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Sinha A, Demir OM, Ellis H, Perera D. Dizziness in an avid cyclist: an unusual presentation of a common problem. Eur Heart J Case Rep 2021; 5:ytab459. [PMID: 34993402 PMCID: PMC8728714 DOI: 10.1093/ehjcr/ytab459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/29/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
Background Presyncope and syncope are common presentations with a wide range of differential diagnoses; when it occurs primarily on exertion, a cardiovascular cause is more likely. Structural abnormalities and primary rhythm disturbances are the usual culprits in these patients. Case summary A 75-year-old gentleman presented with a history of progressive exertional presyncope. His investigations demonstrated normal cardiac structure, function, and rhythm. He underwent an exercise stress test, which demonstrated a significant reduction in peak blood pressure with equivocal electrocardiogram changes and absence of ischaemic symptoms. In view of his age and gender, a computerized tomography coronary angiogram (CTCA) was organized to exclude obstructive coronary artery disease (CAD). Intriguingly, the CTCA demonstrated a severe proximal left anterior descending (LAD) artery stenosis. This stenosis was confirmed to be functionally significant using invasive coronary physiology and was treated with percutaneous coronary intervention. At follow-up, there was no recurrence of exertional presyncope and the patient was continuing to return to his baseline function. Conclusion Presyncope and/or syncope as the sole manifestation of obstructive CAD, in the presence of normal ventricular function and valves, has rarely been reported. Myocardial ischaemia-mediated presyncope and/or syncope may be secondary to numerous mechanisms, which are described in this case report. Revascularization of the functionally significant proximal LAD stenosis resulted in cessation of exertional presyncope in our patient. The long-term outcome of revascularization in patients with presyncope and syncope needs to be further investigated.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London , Westminster Bridge Rd, London SE1 7EH, UK
| | - Ozan M Demir
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London , Westminster Bridge Rd, London SE1 7EH, UK
| | - Howard Ellis
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London , Westminster Bridge Rd, London SE1 7EH, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London , Westminster Bridge Rd, London SE1 7EH, UK
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Kligerman SJ, Bykowski J, Hurwitz Koweek LM, Policeni B, Ghoshhajra BB, Brown MD, Davis AM, Dibble EH, Johnson TV, Khosa F, Ledbetter LN, Leung SW, Liebeskind DS, Litmanovich D, Maroules CD, Pannell JS, Powers WJ, Villines TC, Wang LL, Wann S, Corey AS, Abbara S. ACR Appropriateness Criteria® Syncope. J Am Coll Radiol 2021; 18:S229-S238. [PMID: 33958116 DOI: 10.1016/j.jacr.2021.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
Syncope and presyncope lead to well over one million emergency room visits in the United States each year. Elucidating the cause of syncope or presyncope, which are grouped together given similar etiologies and outcomes, can be exceedingly difficult given the diverse etiologies. This becomes more challenging as some causes, such as vasovagal syncope, are relatively innocuous while others, such as cardiac-related syncope, carry a significant increased risk of death. While the mainstay of syncope and presyncope assessment is a detailed history and physical examination, imaging can play a role in certain situations. In patients where a cardiovascular etiology is suspected based on the appropriate history, physical examination, and ECG findings, resting transthoracic echocardiography is usually considered appropriate for the initial imaging. While no imaging studies are considered usually appropriate when there is a low probability of cardiac or neurologic pathology, chest radiography may be appropriate in certain clinical situations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Julie Bykowski
- University of California San Diego, San Diego, California
| | | | - Bruno Policeni
- Panel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Michael D Brown
- Michigan State University, East Lansing, Michigan, American College of Emergency Physicians
| | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois, American College of Physicians
| | | | - Thomas V Johnson
- Sanger Heart and Vascular Institute, Charlotte, North Carolina, Cardiology expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Steve W Leung
- Gill Heart & Vascular Institute, University of Kentucky, Lexington, Kentucky, Society for Cardiovascular Magnetic Resonance, Program Director, Advanced Cardiovascular Imaging Fellowship, Director of Cardiac MRI, University of Kentucky
| | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California, American Academy of Neurology
| | - Diana Litmanovich
- Harvard Medical School, Boston, Massachusetts, Section Chief, Cardiothoracic, Department of Radiology, Beth Israel Deaconess Medical Center, President, North American Society for Cardiovascular Imaging, Co-Chair, Image Wisely
| | | | | | - William J Powers
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, American Academy of Neurology
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia, Society of Cardiovascular Computed Tomography
| | - Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio, Program Director, Neuroradiology Fellowship, University of Cincinnati
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin, Nuclear cardiology expert
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas, Chief, Cardiothoracic Imaging, UT Southwestern, Member BOD, SCCT, Editor, Radiology - Cardiothoracic Imaging
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