Come organizzare una “Syncope Unit”

Michele Brignoleg

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Syncope management facilities:ESC standards

Optimal standard for quality service delivery:1- Cohesive, structured care pathway - either

d li d ithi i l f ilit

Optimal standard for quality service delivery:

delivered within a single syncope facility or as a more multi-faceted service.

2- Adoption of standardized guidelines-basedapproach for:pp• diagnostic criteria • diagnostic work-up g p• risk stratification • treatment

ESC Guidelines on Management of Syncope

Syncope management facilities:ESC standards

Wh t

ESC standards

Who must managesyncope patients?syncope patients?

The Syncope ExpertThe syncope expert is a single physician or the team of physicians who lead the process of a comprehensive management of the patient from risk stratification to diagnosismanagement of the patient from risk stratification to diagnosis, therapy and follow-up. They usually perform directly the core laboratory tests and have preferential access to hospitalization

d th di ti t t d t l thand any other diagnostic test and eventual therapy.

ESC Guidelines on Management of Syncope

Come organizzare una Syncope UnitCome organizzare una Syncope Unitnel Tuo ospedale:

i criteri GIMSI per la certificazionei criteri GIMSI per la certificazione

Michele Brignoleg

www.gimsi.it

Certificazione GIMSI:Certificazione GIMSI:• Come ottenerla ?• Perché ?

www.gimsi.it

continua

seguesegue

Le S ncope Unit certificate GIMSI nel 2009Le Syncope Unit certificate GIMSI nel 2009:ALESSANDRIABOLZANOCATANIACATANIACENTOCOMOEMPOLI

iFIRENZE ‐ CareggiFIRENZE ‐ Nuovo s. Giovanni di dioFIRENZE ‐ S. Maria nuovaGENOVAGENOVALAVAGNAMESTREMILANO ‐ NiguardaMODENAMODENAMONCALIERINAPOLI – Federico IIOSTIAOSREGGIO EMILIAROMA – S Filippo NeriSERIATETRENTOTRENTO

www.gimsi.it

Le Syncope Unit certificate GIMSI

Le Syncope Unit certificate GIMSI2011 (totale = 47)

AVELLINOy2009 (totale = 21)

ALESSANDRIA

AOSTABARI – UniversitàBARI ‐ Policlinico 

BENTIVOGLIOALESSANDRIABOLZANOCATANIACENTOCOMO

BERGAMOBRESCIA

CARRARACASARANO

COMOEMPOLIFIRENZE ‐ CareggiFIRENZE ‐ Nuovo s. Giovanni di dioFIRENZE ‐ S Maria nuova

CATANZAROCONEGLIANO V.

COSENZAFIRENZE – SM Annunziata

GENOVA S M iFIRENZE ‐ S. Maria nuovaGENOVA‐ V ScassiLAVAGNAMESTREMILANO ‐ Niguarda

GENOVA – S. MartinoIMPERIAMASSA

GROSSETOMILANO ‐ NiguardaMODENAMONCALIERINAPOLI – Federico IIOSTIA

MERCATO S. SEVERINOMILANO – Maugeri

MONTESCANONAPOLI – II UniversitàOSTIA

REGGIO EMILIAROMA – S Filippo NeriSERIATETRENTO

NAPOLI  II UniversitàORBASSANOPINEROLORAVENNATARANTOTRENTO

www.gimsi.it

TARANTOTRADATE

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Le Syncope Unit certificate GIMSI 2011(totale = 47)

Geriatria

Medicina Interna

Medicina d’UrgenzaMedicina d Urgenza

Neurologia

MultidisciplinareMultidisciplinare

Cardiologia

Syncope Unit Project (SUP) Syncope Unit description (n=9) 

Personnels(no.)

Syncope experts #1     in 4 Unitsy p p#2‐4  in 5 Units

Staff #2 in 6 UnitsStaff #2 in 6 Units#>2 in 3 Units

Brignole et al. Europace 2010; 12: 109–118

Volume per centre (patients per month)50th25th 75th maxmin

11ni

ts 20

9

ope

U

12

15

Syn

co

13

28

S

23

28

15 23129 28

23

Number of patientsBrignole et al. Europace 2010; 12: 109–118

Volume per centre(patients per 100,000 inhabitants per year)

50th25th 75th max50th25th 75th max

43Old Unit

R t U it

its 163

57Recent Unit

pe U

n

64

71

ynco

p

132

64

S

220

63

71 1636343 220

181

Number of patients71 1636343 220

Brignole et al. Europace 2010; 12: 109–118

Volume per centre(patients per 100 000 inhabitants per year)(patients per 100,000 inhabitants per year)

M Whit t t 0 03

163160

180Mann‐Whitney test: p=0.03

163120

140

60

80

100

6020

40

60

0

Old Units Recent Units

Brignole et al. Europace 2010; 12: 109–118

Syncope Unit Project (SUP) Management

Referral source

In‐hospital

16%

Out‐hospital13% 60%

Protected discharge

Emergency11%

Emergencyroom

Brignole et al. Europace 2010; 12: 109–118

SUP data in perspectivesSyncope Unit Project (SUP)

Syncope visits per 100,000 inhabitants/year y p p , /yin different settings

General practice 930Emergency room 379SSyncope Unit 163

Certificazione GIMSI:Certificazione GIMSI:• Come ottenerla ?• Perché ?

www.gimsi.it

Perché certificazione GIMSI (1):Perché certificazione GIMSI (1):

• Seguire gli standard proposti dal GIMSI fa• Seguire gli standard proposti dal GIMSI fa migliorare la qualità dell’assistenza

www.gimsi.it

Diagnostic yield

Historical, non‐standardized 42% ‐ 54% Kapoor. N Engl J Med 1983Li ( t ti i ) AHistorical, non standardized

(best clinical practice)42%  54% Linzer (systematic review). Ann

Intern Med 1997Ammirati. G Ital Cardiol 1999Getchell. J Gen Intern Med 1999D l G It l H t J 2003Del Greco. Ital Heart J 2003

Standardized protocols(Syncope facilities)

17% ‐ 24% Ammirati. Eur Heart J 2000Alboni. J Am Coll Cardiol 2001Sarasin. Am J Med 2001(Syncope facilities)Blanc. Eur Heart J 2002Chen. Mayo Clin Proc 2003Shen. Circulation 2004Brignole. Europace 2009g p

Structured algorithms(interactive web‐based, 

2% ‐ 5% Brignole. Eur Heart J 2006Brignole. Europace 2006

remote tutoring)

Knowing the mechanism is a pre‐requisite for preventing future recurrences and related morbidity

Diagnostic yield

Historical, non‐standardized 42% ‐ 54% Kapoor. N Engl J Med 1983Li ( t ti i ) AHistorical, non standardized

(best clinical practice)42%  54% Linzer (systematic review). Ann

Intern Med 1997Ammirati. G Ital Cardiol 1999Getchell. J Gen Intern Med 1999D l G It l H t J 2003Del Greco. Ital Heart J 2003

Standardized protocols(Syncope facilities)

17% ‐ 24% Ammirati. Eur Heart J 2000Alboni. J Am Coll Cardiol 2001Sarasin. Am J Med 2001(Syncope facilities)Blanc. Eur Heart J 2002Chen. Mayo Clin Proc 2003Shen. Circulation 2004Brignole. Europace 2009g p

Structured algorithms(interactive web‐based, 

2% ‐ 5% Brignole. Eur Heart J 2006Brignole. Europace 2006

remote tutoring)

K i th h i i i it f tiKnowing the mechanism is a pre‐requisite for preventing future recurrences and related morbidity

Perché certificazione GIMSI (2):Perché certificazione GIMSI (2):

• Lo studio SUP ha confermato che seguire gliLo studio SUP ha confermato che seguire gli standard proposti dal GIMSI fa migliorare la qualità dell’assistenza

www.gimsi.it

AIACAssociazione ItalianaAritmologia eC di ti l i

Syncope Unit ProjectCardiostimolazione

Syncope Unit ProjectA prospective systematic guideline-based evaluation andA prospective systematic guideline based evaluation and

treatment of patients referred to the Syncope Units of general hospitalsgeneral hospitals

Brignole et al. Europace 2010; 12: 109–118

An official study of Associazione Italiana di Aritmologia eAn official study of Associazione Italiana di Aritmologia e Cardiostimolazione (AIAC) 

Syncope Unit Project (SUP) Methods

• Ob ti l ti i t f• Observational prospective registry from 9 Italian Syncope Units

• Consecutive patients from March 15th to September 15ht 2008to September 15ht, 2008

Syncope Unit Project (SUP) Management

Diagnostic flow

941

50 (5%)

Eligible

Not e al able50 (5%)

Analyzed 891

Not evaluable

191 (21%)Diagnosis madeat initial evaluation 1.2±1.5 testsat initial evaluation

541 (61%)Early diagnosish 2.8±1.6 tests( )

with investigations

159 (18%)No diagnosis

2.8±1.6 tests

159 (18%)No diagnosis(follow‐up) 3.5±1.8 tests

Syncope Unit Project (SUP) Management

Performed Diagnostic NND

Diagnostic yield (n=700 pts)g

Tilt testing 443 53% 1.9EP study 40 35% 2.9In-hospital ECG monitoring 80 17% 5.7Carotid sinus massage 509 12% 8.2Holter monitoring 166 9% 11Coronary angiography 14 7% 14Brain CT scan and/or MRI scan 73 7% 15Brain CT scan and/or MRI scan 73 7% 15EEG 34 6% 17Echocardiogram 269 3% 34Exercise test 41 2% 41Basic blood chemistry tests 298 2% 60Total number of tests 2006 18% 5.4Mean n° of tests per patient 2.9±1.8 - -

Syncope Unit Project (SUP) Management

28%

58%60%

75%

Echocardiogram

Tilt testing

15%

38%

28%

43%

53%

24‐hour Holter

Blood tests

c oca d og a

4%

6%

15%

8%

21%

EEG

CT scan/MRI

New units

5%

4%

5%

7%

9%

EP study

Exercise testNew units

Old units

0%

1%4%

5%

ELR

Coronary angio1

6%

80%1%

57%

ILR

Carotid sinus massage

6%

0 20 40 60 80 100

ILR

Syncope Unit Project (SUP) Management

Case mix

Orthostatichypotension

CardiacArrhythmia

StructuralCardio-P l

Non-syncopalReflex yp y Pulmonary

1 2 3 4 5• Vasovagal• CSS• Situational

• Classical OH form

Delayed OH

• BradySick sinusAV blockPM dysf

T h

4• ACS• Aortic

Stenosis• Atrial

5• Metabolic• Epilepsy• Intoxications

* Situational

• Atypical• Likely reflex

• Delayed OH form (progressive)

• TachyVTSVT

• High risk of SCD

Atrial myxoma

• Pulmonary embolism

• Others

• Drop-attacks• Psychogenic • TIA• Falls

SCD • Others Falls

67% 4% 5% 1% 5%

Unknown Cause = 18%

Perché certificazione GIMSI (3):Perché certificazione GIMSI (3): • Attesta che la Tua Syncope Unit ha organizzazione e struttura standardizzata in accordo con le raccomandazioni della SEC• Dà visibilità alla Tua Syncope Unit a livello locale (pazienti, colleghi, ecc)• Dà visibilità alla Tua Syncope Unit a livello nazionale (sito web GIMSI, organizzazione Corsi GIMSI regionali, ecc)

Ti i t t ti i t ll ti d l i t• Ti aiuta a tenerti aggiornato sulla gestione del paziente con sincope• Ti dà l’opportunità di partecipare attivamente al Registro GIMSITi dà l opportunità di partecipare attivamente al Registro GIMSI

www.gimsi.it

SINCOPE2 0 1 1

pertanto…..

Se pensi che il tuo ospedale ha i requisiti, fai subito domanda direquisiti, fai subito domanda di certificazione. Sarà valutata e certificata già nel corso delSarà valutata e certificata già nel corso del 2011

www.gimsi.it