Fátima Dumas Cintra
Professora Livre Docente em Cardiologia pela Universidade Federal de São Paulo
Professor Adjunto Escola Paulista de Medicina
Novas Diretrizes para diagnóstico e tratamento da
Síncope
2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Aug;14(8):e155-e217
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,
Síncope é definida por perda transitória da conciência,
secundária a hipoperfusão cerebral difusa, de início súbito,
curta duração e recuperação rápida e espontânea.
Definição
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,
Definição
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 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 ;39(21):1883-1948.
Condições Diagnosticadas como Síncope Incorretamente
1-Brignole M, Alboni P, Benditt D, et al. Eur Heart J 2001;22(15):1256-1306. 2-Brignole M, Alboni P, Benditt D, et al. Update 2004. Europace 2004;6:467-537. 3- Moya A, Sutton R, Ammirati F, et al. Eur Heart J. 2009 Nov;30(21):2631-71.
Fisiopatologia Síncope Vasovagal
Prognóstico
Fisiopatologia Síncope Vasovagal
Avaliação Diagnóstica Síncope
2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Aug;14(8):e155-e217
Fisiopatologia Síncope Vasovagal
Avaliação Diagnóstica Síncope
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,
Avaliação Diagnóstica Síncope
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 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 ;39(21):1883-1948.
Avaliação Diagnóstica Síncope
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 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 ;39(21):1883-1948.
Estratificação de Risco pela História Pregressa
Avaliação Diagnóstica Síncope
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 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 ;39(21):1883-1948.
Fisiopatologia Síncope Vasovagal
Avaliação Diagnóstica Síncope
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,
Fisiopatologia Síncope Vasovagal
Fisiopatologia Síncope Vasovagal
Avaliação Diagnóstica Síncope
Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope. Heart Rhythm. 2017
Anormalidade ECG
Idade Avançada
Evidência ou
Historia de doença
cardiovascular
/arritmia
Fisiopatologia Síncope Vasovagal
Atendimento Protocolar
Atendimento Protocolar com base nas Diretrizes
Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T; Evaluation of Guidelines in Syncope Study 2 ( EGSYS-2) GROUP. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace. 2006;8(8):644-50.
Hipótese: Atendimento protocolar (tomada de decisão baseada nas diretrizes)
melhora a capacidade diagnóstica de pacientes admitidos com síncope com
menor consumo de recursos.
Fisiopatologia Síncope Vasovagal
Atendimento Protocolar
Atendimento Protocolar com base nas Diretrizes
Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T; Evaluation of Guidelines in Syncope Study 2 ( EGSYS-2) GROUP. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace. 2006;8(8):644-50.
Fisiopatologia Síncope Vasovagal
Atendimento Protocolar
Atendimento Protocolar com base nas Diretrizes
Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T; Evaluation of Guidelines in Syncope Study 2 ( EGSYS-2) GROUP. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace. 2006;8(8):644-50.
Fisiopatologia Síncope Vasovagal
Atendimento Protocolar
Atendimento Protocolar com base nas Diretrizes
Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T; Evaluation of Guidelines in Syncope Study 2 ( EGSYS-2) GROUP. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace. 2006;8(8):644-50.
Fisiopatologia Síncope Vasovagal
Atendimento Protocolar
Atendimento Protocolar com base nas Diretrizes
Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T; Evaluation of Guidelines in Syncope Study 2 ( EGSYS-2) GROUP. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace. 2006;8(8):644-50.
Fisiopatologia Síncope Vasovagal
Atendimento Protocolar
Atendimento Protocolar com base nas Diretrizes
Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T; Evaluation of Guidelines in Syncope Study 2 ( EGSYS-2) GROUP. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace. 2006;8(8):644-50.
Fisiopatologia Síncope Vasovagal
Atendimento Protocolar
Atendimento Protocolar com base nas Diretrizes
Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T; Evaluation of Guidelines in Syncope Study 2 ( EGSYS-2) GROUP. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace. 2006;8(8):644-50.
Avaliação Diagnóstica Síncope
Avaliação Diagnóstica Direcionada
pela Suspeita Clínica Inicial
Deharo JC, et al. An implantable loop recorder study of highly symptomatic vasovagal patients: the heart rhythm observed during a spontaneous syncope is identical to the recurrent syncope but not correlated with the head-up tilt test or adenosine triphosphate test. J Am Coll Cardiol 2006;47:587–593.
Brignole M, et al, International Study on Syncope of Uncertain Etiology 2 (ISSUE 2) Group. Lack of correlation between the responses to tilt testing and adenosine triphosphate test and the mechanism of spontaneous neurally mediated syncope. Eur Heart J 2006;27:2232–2239.
Avaliação Diagnóstica Síncope
Comparação do Resultado do Tilt
test
com
o
evento
espontâneo
documentado
pelo
Monitor
de
Eventos
Brignole M, et al, International Study on Syncope of Uncertain Etiology 2 (ISSUE 2) Group. Lack of correlation between the responses to tilt testing and adenosine triphosphate test and the mechanism of spontaneous neurally mediated syncope. Eur Heart J 2006;27:2232–2239.
Avaliação Diagnóstica Síncope
- Sensibilidade e especificidade
razoável quando aplicado em
pacientes com SVV verdadeira
Flevari P, et al. Recurrent vasovagal syncope: comparison between clomipramine and nitroglycerin as drug challenges during head-up tilt
testing. Eur Heart J 2009;30:2249–2253.
Avaliação Diagnóstica Síncope
2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Aug;14(8):e155-e217
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,
Holter 24 horas
Holter 7 dias
Monitor de eventos
(Looper)
Patch recorder
Monitor de eventos
Implantável
Fisiopatologia Síncope Vasovagal
Monitor de eventos
Monitor de eventos
Monitor de eventos
Monitor de eventos
Solano A, Menozzi C, Maggi R, Donateo P, Bottoni N, Lolli G, Tomasi C, Croci F, Oddone D, Puggioni E, Brignole M. Incidence, diagnostic yield and safety of the implantable loop-recorder to detect the mechanism of syncope in patients with and without structural heart disease. Eur Heart J. 2004;25(13):1116-9.
Monitor de eventos
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,
Estudo Eletrofisiológico
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. A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J 2006;27:76–82.
Estudo Eletrofisiológico
Linzer M, Yang EH, Estes NA III, Wang P, Vorperian VR, Kapoor WN. Diagnosing syncope. Part 2: Unexplained syncope. Clinical Efficacy
Assessment Project of the American College of Physicians. Ann Intern Med 1997;127:76–86.
Estudo eletrofisiológico
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 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 ;39(21):1883-1948.
Utilidade do EEF: bradicardia sinusal assintomática;
bloqueio bifascicular; suspeita de taquicardia.
Tratamento
Tratamento
Retorno venoso
Débito cardíaco
Atividade simpática
Ventrículo vazio
Mecanorreceptores
Parassimpático
Simpático
Fludrocortisona
b
-bloqueador
Inibidores da
recaptação de
serotonina
Estimulação
cardíaca
artificial
Midodrine
2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Aug;14(8):e155-e217
Retorno venoso
Débito cardíaco
Atividade simpática
FC e Inotropismo
Ventrículo vazio
Mecanorreceptores
Parassimpático
Simpático
Bradicardia Hipotensão
Hipótese: A alteração autonômica observada nos pacientes com síncope
neurocardiogênica poderia ser observada durante a fase do sono REM
Variabilidade da Frequência Cardíaca
Cintra F, Poyares D, DO Amaral A, DE Marchi G, Barreto S, Tufik S, DE Paola A, Guilleminault C. Heart rate variability during sleep in patients with vasovagal syncope. Pacing Clin Electrophysiol. 2005 28(12):1310-6.
Cintra F, Poyares D, DO Amaral A, DE Marchi G, Barreto S, Tufik S, DE Paola A, Guilleminault C. Heart rate variability during sleep in patients with vasovagal syncope. Pacing Clin Electrophysiol. 2005 28(12):1310-6.
Variabilidade da Frequência Cardíaca
Retorno venoso
Débito cardíaco
Atividade simpática
FC e Inotropismo
Ventrículo vazio
Mecanorreceptores
Parassimpático
Simpático
Fludrocortisona
b
-bloqueador
Inibidores da
recaptação de
serotonina
Estimulação
cardíaca
artificial
Midodrine
Bradicardia Hipotensão
Tratamento
Tratamento Hipotensão
Ortostática
Tratamento
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,
