Journal
HEART RHYTHM
Volume 19, Issue 10, Pages 1696-1703Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/j.hrthm.2022.05.023
Keywords
Bifascicular block; Bradyarrhythmia; Empiric pacemaker implantation; Implantable loop recorder; Insertable cardiac monitor; Pacemaker; Traumatic syncope; Unexplained syncope
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Empiric pacemaker implantation significantly reduces the risk of syncope recurrence compared to ILR monitoring in patients with unexplained, recurrent, traumatic syncope and bifascicular block.
BACKGROUND In patients with unexplained syncope and bifascicular block (BFB), syncope may be caused by intermittent atrioventricular (AV) block. When a correlation between syncope and bradyarrhythmia is not documented in these patients, 2 alternative management strategies can be adopted: (1) empiric pacemaker (PM) implantation or (2) long-term continuous electrocardio-graphic monitoring by implantable loop recorder (ILR). OBJECTIVE The purpose of this study was to compare the risk of syncope recurrence associated with empiric PM implantation or ILR monitoring. METHODS A prospective, multicenter, observational study enrolled consecutive patients with unexplained, recurrent, traumatic syncope and BFB who underwent ILR monitoring or empiric PM implantation. The risk and causes of syncope recurrence were assessed and compared between the 2 groups. Individual 1:1 propensity matching of baseline characteristics was performed. RESULTS A total of 309 consecutive patients (age 77.2 +/- 12.2 years; 60.8% male) were enrolled. Propensity matching yielded 89 matched pairs. After median follow-up of 33 months, empiric PM implantation was associated with a significantly lower risk of syncope recurrence than ILR monitoring (19.1 vs 46.1%; P <.001). A total of 35 patients (39.3%) who underwent ILR monitoring developed bradyarrhythmias (68.6% paroxysmal AV block) requiring PM implantation during follow-up. Excluding bradyarrhythmic syncope, the most frequent causes of syncope recurrence in both study groups were reflex syncope and orthostatic hypotension. CONCLUSION In patients with unexplained, recurrent, traumatic syncope and BFB, empiric PM implantation significantly reduced the risk of syncope recurrence in comparison with ILR monitoring. A high rate of patients who underwent ILR monitoring developed bradyarrhythmias requiring PM implantation.
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