Syncope, conduction disturbance, and negative electrophysiological test: Predictive factors and risk score to predict pacemaker implantation during follow-up

Ivo Roca-Luque; Jaume Francisco-Pascual; Gerard Oristrell; Julián Rodríguez-García; Alba Santos-Ortega; Gabriel Martin-Sanchez; Nuria Rivas-Gandara; Jordi Perez-Rodon; Ignacio Ferreira-Gonzalez; David García-Dorado; Angel Moya-Mitjans

doi:10.1016/j.hrthm.2018.12.015

Syncope, conduction disturbance, and negative electrophysiological test: Predictive factors and risk score to predict pacemaker implantation during follow-up

Heart Rhythm. 2019 Jun;16(6):905-912. doi: 10.1016/j.hrthm.2018.12.015. Epub 2018 Dec 18.

Affiliations

¹ Arrhythmia Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain. Electronic address: irlroca@gmail.com.
² Arrhythmia Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
³ Cardiovascular Epidemiology Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
⁴ Cardiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.

PMID: 30576876
DOI: 10.1016/j.hrthm.2018.12.015

Abstract

Background: Patients with syncope and bundle branch block (BBB) are at risk for atrioventricular block (AVB). Electrophysiological study (EPS) can help in identifying patients at higher risk for AVB, but the false-negative rate is remarkable. Few data on the predictors of the need for pacemaker implantation during follow-up have been reported.

Objective: The purpose of this study was to analyze the rate of patients who need pacemaker implantation after negative EPS and predictive factors.

Methods: A single-center prospective study of 159 consecutive patients (73.9 ± 12.1 years; male 64.9%) with syncope and BBB (January 2012-December 2016) and negative EPS was conducted. An implantable loop recorder was implanted.

Results: After 27.9 ± 10.8 months of follow-up, 39 patients (24.8%) underwent pacemaker implantation because of bradyarrhythmia. In the univariate analysis, bifascicular (right BBB + left fascicular block) block, bifascicular block + long PR interval, conduction disturbance different from isolated right BBB, HV ≥60 ms, and HV ≥70 ms after class I drug challenge were predictors of pacemaker implantation. In the multivariate analysis, only bifascicular block (hazard ratio 2.5; 95% confidence interval 1.4-4.8; P = .04) and HV interval ≥60 ms (hazard ratio 3.5; 95% confidence interval 1.8-6.2; P <.001) were statistically significant. A risk score according to the multivariate model identified 3 levels of pacemaker implantation rate (13.5%, 32.7%, and 66.7%; P <.001). No death or severe trauma related to bradyarrhythmia occurred.

Conclusion: The strategy of an implantable loop recorder in patients with syncope and BBB is safe after negative EPS, but some patients might need pacemaker implantation during follow-up. A risk score based on HV ≥60 ms and bifascicular block can be useful in identifying patients at risk for advanced AVB after negative EPS.

Keywords: Conduction disturbance; Electrophysiological study; HV interval; Pacemaker; Syncope.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Aged
Atrioventricular Block* / etiology
Atrioventricular Block* / physiopathology
Atrioventricular Block* / prevention & control
Bundle-Branch Block* / diagnosis
Bundle-Branch Block* / physiopathology
Bundle-Branch Block* / surgery
Cardiac Pacing, Artificial* / methods
Cardiac Pacing, Artificial* / statistics & numerical data
Electrophysiologic Techniques, Cardiac* / methods
Electrophysiologic Techniques, Cardiac* / standards
False Negative Reactions
Female
Follow-Up Studies
Heart Conduction System / physiopathology
Heart Conduction System / surgery
Humans
Male
Pacemaker, Artificial / statistics & numerical data*
Predictive Value of Tests
Prognosis
Risk Assessment* / methods
Risk Assessment* / statistics & numerical data
Syncope* / diagnosis
Syncope* / etiology
Syncope* / prevention & control