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Corvino, A.R.; Russo, V.; Monaco, M.G.L.; Garzillo, E.M.; Guida, D.; Comune, A.; Parente, E.; Lamberti, M.; Miraglia, N. Patient-Worker-Management of Vasovagal Syncope at Work. Encyclopedia. Available online: https://encyclopedia.pub/entry/43565 (accessed on 04 July 2024).
Corvino AR, Russo V, Monaco MGL, Garzillo EM, Guida D, Comune A, et al. Patient-Worker-Management of Vasovagal Syncope at Work. Encyclopedia. Available at: https://encyclopedia.pub/entry/43565. Accessed July 04, 2024.
Corvino, Anna Rita, Vincenzo Russo, Maria Grazia Lourdes Monaco, Elpidio Maria Garzillo, Daniele Guida, Angelo Comune, Erika Parente, Monica Lamberti, Nadia Miraglia. "Patient-Worker-Management of Vasovagal Syncope at Work" Encyclopedia, https://encyclopedia.pub/entry/43565 (accessed July 04, 2024).
Corvino, A.R., Russo, V., Monaco, M.G.L., Garzillo, E.M., Guida, D., Comune, A., Parente, E., Lamberti, M., & Miraglia, N. (2023, April 27). Patient-Worker-Management of Vasovagal Syncope at Work. In Encyclopedia. https://encyclopedia.pub/entry/43565
Corvino, Anna Rita, et al. "Patient-Worker-Management of Vasovagal Syncope at Work." Encyclopedia. Web. 27 April, 2023.
Patient-Worker-Management of Vasovagal Syncope at Work
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This entry is adapted from the peer-reviewed paper 10.3390/ijerph20085460

Syncope is a complex clinical manifestation that presents considerable diagnostic difficulties and, consequently, numerous critical issues regarding fitness for work, especially for high-risk tasks. It is impossible to quantify the exact impact of syncope on work and public safety since it is highly improbable to identify loss of consciousness as the fundamental cause of work or driving-related accidents, especially fatal injuries. Working at high-risk jobs such as public transport operators, in high elevations, or with exposure to moving parts, construction equipment, fireworks, or explosives demand attention and total awareness.

vasovagal syncope worker management occupational safety risk

1. Diagnosis and Treatment

The preliminary step in the diagnostic evaluation of suspected syncopal TLOC consists of an accurate history of present and previous attacks, physical examination, supine and orthostatic blood pressure measurements, and electrocardiogram (ECG). The Calgary Syncope Symptoms Score can be an efficient diagnostic tool to identify patients with vasovagal syncope with 89% sensitivity and 91% specificity, combining seven clinical features of anamnestic and electrocardiographic nature [1]. The CSSS has been validated in the younger population with no evidence of structural heart disease; however, it shows a lower degree of sensitivity and specificity in the elderly population, primarily in the presence of mild cardiovascular disease and increased prevalence of cardiovascular risk [2].
Additional examinations may be performed when needed (1) fast ECG monitoring in cases of suspected arrhythmic syncope; (2) echocardiography in cases of previously diagnosed heart illness, evidence of structural heart disease, or syncope secondary to a cardiovascular etiology; (3) carotid sinus massage (CSM) in patients older than 40; (4) blood tests such as troponin when cardiac ischemia-related syncope is suspected, hematocrit or hemoglobin when bleeding is suspected, oxygen saturation and blood gas analysis when hypoxia is suspected, or D-dimer when pulmonary embolism is detected). After a preliminary clinical evaluation, the head-up tilt test (HUTT) is a useful and effective diagnostic technique for individuals with suspected reflex syncope [3].
The main goals of the treatment of neuro-mediated syncope are the prevention of syncopal recurrences and associated trauma and the improvement of the quality of life. The cornerstone of management is based on patients’ education, lifestyle modification, and reassurance regarding the benign nature of the condition. Avoiding triggers (e.g., hot and crowded environments, prolonged orthostatic position, hypovolemia, coughing, a too-tight collar, etc.) and increased oral hydration and salt intake is further crucial. Similarly, the discontinuation/reduction in hypotensive therapy targeting a systolic BP lower than 140 mmHg, support stockings, physiologic counterpressure techniques, and tilt training can significantly reduce syncope recurrence.
Recurrent and unpredictable reflex syncope, even if it has a benign course, can be disabling and may require patients to undergo pharmacological treatment, especially those that present with recurrent syncope with a very short prodrome phase or without it, as it can expose the patient to the risk of trauma especially when syncope occurs during high-risk activities (e.g., operating machinery, driving, or flying, etc.). The use of fludrocortisone (0.05–0.2 mg once daily) or midodrine (2.5–10 mg, three times daily) may be effective in reducing recurrent syncope in young patients with low-normal BP values and no comorbidities.
The evidence about the optimal pharmacological therapies may be troubled by methodological issues such as the paucity of randomized controlled studies, the small size of study cohorts, and the short follow-up duration.
Dual chamber pacing is recommended in extremely selective reflex syncope patients who are older than 40 and have severe, repeated, unpredictable syncopal episodes with confirmed asystole caused by either CSM, tilt testing, or monitored using a monitoring system [4][5]. The design of closed-loop stimulation, one of the pacing algorithms that are now available, is expected to trigger pacing early and at a sufficient rate before a drop in blood pressure, as has been seen during the tilt test [6][7][8][9].
A well-structured clinical-diagnostic procedure is a benchmark not only for the clinical management of the patient but also plays a fundamental role, with social and economic repercussions, on the patient’s quality of life and work.

2. Risk Stratification

To improve a diagnostic and therapeutic approach, risk classification of patients who present to emergency departments (ED) with syncope is crucial. Several scales are available in the literature to help the emergency physician stratify the clinical risks of patients with syncope to either guide them to hospital admission or discharge them after appropriate outpatient assessment [10][11][12]. However, after the stratification of the clinical risks, it is also necessary to consider all other aspects that could be influenced by the occurrence of syncope and its potential recurrence during the patient’s daily life, such as the patient’s job and if there is an association of syncope with it. Surely, the resumption of a dangerous job must be subordinated to a good diagnostic and therapeutic process and to a stratification of the risk of accident and must certainly include the necessary precautions in order to avoid endangering the life of the patient and the possible third parties. In addition, there is a lack of individualized advice regarding the timing and safety of driving and work resumption after syncope. This could be the cause of an unjustified delay in returning to work and could lead to a negative psychological impact on the patient. However, it could be harmful if the patient decides on his/her own to resume a high-risk job without proper precautions. This could lead to higher costs for society and employers.
No validated criteria or indicators are currently available for the stratification of the occupational risk of a patient with syncope who must resume his work activity.
Only the Canadian Cardiovascular Society has provided some numerical indicators which, starting from a risk of road accident due to syncope considered acceptable (1/20000 per year), allow to establish which patients can resume driving and how long after a syncopal event. These indicators depend on multiple factors such as driving time, the type of vehicle, the risk of recurrence at 1 year, and the likelihood that an accident will actually occur as a result of syncope while driving [13].
Work risk stratification has a primary role in identifying and managing all those workers exposed to tasks with a high intrinsic risk.

3. Return to Work

Several studies have suggested that syncope is associated with a reduced quality of life comparable to that of patients with chronic disorders [14][15]. Probably, one of the main reasons for the poor quality of life after syncope could be the relationship with work activity. Van Dijk et al. reported that half of the patients with syncope described that it influenced their ability to work [14]. However, there is a significant lack of literature on the subject as a large sector of the working population is not involved.
The first study to show a substantial correlation between syncope and safe work performance, including occupational injuries and job termination, involved individuals with syncope in Denmark [16]. The study’s key findings showed that occupational accidents in syncope patients were more common among employed people with syncope than among the general employed population and that risk rose by an additional factor of 1.4 among those who experienced recurrent syncope [17]. The risk of any outcome was highest in patients with younger age, comorbidities, or unfavorable socioeconomic status; 91.6 percent of people with syncope maintained or returned to work after hospitalization [18]; however, the 2-year risk of termination of employment after syncope was 31.3 percent, which was two folds of the reference population [19].
In the study by Sakaguchi and Li, the authors reviewed different guidelines for resuming private driving for patients with vasovagal syncope. The main finding of the review was that patients with a low risk of syncope recurrence, i.e., less than 22%, can return to driving with minimal or no restrictions [20]. Sorajja et al. discussed the possible role of driving itself as a potential cause of syncope [21]. Out of 3877 patients who experienced syncope during the study period, 381 workers (9.8%) had syncopal episodes while driving. In 37.3% of cases, the main cause of syncope while driving was identified as neurally mediated, which is uncommon in a seated position, while cardiac arrhythmias represented only 11.8% of the causes. The authors suggested several mechanisms to explain the higher frequency of neuro mediated syncope among drivers with syncope, such as unfavorable microclimate and exceedingly high temperatures inside the vehicle, strong emotional stimulation while driving, and venous-type alterations [22]. It should be noted that the risk of syncope recurrence and the causes of syncope were both similar in patients who fainted while driving and those with non-driving related syncope. Therefore, the clinical management of workers who experience syncope while driving may be similar to those in the general syncope patient population [18][23][24].
Given the lack of convincing data about the relationship between syncope and various work activities, to date, only recommendations regarding professional driving have been established, while there are no suggestions regarding the execution of professional activities with high accident risks [25][26][27][28]. It should be stressed that several characteristics that can cause neurally induced syncope may be present in some typical working activities [29]. Indeed, high ambient temperatures, high humidity, and rapid temperature variations are examples of an unfavorable microenvironment, besides wearing heavy protective clothing, which may be a contributing factor to temporary orthostatic intolerance or presyncope, which in turn causes syncope. In this scenario, it is crucial to point out that certain low-cost adjustments in the physical setting of the workplace, gained, for example, by placing an air conditioner, which might remedy the worker’s problem.
The results of a survey carried out in preparation for the First International Workshop on Risk Stratification of Syncope in the Emergency Department reported that 96% of 27 expert physicians consider the patient’s work history essential in managing Emergency cases of syncope. Among the doctors interviewed, 88% reported that, in the face of a lack of evidence-based recommendations in the literature, the management of patients, particularly their return to work, was mainly based on individual experience [30].
Return to work must be assessed by an experienced occupational physician, and changes to the work environment or organization may be suggested. A period of removal from high-risk job tasks (3 to 6 months or more) and regular follow-up are essential for monitoring clinical fitness to return to work. A multidisciplinary approach, including continuous training on occupational safety, could reduce occupational injuries due to syncope relapses and promote a safe and appropriate return to work for patients with syncope.

4. Focus on Fitness for Work after Pacemaker (PM) Implantation

There are few studies in the literature investigating workers’ return to work suffering from vasovagal syncope treated with a PM implant. Workers affected by cardioinhibitory syncope treated with a PM implant could have problems returning to work, especially in the case of work environments with exposure to electromagnetic radiation. One of the most frequent exposures to electromagnetic radiation in the workplace is due to spot, industrial welding machines, and electric motors, which could represent a problem for exposed workers who have recently undergone PM implantation. While welding equipment in the 100–200 amperes range is unlikely to produce significant electromagnetic interference (EMI), welding with industrial power equipment more significant than 500 amperes can be a problem as it can inhibit pacemakers.
Therefore, for any pacemaker-dependent patient, it is paramount to assess potential EM sources in the work environment before the patient is allowed to return to their occupation to ensure that the pacemaker is not inhibited [28].
Currently, there are no clear regulations regarding the safe management of pacemakers or ICD workers exposed to high electromagnetic fields (EMF). The interim European directive on electromagnetic fields (2004/40/EC) requires employers to consider the safety of workers at particular risk. In workplaces with high levels of EMF exposure, employees with PMs or ICDs are generally removed from the workplace and are assigned to other tasks or are paid a pension with additional costs to employers and society, in addition to the negative psychological implications for the worker.
In pacemakers or their interrogation telemetry, static magnetic fields (0 Hz) created by objects with permanent magnets have been demonstrated to cause EMI. Exposure to a static magnetic field in pacemakers can trigger a change to an asynchronous pacing mode. Examples of equipment that can create static magnetic fields include hard drives in portable media players and laptop computers, as well as small neodymium magnets and wireless headphones. Similarly, magnetic resonance imaging equipment’s static magnetic fields frequently create EMI. However, the data on EMI from alternating extremely low-frequency magnetic fields (<50 Hz) are scanty.

References

  1. Sheldon, R.; Rose, S.; Connolly, S.; Ritchie, D.; Koshman, M.L.; Frenneaux, M. Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur. Heart J. 2006, 27, 344–350.
  2. Expósito, V.; Guzmán, J.C.; Orava, M.; Armaganijan, L.; Morillo, C.A. Usefulness of the Calgary Syncope Symptom Score for the diagnosis of vasovagal syncope in the elderly. Europace 2013, 15, 1210–1214.
  3. Sutton, R.; Fedorowski, A.; Olshansky, B.; Gert van Dijk, J.; Abe, H.; Brignole, M.; de Lange, F.; Kenny, R.A.; Lim, P.B.; Moya, A.; et al. Tilt testing remains a valuable asset. Eur. Heart J. 2021, 42, 1654–1660.
  4. Brignole, M.; Russo, V.; Arabia, F.; Oliveira, M.; Pedrote, A.; Aerts, A.; Rapacciuolo, A.; Boveda, S.; Deharo, J.C.; Maglia, G.; et al. Cardiac pacing in severe recurrent reflex syncope and tilt-induced asystole. Eur. Heart J. 2021, 42, 508–516.
  5. Glikson, M.; Nielsen, J.C.; Kronborg, M.B.; Michowitz, Y.; Auricchio, A.; Barbash, I.M.; Barrabés, J.A.; Boriani, G.; Braunschweig, F.; Brignole, M.; et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronisation therapy. Eur. Heart J. 2021, 42, 3427–3520.
  6. Russo, V.; Rago, A.; De Rosa, M.; Papa, A.A.; Simova, I.; Petrov, I.; Bonev, N.; Gargaro, A.; Golino, P.; Nigro, G. Does cardiac pacing reduce syncopal recurrences in cardioinhibitory vaso-vagal syncope patients selected with head-up tilt test? Analysis of a 5-year follow-up database. Int. J. Cardiol. 2018, 270, 149–153.
  7. Russo, V.; Rago, A.; Papa, A.A.; Golino, P.; Calabrò, R.; Russo, M.G.; Nigro, G. The effect of dual-chamber closed-loop stimulation on syncope recurrence in healthy patients with tilt-induced vasovagal cardioinhibitory syncope: A prospective, randomised, single-blind, crossover study. Heart 2013, 99, 1609–1613.
  8. Russo, V.; Anguera, I.; de Lange, F.J.; De Ruvo, E.; Taieb, J.; Zardini, M.; Nigro, G.; Giacopelli, D.; Gargaro, A.; Brignole, M. Heart rate distribution in paced and non-paced patients with severe recurrent reflex syncope and tilt-induced asystole: Findings from the BIOSync CLS study. Int. J. Cardiol. 2021, 335, 52–54.
  9. Tomaino, M.; Russo, V.; Giacopelli, D.; Gargaro, A.; Brignole, M. Cardiac Pacing in Cardioinhibitory Reflex Syncope: Clinical Use of Closed-loop Stimulation. Arrhythm. Electrophysiol. Rev. 2021, 10, 244–249.
  10. Costantino, G.; Perego, F.; Dipaola, F.; Borella, M.; Galli, A.; Cantoni, G.; Dell’Orto, S.; Dassi, S.; Filardo, N.; Duca, P.G.; et al. Short and Long-Term Prognosis of Syncope, Risk Factors and Role of Hospital Admission. Results from the STePS (Short-Term Prognosis of Syncope) Study. J. Am. Coll. Cardiol. 2008, 51, 276–283.
  11. Ammirati, F.; Colivicchi, F.; Minardi, G.; De Lio, L.; Terranova, A.; Scaffidi, G.; Rapino, S.; Proietti, F.; Bianchi, C.; Uguccioni, M.; et al. The management of syncope in the hospital: The OESIL Study (Osservatorio Epidemiologico della Sincope nel Lazio). G. Ital. Cardiol. 1999, 29, 533–539.
  12. Dipaola, F.; Costantino, G.; Perego, F.; Borella, M.; Galli, A.; Cantoni, G.; Barbic, F.; Casella, F.; Duca, P.G.; Furlan, R.; et al. San Francisco Syncope Rule, Osservatorio Epidemiologico sulla Sincope nel Lazio risk score, and clinical judgment in the assessment of short-term outcome of syncope. Am. J. Emerg. Med. 2010, 28, 432–439.
  13. Simpson, C.; Dorian, P.; Gupta, A.; Hamilton, R.; Hart, S.; Hoffmaster, B.; Klein, G.; Krahn, A.; Kryworuk, P.; Mitchell, L.B.; et al. CCS Consensus Conference 2003: Assessment of the cardiac patient for fitness to drive and fly. Executive Summary. Can. J. Cardiol. 2004, 20, 1313–1323.
  14. van Dijk, N.; Sprangers, M.A.; Colman, N.; Boer, K.R.; Wieling, W.; Linzer, M. Clinical factors associated with quality of life in patients with transient loss of consciousness. J. Cardiovasc. Electrophysiol. 2006, 17, 998–1003.
  15. Linzer, M.; Pontinen, M.; Gold, D.T.; Divine, G.W.; Felder, A.; Brooks, W.B. Impairment of physical and psychosocial function in recurrent syncope. J. Clin. Epidemiol. 1991, 44, 1037–1043.
  16. Ganzeboom, K.S.; Mairuhu, G.; Reitsma, J.B.; Linzer, M.; Wieling, W.; van Dijk, N. Lifetime cumulative incidence of syncope in the general population: A study of 549 Dutch subjects aged 35–60 years. J. Cardiovasc. Electrophysiol. 2006, 17, 1172–1176.
  17. Ruwald, M.H.; Hansen, M.L.; Lamberts, M.; Hansen, C.M.; Højgaard, M.V.; Køber, L.; Torp-Pedersen, C.; Hansen, J.; Gislason, G.H. The relation between age, sex, comorbidity, and pharmacotherapy and the risk of syncope: A Danish nationwide study. Europace 2012, 14, 1506–1514.
  18. Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS); Moya, A.; Sutton, R.; Ammirati., F.; Blanc, J.J.; Brignole, M.; et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur. Heart J. 2009, 30, 2631–2671.
  19. Solbiati, M.; Casazza, G.; Dipaola, F.; Rusconi, A.M.; Cernuschi, G.; Barbic, F.; Montano, N.; Sheldon, R.S.; Furlan, R.; Costantino, G. Syncope recurrence and mortality: A systematic review. Europace 2015, 7, 300–308.
  20. Sakaguchi, S.; Li, H. Syncope and driving, flying and vocational concerns. Pro. Cardiovasc. Dis. 2013, 55, 454–463.
  21. Sorajja, D.; Nesbitt, G.C.; Hodge, D.O.; Low, P.A.; Hammill, S.C.; Gersh, B.J.; Shen, W.K. Syncope while driving: Clinical characteristics, causes, and prognosis. Circulation 2009, 120, 928–934.
  22. Mosqueda-Garcia, R.; Furlan, R.; Tank, J.; Fernandez-Violante, R. The elusive pathophysiology of neurally mediated syncope. Circulation 2000, 102, 2898–2906.
  23. Epstein, A.E.; Miles, W.M.; Benditt, D.G.; Camm, A.J.; Darling, E.J.; Friedman, P.L.; Garson, A., Jr.; Harvey, J.C.; Kidwell, G.A.; Klein, G.J.; et al. Personal and public safety issues related to arrhythmias that may affect consciousness: Implications for regulation and physician recommendations. A medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology. Circulation 1996, 94, 1147–1166.
  24. Epstein, A.E.; Baessler, C.A.; Curtis, A.B.; Estes, N.A., 3rd; Gersh, B.J.; Grubb, B.; Mitchell, L.B.; American Heart Association; Heart Rhythm Society. Addendum to “Personal and public safety issues related to arrhythmias that may affect consciousness: Implications for regulation and physician recommendations: A medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology”: Public safety issues in patients with implantable defibrillators: A scientific statement from the American Heart Association and the Heart Rhythm Society. Circulation 2007, 115, 1170–1176.
  25. Miles, W.M. Driving issues related to arrhythmic syncope. Cardiol. Clin. 1997, 15, 327–339.
  26. Bänsch, D.; Brunn, J.; Castrucci, M.; Weber, M.; Gietzen, F.; Borggrefe, M.; Breithardt, G.; Block, M. Syncope in patients with an implantable cardioverter–defibrillator: Incidence, prediction and implications for driving restrictions. J. Am. Coll. Cardiol. 1998, 31, 608–615.
  27. Blitzer, M.L.; Saliba, B.C.; Ghantous, A.E.; Marieb, M.A.; Schoenfeld, M.H. Causes of impaired consciousness while driving a motorised vehicle. Am. J. Cardiol. 2003, 91, 1373–1374.
  28. Maas, R.; Ventura, R.; Kretzschmar, C.; Aydin, A.; Schuchert, A. Syncope, driving recommendations, and clinical reality: Survey of patients. BMJ 2003, 326, 21.
  29. Yerra, L.; Reddy, P.C. Effects of Electromagnetic Interference on Implanted Cardiac Devices and Their Management. Cardiol. Rev. 2007, 15, 304–309.
  30. Barbic, F.; Casazza, G.; Zamunér, A.R.; Costantino, G.; Orlandi, M.; Dipaola, F.; Capitanio, C.; Achenza, S.; Sheldon, R.; Furlan, R. Driving and working with syncope. Auton. Neurosci. Basic Clin. 2014, 184, 46–52.
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Subjects: Public, Environmental & Occupational Health
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Anna Rita Corvino
,
Vincenzo Russo
,
Maria Grazia Lourdes Monaco
,
Elpidio Maria Garzillo
,
Daniele Guida
,
Angelo Comune
,
Erika Parente
,
Monica Lamberti
,
Nadia Miraglia
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Update Date: 28 Apr 2023
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