Comprehensive syncope evaluation in HCM reduced ICD implantation rates from ~26% to 12.3% without increasing sudden cardiac death or syncope recurrence.
Does comprehensive syncope evaluation reduce unnecessary ICD implantations without compromising safety in patients with hypertrophic cardiomyopathy and syncope?
A comprehensive, multidisciplinary evaluation of syncope in patients with hypertrophic cardiomyopathy safely reduces unnecessary ICD implantations without increasing the risk of sudden cardiac death or recurrent syncope.
Abstract Background Hypertrophic cardiomyopathy (HCM) is the most prevalent genetic myocardial disorder. Syncope, a frequent event in HCM, is often undetermined, and raises concerns about sudden cardiac death (SCD) leading to overutilization of implantable cardioverter-defibrillators (ICDs). Whether a comprehensive evaluation of syncope may reduce unnecessary ICD implantation while maintaining safety is unknown. Aim of this study was to investigate the impact of in-depth syncope assessment on ICD implantation and clinical outcomes in patients with HCM. Methods This retrospective multicenter study analyzed data from three referral centers between 1989 and 2023. Patients with HCM and syncope were categorized into those undergoing comprehensive syncope evaluation (≥2 diagnostic tests specific for syncope) and standard of care. Propensity score matching (PSM) was performed (2:1) to balance baseline differences by age, left atrium diameter, obstructive physiology and SCD risk. The primary endpoint was a composite of SCD and appropriate ICD interventions. Recurrent syncope was also recorded. Results Overall, syncope was reported in 460/2621 (17.6%) of HCM patients: 75 had undergone comprehensive evaluation while 385 standard care. After the 2:1 PSM, the 75 patients from the comprehensive group were compared to 150 from the standard care group. Comprehensive assessment significantly reduced ICD implantation rates both pre- (12.3% vs. 25.2%, p=0.008) and post-matching (12.3% vs. 26.0%, p=0.011), but had comparable rates of SCD or appropriate ICD shocks (p=0.832 - Figure). Syncope recurrence rates did not differ between groups (16.0% vs. 15.3%, p=0.897). Comprehensive evaluation clarified syncope etiology in 75% of cases, significantly reducing unexplained syncope. Only 33/460 (7.2%) patients received a loop recorder (N=1621.3% vs 174.4%, in comprehensive assessment vs standard care, respectively p0.001). Conclusion Comprehensive syncope evaluation in HCM was associated with reduced ICD implantations without compromising safety or increasing syncope recurrence. A tailored, multidisciplinary approach may help optimize care whenever an unexplained syncope is reported.Event-free survival at follow-up
Fumagalli et al. (2025) studied this question. Comprehensive syncope evaluation in HCM reduced ICD implantation rates from ~26% to 12.3% without increasing sudden cardiac death or syncope recurrence.
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