Triggering of cardiovascular incidents by micturition and defecation

Out-of-hospital cardiac arrests in the toilet in Japan: a population-based descriptive study

Aim

This study aimed to reveal the characteristics and outcomes of patients with out‐of‐hospital cardiac arrests (OHCAs) occurring in the toilet. These traits provide useful clues for the prevention of OHCAs and the improvement of prehospital care for these patients.

Methods

Out‐of‐hospital cardiac arrest data were obtained from the population‐based, Utstein‐style registry in Osaka City, Japan, between 2009 and 2015. This study identified patients with OHCAs that occurred inside the toilet. The primary end‐point was 1‐month survival with favorable neurological outcome after OHCA.

Results

During the 7‐year study period, a total of 18,458 OHCAs were identified. Of these cases, 849 (4.6%) occurred inside the toilet. Among them, the analysis included 733 patients. The distribution depicting monthly OHCA occurrences showed that OHCAs tended to occur in cold months (28.1% [206/733] from October to December and 30.0% [220/733] from January to March). Most OHCAs occurring inside the toilet were of cardiac origin (91.5% [671/733]), and 36.2% (265/733) were witnessed by bystanders. The proportion of patients with ventricular fibrillation was 5.2% (38/733) and those receiving shocks by public‐access automated external defibrillators was 0.4% (3/733). The proportion of patients with 1‐month survival with favorable neurological outcome was 1.9% (14/733).

Conclusions

Out‐of‐hospital cardiac arrests occurring inside the toilet accounted for 4.6% of all OHCAs and were frequently observed during cold months, and their outcome was poor. Establishment of preventive measures against OHCAs occurring in the toilet as well as earlier recognition of OHCAs are needed.

Clinical characteristics of stroke occurring in the toilet: Are older adults more vulnerable?

AIM

While autonomic imbalance during defecation/micturition can cause hemodynamic instability, stroke occurring in the toilet has rarely been investigated. The objective of the present study was to clarify the frequency and clinical characteristics of toilet-related stroke.

METHODS

Clinical data prospectively acquired between January 2011 and December 2015 on 1939 patients with acute stroke (1224 cerebral infarctions [CI], 505 intracerebral hemorrhages [ICH] and 210 subarachnoid hemorrhages [SAH]) were reviewed to identify patients with a toilet-related stroke. For each stroke type, the ratios of stroke occurring during defecation/micturition to those occurring during other activities were calculated. Subsequently, how patients with toilet-related stroke were brought to medical attention was investigated. Whether older patients (aged >65 years) had an elevated ratio of toilet-related stroke was investigated in each stroke type.

RESULTS

A total of 108 patients (41 CI, 37 ICH and 30 subarachnoid hemorrhages) sustained a stroke in the toilet. The ratio of toilet-related stroke was highest in subarachnoid hemorrhages (14.3%), followed by ICH (7.3%). Circadian differences existed among the three stroke types: toilet-related CI were more likely to occur in the night-time than ICH. Patients with toilet-related CI were significantly more likely to sustain cardioembolic stroke. In all three stroke types, <40% of patients could call for help by themselves. Older patients showed a significantly higher proportion of toilet-related stroke in CI, but not in hemorrhagic strokes.

CONCLUSIONS

The toilet is a closed space where stroke occurs disproportionately frequently. Effort to reduce the incidence of toilet-related strokes is warranted, as early patient detection is not always feasible. Geriatr Gerontol Int 2018; 18: 250-255.

Cardiac arrest in the toilet: clinical characteristics and resuscitation profiles

OBJECTIVES

The great majority of non-traumatic cardiac arrests (CA) occur at home. The toilet is a closed and private room where CA occurs frequently. However, due to the feelings of privacy that are associated with this room, the circumstances and causes of CA in the toilet have rarely been investigated.

METHODS

A retrospective study was conducted to clarify clinical characteristics and resuscitation profiles of patients sustaining CA in the toilet.

RESULTS

Among 907 CA patients treated during a 4-year period, 101 (11 %) sustained CA in the toilet. While the collapse was witnessed in only 10 % of these patients, return of spontaneous circulation (ROSC) was achieved in 41 %. However, the long-term survival rate was 1 %. Multivariate regression analysis revealed that a history of cardiac diseases was predictive of CA in the toilet (odds ratio 3.045; 95 % confidence interval 1.756-5.282) but that there was no correlation with advanced age. The frequency of CA in the toilet may be influenced moderately by seasonal/circadian variations. The 101 patients were classified into four subgroups according to mode of discovery of CA. The frequency of ROSC was highest in those who collapsed in the presence of caregivers and lowest in those whose collapse were discovered later by family members being worried that the patient stayed in the toilet "too long." Imaging studies revealed life-threatening extra-cardiac lesions responsible for CA, such as subarachnoid hemorrhage and aortic dissection, in 23 % of the patient cohort.

CONCLUSIONS

The rarity of long-term survival among individuals sustaining CA in the toilet is mainly due to the delay in discovering the individual who collapsed. Although a history of cardiac diseases is a risk factor, predicting who may sustain CA in the toilet remains difficult due to etiological heterogeneity.

Acute risk factors for myocardial infarction

Increased knowledge concerning the triggering of acute cardiovascular diseases has yielded a change in philosophical approach to this field. During the last decade, clinical evidence suggested that the term acute risk factors can be used for the activities and events that suddenly and transiently increase the risk of acute cardiac diseases. External triggers, such as heavy physical activity, emotional stress, eating, cold or heat exposure, coffee or alcohol consumption, cocaine or marijuana use and sexual intercourse are recognized as most important acute risk factors. It is likely that the morning hours may be considered as an endogenous, external triggering independent acute risk factor related to physiological sympathetic arousal. The features of triggering have been best described for an acute myocardial infarction whose moment of onset appears to be the result of a dynamic interaction between an endogenous response to acute risk factors and patient vulnerability. In this article, pathophysiological changes implicated as internal triggering mechanisms are summarized and the terms sympathetic and parasympathetic triggering patterns are introduced. A highly individual approach tailored both to protect against acute risk factors and to reduce patient vulnerability could provide a more complete protection from myocardial infarction and other coronary incidents. Lifestyle modifications, regular physical activity and adequate drug regimens may at least prove able to defer the occurrence of coronary thrombosis, thereby providing time for the development of collateral vessels, plaque stabilization or invasive/surgical treatment.