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Devices and the older patient with syncope

Devices and the older patient with syncope. Michael Gammage, Reader in Cardiovascular Medicine MHRA Committee for Safety of Devices. Those who suffer from frequent and severe fainting often die suddenly Hippocrates, 1000 BC. Falling Man, Rodin. A brief history of devices….

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Devices and the older patient with syncope

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  1. Devices and the older patient with syncope Michael Gammage, Reader in Cardiovascular Medicine MHRA Committee for Safety of Devices

  2. Those who suffer from frequent and severe fainting often die suddenly • Hippocrates, 1000 BC Falling Man, Rodin

  3. A brief history of devices…. • Seymour Furman, cardiac surgeon in New York, first demonstrated effective endocardial pacing in a patient in 1958 • Pacing lead seemed most stable in the RV apex • Senning and Elmquist undertook first fully implantable pacing procedure in Stockholm in 1958 • Device failed within 12 hours

  4. Moving forward 50 years…. • Implantable device therapy has moved on significantly to include three main categories • Pacing for bradycardia • Pacing to improve cardiac function • Cardiac resynchronisation therapy • Implantable cardioverter defibrillators (ICDs) • In addition, there are also implantable loop recorders (ILRs), also classified by the MHRA as Active Implantable Medical Devices (AIMDs)

  5. Does age matter with devices? Is there age discrimination? Reduced number of implants Increased number of implants Do older patients respond differently? Less response to device therapy/use Greater response to device therapy/use Is syncope different in older people? Less device-relevant pathology More device-relevant therapy

  6. Is there age discrimination? Reduced number of implants Increased number of implants

  7. National variation in implant rates Data corrected for age and sex (except CRT)

  8. Patient Age – All Devices, New Implants 2007 > 65 years = 84% > 70 years = 76% > 75 years = 62% > 85 years = 23%

  9. Primary Aetiology at Implant At least 70% of aetiology likely to be age-related

  10. New Pacemaker Implant Rates – UK Trends

  11. New ICD Implant Rates – UK Trends

  12. Do older patients respond differently? Less response to device therapy/use Greater response to device therapy/use Different response to device therapy/use

  13. 0.8 0.6 Mortality proportion 0.4 VVI VVIR 0.2 DDD Time after entry to trial (years) 0.0 1772 1546 1079 332 124 0 1 2 3 4 5 UKPACE – All cause mortality No differences

  14. 0.15 0.10 Proportion with endpoint VVI/VVIR 0.05 DDD Time after entry to trial (years) 843 710 431 0.0 827 725 394 0.0 0.5 1.0 1.5 2.0 2.5 3.0 UKPACE - Time to specified cardiovascular events Atrial fibrillation

  15. Is syncope different in older people? Less device-relevant pathology? More device-relevant therapy?

  16. Causes of Syncope William Stokes Robert Adams • Neurally-mediated reflex syncopal syndromes • Vasovagal, carotid sinus, situational, neuralgia • Orthostatic • Cardiac Arrhythmias • Bradycardia, tachycardia • Structural Cardiac or Cardiopulmonary Disease

  17. Causes of Loss of Consciousness Data pooled from 6 population-based studies performed in the 1980’s N = 1499 patients The cause was undetermined in 35% of all cases of syncope Of those with a cardiac cause (n=245), the majority (n=195) were due to a primary arrhythmic mechanism Causes of LOC 35% 38% 10% 17% NM & Orthostatic Cardiac Neuro-psychiatric Unknown

  18. Causes of Loss of Consciousness Data pooled from 3 referral Syncope Units in 2001 N = 342 patients The cause was undetermined in 18% of all cases of syncope Of those with a cardiac cause (n=78), the majority (n=68) were due to a primary arrhythmic mechanism Causes of LOC 18% 1% 58% 23% NM & Orthostatic Cardiac Neuro-psychiatric Unknown Alboni P et al, JACC 2001;37:1921-8

  19. Prognostic stratification • Risk stratification: • age > 45 years • history of congestive heart disease • history of ventricular arrhythmias • abnormal ECG • Arrhythmias or death within one year: • 4 - 7% of patients with 0 factors • 58 - 80% in patients with 3 factors

  20. Catching the spontaneous episode… • Implantable Loop Recorder • ~ £1500 • Lasts ~ 12 months • Patient and/or auto-activated Evidence suggests higher diagnostic rate in elderly and confused patients

  21. Sudden Cardiac Death

  22. Indications for ICD www.nice.org.uk/TA95 • Primary prevention • MI > 4 weeks previously and • Either: • LVEF < 35%, NYHA < III + • Non-sustained VT on Holter + • Inducible VT on EP testing • Or: • LVEF < 30%, NYHA < III + • QRS duration > 120 msec • Familial cardiac condition with risk of sudden death • Secondary prevention • Survivors of VT/VF cardiac arrest • Spontaneous VT causing syncope • Sustained VT without syncope/cardiac arrest with LVEF < 35%, NYHA Class < III No mention of age!

  23. Conclusions No clear evidence for age discrimination with regard to device use in older patients Older patients are more likely to have syncope with underlying pathology requiring pacing or ICD therapy Older patients may be less suitable for ICDs by virtue of co-existing pathology Older patients may have a higher diagnostic yield from implantable loop recorders

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