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Research Article
27 January 2021

Do implantable loop recorders impact the survival of patients with recurrent unexplained syncope?

Abstract

Aim: This study compares the outcomes of patients who receive an implantable loop recorder (ILR) for unexplained syncope to a control group without the diagnostic device in German claims data. Methods  and materials: Patients with ILR were matched to a control group based on prior syncope events, age, gender and Charlson Comorbidity index (CCI). Survival, syncope hospitalizations, treatment and costs were compared. Results/conclusion: Four hundred and twelve ILR patients were matched with controls, mean age was 68, mean CCI was 2.7, 42% females. ILR patients lived on average 1.2 years longer than patients in the control group. Twenty-five percent of ILR patients received a therapeutic device compared with 5% in the control group. ILRs might help to diagnose and treat patients with positive impact on survival.

Supplementary Material

File (suppl_file.docx)

References

Papers of special note have been highlighted as: •• of considerable interest
1.
Brignole M, Moya A, de Lange FJ et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur. Heart J. 39(21), 1883–1948 (2018).
•• The ESC Syncope Guidelines present evidence and recommendations regarding which investigations are most relevant and likely to lead to a diagnosis in syncope patients. They include a meta-analysis showing that implantable loop recorders are 3.6-times more likely to reach a diagnosis than conventional testing.
2.
Soteriades ES, Evans JC, Larson MG et al. Incidence and prognosis of syncope. N. Engl. J. Med. 347(12), 878–885 (2002).
•• Shows higher mortality for patients with recurrent syncope and a cardiac cause.
3.
Yasa E, Ricci F, Magnusson M, Sutton R, Gallina S, De Caterina R. Cardiovascular risk after hospitalisation for unexplained syncope and orthostatic hypotension. Heart 104(6), 487–493 (2018).
•• Shows that a hospitalization for unexplained syncope is associated with a higher risk of cardiovascular death and all-cause mortality. Patients have a higher risk of coronary events, strokes, heart failure and aortic stenosis.
4.
Ricci F, Sutton R, Palermi S et al. Prognostic significance of noncardiac syncope in the general population: a systematic review and meta-analysis. J. Cardiovasc. Electrophysiol. 29(12), 1641–1647 (2018).
•• Summarized the evidence for a higher all-cause mortality in patients with previous hospitalization for unexplained syncope.
5.
Sun BC. Quality-of-life, health service use, and costs associated with syncope. Prog. Cardiovasc. Dis. 55, 370–375 (2013).
6.
Linzer M, Pontinen M, Gold DT, Divine GW, Felder A, Brooks WB. Impairment of physical and psychosocial function in recurrent syncope. J. Clin. Epidemiol. 44, 1037–1043 (1991).
7.
van Dijk N, Sprangers MA, Colman N, Boer KR, Wieling W, Linzer M. Clinical factors associated with quality of life in patients with transient loss of consciousness. J. Cardiovasc. Electrophysiol. 17, 998–1003 (2006).
8.
Linzer M, Gold DT, Pontinen M, Divine GW, Felder A, Brooks WB. Recurrent syncope as a chronic disease: preliminary validation of a disease-specific measure of functional impairment. J. Gen. Intern. Med. 9(4), 181–186 (1994).
9.
Anderson JB, Czosek RJ, Knilans TK, Marino BS. The effect of paediatric syncope on health-related quality of life. Cardiol. Young. 22(5), 583–588 (2012).
10.
Numé AK, Kragholm K, Carlson N et al. Syncope and its impact on occupational accidents and employment. Circ. Cardiovasc. Qual. Outcomes 10(4), e003202 (2017).
11.
Bartoletti A, Fabiani P, Bagnoli L et al. Physical injuries caused by a transient loss of consciousness: main clinical characteristics of patients and diagnostic contribution of carotid sinus massage. Eur. Heart J. 29(5), 618–624 (2017).
12.
Rogers G, O'Flynn N. NICE guideline: transient loss of consciousness (blackouts) in adults and young people. Br. J. Gen. Pract. 61(582), 40–42 (2012).
13.
Shen WK, Sheldon RS, Benditt DG et al. 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. J. Am. Coll. Cardiol. 70(5), e39–e110 (2017).
14.
Edvardsson N, Frykman V, van Mechelen R et al. Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry. Europace 13(2), 262–269 (2011).
•• This observational registry showed that syncope evaluations are unstructured, which results in low diagnostic yield. Some tests are repeated many times, patients undergo various expensive diagnostic tests with low diagnostic yield and see three specialists without receiving a diagnosis.
15.
Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J. Clin. Epidemiol. 47(11), 1245–1251 (1994).
16.
Brignole M, Auricchio A, Baron-Esquivias G et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur. Heart J. 34(29), 2281–2329 (2013).
17.
National Institute for Health and Care Excellence (NICE). Implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure. NICE Technology Appraisal Guidance 314 (2014).
18.
Priori SG, Blomström-Lundqvist C, Mazzanti A et al ; Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Europace 17(11), 1601–1687 (2015).
19.
Shaw DB, Kekwick CA, Veale D, Gowers J, Whistance T. Survival in second degree atrioventricular block. Br. Heart J. 53, 587–593 (1985).
20.
Shaw DB, Eraut D. Prevalence and morbidity of heart block in Devon. Br. Med. J. 1, 144–147 (1970).
21.
Simon AB, Zloto AE. Atrioventricular block: natural history after permanent ventricular pacing. Am. J. Cardiol. 41, 500–507 (1978).
22.
Connolly SJ, Hallstrom AP, Cappato R et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. Eur. Heart J. 21(24), 2071–2078 (2000).
23.
European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur. Heart J. 31(19), 2369–2429 (2010).
24.
Edvardsson N, Wolff C, Tsintzos S, Rieger G, Linker NJ. Costs of unstructured investigation of unexplained syncope: insights from a micro-costing analysis of the observational PICTURE registry. Europace 17(7), 1141–1148 (2015).
25.
Vitale E, Ungar A, Maggi R et al. Discrepancy between clinical practice and standardized indications for an implantable loop recorder in patients with unexplained syncope. Europace 12(10), 1475–1479 (2010).
26.
Castelnuovo E, Stein K, Pitt M, Garside R, Payne E. The effectiveness and cost-effectiveness of dual-chamber pacemakers compared with single-chamber pacemakers for bradycardia due to atrioventricular block or sick sinus syndrome: systematic review and economic evaluation. Health Technol. Assess. 9(43), iii; xi–xiii, 1–246 (2005).
27.
van Eck JW, van Hemel NM, Kelder JC et al ; FOLLOWPACE Investigators. Poor health-related quality of life of patients with indication for chronic cardiac pacemaker therapy. Pacing Clin. Electrophysiol. 31(4), 480–486 (2008).
28.
Udo EO, Zuithoff NP, van Hemel NM et al. Incidence and predictors of short- and long-term complications in pacemaker therapy: the FOLLOWPACE study. Heart Rhythm 9(5), 728–735 (2012).
29.
Lamas GA, Orav EJ, Stambler BS et al. Quality of life and clinical outcomes in elderly patients treated with ventricular pacing as compared with dual-chamber pacing. Pacemaker Selection in the Elderly Investigators. N. Engl. J. Med. 338(16), 1097–1104 (1998).
30.
Kirchhof P, Benussi S, Kotecha D et al ; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur. Heart J. 37(38), 2893–2962 (2016).
31.
Thygesen SK, Christiansen CF, Christensen S, Lash TL, Sørensen HT. The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish National Registry of Patients. BMC Med. Res. Methodol. 11, 83 (2011).
32.
Ruwald MH, Hansen ML, Lamberts M et al. Accuracy of the ICD-10 discharge diagnosis for syncope. Europace 15(4), 595–600 (2012).