiac/ LV function”

N = 463

Control Group:

N

=

170

EF < 50%

AFib/ Flutter

Acute coronary syndrome CHF exacerbation Limited Echo Incomplete data

Exclusion

Diagnosis of Syncope.

Exclusion