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Lampert R, Chung EH, Ackerman MJ, Arroyo AR, Darden D, Deo R, Dolan J, Etheridge SP, Gray BR, Harmon KG, James CA, Kim JH, Krahn AD, La Gerche A, Link MS, MacIntyre C, Mont L, Salerno JC, Shah MJ. 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play. Heart Rhythm 2024; 21:e151-e252. [PMID: 38763377 DOI: 10.1016/j.hrthm.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 05/21/2024]
Abstract
Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.
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Affiliation(s)
- Rachel Lampert
- Yale University School of Medicine, New Haven, Connecticut
| | - Eugene H Chung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Rajat Deo
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joe Dolan
- University of Utah, Salt Lake City, Utah
| | | | - Belinda R Gray
- University of Sydney, Camperdown, New South Wales, Australia
| | | | | | | | - Andrew D Krahn
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Andre La Gerche
- Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | | | - Lluis Mont
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Jack C Salerno
- University of Washington School of Medicine, Seattle, Washington
| | - Maully J Shah
- Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania
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2
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Wakita R, Aida J, Baba Y, Utsumi N, Nakayama A, Maeda S. Transient bradycardia during local anaesthesia to the oral cavity under intravenous sedation and its associate factors: a prospective observational study. BMC Oral Health 2024; 24:1165. [PMID: 39354469 PMCID: PMC11443804 DOI: 10.1186/s12903-024-04940-0] [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: 05/10/2024] [Accepted: 09/20/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND Local anaesthesia in dental procedures is generally safe, although the occurrence of transient bradycardia (TB) has occasionally been reported. TB is often associated with two reflexes, the trigeminal cardiac reflex (TCR) and the vasovagal reflex (VVR) and is characterised by a rapid decrease in heart rate (HR) and blood pressure (BP). The prevalence of TCR is considered low, and its predictors have not been thoroughly investigated, although an association with the gag reflex has been suggested in recent years. METHODS This prospective study assessed TB occurrence during local anaesthesia and its potential associated factors. A comprehensive questionnaire was used to categorise discomforts during dental treatment, and various anxiety scales were used to measure patients' anxiety levels. We investigated HR variability during local anaesthesia administration under sedation and the association between the incidence of TB and gag reflex. Subsequently, logistic regression analysis was performed to assess factors associated with TB occurrence. RESULTS The prospective analysis included 188 patients of 234 initial patients. The analysis revealed a high TB incidence rate of 41% during local anaesthesia administration under sedation. No severe hypotensive events occurred, indicating a relatively benign nature of TB during local anaesthesia. TB occurrence was significantly higher in the group of patients with the gag reflex. Further analysis revealed that both gag reflex and trait anxiety were significantly associated with TB occurrence, whereas dental phobia did not directly correlate with TB. CONCLUSION This study highlights the prominent occurrence of TB during local anaesthesia in dental treatment, which is primarily attributed to TCR activation. The identification of gag reflex and trait anxiety as independent factors associated with TB development may pave the way for TB prevention measures. Further research is required to clarify the mechanisms of TCR and perform safer dental procedures under sedation. Future studies should also aim to elucidate the precise mechanisms underlying TB during local anaesthesia through direct measurements of neural activity. A better understanding of TB in dentistry is crucial for improving patient safety and optimising dental practice protocols.
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Affiliation(s)
- Ryo Wakita
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan.
| | - Jun Aida
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
| | - Yukiko Baba
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
| | - Nozomi Utsumi
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
| | - Ayumu Nakayama
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
| | - Shigeru Maeda
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8549, Japan
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3
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Russo V, Caturano A, Migliore F, Guerra F, Francia P, Nesti M, Conte G, Perini AP, Mascia G, Albani S, Marchese P, Santobuono VE, Dendramis G, Rossi A, Attena E, Ghidini AO, Sciarra L, Palamà Z, Baldi E, Romeo E, D'Onofrio A, Nigro G. Long-term clinical outcomes of patients with drug-induced type 1 Brugada electrocardiographic pattern: A nationwide cohort registry study. Heart Rhythm 2024; 21:555-561. [PMID: 38242222 DOI: 10.1016/j.hrthm.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND There are limited real-world data on the extended prognosis of patients with drug-induced type 1 Brugada electrocardiogram (ECG). OBJECTIVE We assessed the clinical outcomes and predictors of life-threatening arrhythmias in patients with drug-induced type 1 Brugada ECG. METHODS This multicenter retrospective study, conducted at 21 Italian and Swiss hospitals from July 1997 to May 2021, included consecutive patients with drug-induced type 1 ECG. The primary outcome, a composite of appropriate ICD therapies and sudden cardiac death, was assessed along with the clinical predictors of these events. RESULTS A total of 606 patients (mean age 49.7 ± 14.7 years; 423 [69.8%] men) were followed for a median of 60.3 months (interquartile range 23.0-122.4 months). Nineteen patients (3.1%) experienced life-threatening arrhythmias, with a median annual event rate of 0.5% over 5 years and 0.25% over 10 years. The SCN5A mutation was the only predictor of the primary outcome (hazard ratio 4.54; P = .002), whereas a trend was observed for unexplained syncope (hazard ratio 3.85; P = .05). In patients who were asymptomatic at presentation, the median annual rate of life-threatening arrhythmias is 0.24% over 5 years and increases to 1.2% if they have inducible ventricular fibrillation during programmed ventricular stimulation. CONCLUSION In patients with drug-induced type 1 Brugada ECG, the annual risk of life-threatening arrhythmias is low, with the SCN5A mutation as the only independent predictor. Unexplained syncope correlated with worse clinical outcomes. Ventricular fibrillation inducibility at programmed ventricular stimulation significantly increases the median annual rate of life-threatening arrhythmias from 0.24% to 1.2% over 5 years.
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Affiliation(s)
- Vincenzo Russo
- Division of Cardiology, Department of Medical Translational Sciences University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Federico Guerra
- Azienda Ospedaliera Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Pietro Francia
- Azienda Ospedaliero-Universitaria Sant'Andrea, Rome, Italy
| | - Martina Nesti
- Cardiovascular and Neurological Department, Ospedale San Donato, Arezzo, Italy
| | - Giulio Conte
- Cardiocentro Ticino Foundation, Lugano, Switzerland
| | | | | | | | | | - Vincenzo Ezio Santobuono
- Cardiology Unit, Department of Interdisciplinary Medicine and Policlinico of Bari, University of Bari "Aldo Moro", Bari, Italy
| | - Gregory Dendramis
- Cardiology Unit, Clinical and Interventional Arrhythmology, ARNAS, Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | | | | | | | | | | | | | - Emanuele Romeo
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy
| | - Antonio D'Onofrio
- Monaldi Hospital, Departmental Unit of Electrophysiology, Evaluation and Treatment of Arrhythmias, Naples, Italy
| | - Gerardo Nigro
- Division of Cardiology, Department of Medical Translational Sciences University of Campania "Luigi Vanvitelli", Naples, Italy
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4
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Wu S, Chen Z, Gao Y, Shu S, Chen F, Wu Y, Dai Y, Zhang S, Chen K. Development and Validation of a Novel Predictive Model for the Early Differentiation of Cardiac and Non-Cardiac Syncope. Int J Gen Med 2024; 17:841-853. [PMID: 38463438 PMCID: PMC10924787 DOI: 10.2147/ijgm.s454521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/26/2024] [Indexed: 03/12/2024] Open
Abstract
Background The diagnosis of cardiac syncope remains a challenge. This study sought to develop and validate a diagnostic model for the early identification of individuals likely to have a cardiac cause. Methods 877 syncope patients with a determined cause were retrospectively enrolled at a tertiary heart center. They were randomly divided into the training set and validation set at a 7:3 ratio. We analyzed the demographic information, medical history, laboratory tests, electrocardiogram, and echocardiogram by the least absolute shrinkage and selection operator (LASSO) regression for selection of key features. Then a multivariable logistic regression analysis was performed to identify independent predictors and construct a diagnostic model. The receiver operating characteristic curves, area under the curve (AUC), calibration curves, and decision curve analysis were used to evaluate the predictive accuracy and clinical value of this nomogram. Results Five independent predictors for cardiac syncope were selected: BMI (OR 1.088; 95% CI 1.022-1.158; P =0.008), chest symptoms preceding syncope (OR 5.251; 95% CI 3.326-8.288; P <0.001), logarithmic NT-proBNP (OR 1.463; 95% CI 1.240-1.727; P <0.001), left ventricular ejection fraction (OR 0.940; 95% CI 0.908-0.973; P <0.001), and abnormal electrocardiogram (OR 6.171; 95% CI 3.966-9.600; P <0.001). Subsequently, a nomogram based on a multivariate logistic regression model was developed and validated, yielding AUC of 0.873 (95% CI 0.845-0.902) and 0.856 (95% CI 0.809-0.903), respectively. The calibration curves showcased the nomogram's reasonable calibration, and the decision curve analysis demonstrated good clinical utility. Conclusion A diagnostic tool providing individualized probability predictions for cardiac syncope was developed and validated, which may potentially serve as an effective tool to facilitate early identification of such patients.
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Affiliation(s)
- Sijin Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Zhongli Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Gao
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Songren Shu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Feng Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Ying Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Dai
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Shu Zhang
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Keping Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Zangiabadian M, Soltani K, Gholinejad Y, Yahya R, Bastami S, Akbarzadeh MA, Sharifian Ardestani M, Aletaha A. Predictors of pacemaker requirement in patients with implantable loop recorder and unexplained syncope: A systematic review and meta-analysis. Clin Cardiol 2024; 47:e24221. [PMID: 38402528 PMCID: PMC10823547 DOI: 10.1002/clc.24221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 02/26/2024] Open
Abstract
Identifying the underlying cause of unexplained syncope is crucial for appropriate management of recurrent syncopal episodes. Implantable loop recorders (ILRs) have emerged as valuable diagnostic tools for monitoring patients with unexplained syncope. However, the predictors of pacemaker requirement in patients with ILR and unexplained syncope remain unclear. In this study, we shed light on these prognostic factors. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane CENTRAL were systematically searched until May 04, 2023. Studies that evaluated the predictors of pacemaker requirement in patients with implantable loop recorder and unexplained syncope were included. The "Quality In Prognosis Studies" appraisal tool was used for quality assessment. The pooled odds ratio (OR) with 95% confidence intervals (CIs) was calculated. The publication bias was evaluated using Egger's and Begg's tests. Ten studies (n = 4200) were included. Right bundle branch block (OR: 3.264; 95% CI: 1.907-5.588, p < .0001) and bifascicular block (OR: 2.969; 95% CI: 1.859-4.742, p < .0001) were the strongest predictors for pacemaker implantation. Pacemaker requirement was more than two times in patients with atrial fibrillation, sinus bradycardia and first degree AV block. Valvular heart disease, diabetes mellitus, and hypertension were also significantly more in patients with pacemaker implantation. Age (standardized mean difference [SMD]: 0.560; 95% CI: 0.410/0.710, p < .0001) and PR interval (SMD: 0.351; 95% CI: 0.150/0.553, p = .001) were significantly higher in patients with pacemaker requirement. Heart conduction disorders, atrial arrhythmias and underlying medical conditions are main predictors of pacemaker device implantation following loop recorder installation in unexplained syncopal patients.
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Affiliation(s)
- Moein Zangiabadian
- Endocrinology and Metabolism Re‐search Center, Institute of Basic and Clinical Physiology SciencesKerman University of Medical SciencesKermanIran
| | - Kiarash Soltani
- Shahid Beheshti University of Medical SciencesSchool of MedicineTehranIran
| | - Yasaman Gholinejad
- Shahid Beheshti University of Medical SciencesSchool of MedicineTehranIran
| | - Reyhane Yahya
- Shahid Beheshti University of Medical SciencesSchool of MedicineTehranIran
| | - Shayan Bastami
- Shahid Beheshti University of Medical SciencesSchool of MedicineTehranIran
| | | | | | - Azadeh Aletaha
- Evidence Based Medicine Research Center, Endocrinology and Metabolism Clinical Sciences InstituteTehran University of medical SciencesTehranIran
- Endocrinology and Metabolism Clinical Sciences Institute, Endocrinology and Metabolism Research CenterTehran University of Medical SciencesTehranIran
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6
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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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7
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Torabi P, Hamrefors V, Sutton R, Brignole M, Fedorowski A. Definitive aetiology of unexplained syncope after cardiovascular autonomic tests in a tertiary syncope unit. Europace 2023; 25:euad247. [PMID: 37589189 PMCID: PMC10505743 DOI: 10.1093/europace/euad247] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/24/2023] [Accepted: 08/13/2023] [Indexed: 08/18/2023] Open
Abstract
AIMS Syncope is a common condition with many possible causes, ranging from benign to life-threatening aetiologies. Establishing a diagnosis can be difficult, and specialized syncope units, using cardiovascular autonomic tests (CATs), including a head-up tilt test, can increase the diagnostic yield. However, up to one-fifth of examined patients have inconclusive CAT results. The aim of the present study was to investigate the predictive value of history, and clinical findings for unexplained syncope after CAT and characterize the group with negative results. METHODS AND RESULTS Consecutive syncope patients [n = 2663, 61% women, median age 52 (32-69) years] were evaluated and CAT explained aetiology of syncope in 79% of cases, whereas 21% remained unexplained. Predictors of negative CAT were older age at first syncope (+8% higher odds per 10-year increment, P = 0.042), higher supine heart rate (HR; +12% per 10 b.p.m.; P = 0.003), absence of prodromes (+48%; P < 0.001), hypertension (+45%; P = 0.003), diabetes (+82%; P < 0.001), heart failure (+98%; P = 0.014), and coronary artery disease (+51%; P = 0.027). Compared with vasovagal syncope, patients with negative CAT were older, reported more often the absence of prodromes, and had a higher burden of cardiovascular comorbidities. CONCLUSION A cardiovascular autonomic test established the cause of syncope in 79% of patients evaluated in a syncope unit. Syncope without prodromes and cardiovascular comorbidities were significant predictors of failure to reveal an aetiology from assessment by CAT. These are known risk factors for cardiac syncope and patients with inconclusive CAT warrant further investigation.
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Affiliation(s)
- Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Clinical Physiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milano, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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8
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Aegisdottir HM, Thorolfsdottir RB, Sveinbjornsson G, Stefansson OA, Gunnarsson B, Tragante V, Thorleifsson G, Stefansdottir L, Thorgeirsson TE, Ferkingstad E, Sulem P, Norddahl G, Rutsdottir G, Banasik K, Christensen AH, Mikkelsen C, Pedersen OB, Brunak S, Bruun MT, Erikstrup C, Jacobsen RL, Nielsen KR, Sørensen E, Frigge ML, Hjorleifsson KE, Ivarsdottir EV, Helgadottir A, Gretarsdottir S, Steinthorsdottir V, Oddsson A, Eggertsson HP, Halldorsson GH, Jones DA, Anderson JL, Knowlton KU, Nadauld LD, Haraldsson M, Thorgeirsson G, Bundgaard H, Arnar DO, Thorsteinsdottir U, Gudbjartsson DF, Ostrowski SR, Holm H, Stefansson K. Genetic variants associated with syncope implicate neural and autonomic processes. Eur Heart J 2023; 44:1070-1080. [PMID: 36747475 DOI: 10.1093/eurheartj/ehad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 11/22/2022] [Accepted: 01/05/2023] [Indexed: 02/08/2023] Open
Abstract
AIMS Syncope is a common and clinically challenging condition. In this study, the genetics of syncope were investigated to seek knowledge about its pathophysiology and prognostic implications. METHODS AND RESULTS This genome-wide association meta-analysis included 56 071 syncope cases and 890 790 controls from deCODE genetics (Iceland), UK Biobank (United Kingdom), and Copenhagen Hospital Biobank Cardiovascular Study/Danish Blood Donor Study (Denmark), with a follow-up assessment of variants in 22 412 cases and 286 003 controls from Intermountain (Utah, USA) and FinnGen (Finland). The study yielded 18 independent syncope variants, 17 of which were novel. One of the variants, p.Ser140Thr in PTPRN2, affected syncope only when maternally inherited. Another variant associated with a vasovagal reaction during blood donation and five others with heart rate and/or blood pressure regulation, with variable directions of effects. None of the 18 associations could be attributed to cardiovascular or other disorders. Annotation with regard to regulatory elements indicated that the syncope variants were preferentially located in neural-specific regulatory regions. Mendelian randomization analysis supported a causal effect of coronary artery disease on syncope. A polygenic score (PGS) for syncope captured genetic correlation with cardiovascular disorders, diabetes, depression, and shortened lifespan. However, a score based solely on the 18 syncope variants performed similarly to the PGS in detecting syncope risk but did not associate with other disorders. CONCLUSION The results demonstrate that syncope has a distinct genetic architecture that implicates neural regulatory processes and a complex relationship with heart rate and blood pressure regulation. A shared genetic background with poor cardiovascular health was observed, supporting the importance of a thorough assessment of individuals presenting with syncope.
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Affiliation(s)
- Hildur M Aegisdottir
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
| | | | | | | | | | | | | | | | | | - Egil Ferkingstad
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | - Patrick Sulem
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | | | | | - Karina Banasik
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3A, Copenhagen 2200, Denmark
| | - Alex Hoerby Christensen
- The Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 1, Herlev 2730, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
| | - Christina Mikkelsen
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Blegdamsvej 3A, Copenhagen 2200, Denmark
| | - Ole Birger Pedersen
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
- Department of Clinical Immunology, Zealand University Hospital - Køge, Lykkebækvej 1, Køge 4600, Denmark
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3A, Copenhagen 2200, Denmark
| | - Mie Topholm Bruun
- Department of Clinical Immunology, Odense University Hospital, J. B. Winsløws Vej 4, Odense 5000, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
- Department of Clinical Medicine, Aarhus University, Nordre Ringgade 1, Aarhus 8000, Denmark
| | - Rikke Louise Jacobsen
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Kaspar Rene Nielsen
- Department of Clinical Immunology, Aalborg University Hospital, Urbansgade 32, Aalborg 9000, Denmark
| | - Erik Sørensen
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Michael L Frigge
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | | | | | - Anna Helgadottir
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | | | | | - Asmundur Oddsson
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | | | | | - David A Jones
- Precision Genomics, Intermountain Healthcare, 600 S. Medical Center Drive, Saint George, UT 84790, USA
| | - Jeffrey L Anderson
- Intermountain Medical Center, Intermountain Heart Institute, 5171 S. Cottonwood Street Building 1, Salt Lake City, UT 84107, USA
- Department of Internal Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Kirk U Knowlton
- Intermountain Medical Center, Intermountain Heart Institute, 5171 S. Cottonwood Street Building 1, Salt Lake City, UT 84107, USA
- School of Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Lincoln D Nadauld
- Precision Genomics, Intermountain Healthcare, 600 S. Medical Center Drive, Saint George, UT 84790, USA
- School of Medicine, Stanford University, 291 Campus Drive, Stanford, CA 94305, USA
| | | | - Magnus Haraldsson
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
- Department of Psychiatry, Landspitali, The National University Hospital of Iceland, Hringbraut, Reykjavik 101, Iceland
| | - Gudmundur Thorgeirsson
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
- Department of Medicine, Landspitali, The National University Hospital of Iceland, Hringbraut, Reykjavik 101, Iceland
| | - Henning Bundgaard
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
- The Capital Regions Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - David O Arnar
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
- Department of Medicine, Landspitali, The National University Hospital of Iceland, Hringbraut, Reykjavik 101, Iceland
| | - Unnur Thorsteinsdottir
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
| | - Daniel F Gudbjartsson
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- School of Engineering and Natural Sciences, University of Iceland, Hjardarhagi 4, Reykjavik 107, Iceland
| | - Sisse R Ostrowski
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Hilma Holm
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | - Kari Stefansson
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
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9
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Killu AM, Yang M, Naksuk N, Tri J, Li X, Asirvatham R, Asirvatham SJ, Cha YM. Stellate ganglia stimulation counteracts vagal stimulation by significantly increasing heart rate and blood pressure. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01516-w. [PMID: 36892802 DOI: 10.1007/s10840-023-01516-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 02/16/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Vasovagal syncope (VVS) is the leading cause of syncope. The most frequent mechanism is that of a cardioinhibitory response, vasodepressor response, or mixture of both. Neural stimulation that negates or overcomes the effects of vagal tone may be used as a treatment strategy for VVS. METHODS Six male canines were studied. Stimulation (10-Hz, 2 ms pulse duration, 2 min duration) of the cervical vagus (CV), thoracic vagus (TV), and stellate ganglia (SG) was performed using needle electrodes at 3 V, 5 V, and 10 V output. SG stimulation at an output of 10 V overlaying TV stimulation at the same output was performed. Heart rate (HR), blood pressure (BP), and cardiac output (CO) were measured before, during, and after stimulation. RESULTS Right cervical vagal stimulation was associated with significant hemodynamic changes. HR, SBP, and DBP were reduced (107 ± 16 vs. 78 ± 15 bpm [P < 0.0001], 116 ± 24 vs. 107 ± 28 mmHg [P = 0.002] and 71 ± 18 vs. 58 ± 20 mmHg [P < 0.0001]), respectively, while left cervical vagal stimulation had minimal changes. CV stimulation was associated with greater hemodynamic changes than TV stimulation. Left and right SG stimulation significantly increased systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR at 5 V and 10 V, which could be observed within 30 s after stimulation. An output-dependent increase in hemodynamic parameters was seen with both left and right SG stimulation. No difference between left and right SG stimulation was seen. SG stimulation overlay significantly increased HR, BP, and CO from baseline vagal stimulation bilaterally. CONCLUSIONS Stellate ganglia stimulation leads to increased HR and BP despite significant vagal stimulation. This may be exploited therapeutically in the management of vasovagal syncope.
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Affiliation(s)
- Ammar M Killu
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mei Yang
- Department of Cardiology, Xinhua Hospital, 1665 Kongjiang Rd, Yangpu Qu, Shanghai Shi, 200000, China
| | - Niyada Naksuk
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jason Tri
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Xuping Li
- Department of Cardiovascular medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Roshini Asirvatham
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Yong-Mei Cha
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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10
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Williams EL, Khan FM, Claydon VE. Counter pressure maneuvers for syncope prevention: A semi-systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:1016420. [PMID: 36312294 PMCID: PMC9606335 DOI: 10.3389/fcvm.2022.1016420] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/20/2022] [Indexed: 11/24/2022] Open
Abstract
Physical counter pressure maneuvers (CPM) are movements that are recommended to delay or prevent syncope (fainting) by recruiting the skeletal muscle pump to augment cardiovascular control. However, these recommendations are largely based on theoretical benefit, with limited data evaluating the efficacy of CPM to prevent syncope in the real-world setting. We conducted a semi-systematic literature review and meta-analysis to assess CPM efficacy, identify literature gaps, and highlight future research needs. Articles were identified through a literature search (PubMed, April 2022) of peer-reviewed publications evaluating the use of counter pressure or other lower body maneuvers to prevent syncope. Two team members independently screened records for inclusion and extracted data. From 476 unique records identified by the search, 45 met inclusion criteria. Articles considered various syncopal conditions (vasovagal = 12, orthostatic hypotension = 8, postural orthostatic tachycardia syndrome = 1, familial dysautonomia = 2, spinal cord injury = 1, blood donation = 10, healthy controls = 11). Maneuvers assessed included hand gripping, leg fidgeting, stepping, tiptoeing, marching, calf raises, postural sway, tensing (upper, lower, whole body), leg crossing, squatting, “crash” position, and bending foreword. CPM were assessed in laboratory-based studies (N = 28), the community setting (N = 4), both laboratory and community settings (N = 3), and during blood donation (N = 10). CPM improved standing systolic blood pressure (+ 14.8 ± 0.6 mmHg, p < 0.001) and heart rate (+ 1.4 ± 0.5 bpm, p = 0.006), however, responses of total peripheral resistance, stroke volume, or cerebral blood flow were not widely documented. Most patients experienced symptom improvement following CPM use (laboratory: 60 ± 4%, community: 72 ± 9%). The most prominent barrier to employing CPM in daily living was the inability to recognize an impending faint. Patterns of postural sway may also recruit the skeletal muscle pump to enhance cardiovascular control, and its potential as a discrete, proactive CPM needs further evaluation. Physical CPM were successful in improving syncopal symptoms and producing cardiovascular responses that may bolster against syncope; however, practical limitations may restrict applicability for use in daily living.
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11
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Zaidi S, Ahmed R, Jallad A. A Complete Workup of Recurrent Syncope Caused by Significant Left Main Coronary Artery Stenosis. Cureus 2022; 14:e25909. [PMID: 35844325 PMCID: PMC9278799 DOI: 10.7759/cureus.25909] [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] [Accepted: 06/13/2022] [Indexed: 11/05/2022] Open
Abstract
Syncope is usually caused by cerebral hypoperfusion. Differentials to consider during the workup of syncope includes vasovagal, orthostatic, drug-induced, arrhythmia, structural heart disease, and ischemic cardiomyopathy. An 81-year-old African American man with recurrent witnessed syncopal events and newly diagnosed heart failure underwent extensive cardiac workup including electrocardiograms (EKG), echocardiogram, Holter monitor, electrophysiology (EP) study, and coronary angiogram. The workup revealed ischemic ventricular tachycardia in the setting of significant coronary artery disease including 80% distal left main disease. The patient underwent a coronary artery bypass graft (CABG) with subsequent resolution of further syncopal events. The patient was successfully discharged with guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF) and coronary artery disease (CAD). It is very rare for ischemic cardiomyopathy to present as syncope; however, it is not unheard of. Extensive transmural ischemia could lead to ventricular arrhythmias, a known cause of syncope. This rare presentation serves as a reminder to consider ischemic heart disease in the evaluation of syncope.
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12
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Risk stratification of sudden cardiac death in Brugada syndrome: an updated review of literature. Egypt Heart J 2022; 74:25. [PMID: 35404008 PMCID: PMC9001772 DOI: 10.1186/s43044-022-00267-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
Brugada syndrome is a rare but serious inherited heart disease that causes sudden cardiac death by polymorphic ventricular tachycardia or ventricular fibrillation. It is an autosomal dominant genetic disease that usually occurs in patients in their forties with a structurally normal heart. Electrically, it manifests by ST elevation segment ≥ 2 mm of at least one right precordial lead (V1 and/or V2). Stratification of sudden cardiac death in Brugada syndrome is not always easy and constitutes a real challenge for the practitioner. In this review, we will present the current state of knowledge for arrhythmic risk stratification and the prevention of sudden cardiac death that can result from this syndrome.
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13
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Simos P, Scott I. Appropriate use of transthoracic echocardiography in the investigation of general medicine patients presenting with syncope or presyncope. Postgrad Med J 2022; 99:postgradmedj-2021-141416. [PMID: 35169024 DOI: 10.1136/postgradmedj-2021-141416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/22/2022] [Indexed: 01/03/2023]
Abstract
STUDY PURPOSE Routine transthoracic echocardiography (TTE) in patients with syncope or presyncope is resource-intensive. We assessed if risk thresholds defined by a validated risk score may identify patients at low risk of cardiac abnormality in whom TTE is unnecessary. STUDY DESIGN We conducted a retrospective study of all general medicine patients with syncope/presyncope presenting to a tertiary hospital between July 2016 and September 2020 and who underwent TTE. The Canadian Syncope Risk Score (CSRS) was used to categorise patients as low to very low risk (score -3 to 0) or moderate to high risk (score ≥1) for serious adverse events at 30 days. A cut-point of 0 was used to calculate the sensitivity, specificity, positive and negative predictive values (PPV and NPV) for CSRS and the odds ratio (OR) of a clinically significant finding on TTE in patients with CSRS ≥1 compared with all patients. RESULTS Among 157 patients, the CSRS categorised 69 (44%) as very low to low risk in whom TTE was normal. In 88 patients deemed moderate to high risk, TTE detected a cardiac abnormality in 24 (27%). A CSRS ≥1 yielded a sensitivity of 100% (95% CI 85.7% to 100%), specificity of 51.1% (95% CI 42.3% to 59.8%), PPV of 26.5% (95% CI 26.3% to 30.1%) and NPV of 100% (95% CI 92.5% to 100%) for cardiac abnormalities and doubled the odds of an abnormality (OR=2.05, 95% CI 1.08 to 3.87, p=0.028). CONCLUSION In general medicine patients with syncope/presyncope, using the CSRS to stratify risk of a cardiac abnormality on TTE can almost halve TTE use.
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Affiliation(s)
- Peter Simos
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia .,School of Clinical Medicine, University of Queensland Faculty of Health and Behavioural Sciences, Herston, Queensland, Australia
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14
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Unexplained Syncope: The Importance of the Electrophysiology Study. HEARTS 2021. [DOI: 10.3390/hearts2040038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Syncope of cardiac origin may be associated with an increased risk of sudden cardiac death if not treated in a timely and appropriate manner. The diagnostic approach of syncope imposes a significant economic burden on society. The investigation and elucidation of the pathogenetic mechanism of syncope are of great clinical importance, as both prognosis and appropriate therapeutic approaches depend on these factors. The responsible mechanism of presyncope or syncope can only be revealed through the patient history, baseline clinical examination and electrocardiogram. The percentage of patients who are diagnosed with these tests alone exceeds 50%. In patients with a history of organic or acquired heart disease or/and the presence of abnormal findings on the electrocardiogram, a further diagnostic electrophysiology inclusive approach should be followed to exclude life threatening arrhythmiological mechanism. However, if the patient does not suffer from underlying heart disease and does not show abnormal electrocardiographic findings in the electrocardiogram, then the probability in the electrophysiology study to find a responsible cause is small but not absent. The role of a two-step electrophysiology study inclusive risk stratification approach for the effective management of the former is thoroughly discussed in this review.
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15
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Can I Send This Syncope Patient Home From the Emergency Department? J Emerg Med 2021; 61:801-809. [PMID: 34535304 DOI: 10.1016/j.jemermed.2021.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/18/2021] [Accepted: 07/25/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Syncope is a common presentation to the emergency department (ED). A significant minority of these patients have potentially life-threatening pathology. Reliably identifying that patients require hospital admission for further workup and intervention is imperative. CLINICAL QUESTION In patients who present with syncope, is there a reliable decision tool that clinicians can use to predict the risk of adverse outcome and determine who may be appropriate for discharge? EVIDENCE REVIEW Four articles were reviewed. The first retrospective study found no difference in mortality or adverse events in patients admitted for further evaluation rather than discharged home with primary care follow-up. The next two articles examined the derivation and validation of the Canadian Syncope Risk Score (CSRS). After validation with an admission threshold score of -1, the sensitivity and specificity of the CSRS was 97.8% (95% confidence interval [CI] 93.8-99.6%) and 44.3% (95% CI 42.7-45.9%), respectively. The last article looked at the derivation of the FAINT score, a recently developed score to risk stratify syncope patients. A FAINT score of ≥ 1 (any score 1 or higher should be admitted) had a sensitivity of 96.7% (95% CI 92.9-98.8%) and specificity 22.2% (95% CI 20.7-23.8%). CONCLUSIONS Syncope remains a difficult chief symptom to disposition from the ED. The CSRS is modestly effective at establishing a low probability of actionable disease or need for intervention. However, CSRS might not reduce unnecessary hospitalizations. The FAINT score has yet to undergo validation; however, the initial derivation study offers less diagnostic accuracy compared with the CSRS.
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16
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Mascia G, Bona RD, Ameri P, Canepa M, Porto I, Parati G, Crotti L, Brignole M. Brugada syndrome and syncope: a practical approach for diagnosis and treatment. Europace 2021; 23:996-1002. [PMID: 33367713 DOI: 10.1093/europace/euaa370] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/17/2020] [Indexed: 11/13/2022] Open
Abstract
Syncope in patients with Brugada electrocardiogram pattern may represent a conundrum in the decision algorithm because incidental benign forms, especially neurally mediated syncope, are very frequent in this syndrome similarly to the general population. Arrhythmic syncope in Brugada syndrome typically results from a self-terminating sustained ventricular tachycardia or paroxysmal ventricular fibrillation, potentially leading to sudden cardiac death. Distinguishing syncope due to malignant arrhythmias from a benign form is often difficult unless an electrocardiogram is recorded during the episode. We performed a review of the existing literature and propose a practical approach for diagnosis and treatment of the patients with Brugada syndrome and syncope.
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Affiliation(s)
- Giuseppe Mascia
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Roberta Della Bona
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Marco Canepa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Italo Porto
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Lia Crotti
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Milan, Italy
| | - Michele Brignole
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Faint & Fall Programme, Ospedale San Luca, Piazzale Brescia 20, 20149 Milan, Italy.,Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy
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17
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A case of variant angina associated with syncope detected by an implantable loop recorder. J Electrocardiol 2021; 67:115-118. [PMID: 34147012 DOI: 10.1016/j.jelectrocard.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 11/23/2022]
Abstract
The implantable loop recorder (ILR) is a small device used to monitor the electrical activity of the heart by recording a single‑lead bipolar electrocardiograph signal over a long period of time. The ILR is a valid diagnostic tool but has been vastly underused. In addition to arrhythmia, the ILR may be a useful tool for the detection of repolarization disorders in patients with myocardial ischemia.
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18
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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. [Adult advanced life support]. Notf Rett Med 2021; 24:406-446. [PMID: 34121923 PMCID: PMC8185697 DOI: 10.1007/s10049-021-00893-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Köln, Köln, Deutschland
| | - Pierre Carli
- SAMU de Paris, Center Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, Frankreich
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
- Warwick Medical School, University of Warwick, Coventry, Großbritannien
| | - Charles D. Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, Großbritannien
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, Großbritannien
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Schweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Schweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norwegen
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Pordenone, Italien
| | - Gavin D. Perkins
- Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, University of Warwick, Coventry, Großbritannien
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rom, Italien
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rom, Italien
| | - Jerry P. Nolan
- Warwick Medical School, Coventry, Großbritannien, Consultant in Anaesthesia and Intensive Care Medicine Royal United Hospital, University of Warwick, Bath, Großbritannien
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19
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A Rational Evaluation of the Syncope Patient: Optimizing the Emergency Department Visit. ACTA ACUST UNITED AC 2021; 57:medicina57060514. [PMID: 34064050 PMCID: PMC8224075 DOI: 10.3390/medicina57060514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/13/2022]
Abstract
Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a structured approach to the syncope patient in the emergency department, highlighting the evidence supporting the role of clinical judgement and the initial electrocardiogram (ECG) in making the preliminary diagnosis and in safely identifying the patients at low risk of short- and long-term adverse events or admitting the patient if likely to benefit from urgent intervention. Clinical decision tools and additional testing may aid in further stratifying patients and may guide disposition. While hospital admission does not seem to offer additional mortality benefit, the efficient utilization of outpatient testing may provide similar diagnostic yield, preventing unnecessary hospitalizations.
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20
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Környei L, Szabó A, Róth G, Kardos A, Fogarasi A. Frequency of syncope as a presenting symptom in channelopathies diagnosed in childhood. Can the multivariable EGSYS score unmask these children? Eur J Pediatr 2021; 180:1553-1559. [PMID: 33447893 DOI: 10.1007/s00431-020-03913-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/13/2020] [Accepted: 12/16/2020] [Indexed: 11/24/2022]
Abstract
Pediatric syncope raises cardiac etiology concern as it might be the first sign of life-threatening arrhythmia syndromes. Our aim was to study the incidence of syncope as the presenting symptom in children with arrhythmia syndromes, and if known, warning signs are helpful to reveal the arrhythmic origin. All data on children with channelopathy was followed by a tertiary pediatric cardiac center between 2000 and 2018 and data were reviewed retrospectively. Forty-eight patients were enrolled, representing long QT syndrome (n = 39), catecholaminergic polymorphic ventricular tachycardia (n = 5), and Brugada syndrome (n = 4). Presenting symptoms were syncope in 13 cases [27%] (including 7 initially mislabeled as epilepsy) and sudden cardiac arrest (SCA) in 9 cases [19%]. In the rest of the group, the concern for arrhythmic etiology was raised by either an abnormal ECG during sports medicine screening (n = 13) [27%] or a positive family history of channelopathy (n = 13) [27%]. None of the patients presenting with SCA had a prior syncopal history. Six patients presenting with syncope and afterward treated with ICD had an appropriate shock. Description of witnessed syncope was available in eight out of thirteen children presenting with syncope. Multivariable EGSYS score suggested cardiac origin (≥ 3 points) in 7 out of 8 (88%) patients.Conclusions: Syncope was a relatively uncommon presenting symptom of channelopathies in this sample and did not always precede sudden cardiac arrests. However, we found that multivariable EGSYS score can identify syncope of arrhythmic origin, raising suspicion for pediatric channelopathies even in patients previously misdiagnosed with epilepsy. What is known: • Cardiac syncope is rare in children but can be the first sign of a potentially fatal primary arrhythmia syndrome and is frequently misdiagnosed as atypical/therapy-resistant epilepsy. • Multivariate EGSYS score is effective to diagnose cardiac syncope in adults. What is new: • Cardiac syncope as a presenting symptom is not common in children with cardiac channelopathies and is not often present before sudden cardiac arrest. • Multivariable EGSYS score might identify cardiac syncope in children with a hereditary and secondary channelopathy.
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Affiliation(s)
- László Környei
- Gottsegen György Hungarian Institute of Cardiology, Pediatric Heart Center, Haller u. 29, Budapest, 1096, Hungary.
| | - Andrea Szabó
- Gottsegen György Hungarian Institute of Cardiology, Pediatric Heart Center, Haller u. 29, Budapest, 1096, Hungary
| | - György Róth
- Gottsegen György Hungarian Institute of Cardiology, Pediatric Heart Center, Haller u. 29, Budapest, 1096, Hungary
| | - Attila Kardos
- Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - András Fogarasi
- Department of Neurology, Bethesda Children's Hospital, Budapest, Hungary
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21
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Abstract
INTRODUCTION Suspected transient loss of consciousness (T-LOC) and syncope are common causes of hospitalization in older patients. Arrhythmias are the most common cardiac causes of syncope. Although a number of instrumental diagnostic procedures are usually routinely performed in patients with suspected syncope, a 12 leads electrocardiogram (ECG) is the only instrumental test recommended for the initial evaluation of these patients. EVIDENCE ACQUISITION In this paper current literature on this topic will be reviewed, including ECG diagnostic criteria and findings suggestive of cardiac syncope. EVIDENCE SYNTHESIS The ECG may disclose an arrhythmia associated with a high likelihood of syncope, avoiding further evaluations and permitting institution of specific treatment in 7% of patients referred to emergency department. When the cause of syncope remains uncertain after initial evaluation the next step is to assess the risk of major cardiovascular events or sudden cardiac death. An abnormal ECG selected patients with high probabiliry of cardiac syncope. ECG diagnostic criteria and ECG findings suggesting arrhythmic syncope are presented. Indications and potential clinical implications of ECG monitoring will be discussed too. CONCLUSIONS A careful, well-conducted medical history focused on the suspected syncopal event is crucial for the diagnosis. In this setting, the ECG is a mandatory diagnostic tool which, although normal in the majority of patients of syncope, has the potential to identify patients with high likelihood of cardiac syncope due to arrhythmic or cardiopulmonary disorder.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Attilio Del Rosso
- Cardiology Division, San Giuseppe Hospital, Empoli, Firenze, Italy -
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22
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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation 2021; 161:115-151. [PMID: 33773825 DOI: 10.1016/j.resuscitation.2021.02.010] [Citation(s) in RCA: 479] [Impact Index Per Article: 159.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Pierre Carli
- SAMU de Paris, Centre Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, France
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry,UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; South Central Ambulance Service NHS Foundation Trust, Otterbourne,UK
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden, Department of Medicine Solna, Karolinska Institutet,Stockholm, Sweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet Mainz, Germany
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Italy
| | - Gavin D Perkins
- University of Warwick, Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, Coventry, UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL; Royal United Hospital, Bath, UK
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Hu E, Liu X, Chen Q, Wang C. Investigation on the Incidence of Syncope in Children and Adolescents Aged 2-18 Years in Changsha. Front Pediatr 2021; 9:638394. [PMID: 33829003 PMCID: PMC8019745 DOI: 10.3389/fped.2021.638394] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/03/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives: Syncope is a common clinical symptom, while there are less relevant literature and targeted research on childhood morbidity. This article makes a cross-section survey on the incidence of syncope in children and adolescents aged 2-18 years in Changsha. Materials and Methods: There were 4,352 children and adolescents aged 2-18 years randomly selected from six primary and secondary schools and three kindergartens in Changsha from March 2018 to November 2018. There were 4,916 standardized questionnaires issued, and 4,352 (88.53%) valid questionnaires were recovered. Results: (1) Incidence: 17.37% of children and adolescents aged 2-18 years who had at least more than one syncope; the incidence in the adolescence (28.85%) was higher than that in the school age (8.32%) and in the preschool age (2.71%) (P < 0.01). (2) Age at onset: 13.9 ± 3.1 years old, with a peak age of 16 years. (3) Gender difference: The incidence in adolescent females was higher than that in males (31.72 vs. 26.25%, P < 0.05). In inducements, females had higher rates than males in sweltering environment (P < 0.01), whereas males had higher rates than females in urination (P < 0.05). Dizziness, nausea, sweating, and facial pallor were higher in females than in males in presyncope (P < 0.05). Conclusions: The incidence of syncope in children and adolescents aged 2-18 years in Changsha is 17.37%. The incidence of syncope is different between males and females in different age groups; there are gender differences in syncope inducements and presyncope.
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Affiliation(s)
- Erlin Hu
- Department of Pediatric, Changsha Maternal and Child Health Hospital, Hunan Normal University, Changsha, China
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoyan Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatric, Changsha Central Hospital, University of South China, Changsha, China
| | - Qianqian Chen
- Department of Pediatric, Changsha Maternal and Child Health Hospital, Hunan Normal University, Changsha, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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Onuki T, Shoji M, Sugiyama H, Arai S, Yoshikawa K, Mase H, Kurata M, Kikuchi M, Wakatsuki D, Asano T, Suzuki H, Tanno K, Kobayashi Y, Shinke T. Clinical predictors for bradycardia and supraventricular tachycardia necessitating therapy in patients with unexplained syncope monitored by insertable cardiac monitor. Clin Cardiol 2021; 44:683-691. [PMID: 33724499 PMCID: PMC8119800 DOI: 10.1002/clc.23594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/06/2021] [Accepted: 03/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background Insertable cardiac monitors (ICMs) improve diagnostic yield in patients with unexplained syncope. The most of cardiac syncope is arrhythmic causes include paroxysmal bradycardia and supraventricular tachycardia (SVT) in patients with unexplained syncope receiving ICM. Predictors for bradycardia and SVT that necessitate therapy in patients with unexplained syncope are not well known. Hypothesis This study aimed to investigate predictors of bradycardia and SVT necessitating therapy in patients with unexplained syncope receiving ICMs. Methods We retrospectively reviewed medical records of consecutive patients who received ICMs to monitor unexplained syncope. We performed Cox's stepwise logistic regression analysis to identify significant independent predictors for bradycardia and SVT. Results One hundred thirty‐two patients received ICMs to monitor unexplained syncope. During the 17‐month follow‐up period, 19 patients (14%) needed pacemaker therapy for bradycardia; 8 patients (6%) received catheter ablation for SVT. The total estimated diagnostic rates were 34% and 48% at 1 and 2 years, respectively. Stepwise logistic regression analysis indicated that syncope during effort (odds ratio [OR] = 3.41; 95% confidence interval [CI], 1.21 to 9.6; p = .02) was an independent predictor for bradycardia. Palpitation before syncope (OR = 9.46; 95% CI, 1.78 to 50.10; p = .008) and history of atrial fibrillation (OR = 10.1; 95% CI, 1.96 to 52.45; p = .006) were identified as significant independent predictors for SVT. Conclusion Syncope during effort, and palpitations or history of atrial fibrillation were independent predictors for bradycardia and for SVT. ICMs are useful devices for diagnosing unexplained syncope.
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Affiliation(s)
- Tatsuya Onuki
- Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan
| | - Makoto Shoji
- Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan
| | - Hiroto Sugiyama
- Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan
| | - Shuhei Arai
- Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan
| | - Kosuke Yoshikawa
- Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan
| | - Hiroshi Mase
- Division of Cardiology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Masaaki Kurata
- Division of Cardiology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Miwa Kikuchi
- Cardiovascular Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Daisuke Wakatsuki
- Division of Cardiology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Taku Asano
- Division of Cardiology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Kaoru Tanno
- Cardiovascular Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Youichi Kobayashi
- Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University, Tokyo, Japan
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Malik BR, Ali Rudwan AM, Abdelghani MS, Mohsen M, Khan SHA, Aljefairi N, Mahmoud E, Asaad N, Hayat SA. Brugada Syndrome: Clinical Features, Risk Stratification, and Management. Heart Views 2020; 21:88-96. [PMID: 33014301 PMCID: PMC7507903 DOI: 10.4103/heartviews.heartviews_44_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/29/2020] [Indexed: 01/25/2023] Open
Abstract
In 1992, the Brugada brothers published a patient series of aborted sudden death, who were successfully resuscitated from ventricular fibrillation (VF). These patients had a characteristic coved ST-segment elevation in the right precordial leads on their 12-lead electrocardiogram with no apparent structural heart abnormality. This disease was referred to as “right bundle branch block, persistent ST-segment elevation, and sudden death syndrome.” The term Brugada syndrome (BrS) was first coined for this new arrhythmogenic entity in 1996. BrS is more prevalent in Southeast Asian ethnic groups and was considered a familial disease due to the presence of syncope and/or sudden deaths in several members of the same family, however, the genetic alteration was only noted in 1998. The genetic characterization of BrS has proven to be challenging. The most common and well-established BrS genotype involves loss-of-function mutations in the SCN5A gene, but only represents between 15% and 30% of the diagnosed patients. Patients with BrS can present with a range of symptoms which can include syncope, seizures, and nocturnal agonal breathing due to polymorphic ventricular tachycardia or VF. If these arrhythmias are sustained, sudden cardiac death may result. Despite the significant progress on the understanding of BrS over the last two decades, there remain a number of uncertainties and challenges; we present an update review on the subject.
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Affiliation(s)
| | | | | | - Mohammed Mohsen
- Department of Electrophysiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Shahul Hameed A Khan
- Department of Electrophysiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Nora Aljefairi
- Department of Electrophysiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Elsayed Mahmoud
- Department of Electrophysiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Nidal Asaad
- Department of Electrophysiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Sajad Ahmed Hayat
- Department of Electrophysiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Perego M, Porteiro Vàzquez DM, Ramera L, Lombardo SF, Pane C, Bontempi LV, Santilli RA. Heart rhythm characterisation during unexplained transient loss of consciousness in dogs. Vet J 2020; 263:105523. [PMID: 32928492 DOI: 10.1016/j.tvjl.2020.105523] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
The identification of the heart rhythm during an episode of transient loss of consciousness (TLOC) is considered the reference standard method to elucidate the underlying aetiology. This study aimed to characterise heart rhythm in dogs during TLOC using Holter and external loop recorder monitoring. We retrospectively reviewed 24-h Holter monitoring and external loop recorder tracings from 8084 dogs. Heart rhythms from dogs that experienced TLOC during the recording was analysed to identify rhythm disturbances that occurred during episodes of TLOC. Electrocardiograms (ECGs) were subsequently categorised into Type 1 (ventricular arrest), Type 2 (sinus bradycardia), Type 3 (no/slight rhythm variations), and Type 4 (tachycardia). Transient LOC was documented in 92 dogs over 230 episodes of TLOC. Percentage of cases with ECGs compatible with each classification were as follows: 72.1%, Type 1; 6.1%, Type 2; 20.9%, Type 3; and 0.9%, Type 4. Cardiac rhythm during the TLOC could have been a consequence of a neurocardiogenic mechanism in 46.7% cases, while intrinsic rhythm disturbances of the sinus node or of the atrioventricular node were diagnosed in 31.5% cases. In two cases, tachycardia was the possible cause of the TLOC. ECG patterns in dogs presenting with multiple TLOC episodes were completely reproducible during each episode. TLOC in dogs was primarily caused by ventricular arrest. Most dogs with TLOC had electrocardiographic finding suggestive of a reflex or neurally-mediated syncope, but one third had an ECG more suggestive of a conduction disorder. Distinguishing these two entities could help inform diagnostic, therapeutic, and prognostic plans.
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Affiliation(s)
- M Perego
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017, Samarate, Varese, Italy; Ospedale Veterinario I Portoni Rossi, Via Roma 57, 40069, Zola Predosa, Bologna, Italy
| | | | - L Ramera
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017, Samarate, Varese, Italy
| | - S F Lombardo
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017, Samarate, Varese, Italy; Ospedale Veterinario I Portoni Rossi, Via Roma 57, 40069, Zola Predosa, Bologna, Italy
| | - C Pane
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017, Samarate, Varese, Italy
| | - L V Bontempi
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017, Samarate, Varese, Italy
| | - R A Santilli
- Clinica Veterinaria Malpensa, Viale Marconi 27, 21017, Samarate, Varese, Italy; Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853 USA.
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de Sousa Bispo J, Azevedo P, Mota T, Fernandes R, Guedes J, Candeias R, Marques NS, Camacho A, Jesus I. EGSYS score for the prediction in cardiac etiology in syncope: Is it useful in an out-patient setting? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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de Sousa Bispo J, Azevedo P, Mota T, Fernandes R, Guedes J, Candeias R, Marques NS, Camacho A, Jesus I. EGSYS score for the prediction of cardiac etiology in syncope: Is it useful in an outpatient setting? Rev Port Cardiol 2020; 39:255-261. [PMID: 32534800 DOI: 10.1016/j.repc.2019.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/25/2019] [Accepted: 09/22/2019] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The EGSYS score uses clinical variables to predict which patients may have cardiac (CS) or non-cardiac syncope (NCS) and has been validated in the emergency department setting. This study aims to determine whether the score has the same applicability in an outpatient setting. METHODS In this retrospective study of all patients observed in the outpatient setting of a hospital with a syncope unit between January 2015 and December 2016, the EGSYS score was calculated for each patient, and its sensitivity and specificity were determined for the prediction of CS in patients with score ≥3. RESULTS A total of 224 patients, mean age 64.3±21.7 years, 116 (51.8%) male, were analyzed. In the 163 (72.7%) patients with confirmed syncope, CS was diagnosed in 27 (16.6%) and NCS in 136 (83.4%). The EGSYS score was ≥3 in 40 (20.0%) patients with NCS and in 13 (48.1%) with CS. A positive score had a sensitivity of 48.2% (95% CI: 28.7-68.1), a specificity of 77.9% (95% CI: 70.0-84.6), and a positive and negative predictive value of 30.2% (95% CI: 20.8-41.8) and 88.3% (95% CI: 83.9-91.7), respectively. CONCLUSION The EGSYS score has limited usefulness in an outpatient setting, where observed patients have already been been medically assessed. Given its high specificity and negative predictive value, it may be useful to reassure low-risk patients and family members.
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Affiliation(s)
- João de Sousa Bispo
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal; Algarve Biomedical Center, Faro, Portugal.
| | - Pedro Azevedo
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal
| | - Teresa Mota
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal
| | - Raquel Fernandes
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal
| | - João Guedes
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal
| | - Rui Candeias
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal
| | - Nuno Silva Marques
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal; Algarve Biomedical Center, Faro, Portugal
| | - Ana Camacho
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal
| | - Ilídio Jesus
- Serviço de Cardiologia, Hospital de Faro, Centro Hospitalar Universitário do Algarve, EPE, Faro, Portugal
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Schattner A. The Wide-Ranging Spectrum of Cough-Induced Complications and Patient Harm. Am J Med 2020; 133:544-551. [PMID: 32007456 DOI: 10.1016/j.amjmed.2019.12.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 12/25/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Abstract
Cough is one of the most common complaints encountered in every setting; however, complications associated with coughing have received relatively little attention. An exhaustive systematic review of the English literature revealed an exceedingly large and varied spectrum of cough-induced complications affecting many systems, including upper airways, chest wall and thorax, abdominal wall, heart and aorta, central nervous system, eye, gastrointestinal tract, urogenital system, and emotional and psychological harm. Prospective studies and prevalence data are conspicuously missing. Reported cough-induced pathology ranges from rare (the majority) to common and from trivial (eg, lightheadedness, subconjunctival hemorrhage) to severe and life-threatening (eg, cervical artery dissection, rupture of a normal spleen). Other seemingly benign entities may mask a serious underlying pathology (eg, cough headache, cough syncope). A substantial proportion of patients experience anxiety and insomnia, and their quality of life is affected. Thus, the wide spectrum of cough-induced pathology need to be recognized and considered in patients complaining of cough. Suppression of cough must not be neglected in patients at risk, and areas of uncertainty need to be clarified by future prospective studies.
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Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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Lee SH, Kim TH, Oh YS, Oh S, Choi JI, Kim JB, Nah JC, Im SI, Kang KW, Han S, Kim JS. Usefulness of an Implantable Loop Recorder in Diagnosing Unexplained Syncope and Predictors for Pacemaker Implantation. J Korean Med Sci 2020; 35:e11. [PMID: 31920017 PMCID: PMC6955436 DOI: 10.3346/jkms.2020.35.e11] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/06/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND An implantable loop recorder (ILR) is an effective tool for diagnosing unexplained syncope (US). We examined the diagnostic utility of an ILR in detecting arrhythmic causes of US and determining which clinical factors are associated with pacemaker (PM) implantation. METHODS This retrospective, multicenter, observational study was conducted from February 2006 to April 2018 at 11 hospitals in Korea. Eligible patients with recurrent US received an ILR to diagnose recurrent syncope and document arrhythmia. RESULTS A total of 173 US patients (mean age, 67.6 ± 16.5 years; 107 men [61.8%]) who received an ILR after a negative conventional workup were enrolled. During a mean follow-up of 9.4 ± 11.1 months, 52 patients (30.1%) had recurrent syncope, and syncope-correlated arrhythmia was confirmed in 34 patients (19.7%). The ILR analysis showed sinus node dysfunction in 24 patients (70.6%), supraventricular tachyarrhythmia in 4 (11.8%), ventricular arrhythmia in 4 (11.8%), and sudden atrioventricular block in 2 (5.9%). Overall, ILR detected significant arrhythmia in 99 patients (57.2%) irrespective of syncope. Among patients with clinically relevant arrhythmia detected by ILR, PM implantation was performed in 60 (34.7%), an intra-cardiac defibrillator in 5 (2.9%), and catheter ablation in 4 (2.3%). In a Cox regression analysis, history of paroxysmal atrial fibrillation (PAF) (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.33-4.12; P < 0.01) and any bundle branch block (BBB) (HR, 2.52; 95% CI, 1.09-5.85; P = 0.03) were significantly associated with PM implantation. CONCLUSION ILR is useful for detecting syncope-correlated arrhythmia in patients with US. The risk of PM is high in US patients with a history of PAF and any BBB.
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Affiliation(s)
- Sung Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Seil Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jin Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jong Chun Nah
- Division of Cardiology, Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sung Il Im
- Division of Cardiology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Ki Woon Kang
- Division of Cardiology, Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - June Soo Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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MILAN DAVID, KLEIN HELMUT, GIMBEL JROD, KNILANS TIMOTHY, MIRRO MICHAEL, ZIRILLE FRANCIS. Considering the Need to Expand the Indications for Wearable Defibrillator Therapy. J Innov Card Rhythm Manag 2019; 10:3751-3760. [PMID: 32494421 PMCID: PMC7252810 DOI: 10.19102/icrm.2019.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Syncope, conduction disturbance, and negative electrophysiological test: Predictive factors and risk score to predict pacemaker implantation during follow-up. Heart Rhythm 2019; 16:905-912. [PMID: 30576876 DOI: 10.1016/j.hrthm.2018.12.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Indexed: 12/27/2022]
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Moradi M, Farhadian M, Kazemi M. Assessing post-cardiac stress test heart rate recovery and systolic blood pressure recovery in patients suffering from vasovagal syncope. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2019. [DOI: 10.29333/ejgm/93476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Luiting S, Jansen S, Seppälä LJ, Daams JG, van der Velde N. Effectiveness of Cardiovascular Evaluations and Interventions on Fall Risk: A Scoping Review. J Nutr Health Aging 2019; 23:330-337. [PMID: 30932131 PMCID: PMC6507528 DOI: 10.1007/s12603-019-1165-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/12/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Cardiovascular abnormalities are consistently associated with fall risk in older people. However, little research has been done to assess the effect of cardiovascular interventions on fall risk. The aim of this scoping review is to explore the current literature on the effectiveness of cardiovascular evaluations and interventions in reducing fall risk in older people. DESIGN Scoping review. DATA SOURCES Medline, Cochrane Library, and WHO ICTRP Search Portal were systematically searched. SELECTION CRITERIA Randomized controlled trials (RCTs) and intervention studies of community-dwelling adults aged ≥50 years or with a mean age of >60 years that assessed the effect of a cardiovascular assessment and interventions in reducing fall risk. Key search concepts were "falls" and "aged", and terms for different cardiovascular evaluations and interventions were included. The Cochrane Checklist for risk of bias and the ROBINS-I tool were used to assess the quality of the studies. RESULTS Seven studies were included. The majority showed a reduction in falls after cardiovascular evaluation and intervention. Two out of four studies that focused on carotid sinus hypersensitivity (CSH) as a modifiable cardiovascular risk factor for falls, showed a significant reduction in falls after pacemaker implantation. Two studies that looked at sinus node dysfunction (SND) both showed a significant reduction in falls after pacemaker implantation. One study showed that 33% of the patients experienced a fall after cardiovascular evaluation and intervention, whereas all patients fell before assessment. CONCLUSIONS The majority of the included studies showed a reduction in falls after the intervention. However, the number of published papers regarding the effect of cardiovascular assessment and interventions on falls is small. A standardized assessment of cardiovascular risk factors may be essential in preventing falls in older adults and could consequently reduce injuries, loss of quality of life, deaths, and fall-related expenditures.
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Affiliation(s)
- S Luiting
- Nathalie van der Velde, PhD, Amsterdam University Medical Center, Department of Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam 1105AZ, the Netherlands, Tel. nr: +31 20-5665991, e-mail:
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The Association of Kidney Function and Albuminuria With the Risk and Outcomes of Syncope: A Population-Based Cohort Study. Can J Cardiol 2018; 34:1631-1640. [PMID: 30527152 DOI: 10.1016/j.cjca.2018.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/15/2018] [Accepted: 08/23/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The risks and subsequent outcomes of syncope among seniors with chronic kidney disease (CKD) are unclear. METHODS We conducted a population-based retrospective cohort study of 272,146 patients ≥ 66 years old, in Ontario, Canada, from April 1, 2006, to March 31, 2016. Using administrative health care databases, we examined the association of estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (ACR) with incident syncope and the association of incident syncope with the composite outcome of myocardial infarction, stroke, and death by levels of eGFR/ACR, using adjusted Cox proportional hazards models. RESULTS A total of 15,074 incident syncopal events occurred during the study period. The adjusted risk for syncope was higher with a lower eGFR and higher ACR in a stepwise manner (eGFR 60 to < 90: HR 1.17 [1.09-1.26] vs eGFR < 30: HR 1.67 (1.50-1.87) with eGFR ≥ 90 referent; ACR > 30: HR 1.15 [1.07-1.24] with ACR < 3 referent). Among the 12,710 patients with a first syncope event and 1 year of follow-up, the adjusted risk for the composite outcome was higher with a lower eGFR and higher ACR in a stepwise manner (eGFR 60 to < 90: HR 1.05 [0.90-1.22] vs eGFR < 30: HR 1.62 [1.34-1.96] with eGFR ≥ 90 referent; ACR > 30: HR 1.77 [1.60-1.96], ACR < 3 referent). CONCLUSIONS A lower eGFR and higher ACR are associated with a higher risk of a hospital encounter for syncope and of related complications among persons of advanced age.
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Roca-Luque I, Oristrell G, Francisco-Pasqual J, Rodríguez-García J, Santos-Ortega A, Martin-Sanchez G, Rivas-Gandara N, Perez-Rodon J, Ferreira-Gonzalez I, García-Dorado D, Moya-Mitjans A. Predictors of positive electrophysiological study in patients with syncope and bundle branch block: PR interval and type of conduction disturbance. Clin Cardiol 2018; 41:1537-1542. [PMID: 30251426 DOI: 10.1002/clc.23079] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/22/2018] [Accepted: 09/20/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Electrophysiological study (EPS) is indicated in patients with syncope and bundle branch block (BBB). Data about predictors of positive EPS in these patients is scarce. OBJECTIVE To assess clinical and electrocardiographic (ECG) predictors of positive EPS in patients with syncope and BBB. METHODS Observational single-center study that included all consecutive patients with syncope and BBB that underwent EPS from January 2011 to June 2017. Results of EPS were considered positive according to current ESC syncope guidelines. RESULTS During study period, 271 patients were included (64.9% male, age: 73.9 ± 12.2 years, number of syncopal episodes: 2.4 ± 2.5, LVEF: 56.1 ± 9.9%). Type of BBB: RBBB + LAFB/LPFB in 39.8%, isolated LBBB in 38.7% and isolated RBBB in 18.5% of the patients. Duration of QRS and PR interval were 141.9 ± 16.7 and 182.8 ± 52.2 milliseconds. EPS was positive in 41.7% of the patients. In multivariate analysis, conduction disturbance pattern and long PR interval (OR 8.6; 2.9-25; P < 0.0001) were predictors of positive EPS. Conduction disturbance patterns related with positive EPS were: BBB different than isolated RBBB (OR 15.2; 2.2-23.4; P = 0.005), LBBB or RBBB+long PR + left fascicular block (OR 4.5; 1.06-20.01; P < 0.042), and RBBB+left fascicular block compared with LBBB (OR 4.8; 1.2-16.7; P = 0.025). Clinical factors and syncope characteristics were not related with EPS result. CONCLUSIONS Diagnostic yield of EPS in patients with syncope and BBB is moderate (41%). Type of conduction disturbance pattern and PR interval are associated with the electrophysiological (EP) test result. Patients with LBBB or bifascicular block have the highest rate of positive EP test. Long PR interval increases the proportion of positive EPS in all conduction disturbance patterns.
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Affiliation(s)
- Ivo Roca-Luque
- Arrhythmia Unit. Cardiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gerard Oristrell
- Cardiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | - Alba Santos-Ortega
- Arrhythmia Unit. Cardiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gabriel Martin-Sanchez
- Arrhythmia Unit. Cardiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Nuria Rivas-Gandara
- Arrhythmia Unit. Cardiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Perez-Rodon
- Arrhythmia Unit. Cardiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ignacio Ferreira-Gonzalez
- Cardiovascular epidemiology Unit. Cardiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Angel Moya-Mitjans
- Arrhythmia Unit. Cardiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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[Transient loss of consciousness : Algorithm for the (differential) diagnosis of syncope at emergency department]. Med Klin Intensivmed Notfmed 2018; 114:410-419. [PMID: 30413862 DOI: 10.1007/s00063-018-0501-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/24/2018] [Accepted: 06/10/2018] [Indexed: 10/27/2022]
Abstract
Transient loss of consciousness (TLoC) is a common complaint leading to presentation at the emergency department. This comprises a heterogeneous group of disorders including cerebral events, metabolic disturbances, intoxication, psychogenic patterns or any form of syncope. While many causes are benign and self-limited not requiring extensive in-hospital evaluation, others are potentially severe. The optimal evaluation of patients with TLoC/syncope follows a risk-adapted diagnostic algorithm in order to exclude life-threatening conditions and to identify those with high risk for further deterioration like structural heart diseases requiring further diagnostic evaluation. Low-risk patients can be discharged without further extensive diagnostic work up. This article presents an algorithm for structured, evidence-based care of the syncope patient in accordance with the recently launched "2018 ESC guidelines for the diagnosis and management of syncope" in order to ensure that patients requiring hospitalization are managed appropriately and those with benign causes are discharged safely. The English version of this algorithm is available at the end of the article under "Supplementary Material".
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Abstract
Syncope is a frequent condition, owing to a transient global cerebral hypoperfusion, that may depend on a reduction of vascular total peripheral resistance and/or cardiac output. Cardiac syncope doubled the risk of death from any cause and increased the risk of nonfatal and fatal cardiovascular events. Arrhythmias are the most common cardiac causes of syncope. Both bradyarrhythmias and tachyarrhythmias may predispose to syncope. The first line evaluation relies on clinical history, physical examination, active standing test, 12-lead echocardiogram. The diagnostic yield of electrophysiological study in detecting the cause of syncope depends highly on the pretest probability.
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Affiliation(s)
- Andrea Ungar
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Azienda Ospedaliero Universitaria Careggi, Viale Pieraccini 6, Florence 50139, Italy.
| | - Martina Rafanelli
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Azienda Ospedaliero Universitaria Careggi, Viale Pieraccini 6, Florence 50139, Italy
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Park BS, Lee YJ, Park JH, Kim IH, Park SH, Lee HJ, Park KM. Alterations of brain network hubs in reflex syncope: Evidence from a graph theoretical analysis based on DTI. Brain Behav 2018; 8:e01006. [PMID: 29791077 PMCID: PMC5991578 DOI: 10.1002/brb3.1006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/16/2018] [Accepted: 04/23/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE We evaluated global topology and organization of regional hubs in the brain networks and microstructural abnormalities in the white matter of patients with reflex syncope. METHODS Twenty patients with reflex syncope and thirty healthy subjects were recruited, and they underwent diffusion tensor imaging (DTI) scans. Graph theory was applied to obtain network measures based on extracted DTI data, using DSI Studio. We then investigated differences in the network measures between the patients with reflex syncope and the healthy subjects. We also analyzed microstructural abnormalities of white matter using tract-based spatial statistics analysis (TBSS). RESULTS Measures of global topology were not different between patients with reflex syncope and healthy subjects. However, in reflex syncope patients, the strength measures of the right angular, left inferior frontal, left middle orbitofrontal, left superior medial frontal, and left middle temporal gyrus were lower than in healthy subjects. The betweenness centrality measures of the left middle orbitofrontal, left fusiform, and left lingual gyrus in patients were lower than those in healthy subjects. The PageRank centrality measures of the right angular, left middle orbitofrontal, and left superior medial frontal gyrus in patients were lower than those in healthy subjects. Regarding the analysis of the white matter microstructure, there were no differences in the fractional anisotropy and mean diffusivity values between the two groups. CONCLUSIONS We have identified a reorganization of network hubs in the brain network of patients with reflex syncope. These alterations in brain network may play a role in the pathophysiologic mechanism underlying reflex syncope.
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Affiliation(s)
- Bong Soo Park
- Department of Internal medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Yoo Jin Lee
- Department of Internal medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin-Han Park
- Department of Internal medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Il Hwan Kim
- Department of Internal medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Si Hyung Park
- Department of Internal medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ho-Joon Lee
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Tilt testing and what you should know about it - Experience with 835 consecutive patients with syncope of unknown origin. Int J Cardiol 2018; 258:90-96. [DOI: 10.1016/j.ijcard.2018.01.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 01/22/2018] [Indexed: 11/22/2022]
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Kim N, Bae MH. Left Main Coronary Artery Stenosis Presenting as Syncope with Brugada Type Electrocardiography. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2018. [DOI: 10.18501/arrhythmia.2018.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Champagne PO, Bojanowski MW. Craniocervical Junction Meningiomas without Hydrocephalus Presenting Solely with Syncope: Report of 2 Cases. World Neurosurg 2018; 114:161-164. [PMID: 29551725 DOI: 10.1016/j.wneu.2018.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 02/27/2018] [Accepted: 03/01/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To our knowledge, there have not been any reported cases of a meningioma of the craniocervical region presenting solely with syncope as its initial symptom. Only 1 case of meningioma presenting with syncope has been published, but it was associated with hydrocephalus. We report 2 cases of syncope caused by a craniocervical junction meningioma, with syncope being the sole presenting symptom and without hydrocephalus. We discuss the possible pathophysiology, as well as the clinical relevance of this type of presentation. METHODS We reviewed the charts, operative details, and imagery of 2 cases of meningioma in the region of the craniocervical junction, with syncope as their sole presenting feature. We also reviewed the literature. RESULTS In 1 case the syncope occurred spontaneously. In the other, it occurred during a Valsalva maneuver. Both meningiomas were surgically removed via a retromastoid approach. There was no recurrence of syncope following surgery. Following a literature review, we found 1 case of posterior fossa meningioma presenting with syncope, but hydrocephalus was also present. CONCLUSION Syncope can be the sole manifestation of a meningioma of the craniocervical junction. Such syncopes are a consequence of transient dysfunction of the autonomous pathways in the medulla and/or of the medulla's output. In the absence of other causes of syncope, a meningioma in this region, even in the absence of hydrocephalus, should not be considered as fortuitous, but rather as the actual cause of syncope. Recognizing this possibility offers the potential for proper diagnosis and appropriate treatment of the syncope.
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Affiliation(s)
- Pierre-Olivier Champagne
- Division of Neurosurgery, University of Montreal Hospital Center (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, University of Montreal Hospital Center (CHUM), Montreal, Quebec, Canada.
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 993] [Impact Index Per Article: 165.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Guimarães RB, Essebag V, Furlanetto M, Yanez JPG, Farina MG, Garcia D, Almeida ED, Stephan L, Lima GG, Leiria TLL. Structural heart disease as the cause of syncope. ACTA ACUST UNITED AC 2018. [PMID: 29513795 PMCID: PMC5856435 DOI: 10.1590/1414-431x20176989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We described the clinical evolution of patients with structural heart disease presenting at the emergency room with syncope. Patients were stratified according to their syncope etiology and available scores for syncope prognostication. Cox proportional hazard models were used to investigate the relationship between etiology of the syncope and event-free survival. Of the 82,678 emergency visits during the study period, 160 (0.16%) patients were there due to syncope, having a previous diagnosis of structural heart disease. During the median follow-up of 33.8±13.8 months, mean age at the qualifying syncope event was 68.3 years and 40.6% of patients were male. Syncope was vasovagal in 32%, cardiogenic in 57%, orthostatic hypotension in 6%, and of unknown causes in 5% of patients. The primary composite endpoint death, readmission, and emergency visit in 30 days was 39.4% in vasovagal syncope and 60.6% cardiogenic syncope (P<0.001). Primary endpoint-free survival was lower for patients with cardiogenic syncope (HR=2.97, 95%CI=1.94-4.55; P<0.001). The scores were analyzed for diagnostic performance with area under the curve (AUC) and did not help differentiate patients with an increased risk of adverse events. The differential diagnosis of syncope causes in patients with structural heart disease is important, because vasovagal and postural hypotension have better survival and less probability of emergency room or hospital readmission. The available scores are not reliable tools for prognosis in this specific patient population.
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Affiliation(s)
- R B Guimarães
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - V Essebag
- Sacre Coeur Hospital of Montreal, University of Montreal, Montreal, Quebec, Canada.,McGill University Health Center Research Institute, McGill University, Montreal, Quebec, Canada
| | - M Furlanetto
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - J P G Yanez
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - M G Farina
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - D Garcia
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - E D Almeida
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - L Stephan
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - G G Lima
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - T L L Leiria
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
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Adlakha H, Gupta R, Hassan R, Kern JH. Association Between Baseline Blood Pressures, Heart Rates, and Vasovagal Syncope in Children and Adolescents. Cureus 2018; 10:e2119. [PMID: 29600123 PMCID: PMC5873830 DOI: 10.7759/cureus.2119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Vasovagal syncope is the most common cause of syncope in children and adults, accounting for 50-66% of unexplained syncope. There are no studies establishing the relationship between syncope, baseline heart rate, and blood pressure. OBJECTIVE To identify a possible association between baseline blood pressure and heart rate with syncope. DESIGN/METHODS We conducted a questionnaire-based chart review study. A questionnaire was distributed to the guardian of children between eight and 18 years of age who attended the Pediatric Ambulatory Care Clinic at Flushing Hospital Medical Center. Based on the responses in the questionnaire, subjects were classified either as cases (positive for syncope) or controls (negative for syncope). Children and adolescents with neurological, cardiac, or any medical condition that can cause syncopal episodes were excluded from the study. Data collected from the questionnaire included age, gender, ethnicity, medical history, family history of syncope, and the amount of salt used in food. Anthropometric and vital signs for the current visit (height, weight, BMI, blood pressure, and heart rate) and vital signs from two previous visits were collected from electronic medical records. The data was analyzed using t-test and chi-square test with Microsoft Excel software (Microsoft Office Standard, v. 14, Microsoft; 2010); p<0.05 was considered significant. RESULTS A total of 197 subjects were included in this study. There were 18 cases and 179 controls. Of the cases, (4/18) 22.2% were more likely to have a systolic blood pressure lower than the 10th percentile for their gender, age, and height as compared with controls (7/179) 3.9%, p = 0.003. The subjects with a history of syncope were more likely to add salt to their food (p = 0.004). There were no significant differences between cases and controls for age, gender, ethnicity between cases and controls for systolic blood pressure. No significant difference was observed between the heart rates of cases and controls. CONCLUSIONS Children and adolescents with syncope were more likely to have a systolic blood pressure lower than the 10th percentile, and there was no difference in the baseline heart rate. In addition, children with syncope were more likely to add salt to their food.
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Affiliation(s)
- Himanshu Adlakha
- Pediatrics, Pediatric Cardiology, Flushing Hospital Medical Center, Mount Sinai School of Medicine
| | - Ruchi Gupta
- Pediatrics, Flushing Hospital Medical Center
| | - Romana Hassan
- Pediatrics, Shadan Institute of Medical Sciences, India
| | - Jeffrey H Kern
- Pediatric Cardiology, Weil Cornell Medicine, New York Presbyterian Hospital, New York, Ny, Flushing Hospital Medical Centre
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Benditt DG, Adkisson WO, Sutton R, Mears RK, Sakaguchi S. Ambulatory diagnostic ECG monitoring for syncope and collapse: An assessment of clinical practice in the United States. Pacing Clin Electrophysiol 2018; 41:203-209. [PMID: 29314105 DOI: 10.1111/pace.13265] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/19/2017] [Accepted: 11/04/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Diagnostic ambulatory electrocardiogram (AECG) monitoring is widely used for evaluating syncope and collapse, and practice guidelines provide recommendations regarding optimal AECG device selection. However, whether physicians utilize AECGs in accordance with the pertinent guidelines is unclear. This study assessed utilization of AECG monitoring systems for syncope and collapse diagnosis by physicians in the United States. METHODS AND RESULTS A quantitative survey was undertaken of physicians comprising multiple specialties (emergency department, n = 35; primary care, n = 35; hospitalists, n = 30; neurologists, n = 30; nonimplanting, n = 34, and implanting-cardiologists, n = 35). Depending on specialty, respondents reported that neural-reflex and orthostatic causes accounted for 17-23%, cardiac causes for 12-20%, and "neurological causes" (specifically psychogenic pseudo-syncope/pseudo-seizures and acute cerebrovascular conditions) for 7-12% of their syncope/collapse cases. The choice of AECG technology varied by specialty. Thus, despite patients having daily symptoms, 25% of respondents chose an AECG technology other than a Holter-type monitor. Conversely, when monitoring for infrequent events (e.g., less than monthly), 12-18% indicated that they would choose a 24- to 48-hour Holter, 20-34% would choose either a conventional event recorder or a mobile cardiac telemetry system, and only 53-65% would select an insertable cardiac monitor. CONCLUSIONS In evaluation of syncope/collapse, most U.S. clinicians across specialties use AECGs appropriately, but in a substantial minority there remains discordance between choice of AECG technology and guideline-based recommendations.
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Affiliation(s)
- David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Wayne O Adkisson
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | - Scott Sakaguchi
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
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Hospital-Confirmed Acute Myocardial Infarction: Prehospital Identification Using the Medical Priority Dispatch System. Prehosp Disaster Med 2017; 33:29-35. [DOI: 10.1017/s1049023x1700704x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AbstractIntroductionEarly recognition of an acute myocardial infarction (AMI) can increase the patient’s likelihood of survival. As the first point of contact for patients accessing medical care through emergency services, emergency medical dispatchers (EMDs) represent the earliest potential identification point for AMIs. The objective of the study was to determine how AMI cases were coded and prioritized at the dispatch point, and also to describe the distribution of these cases by patient age and gender.Hypothesis/ProblemNo studies currently exist that describe the EMD’s ability to correctly triage AMIs into Advanced Life Support (ALS) response tiers.MethodsThe retrospective descriptive study utilized data from three sources: emergency medical dispatch, Emergency Medical Services (EMS), and emergency departments (EDs)/hospitals. The primary outcome measure was the distributions of AMI cases, as categorized by Chief Complaint Protocol, dispatch priority code and level, and patient age and gender. The EMS and ED/hospital data came from the Utah Department of Health (UDoH), Salt Lake City, Utah. Dispatch data came from two emergency communication centers covering the entirety of Salt Lake City and Salt Lake County, Utah.ResultsOverall, 89.9% of all the AMIs (n=606) were coded in one of the three highest dispatch priority levels, all of which call for ALS response (called CHARLIE, DELTA, and ECHO in the studied system). The percentage of AMIs significantly increased for patients aged 35 years and older, and varied significantly by gender, dispatch level, and chief complaint. A total of 85.7% of all deaths occurred among patients aged 55 years and older, and 88.9% of the deaths were handled in the ALS-recommended priority levels.ConclusionAcute myocardial infarctions may present as a variety of clinical symptoms, and the study findings demonstrated that more than one-half were identified as having chief complaints of Chest Pain or Breathing Problems at the dispatch point, followed by Sick Person and Unconscious/Fainting. The 35-year age cutoff for assignment to higher priority levels is strongly supported. The Falls and Sick Person Protocols offer opportunities to capture atypical AMI presentations.ClawsonJJ, GardettI, ScottG, FivazC, BarronT, BroadbentM, OlolaC. Hospital-confirmed acute myocardial infarction: prehospital identification using the Medical Priority Dispatch System. Prehosp Disaster Med. 2018;33(1):29–35.
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Koene RJ, Adkisson WO, Benditt DG. Syncope and the risk of sudden cardiac death: Evaluation, management, and prevention. J Arrhythm 2017; 33:533-544. [PMID: 29255498 PMCID: PMC5728985 DOI: 10.1016/j.joa.2017.07.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/04/2017] [Accepted: 07/04/2017] [Indexed: 12/17/2022] Open
Abstract
Syncope is a clinical syndrome defined as a relatively brief self-limited transient loss of consciousness (TLOC) caused by a period of inadequate cerebral nutrient flow. Most often the trigger is an abrupt drop of systemic blood pressure. True syncope must be distinguished from other common non-syncope conditions in which real or apparent TLOC may occur such as seizures, concussions, or accidental falls. The causes of syncope are diverse, but in most instances, are relatively benign (e.g., reflex and orthostatic faints) with the main risks being accidents and/or injury. However, in some instances, syncope may be due to more worrisome conditions (particularly those associated with cardiac structural disease or channelopathies); in such circumstances, syncope may be an indicator of increased morbidity and mortality risk, including sudden cardiac death (SCD). Establishing an accurate basis for the etiology of syncope is crucial in order to initiate effective therapy. In this review, we focus primarily on the causes of syncope that are associated with increased SCD risk (i.e., sudden arrhythmic cardiac death), and the management of these patients. In addition, we discuss the limitations of our understanding of SCD in relation to syncope, and propose future studies that may ultimately address how to improve outcomes of syncope patients and reduce SCD risk.
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Affiliation(s)
| | | | - David G. Benditt
- From the Cardiac Arrhythmia Center, Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Madeira CL, Craig MJ, Donohoe A, Stephens JR. Things We Do For No Reason: Echocardiogram in Unselected Patients with Syncope. J Hosp Med 2017; 12:984-988. [PMID: 29073313 DOI: 10.12788/jhm.2864] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Syncope is a common cause of emergency department visits and hospitalizations. Echocardiogram is frequently used as a diagnostic tool in the evaluation of syncope, performed in 39% to 91% of patients. The diagnostic yield of echocardiogram for detecting clinically important abnormalities in patients with a normal history, physical examination, and electrocardiogram (ECG), however, is extremely low. In contrast, echocardiograms performed on patients with syncope with a positive cardiac history, abnormal examination, and/or ECG identify an abnormality in up to 29% of cases, though these abnormalities are not always defi nitively the cause of symptoms. Recently updated clinical guidelines for syncope management from the American College of Cardiology now recommend echocardiogram only if initial history or examination suggests a cardiac etiology, or ECG is abnormal. Universal echocardiography in patients with syncope exposes a signifi cant number of patients to unnecessary testing and cost and does not represent evidence-based or high-value patient care.
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Affiliation(s)
- Charles L Madeira
- New York University School of Medicine, Division of General Internal Medicine, Veterans Affairs NY Harbor Healthcare System, Manhattan Campus, New York, New York, USA
| | - Michael J Craig
- University of North Carolina School of Medicine, Department of Internal Medicine, Division of Hospital Medicine, Chapel Hill, North Carolina, USA
| | - Andrew Donohoe
- University of North Carolina School of Medicine, Department of Internal Medicine, Division of Hospital Medicine, Chapel Hill, North Carolina, USA
| | - John R Stephens
- University of North Carolina School of Medicine, Department of Internal Medicine, Division of Hospital Medicine, Chapel Hill, North Carolina, USA.
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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