The diagnostic yield of implantable loop recorders in unexplained syncope: A systematic review and meta-analysis

M. Solbiati, G. Casazza, F. Dipaola, F. Barbic, M. Caldato, N. Montano, R. Furlan, R.S. Sheldon, G. Costantino

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6 Citations (Scopus)

Abstract

Background Guidelines recommend that implantable loop recorders (ILRs) are used in the evaluation of people with recurrent unexplained syncope in the absence of high-risk criteria, and in high-risk patients after a negative evaluation. The aim of this systematic review was to analyze the diagnostic yield of ILRs in these patients. Methods We performed a systematic search in order to retrieve studies enrolling adults undergoing ILR implantation for undetermined syncope. The primary outcome was the overall diagnostic yield, defined as the proportion of patients with syncope recurrence and an available ILR recording or an automatic detection of a significant arrhythmia. Secondary outcomes were the proportions of patients with the specific etiologic diagnoses on the total of subjects and the proportion of an analyzable ECG recording during symptoms. We used a random effects model for the meta-analyses. Results Forty-nine studies, enrolling 4381 subjects, were included. The overall diagnostic yield was 43.9% (95% CI = 40.2%, 47.6%; I2 = 79.8%). The proportions of subjects finally diagnosed with arrhythmic syncope, ventricular arrhythmias, supraventricular arrhythmias and bradyarrhythmias were 26.5%, 2.7%, 4.9% and 18.2%, respectively. The proportion of an analyzable ECG recording during symptoms was 89.5% (95% CI = 86.1%, 92.1%; 1236 subjects; 36 studies; I2 = 44.9%). Median time to diagnosis was 134 days. Heterogeneity is an important limitation to be acknowledged. Conclusions About a half of unexplained syncope subjects implanted with an ILR were diagnosed, and around 50% of them had an arrhythmia. Life-threatening arrhythmias as well as ILR complications and death due to arrhythmic events were very rare. © 2016 Elsevier Ireland Ltd
Original languageEnglish
Pages (from-to)170-176
Number of pages7
JournalInternational Journal of Cardiology
Volume231
DOIs
Publication statusPublished - 2017

Fingerprint

Syncope
Meta-Analysis
Cardiac Arrhythmias
Electrocardiography
Bradycardia
Ireland
Guidelines
Recurrence

Keywords

  • Arrhythmia
  • Diagnosis
  • Implantable loop recorders
  • Syncope
  • Systematic review
  • Article
  • atrial fibrillation
  • bradycardia
  • diagnostic test accuracy study
  • diagnostic value
  • electrocardiogram
  • faintness
  • heart arrhythmia
  • heart atrium flutter
  • heart supraventricular arrhythmia
  • heart ventricle arrhythmia
  • heart ventricle fibrillation
  • heart ventricle tachycardia
  • human
  • implantable cardiac monitor
  • meta analysis
  • presyncope
  • systematic review
  • ambulatory electrocardiography
  • devices
  • differential diagnosis
  • electrode implant
  • recurrent disease
  • reproducibility
  • Diagnosis, Differential
  • Electrocardiography, Ambulatory
  • Electrodes, Implanted
  • Humans
  • Recurrence
  • Reproducibility of Results

Cite this

@article{4c50748e249f4373887214b285f152f1,
title = "The diagnostic yield of implantable loop recorders in unexplained syncope: A systematic review and meta-analysis",
abstract = "Background Guidelines recommend that implantable loop recorders (ILRs) are used in the evaluation of people with recurrent unexplained syncope in the absence of high-risk criteria, and in high-risk patients after a negative evaluation. The aim of this systematic review was to analyze the diagnostic yield of ILRs in these patients. Methods We performed a systematic search in order to retrieve studies enrolling adults undergoing ILR implantation for undetermined syncope. The primary outcome was the overall diagnostic yield, defined as the proportion of patients with syncope recurrence and an available ILR recording or an automatic detection of a significant arrhythmia. Secondary outcomes were the proportions of patients with the specific etiologic diagnoses on the total of subjects and the proportion of an analyzable ECG recording during symptoms. We used a random effects model for the meta-analyses. Results Forty-nine studies, enrolling 4381 subjects, were included. The overall diagnostic yield was 43.9{\%} (95{\%} CI = 40.2{\%}, 47.6{\%}; I2 = 79.8{\%}). The proportions of subjects finally diagnosed with arrhythmic syncope, ventricular arrhythmias, supraventricular arrhythmias and bradyarrhythmias were 26.5{\%}, 2.7{\%}, 4.9{\%} and 18.2{\%}, respectively. The proportion of an analyzable ECG recording during symptoms was 89.5{\%} (95{\%} CI = 86.1{\%}, 92.1{\%}; 1236 subjects; 36 studies; I2 = 44.9{\%}). Median time to diagnosis was 134 days. Heterogeneity is an important limitation to be acknowledged. Conclusions About a half of unexplained syncope subjects implanted with an ILR were diagnosed, and around 50{\%} of them had an arrhythmia. Life-threatening arrhythmias as well as ILR complications and death due to arrhythmic events were very rare. {\circledC} 2016 Elsevier Ireland Ltd",
keywords = "Arrhythmia, Diagnosis, Implantable loop recorders, Syncope, Systematic review, Article, atrial fibrillation, bradycardia, diagnostic test accuracy study, diagnostic value, electrocardiogram, faintness, heart arrhythmia, heart atrium flutter, heart supraventricular arrhythmia, heart ventricle arrhythmia, heart ventricle fibrillation, heart ventricle tachycardia, human, implantable cardiac monitor, meta analysis, presyncope, systematic review, ambulatory electrocardiography, devices, differential diagnosis, electrode implant, recurrent disease, reproducibility, Diagnosis, Differential, Electrocardiography, Ambulatory, Electrodes, Implanted, Humans, Recurrence, Reproducibility of Results",
author = "M. Solbiati and G. Casazza and F. Dipaola and F. Barbic and M. Caldato and N. Montano and R. Furlan and R.S. Sheldon and G. Costantino",
note = "Cited By :1 Export Date: 2 March 2018 CODEN: IJCDD Correspondence Address: Solbiati, M.; Dipartimento di Medicina Interna e Specializzazioni Mediche, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Italy; email: monica.solbiati@gmail.com Tradenames: Confirm; Reveal; Reveal 9525; Reveal DX; Reveal plus; Reveal XT; Sleuth References: Moya, A., Sutton, R., Ammirati, F., Blanc, J.J., Brignole, M., Dahm, J.B., Deharo, J.C., Wieling, W., Guidelines for the diagnosis and management of syncope (version 2009) (2009) Eur. Heart J., 30, pp. 2631-2671; Soteriades, E.S., Evans, J.C., Larson, M.G., Chen, M.H., Chen, L., Benjamin, E.J., Levy, D., Incidence and prognosis of syncope (2002) N. Engl. J. Med., 347, pp. 878-885; Rose, M.S., Koshman, M.L., Spreng, S., Sheldon, R., The relationship between health-related quality of life and frequency of spells in patients with syncope (2000) J. Clin. Epidemiol., 53, pp. 1209-1216; D'Ascenzo, F., Biondi-Zoccai, G., Reed, M.J., Gabayan, G.Z., Suzuki, M., Costantino, G., Furlan, R., Gaita, F., Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the emergency department with syncope: an international meta-analysis (2013) Int. J. Cardiol., 167, pp. 57-62; Del Rosso, A., Ungar, A., Maggi, R., Giada, F., Petix, N.R., De, S.T., Menozzi, C., Brignole, M., Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: the EGSYS score (2008) Heart, 94, pp. 1620-1626; Solbiati, M., Casazza, G., Dipaola, F., Rusconi, A.M., Cernuschi, G., Barbic, F., Montano, N., Costantino, G., Syncope recurrence and mortality: a systematic review (2015) Europace, 17, pp. 300-308; Costantino, G., Sun, B.C., Barbic, F., Bossi, I., Casazza, G., Dipaola, F., McDermott, D., Furlan, R., Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department (2016) Eur. Heart J., 37, pp. 1493-1498; Brignole, M., Vardas, P., Hoffman, E., Huikuri, H., Moya, A., Ricci, R., Sulke, N., Botto, G.L., Indications for the use of diagnostic implantable and external ECG loop recorders (2009) Europace, 11, pp. 671-687; Krahn, A.D., Klein, G.J., Skanes, A.C., Yee, R., Insertable loop recorder use for detection of intermittent arrhythmias (2004) Pacing Clin. Electrophysiol., 27, pp. 657-664; Brignole, M., Moya, A., Menozzi, C., Garcia-Civera, R., Sutton, R., Proposed electrocardiographic classification of spontaneous syncope documented by an implantable loop recorder (2005) Europace, 7, pp. 14-18; Parry, S.W., Matthews, I.G., Implantable loop recorders in the investigation of unexplained syncope: a state of the art review (2010) Heart, 96, pp. 1611-1616; JPT, H., Green, S., (2011) Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [Updated March 2011], , The Cochrane Collaboration; Whiting, P., Rutjes, A.W.S., Reitsma, J.B., Bossuyt, P.M.M., Kleijnen, J., The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews (2003) BMC Med. Res. Methodol., 3, p. 25; Whiting, P.F., Rutjes, A.W.S., Westwood, M.E., Mallett, S., Deeks, J.J., Reitsma, J.B., Leeflang, M.M.G., Bossuyt, P.M.M., QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies (2011) Ann. Intern. Med., 155, pp. 529-536; Sterne, J.A.C., Sutton, A.J., Ioannidis, J.P.A., Terrin, N., Jones, D.R., Lau, J., Carpenter, J., Higgins, J.P.T., Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials (2011) BMJ, 343, p. d4002; Solbiati, M., Costantino, G., Casazza, G., Dipaola, F., Galli, A., Furlan, R., Montano, N., Sheldon, R., Implantable loop recorder versus conventional diagnostic workup for unexplained recurrent syncope (2016) Cochrane Database Syst. Rev., p. CD011637. , M. Solbiati John Wiley & Sons, Ltd Chichester, UK",
year = "2017",
doi = "10.1016/j.ijcard.2016.12.128",
language = "English",
volume = "231",
pages = "170--176",
journal = "International Journal of Cardiology",
issn = "0167-5273",
publisher = "Elsevier Ireland Ltd",

}

TY - JOUR

T1 - The diagnostic yield of implantable loop recorders in unexplained syncope: A systematic review and meta-analysis

AU - Solbiati, M.

AU - Casazza, G.

AU - Dipaola, F.

AU - Barbic, F.

AU - Caldato, M.

AU - Montano, N.

AU - Furlan, R.

AU - Sheldon, R.S.

AU - Costantino, G.

N1 - Cited By :1 Export Date: 2 March 2018 CODEN: IJCDD Correspondence Address: Solbiati, M.; Dipartimento di Medicina Interna e Specializzazioni Mediche, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Italy; email: monica.solbiati@gmail.com Tradenames: Confirm; Reveal; Reveal 9525; Reveal DX; Reveal plus; Reveal XT; Sleuth References: Moya, A., Sutton, R., Ammirati, F., Blanc, J.J., Brignole, M., Dahm, J.B., Deharo, J.C., Wieling, W., Guidelines for the diagnosis and management of syncope (version 2009) (2009) Eur. Heart J., 30, pp. 2631-2671; Soteriades, E.S., Evans, J.C., Larson, M.G., Chen, M.H., Chen, L., Benjamin, E.J., Levy, D., Incidence and prognosis of syncope (2002) N. Engl. J. Med., 347, pp. 878-885; Rose, M.S., Koshman, M.L., Spreng, S., Sheldon, R., The relationship between health-related quality of life and frequency of spells in patients with syncope (2000) J. Clin. Epidemiol., 53, pp. 1209-1216; D'Ascenzo, F., Biondi-Zoccai, G., Reed, M.J., Gabayan, G.Z., Suzuki, M., Costantino, G., Furlan, R., Gaita, F., Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the emergency department with syncope: an international meta-analysis (2013) Int. J. Cardiol., 167, pp. 57-62; Del Rosso, A., Ungar, A., Maggi, R., Giada, F., Petix, N.R., De, S.T., Menozzi, C., Brignole, M., Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: the EGSYS score (2008) Heart, 94, pp. 1620-1626; Solbiati, M., Casazza, G., Dipaola, F., Rusconi, A.M., Cernuschi, G., Barbic, F., Montano, N., Costantino, G., Syncope recurrence and mortality: a systematic review (2015) Europace, 17, pp. 300-308; Costantino, G., Sun, B.C., Barbic, F., Bossi, I., Casazza, G., Dipaola, F., McDermott, D., Furlan, R., Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department (2016) Eur. Heart J., 37, pp. 1493-1498; Brignole, M., Vardas, P., Hoffman, E., Huikuri, H., Moya, A., Ricci, R., Sulke, N., Botto, G.L., Indications for the use of diagnostic implantable and external ECG loop recorders (2009) Europace, 11, pp. 671-687; Krahn, A.D., Klein, G.J., Skanes, A.C., Yee, R., Insertable loop recorder use for detection of intermittent arrhythmias (2004) Pacing Clin. Electrophysiol., 27, pp. 657-664; Brignole, M., Moya, A., Menozzi, C., Garcia-Civera, R., Sutton, R., Proposed electrocardiographic classification of spontaneous syncope documented by an implantable loop recorder (2005) Europace, 7, pp. 14-18; Parry, S.W., Matthews, I.G., Implantable loop recorders in the investigation of unexplained syncope: a state of the art review (2010) Heart, 96, pp. 1611-1616; JPT, H., Green, S., (2011) Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [Updated March 2011], , The Cochrane Collaboration; Whiting, P., Rutjes, A.W.S., Reitsma, J.B., Bossuyt, P.M.M., Kleijnen, J., The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews (2003) BMC Med. Res. Methodol., 3, p. 25; Whiting, P.F., Rutjes, A.W.S., Westwood, M.E., Mallett, S., Deeks, J.J., Reitsma, J.B., Leeflang, M.M.G., Bossuyt, P.M.M., QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies (2011) Ann. Intern. Med., 155, pp. 529-536; Sterne, J.A.C., Sutton, A.J., Ioannidis, J.P.A., Terrin, N., Jones, D.R., Lau, J., Carpenter, J., Higgins, J.P.T., Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials (2011) BMJ, 343, p. d4002; Solbiati, M., Costantino, G., Casazza, G., Dipaola, F., Galli, A., Furlan, R., Montano, N., Sheldon, R., Implantable loop recorder versus conventional diagnostic workup for unexplained recurrent syncope (2016) Cochrane Database Syst. Rev., p. CD011637. , M. Solbiati John Wiley & Sons, Ltd Chichester, UK

PY - 2017

Y1 - 2017

N2 - Background Guidelines recommend that implantable loop recorders (ILRs) are used in the evaluation of people with recurrent unexplained syncope in the absence of high-risk criteria, and in high-risk patients after a negative evaluation. The aim of this systematic review was to analyze the diagnostic yield of ILRs in these patients. Methods We performed a systematic search in order to retrieve studies enrolling adults undergoing ILR implantation for undetermined syncope. The primary outcome was the overall diagnostic yield, defined as the proportion of patients with syncope recurrence and an available ILR recording or an automatic detection of a significant arrhythmia. Secondary outcomes were the proportions of patients with the specific etiologic diagnoses on the total of subjects and the proportion of an analyzable ECG recording during symptoms. We used a random effects model for the meta-analyses. Results Forty-nine studies, enrolling 4381 subjects, were included. The overall diagnostic yield was 43.9% (95% CI = 40.2%, 47.6%; I2 = 79.8%). The proportions of subjects finally diagnosed with arrhythmic syncope, ventricular arrhythmias, supraventricular arrhythmias and bradyarrhythmias were 26.5%, 2.7%, 4.9% and 18.2%, respectively. The proportion of an analyzable ECG recording during symptoms was 89.5% (95% CI = 86.1%, 92.1%; 1236 subjects; 36 studies; I2 = 44.9%). Median time to diagnosis was 134 days. Heterogeneity is an important limitation to be acknowledged. Conclusions About a half of unexplained syncope subjects implanted with an ILR were diagnosed, and around 50% of them had an arrhythmia. Life-threatening arrhythmias as well as ILR complications and death due to arrhythmic events were very rare. © 2016 Elsevier Ireland Ltd

AB - Background Guidelines recommend that implantable loop recorders (ILRs) are used in the evaluation of people with recurrent unexplained syncope in the absence of high-risk criteria, and in high-risk patients after a negative evaluation. The aim of this systematic review was to analyze the diagnostic yield of ILRs in these patients. Methods We performed a systematic search in order to retrieve studies enrolling adults undergoing ILR implantation for undetermined syncope. The primary outcome was the overall diagnostic yield, defined as the proportion of patients with syncope recurrence and an available ILR recording or an automatic detection of a significant arrhythmia. Secondary outcomes were the proportions of patients with the specific etiologic diagnoses on the total of subjects and the proportion of an analyzable ECG recording during symptoms. We used a random effects model for the meta-analyses. Results Forty-nine studies, enrolling 4381 subjects, were included. The overall diagnostic yield was 43.9% (95% CI = 40.2%, 47.6%; I2 = 79.8%). The proportions of subjects finally diagnosed with arrhythmic syncope, ventricular arrhythmias, supraventricular arrhythmias and bradyarrhythmias were 26.5%, 2.7%, 4.9% and 18.2%, respectively. The proportion of an analyzable ECG recording during symptoms was 89.5% (95% CI = 86.1%, 92.1%; 1236 subjects; 36 studies; I2 = 44.9%). Median time to diagnosis was 134 days. Heterogeneity is an important limitation to be acknowledged. Conclusions About a half of unexplained syncope subjects implanted with an ILR were diagnosed, and around 50% of them had an arrhythmia. Life-threatening arrhythmias as well as ILR complications and death due to arrhythmic events were very rare. © 2016 Elsevier Ireland Ltd

KW - Arrhythmia

KW - Diagnosis

KW - Implantable loop recorders

KW - Syncope

KW - Systematic review

KW - Article

KW - atrial fibrillation

KW - bradycardia

KW - diagnostic test accuracy study

KW - diagnostic value

KW - electrocardiogram

KW - faintness

KW - heart arrhythmia

KW - heart atrium flutter

KW - heart supraventricular arrhythmia

KW - heart ventricle arrhythmia

KW - heart ventricle fibrillation

KW - heart ventricle tachycardia

KW - human

KW - implantable cardiac monitor

KW - meta analysis

KW - presyncope

KW - systematic review

KW - ambulatory electrocardiography

KW - devices

KW - differential diagnosis

KW - electrode implant

KW - recurrent disease

KW - reproducibility

KW - Diagnosis, Differential

KW - Electrocardiography, Ambulatory

KW - Electrodes, Implanted

KW - Humans

KW - Recurrence

KW - Reproducibility of Results

U2 - 10.1016/j.ijcard.2016.12.128

DO - 10.1016/j.ijcard.2016.12.128

M3 - Article

VL - 231

SP - 170

EP - 176

JO - International Journal of Cardiology

JF - International Journal of Cardiology

SN - 0167-5273

ER -