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Klop M, Maier AB, Meskers CGM, Steiner JM, Helsloot DO, van Wezel RJA, Claassen JAHR, de Heus RAA. The effect of a change in antihypertensive treatment on orthostatic hypotension in older adults: A systematic review and meta-analysis. Exp Gerontol 2024; 193:112461. [PMID: 38772447 DOI: 10.1016/j.exger.2024.112461] [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: 03/21/2024] [Revised: 05/07/2024] [Accepted: 05/15/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Orthostatic hypotension (OH) is common in older adults with hypertension. Antihypertensive treatment (AHT) prevents cardio- and cerebrovascular events. However, physicians are concerned to cause OH, making them hesitant to initiate or augment AHT in older adults with hypertension. METHODS We systematically researched electronic databases for trials with older participants (≥65 years) with hypertension and OH assessment after initiating, discontinuing, or augmenting AHT. Study quality was assessed using the ROBINS-I tool. Meta-analyses on OH prevalence and postural blood pressure (BP) drop were performed. RESULTS Twenty-five studies (26,695 participants) met inclusion criteria, of which fifteen could be included in the meta-analyses. OH prevalence decreased after AHT initiation or augmentation (risk ratio 0.39 (95 % CI = 0.21-0.72; I2 = 47 %; p < 0.01), n = 6 studies), but also after AHT discontinuation (risk ratio 0.39 (95 % CI = 0.28-0.55; I2 = 0 %; p < 0.01), n = 2 studies). Postural BP drop did not change after initiation or augmentation of AHT (mean difference 1.07 (95 % CI = -0.49-2.64; I2 = 92 %; p = 0.18), n = 11 studies). The main reason for ten studies not to be included in the meta-analyses was absence of baseline OH data. Most of these studies reported OH incidences between 0 and 2 %. Studies were heterogeneous in OH assessment methods (postural change, timing of BP measurements, and OH definition). Risk of bias was moderate to serious in twenty studies. CONCLUSION Results suggest that AHT initiation or augmentation decreases OH prevalence, implying that the risk of inducing OH may be overestimated in current AHT decision-making in older adults. However, the overall low level of evidence and the finding that AHT discontinuation reduces OH prevalence limit firm conclusions at present and highlight an important research gap. Future AHT trials in older adults should measure OH in a standardized protocol, adhering to consensus guidelines to overcome these limitations.
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Affiliation(s)
- Marjolein Klop
- Department of Neurobiology, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands; Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andrea B Maier
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Julika M Steiner
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - D Odette Helsloot
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Richard J A van Wezel
- Department of Neurobiology, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands; Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Enschede, the Netherlands; OnePlanet Research Center, Radboud University, Nijmegen, the Netherlands
| | - Jurgen A H R Claassen
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Rianne A A de Heus
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands.
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Steinhauer B, Dütschler S, Spicher J, Aerschmann S, Ambord N, Bartkowiak J, Tawo S, Thalmann G, Servatius H, Noti F, Seiler J, Baldinger S, Haeberlin A, Madaffari A, Tanner H, Reichlin T, Roten L. Patient satisfaction, safety, and efficacy of nurse-led compared to physician-led implantation of cardiac monitors. Eur J Cardiovasc Nurs 2024; 23:452-457. [PMID: 37851866 DOI: 10.1093/eurjcn/zvad103] [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: 12/30/2022] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
AIMS Implantation of an implantable cardiac monitor (ICM) is a simple procedure, but adds significant and increasing workload to the arrhythmia service. In 2020, we established a nurse-led ICM implantation service. We aimed to analyse patient satisfaction, adverse events during implant, and ICM re-interventions with nurse-led ICM implantation (N-Implant) compared to physician-led ICM implantation (P-Implant). METHODS AND RESULTS From January 2020 to December 2021, we included all consecutive patients implanted with an ICM in a prospective registry. We collected data on patient characteristics, implant procedure, and follow-up. Patients were interviewed by phone four weeks after ICM implantation.Of 321 patients implanted with an ICM (median age 67 years; 33% women), 189 (59%) were N-Implants. More N-Implants were performed in the outpatient clinic compared to P-Implants (95% vs. 8%; P < 0.001). Two N-Implant patients experienced vaso-vagal reaction during implantation (1%), whereas no adverse events occurred during P-Implant (P = 0.51). A total of 297 patients (93%) completed the questionnaire. Duration of pain was shorter and wound closure after 2 weeks better following N-Implant (P = 0.019 and P = 0.018). A minor bruise or swelling at the implant site was reported more frequently after N-Implant (P = 0.003 and P = 0.041). Patient satisfaction was excellent with both N-Implant and P-Implant (99% and 97%; P = 0.16). After a median follow-up of 242 days (range 7-725 days), five ICMs (2%) were explanted prematurely, without differences among groups. Reasons for premature explants were local discomfort (n = 2), infection, MRI, and ICM malfunction. CONCLUSION Nurse-led ICM implantation has excellent patient satisfaction without compromising safety. N-Implant both expands nursing competencies and reduces physician workload.
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Affiliation(s)
- Barbara Steinhauer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Sophie Dütschler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Jasmin Spicher
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Sarah Aerschmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Nicole Ambord
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Joanna Bartkowiak
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Serlha Tawo
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Gregor Thalmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Jens Seiler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Samuel Baldinger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - Antonio Madaffari
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
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Francisco-Pascual J, Lal-Trehan Estrada N. Syncope. Med Clin (Barc) 2024; 162:606-612. [PMID: 38388319 DOI: 10.1016/j.medcli.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 02/24/2024]
Affiliation(s)
- Jaume Francisco-Pascual
- Unitat d'Arrítmies, Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, España.
| | - Nisha Lal-Trehan Estrada
- Unitat d'Arrítmies, Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, España
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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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Vogel M, Fischer T. [Syncopes - differential diagnoses and treatment]. Dtsch Med Wochenschr 2024; 149:521-531. [PMID: 38621687 DOI: 10.1055/a-2186-1100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Syncope is a sudden loss of consciousness (transient loss of consciousness, TLOC) caused by a lack of cerebral perfusion that resolves spontaneously and completely after a short period of time 1. With a lifetime prevalence of 40% and constituting about 1% of all emergency department admissions, syncope is a common and medically relevant problem 2 3. The underlying causes of syncope are diverse and associated with significantly different prognoses. A structured approach is essential to identify high-risk patients and ensure appropriate treatment. This article aims at providing an overview of the current recommendations for the diagnosis and treatment of syncope.
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Numeroso F, Bottaro L, Younes A, Ungar A, Cabassi A. Incidence and risk factors for non-cardiac syncope in a cohort of patients addressing an accredited Arterial Hypertension Center: the Innocent Study. Minerva Med 2024; 115:143-150. [PMID: 38629908 DOI: 10.23736/s0026-4806.24.09200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
BACKGROUND Hypotensive susceptibility in hypertensive patients could facilitate orthostatic hypotension, syncope and fall. The aim of this study was to identify incidence, clinical form, complications and risk factors for non-cardiac syncope in a cohort of hypertensive patients. METHODS This is an observational, case-controlled, retrospective study carried out on 168 patients, evaluated at the Hypertension Center of the University Hospital of Parma (Italy). Based on the presence of episodes of syncope during the six months prior to enrolment, we identified cases and controls and then we compared them to personal data, comorbidities, current drug regimens, presence of orthostatic hypotension, office and ambulatory blood pressure monitoring (ABPM) blood pressure (BP) values. RESULTS In patients with previous syncopal episodes (29.8% of total), we more frequently found female gender, comorbidities associated with autonomic dysfunction, diuretics and non-CV drugs potentially associated with hypotension in their current drug regimen, orthostatic hypotension and lower office and ABPM BP values. CONCLUSIONS To identify hypertensive patients at higher risk for syncope and falls, physicians should focus on comorbidities and current drug regimens, systematically perform an active standing test to identify orthostatic hypotension, employ ABPM to compare BP values with the pre-established target and highlight systolic BP drops and abnormalities suggesting concomitant autonomic dysfunction. The modulation of antihypertensive therapy is an effective tool to counteract the risk of non-cardiac syncope, with possible trauma or other negative influences.
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Affiliation(s)
- Filippo Numeroso
- Emergency Department, University Hospital of Parma, Parma, Italy -
| | - Luca Bottaro
- Postgraduate School of Internal Medicine, University of Parma, Parma, Italy
| | - Ali Younes
- Postgraduate School of Internal Medicine, University of Parma, Parma, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Aderville Cabassi
- Unit of Cardiorenal and Hypertension Research, Clinic of General Medicine and Medical Therapy, Parma, Italy
- Unit of Physiopathology, University Hospital of Parma, University of Parma, Parma, Italy
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Numeroso F, Casagranda I, Lerza R, Ungar A. Current ED syncope management in Italian hospitals and prospects for optimization: a national survey. Intern Emerg Med 2024; 19:777-786. [PMID: 37962787 DOI: 10.1007/s11739-023-03463-w] [Citation(s) in RCA: 2] [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: 07/15/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023]
Abstract
To investigate current ED management of patients with syncope in Italy and opportunities for optimization, we carried out a questionnaire survey involving 102 directors of ED facilities in our country, of any complexity level, with 55.9% located in the North, 97% equipped with an ED Observation Unit (EDOU), and 21.8% with an outpatient Syncope Unit (SU). 43.6% of EDs management is not standardized. Clinical judgment and monitoring are the main factors leading management while old age and neuropsychic comorbidities the most hindering it. More than one third of ED facilities treats fewer than half of patients in EDOU. Most of respondents (73.7%) reported an admission rate within 20%, primarily in cardiology, in the case of an established or suspected cardiac etiology of syncope. In most centers, the referral to the general practitioner is the priority path at discharge from ED. Nearly 50% of participants rated syncope management in their own center as sub-optimal. To optimize it, 98% of them believe that is appropriate to implement a standardized approach, with and a large majority focusing on increasing diagnostic yield and safety; other priorities include application of guidelines, implementation of care pathways, enhancement of the role of EDOU, and direct path to the SU. This study highlights that the management of syncope patients in our country requires a further improvement, especially through standardization of pathways and adoption of innovative organizational solutions. Admissions appear to be lower than reported in the literature but this finding must be confirmed by a multicentric study based on direct collection of data.
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Affiliation(s)
- Filippo Numeroso
- Emergency Department, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy.
| | - Ivo Casagranda
- Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy
| | - Roberto Lerza
- Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Andrea Ungar
- Geriatric and Intensive Care Unit, Careggi Hospital and University of Florence, Florence, Italy
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van Dijk JG, Sheldon R, Sutton R. Making certain that noninvasive therapy for vasovagal syncope has failed before proceeding to invasive interventions. Europace 2024; 26:euae081. [PMID: 38619827 PMCID: PMC11055496 DOI: 10.1093/europace/euae081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 04/16/2024] Open
Abstract
There is a perceived need to express concisely the advice of guidelines in the context of consideration of invasive management of highly symptomatic vasovagal syncope. In response to this need the table is presented as a checklist and the text adds explanation and details. It is anticipated that this will prove to be of value for clinicians.
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Affiliation(s)
- J Gert van Dijk
- Department of Neurology, University of Leiden Medical Centre, Leiden, Netherlands
| | - Robert Sheldon
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
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van Zanten S, Sutton R, Hamrefors V, Fedorowski A, de Lange FJ. Tilt table testing, methodology and practical insights for the clinic. Clin Physiol Funct Imaging 2024; 44:119-130. [PMID: 37839043 DOI: 10.1111/cpf.12859] [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: 04/25/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value.
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Affiliation(s)
- Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Pevy N, Christensen H, Walker T, Reuber M. Predicting the cause of seizures using features extracted from interactions with a virtual agent. Seizure 2024; 114:84-89. [PMID: 38091849 DOI: 10.1016/j.seizure.2023.11.022] [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: 07/03/2023] [Revised: 10/29/2023] [Accepted: 11/17/2023] [Indexed: 01/23/2024] Open
Abstract
OBJECTIVE A clinical decision tool for Transient Loss of Consciousness (TLOC) could reduce currently high misdiagnosis rates and waiting times for specialist assessments. Most clinical decision tools based on patient-reported symptom inventories only distinguish between two of the three most common causes of TLOC (epilepsy, functional /dissociative seizures, and syncope) or struggle with the particularly challenging differentiation between epilepsy and FDS. Based on previous research describing differences in spoken accounts of epileptic seizures and FDS seizures, this study explored the feasibility of predicting the cause of TLOC by combining the automated analysis of patient-reported symptoms and spoken TLOC descriptions. METHOD Participants completed an online web application that consisted of a 34-item medical history and symptom questionnaire (iPEP) and spoken interaction with a virtual agent (VA) that asked eight questions about the most recent experience of TLOC. Support Vector Machines (SVM) were trained using different combinations of features and nested leave-one-out cross validation. The iPEP provided a baseline performance. Inspired by previous qualitative research three spoken language based feature sets were designed to assess: (1) formulation effort, (2) the proportion of words from different semantic categories, and (3) verb, adverb, and adjective usage. RESULTS 76 participants completed the application (Epilepsy = 24, FDS = 36, syncope = 16). Only 61 participants also completed the VA interaction (Epilepsy = 20, FDS = 29, syncope = 12). The iPEP model accurately predicted 65.8 % of all diagnoses, but the inclusion of the language features increased the accuracy to 85.5 % by improving the differential diagnosis between epilepsy and FDS. CONCLUSION These findings suggest that an automated analysis of TLOC descriptions collected using an online web application and VA could improve the accuracy of current clinical decisions tools for TLOC and facilitate clinical stratification processes (such as ensuring appropriate referral to cardiological versus neurological investigation and management pathways).
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Affiliation(s)
- Nathan Pevy
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK.
| | - Heidi Christensen
- Department of Computer Science, University of Sheffield, Sheffield, UK
| | - Traci Walker
- Division of Human Communication Sciences, University of Sheffield, Sheffield, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
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Aamir A, Jamil Y, Bilal M, Diwan M, Nashwan AJ, Ullah I. Artificial Intelligence in Enhancing Syncope Management - An Update. Curr Probl Cardiol 2024; 49:102079. [PMID: 37716544 DOI: 10.1016/j.cpcardiol.2023.102079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/18/2023]
Abstract
This review looks into the use of Artificial Intelligence (AI) in the management of syncope, a condition characterized by a brief loss of consciousness caused by cerebral hypoperfusion. With rising prevalence, high costs, and difficulty in diagnosis and risk stratification, syncope poses significant healthcare challenges. AI has the potential to improve symptom differentiation, risk assessment, and patient management. Machine learning, specifically Artificial Neural Networks, has shown promise in accurate risk stratification. AI-powered clinical decision support tools can improve patient evaluation and resource utilization. While AI holds great promise for syncope management, challenges such as data quality, class imbalance, and defining risk categories remain. Ethical concerns about patient privacy, as well as the need for human empathy, complicate AI integration. Collaboration among data scientists, clinicians, and ethics experts is critical for the successful implementation of AI, which has the potential to improve patient outcomes and healthcare efficiency in syncope management.
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Affiliation(s)
- Alifiya Aamir
- Dow University of Health Sciences, Karachi, Pakistan
| | - Yumna Jamil
- Dow University of Health Sciences, Karachi, Pakistan
| | - Maham Bilal
- Dow University of Health Sciences, Karachi, Pakistan
| | | | | | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan; Department of Internal Medicine, Khyber Teaching Hospital, Peshawar, Pakistan
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Russo V, Parente E, Comune A, Laezza N, Rago A, Nigro G, Brignole M. Clinical features and response at head-up tilt test of patients with situational syncope. Heart 2023; 110:35-39. [PMID: 37527918 DOI: 10.1136/heartjnl-2023-322943] [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: 05/11/2023] [Accepted: 07/13/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVE The study compared clinical characteristics and response at head-up tilt test (HUTT) between situational (SS) and vasovagal syncope (VVS). METHODS Consecutive patients who underwent nitroglycerin-potentiated HUTT were retrospectively dichotomised into two groups: those with a history of SS and those with a history of VVS. The patients with SS were further subdivided into patients with SS alone and with SS and at least one episode of VVS. RESULTS 1285 patients were enrolled: 246 (19.1%) had SS (SS alone in 121 and SS+VVS in 125). Patients with SS were older (48.8±20.0 vs 44.4±19.1, p=0.007) and more frequently male (57.3% vs 47.7%, p=0.001). At multivariable analysis, smoking habit (OR 2.28; p<0.0001), history of traumatic syncope (OR 2.29; p=0.0001) and ACE inhibitors/angiotensin II receptor blockers (OR 4.74; p<0.0001) were independently associated with SS. HUTT was positive in 175 (71.1%) patients with SS and in 737 (70.9%) patients with VVS (p=0.9). Patients with SS showed more mixed (42.3% vs 32.0%, p=0.002) and vasodepressor forms (10.6% vs 6.1%, p=0.01) and less cardioinhibitory responses compared with others (18.3% vs 32.8%, p<0.0001). CONCLUSIONS Compared with VVS, patients with SS have different clinical characteristics and a higher prevalence of hypotensive drugs leading to hypotensive susceptibility. The positivity rate of HUTT is high and similar to that of VVS, although patients with SS show a higher prevalence of hypotensive responses.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Nunzia Laezza
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
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Hulsey B. Recognizing postural orthostatic tachycardia syndrome in primary care. JAAPA 2023; 36:14-19. [PMID: 37943688 DOI: 10.1097/01.jaa.0000991396.00397.be] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
ABSTRACT Postural orthostatic tachycardia syndrome (POTS) is a complex autonomic disorder characterized by abnormal tachycardia on standing. This disorder predominantly affects young women, with a peak incidence between ages 20 and 30 years. POTS often is associated with a variety of symptoms, including dizziness, palpitations, fatigue, generalized weakness, anxiety, and exercise intolerance, which can significantly impair patient quality of life. Primary care providers (PCPs) often are the first healthcare professionals to whom patients present. This article provides an overview of POTS, including diagnostic criteria and the importance of a thorough clinical evaluation to rule out other causes of symptoms. PCPs play a critical role in the comprehensive approach to care, involving patient education, lifestyle modifications, and treatment to improve outcomes and enhance patient quality of life.
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Affiliation(s)
- Brittney Hulsey
- Brittney Hulsey is an assistant professor at A.T. Still University in Mesa, Ariz., and practices at Village Medical in Gilbert, Ariz. The author has disclosed no potential conflicts of interest, financial or otherwise
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14
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Stewart JM, van Dijk JG, Balaji S, Sutton R. A framework to simplify paediatric syncope diagnosis. Eur J Pediatr 2023; 182:4771-4780. [PMID: 37470792 PMCID: PMC10640507 DOI: 10.1007/s00431-023-05114-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
This paper aims to improve the diagnosis of syncope and transient loss of consciousness (TLOC) in children. Diagnostic problems stem, first, from some causes spanning various disciplines, e.g. cardiology, neurology and psychiatry, while the most common cause, vasovagal syncope, is not embraced by any specialty. Second, clinical variability is huge with overlapping signs and symptoms. Third, the approach to TLOC/syncope of the European Society of Cardiology (ESC) is underused in childcare. We explain the ESC guidelines using an additional paediatric literature review. Classification of TLOC and syncope is hierarchic and based on history taking. Loss of consciousness (LOC) is defined using three features: abnormal motor control including falling, reduced responsiveness and amnesia. Adding a < 5 min duration and spontaneous recovery defines TLOC. TLOC simplifies diagnosis by excluding long LOC (e.g. some trauma, intoxications and hypoglycaemia) and focussing on syncope, tonic-clonic seizures and functional TLOC. Syncope, i.e. TLOC due to cerebral hypoperfusion, is divided into reflex syncope (mostly vasovagal), orthostatic hypotension (mostly initial orthostatic hypotension in adolescents) and cardiac syncope (arrhythmias and structural cardiac disorders). The initial investigation comprises history taking, physical examination and ECG; the value of orthostatic blood pressure measurement is unproven in children but probably low. When this fails to yield a diagnosis, cardiac risk factors are assessed; important clues are supine syncope, syncope during exercise, early death in relatives and ECG abnormalities. Conclusions: In adults, the application of the ESC guidelines reduced the number of absent diagnoses and costs; we hope this also holds for children. What is Known: • Syncope and its mimics are very common in childhood, as they are at other ages. • Syncope and its mimics provide considerable diagnostic challenges. What is New: • Application of the hierarchic framework of transient loss of consciousness (TLOC) simplifies diagnosis. • The framework stresses history-taking to diagnose common conditions while keeping an eye on cardiac danger signs.
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Affiliation(s)
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC, Leiden, The Netherlands.
| | | | - Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital Campus, Imperial College, London, UK
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15
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Ghariq M, van den Hout WB, Dekkers OM, Bootsma M, de Groot B, Groothuis JGJ, Harms MPM, Hemels MEW, Kaal ECA, Koomen EM, de Lange FJ, Peeters SYG, van Rossum IA, Rutten JHW, van Zwet EW, van Dijk JG, Thijs RD. Diagnostic and societal impact of implementing the syncope guidelines of the European Society of Cardiology (SYNERGY study). BMC Med 2023; 21:365. [PMID: 37743496 PMCID: PMC10518933 DOI: 10.1186/s12916-023-03056-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Syncope management is fraught with unnecessary tests and frequent failure to establish a diagnosis. We evaluated the potential of implementing the 2018 European Society of Cardiology (ESC) Syncope Guidelines regarding diagnostic yield, accuracy and costs. METHODS A multicentre pre-post study in five Dutch hospitals comparing two groups of syncope patients visiting the emergency department: one before intervention (usual care; from March 2017 to February 2019) and one afterwards (from October 2017 to September 2019). The intervention consisted of the simultaneous implementation of the ESC Syncope Guidelines with quick referral routes to a syncope unit when indicated. The primary objective was to compare diagnostic accuracy using logistic regression analysis accounting for the study site. Secondary outcome measures included diagnostic yield, syncope-related healthcare and societal costs. One-year follow-up data were used to define a gold standard reference diagnosis by applying ESC criteria or, if not possible, evaluation by an expert committee. We determined the accuracy by comparing the treating physician's diagnosis with the reference diagnosis. RESULTS We included 521 patients (usual care, n = 275; syncope guidelines intervention, n = 246). The syncope guidelines intervention resulted in a higher diagnostic accuracy in the syncope guidelines group than in the usual care group (86% vs.69%; risk ratio 1.15; 95% CI 1.07 to 1.23) and a higher diagnostic yield (89% vs. 76%, 95% CI of the difference 6 to 19%). Syncope-related healthcare costs did not differ between the groups, yet the syncope guideline implementation resulted in lower total syncope-related societal costs compared to usual care (saving €908 per patient; 95% CI €34 to €1782). CONCLUSIONS ESC Syncope Guidelines implementation in the emergency department with quick referral routes to a syncope unit improved diagnostic yield and accuracy and lowered societal costs. TRIAL REGISTRATION Netherlands Trial Register, NTR6268.
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Affiliation(s)
- M Ghariq
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - B de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G J Groothuis
- Department of Cardiology, Diakonessenhuis, Utrecht, The Netherlands
| | - M P M Harms
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E C A Kaal
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E M Koomen
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - F J de Lange
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - S Y G Peeters
- Department of Emergency Medicine, Flevo Hospital, Almere, The Netherlands
| | - I A van Rossum
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - J H W Rutten
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - R D Thijs
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
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16
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Stec S, Wileczek A, Reichert A, Śledź J, Kosior J, Jagielski D, Polewczyk A, Zając M, Kutarski A, Karbarz D, Zyśko D, Nowarski Ł, Stodółkiewicz-Nowarska E. Shared Decision Making and Cardioneuroablation Allow Discontinuation of Permanent Pacing in Patients with Vagally Mediated Bradycardia. J Cardiovasc Dev Dis 2023; 10:392. [PMID: 37754821 PMCID: PMC10532162 DOI: 10.3390/jcdd10090392] [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: 07/17/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Safe discontinuation of pacemaker therapy for vagally mediated bradycardia is a dilemma. The aim of the study was to present the outcomes of a proposed diagnostic and therapeutic process aimed at discontinuing or not restoring pacemaker therapy (PPM) in patients with vagally mediated bradycardia. METHODS The study group consisted of two subgroups of patients with suspected vagally mediated bradycardia who were considered to have PPM discontinued or not to restore their PPM if cardioneuroablation (CNA) would successfully treat their bradycardia. A group of 3 patients had just their pacemaker explanted but reimplantation was suggested, and 17 patients had preexisting pacemakers implanted. An invasive electrophysiology study was performed. If EPS was negative, extracardiac vagal nerve stimulation (ECVS) was performed. Then, patients with positive ECVS received CNA. Patients with an implanted pacemaker had it programmed to pace at the lowest possible rate. After the observational period and control EPS including ECVS, redo-CNA was performed if pauses were induced. The decision to explant the pacemaker was obtained based on shared decision making (SDM). RESULTS After initial clinical and electrophysiological evaluation, 17 patients were deemed eligible for CNA (which was then performed). During the observational period after the initial CNA, all 17 patients were clinically asymptomatic. The subsequent invasive evaluation with ECVS resulted in pause induction in seven (41%) patients, and these patients underwent redo-CNA. Then, SDM resulted in the discontinuation of pacemaker therapy or a decision to not perform pacemaker reimplantation in all the patients after CAN. The pacemaker was explanted in 12 patients post-CNA, while in 2 patients explantation was postponed. During a median follow-up of 18 (IQR: 8-22) months, recurrent syncope did not occur in the CNA recipients. CONCLUSIONS Pacemaker therapy in patients with vagally mediated bradycardia could be discontinued safely after CNA.
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Affiliation(s)
- Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Antoni Wileczek
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Agnieszka Reichert
- Department of Invasive Cardiology, County Specialistic Hospital, 37-450 Stalowa Wola, Poland
| | - Janusz Śledź
- El-Medica, EP-NETWORK, 26-110 Skarzysko-Kamienna, Poland
| | - Jarosław Kosior
- Department of Cardiology, Masovian Specialist Hospital, 26-617 Radom, Poland
| | - Dariusz Jagielski
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, 50-981 Wroclaw, Poland
- Faculty of Medicine, Wrocław University of Science and Technology, 50-370 Wroclaw, Poland
| | - Anna Polewczyk
- Department of Physiology, Pathophysiology and Clinical Immunology, Institute of Medical Sciences, Jan Kochanowski University, 25-369 Kielce, Poland
- Department of Cardiac Surgery, Świętokrzyskie Center of Cardiology, 25-736 Kielce, Poland
| | - Magdalena Zając
- Department of Special Pedagogy and Speech Therapy, Kazimierz Wielki University, 85-064 Bydgoszcz, Poland
| | - Andrzej Kutarski
- Department of Cardiology, Medical University, 20-059 Lublin, Poland
| | | | - Dorota Zyśko
- Department of Emergency Medicine, Wrocław Medical University, 50-367 Wroclaw, Poland
| | - Łukasz Nowarski
- Vascular Surgery Department, The Brothers of Saint John of God Hospital, 31-061 Krakow, Poland
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Fedorowski A, Kulakowski P, Brignole M, de Lange FJ, Kenny RA, Moya A, Rivasi G, Sheldon R, Van Dijk G, Sutton R, Deharo JC. Twenty-five years of research on syncope. Europace 2023; 25:euad163. [PMID: 37622579 PMCID: PMC10450792 DOI: 10.1093/europace/euad163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last 25 years, the Europace journal has greatly contributed to dissemination of research and knowledge in the field of syncope. More than 400 manuscripts have been published in the journal. They undoubtedly improved our understanding of syncope. This symptom is now clearly differentiated from other forms of transient loss of consciousness. The critical role of vasodepression and/or cardioinhibition as final mechanisms of reflex syncope is emphasized. Current diagnostic approach sharply separates between cardiac and autonomic pathways. Physiologic insights have been translated, through rigorously designed clinical trials, into non-pharmacological or pharmacological interventions and interventional therapies. The following manuscript is intended to give the reader the current state of the art of knowledge of syncope by highlighting landmark contributions of the Europace journal.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Piotr Kulakowski
- Department of Cardiology, Medical Centre for Postgraduate Education, Grochowski Hospital, Ul. Grenadierow 51/59, 04-073 Warsaw, Poland
| | - Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Piazzale Brescia 20, 20149 Milan, Italy
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, 152-160 Pearse St, Dublin, Ireland
- Mercer Institute for Successful Ageing, St. James Hospital, James St, Dublin 8, D08 NHY1Ireland
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, Carrer de Sabino Arana 5-19, 08028 Barcelona, Spain
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Robert Sheldon
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute, 3310 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Gert Van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, Du Cane Road, London, W12 0HS, United Kingdom
| | - Jean-Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France and Aix Marseille Université, C2VN, 264 Rue Saint-Pierre, 13005 Marseille, France
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18
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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: 2] [Impact Index Per Article: 2.0] [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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Ludwig B, Olbert E, Trimmel K, Seidel S, Rommer PS, Müller C, Struhal W, Berger T. [Myalgic encephalomyelitis/chronic fatigue syndrome: an overview of current evidence]. DER NERVENARZT 2023; 94:725-733. [PMID: 36695893 PMCID: PMC9875188 DOI: 10.1007/s00115-022-01431-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 01/26/2023]
Abstract
Over the past 5 years both media and scientific interest has surged regarding the disorder myalgic encephalomyelitis and chronic fatigue syndrome (ME/CFS), not least because of the clinically similar manifestation in long COVID or post-COVID. In this review we discuss the process of clinical diagnosis and randomized controlled therapeutic studies on ME/CFS, and the similarities or differences to long COVID and post-COVID. So far, neither clear pathophysiologically causal nor therapeutic evidence-based results on ME/CFS have been identified in the many years of scientific research. Given the evident psychiatric comorbidity rates in patients with a diagnosis of ME/CFS, a psychosomatic etiology of this syndrome should be considered. Furthermore, a precise and reliable diagnostic classification based on stricter criteria would benefit both pathophysiological and therapeutic research.
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Affiliation(s)
- Birgit Ludwig
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Elisabeth Olbert
- Universitätsklinik für Neurologie, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Tulln, Österreich
| | - Karin Trimmel
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Stefan Seidel
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Paulus S Rommer
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Christian Müller
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Walter Struhal
- Universitätsklinik für Neurologie, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Tulln, Österreich
| | - Thomas Berger
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
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20
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Prakash A, Sutton R. Prospective randomized study comparing permanent pacing with rate drop response and closed loop stimulation in patients with vasovagal syncope where permanent pacing is indicated and selected as the appropriate treatment option. J Cardiovasc Electrophysiol 2023; 34:1744-1749. [PMID: 37393604 DOI: 10.1111/jce.15991] [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: 03/20/2023] [Revised: 06/10/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Pacing for vasovagal syncope is established. Two pacing algorithms are available. The rate-drop-response (RDR-Medtronic) is triggered by falling heart rate acting with modified rate-hysteresis. The closed loop stimulation or system (CLS-Biotronik) is triggered by impedance changes in the right ventricle reflecting falling volume and rising contractility. These are very different physiologically. Both algorithms carry favorable reports in clinical use. METHODS A randomized-controlled superiority trial is proposed to compare the two algorithms for the control of vasovagal syncope in patients for whom pacing is indicated by current guidelines in North America and Europe. Available recent evidence may be seen as supporting superiority of CLS. No comparison between the two algorithms has been made. In this trial, patients will be centrally randomized to one or other algorithm on a 1:1 basis. Two-hundred-seventy-six patients in each group will be recruited. Sample size is determined using a confidence interval of 95%, a power of 90%, and a drop-out rate of 10% to detect an 11% difference between CLS and RDR. Recurrent symptom comparison will be made by an independent committee. The Co-primary endpoints will be recurrent syncope burden compared with that in 24-months preimplant, and occurrence of syncope in 24-months follow-up. Each outcome will be compared between the two algorithms. Secondary endpoints will be program and drug therapy changes over 24-months follow-up and quality of life by questionnaire at baseline,1 and 2 years. RESULTS AND CONCLUSIONS These are anticipated to clarify the device algorithm choice and, therefore, to improve patient care.
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Affiliation(s)
- Atul Prakash
- Rutgers Medical School, Newark, New Jersey, USA
- Prime Health Care, Newark, New Jersey, USA
- St Mary's General Hospital, Passaic, New Jersey, USA
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital Campus of National Heart & Lung Institute, Imperial College, London, UK
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21
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Butlin M, Cox JR, Tan I, Avolio AP, Bentley GJ. Bilateral cuff-induced lower limb post-ischemia hyperemia as a method for acute reduction in blood pressure for cuffless blood pressure device testing. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38083571 DOI: 10.1109/embc40787.2023.10341156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Development and testing of cuffless blood pressure (BP) devices requires methods to increase and decrease BP. This is also required by cuffless BP validation standards. Pharmacological interventions, whilst successful, are not always feasible for all subpopulations or research settings. Non-pharmacological approaches for increasing BP are available, however, methods for decreasing BP are not well described. This study investigates the hyperemic response following bilateral leg-cuff ischemia as a method for acute BP lowering. DESIGN AND METHOD Participants (n=8, 24±8 years, 6 female) had their BP measured by continuous (finger, Peňáz technique) and intermittent (brachial cuff, oscillometric) methods before, during and following 3-minute leg-ischemia with the participant in an upright position. Total peripheral resistance (TPR) and cardiac output (CO) were calculated from finger BP waveforms. Maxima and minima responses in the variables were extracted and compared to resting conditions by repeated measures analysis of covariance. RESULTS During the hyperemic period, systolic BP decreased by -22±3 mmHg (finger) and -6±1 mmHg (brachial). Diastolic BP decreased by -14±5 mmHg (finger) and -4 ±1 mmHg (brachial). Calculated TPR and CO varied, with both decreasing by half and almost doubling during the hyperemic response period. CONCLUSIONS Leg-cuff ischemia provides a controlled, non-pharmacological intervention for decreasing systemic arterial BP. This removes some of the limitations in testing, development and validation of cuffless BP techniques and devices.
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22
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Russo V, Rago A, Grimaldi N, Chianese R, Viggiano A, D’Alterio G, Colonna D, Mattera Iacono A, Papa AA, Spadaro Guerra A, Gargaro A, Rapacciuolo A, Sarubbi B, D’Onofrio A, Nigro G. Remote monitoring of implantable loop recorders reduces time to diagnosis in patients with unexplained syncope: a multicenter propensity score-matched study. Front Cardiovasc Med 2023; 10:1193805. [PMID: 37388638 PMCID: PMC10303931 DOI: 10.3389/fcvm.2023.1193805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 05/02/2023] [Indexed: 07/01/2023] Open
Abstract
Background There are little data on remote monitoring (RM) of implantable loop recorders (ILRs) in patients with unexplained syncope and whether it confers enhanced diagnostic power. Objective To evaluate the effect of RM in ILR recipients for unexplained syncope for early detection of clinically relevant arrhythmias by comparison with a historical cohort with no RM. Methods SyncRM is a propensity score (PS)-matched study prospectively including 133 consecutive patients with unexplained syncope and ILR followed up by RM (RM-ON group). A historical cohort of 108 consecutive ILR patients with biannual in-hospital follow-up visits was used as control group (RM-OFF group). The primary endpoint was the time to the clinician's evaluation of clinically relevant arrhythmias (types 1, 2, and 4 of the ISSUE classification). Results The primary endpoint of arrhythmia evaluation was reached in 38 patients (28.6%) of the RM-ON group after a median time of 46 days (interquartile range, 13-106) and in 22 patients (20.4%) of the RM-OFF group after 92 days (25-368). The PS-matched adjusted ratio of rates of arrhythmia evaluation was 2.53 (95% confidence interval, 1.32-4.86) in the RM-ON vs. RM-OFF group (p = 0.005). Conclusion In our PS-matched comparison with a historical cohort, RM of ILR patients with unexplained syncope was associated with a 2.5-fold higher chance of evaluations of clinically relevant arrhythmias as compared with biannual in-office follow-up visits.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, Naples, Italy
| | - Nicola Grimaldi
- Adult Congenital Heart Disease Unit, Monaldi Hospital, Naples, Italy
| | - Raffaele Chianese
- Cardiology Division, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Aniello Viggiano
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Giuliano D’Alterio
- CardiologyDepartment, Electrophysiology and Cardiac Pacing Unit A.O.R.N. V. Monaldi, Naples, Italy
| | - Diego Colonna
- Adult Congenital Heart Disease Unit, Monaldi Hospital, Naples, Italy
| | | | - Andrea Antonio Papa
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, Naples, Italy
| | | | - Alessio Gargaro
- Clinical Research Unit, Biotronik Italia S.p.A., Cologno, Italy
| | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit, Monaldi Hospital, Naples, Italy
| | - Antonio D’Onofrio
- CardiologyDepartment, Electrophysiology and Cardiac Pacing Unit A.O.R.N. V. Monaldi, Naples, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, Naples, Italy
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23
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Rudokaite J, Ong LLS, Onal Ertugrul I, Janssen MP, Huis In 't Veld EMJ. Predicting vasovagal reactions to needles with anticipatory facial temperature profiles. Sci Rep 2023; 13:9667. [PMID: 37316637 DOI: 10.1038/s41598-023-36207-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 05/31/2023] [Indexed: 06/16/2023] Open
Abstract
Around one-third of adults are scared of needles, which can result in adverse emotional and physical responses such as dizziness and fainting (e.g. vasovagal reactions; VVR) and consequently, avoidance of healthcare, treatments, and immunizations. Unfortunately, most people are not aware of vasovagal reactions until they escalate, at which time it is too late to intervene. This study aims to investigate whether facial temperature profiles measured in the waiting room, prior to a blood donation, can be used to classify who will and will not experience VVR during the donation. Average temperature profiles from six facial regions were extracted from pre-donation recordings of 193 blood donors, and machine learning was used to classify whether a donor would experience low or high levels of VVR during the donation. An XGBoost classifier was able to classify vasovagal groups from an adverse reaction during a blood donation based on this early facial temperature data, with a sensitivity of 0.87, specificity of 0.84, F1 score of 0.86, and PR-AUC of 0.93. Temperature fluctuations in the area under the nose, chin and forehead have the highest predictive value. This study is the first to demonstrate that it is possible to classify vasovagal responses during a blood donation using temperature profiles.
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Affiliation(s)
- Judita Rudokaite
- Department of Cognitive Science and Artificial Intelligence, Tilburg University, Tilburg, The Netherlands.
- Donor Medicine Research, Sanquin Research, Amsterdam, The Netherlands.
- Department of Cognitive Science & Artificial Intelligence, Tilburg University, PO Box 90153, Warandelaan 2 (Room D147), 5000 LE, Tilburg, The Netherlands.
| | - L L Sharon Ong
- Department of Cognitive Science and Artificial Intelligence, Tilburg University, Tilburg, The Netherlands
| | - Itir Onal Ertugrul
- Department of Information and Computing Sciences, Utrecht University, Utrecht, The Netherlands
| | - Mart P Janssen
- Donor Medicine Research, Sanquin Research, Amsterdam, The Netherlands
| | - Elisabeth M J Huis In 't Veld
- Department of Cognitive Science and Artificial Intelligence, Tilburg University, Tilburg, The Netherlands
- Donor Medicine Research, Sanquin Research, Amsterdam, The Netherlands
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24
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Boris JR, Abdallah H, Ahrens S, Chelimsky G, Chelimsky TC, Fischer PR, Fortunato JE, Gavin R, Gilden JL, Gonik R, Grubb BP, Klaas KM, Marriott E, Marsillio LE, Medow MS, Norcliffe-Kaufmann L, Numan MT, Olufs E, Pace LA, Pianosi PT, Simpson P, Stewart JM, Tarbell S, Van Waning NR, Weese-Mayer DE. Creating a data dictionary for pediatric autonomic disorders. Clin Auton Res 2023; 33:301-377. [PMID: 36800049 PMCID: PMC9936127 DOI: 10.1007/s10286-023-00923-3] [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: 12/06/2022] [Accepted: 01/06/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Whether evaluating patients clinically, documenting care in the electronic health record, performing research, or communicating with administrative agencies, the use of a common set of terms and definitions is vital to ensure appropriate use of language. At a 2017 meeting of the Pediatric Section of the American Autonomic Society, it was determined that an autonomic data dictionary comprising aspects of evaluation and management of pediatric patients with autonomic disorders would be an important resource for multiple stakeholders. METHODS Our group created the list of terms for the dictionary. Definitions were prioritized to be obtained from established sources with which to harmonize. Some definitions needed mild modification from original sources. The next tier of sources included published consensus statements, followed by Internet sources. In the absence of appropriate sources, we created a definition. RESULTS A total of 589 terms were listed and defined in the dictionary. Terms were organized by Signs/Symptoms, Triggers, Co-morbid Disorders, Family History, Medications, Medical Devices, Physical Examination Findings, Testing, and Diagnoses. CONCLUSION Creation of this data dictionary becomes the foundation of future clinical care and investigative research in pediatric autonomic disorders, and can be used as a building block for a subsequent adult autonomic data dictionary.
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Affiliation(s)
- Jeffrey R Boris
- Jeffrey R. Boris, MD LLC, P.O. Box 16, Moylan, PA, 19065, USA.
| | | | | | - Gisela Chelimsky
- Children's Hospital of Richmond, Virginia Commonwealth University Health, Richmond, VA, USA
| | | | - Philip R Fischer
- Mayo Clinic, Rochester, MN, USA
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- Khalifa University College of Medicine and Health Sciences, Abu Dhabi, UAE
| | | | | | - Janice L Gilden
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Renato Gonik
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | | | - Erin Marriott
- American Family Children's Hospital, Madison, WI, USA
| | - Lauren E Marsillio
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Stanley Manne Children's Research Institute, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Mohammed T Numan
- University of Texas Houston McGovern Medical School, Houston, TX, USA
| | - Erin Olufs
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Paul T Pianosi
- University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | - Sally Tarbell
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | | | - Debra E Weese-Mayer
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Stanley Manne Children's Research Institute, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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25
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Brignole M, Aksu T, Calò L, Debruyne P, Deharo JC, Fanciulli A, Fedorowski A, Kulakowski P, Morillo C, Moya A, Olshansky B, Piotrowski R, Stec S, Wichterle D. Clinical controversy: methodology and indications of cardioneuroablation for reflex syncope. Europace 2023; 25:euad033. [PMID: 37021351 PMCID: PMC10227654 DOI: 10.1093/europace/euad033] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 04/07/2023] Open
Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Piazzale Brescia 2, 20149 Milano, Italy
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, 34755 Ataşehir/İstanbul, Turkey
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, 00169 Roma, Italy
| | | | - Jean Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, France and Aix Marseille Université, C2VN, 13005 Marseille, France
| | - Alessandra Fanciulli
- Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine, Karolinska Institute, 17177 Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 20502 Malmö, Sweden
| | - Piotr Kulakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Carlos Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, T2N 1N4 Calgary, AB, Canada
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, 08028 Barcelona, Spain
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Hospitals, 52242 Iowa City, IA, USA
| | - Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, 04-073 Warsaw, Poland
| | - Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), 11336 Prague, Czechia
- Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, 11336 Prague, Czechia
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Francisco Pascual J, Jordan Marchite P, Rodríguez Silva J, Rivas Gándara N. Arrhythmic syncope: From diagnosis to management. World J Cardiol 2023; 15:119-141. [PMID: 37124975 PMCID: PMC10130893 DOI: 10.4330/wjc.v15.i4.119] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/02/2023] [Accepted: 04/10/2023] [Indexed: 04/20/2023] Open
Abstract
Syncope is a concerning symptom that affects a large proportion of patients. It can be related to a heterogeneous group of pathologies ranging from trivial causes to diseases with a high risk of sudden death. However, benign causes are the most frequent, and identifying high-risk patients with potentially severe etiologies is crucial to establish an accurate diagnosis, initiate effective therapy, and alter the prognosis. The term cardiac syncope refers to those episodes where the cause of the cerebral hypoperfusion is directly related to a cardiac disorder, while arrhythmic syncope is cardiac syncope specifically due to rhythm disorders. Indeed, arrhythmias are the most common cause of cardiac syncope. Both bradyarrhythmia and tachyarrhythmia can cause a sudden decrease in cardiac output and produce syncope. In this review, we summarized the main guidelines in the management of patients with syncope of presumed arrhythmic origin. Therefore, we presented a thorough approach to syncope work-up through different tests depending on the clinical characteristics of the patients, risk stratification, and the management of syncope in different scenarios such as structural heart disease and channelopathies.
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Affiliation(s)
- Jaume Francisco Pascual
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- Grup de Recerca Cardiovascular, Vall d’Hebron Institut de Recerca, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Pablo Jordan Marchite
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Jesús Rodríguez Silva
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Nuria Rivas Gándara
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
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Russo V, Parente E, Comune A, Laezza N, Rago A, Golino P, Nigro G, Brignole M. The clinical presentation of syncope influences the head-up tilt test responses. Eur J Intern Med 2023; 110:41-47. [PMID: 36639324 DOI: 10.1016/j.ejim.2023.01.001] [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: 10/08/2022] [Revised: 12/08/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Little is still known about the positivity rate of nitroglycerin (NTG) potentiated head-up tilt test (HUTT) according to the history-based clinical features of syncope. The study aimed to compare the HUTT positivity rate and type of responses in patients with classical and non-classical vasovagal syncope (VVS). MATERIALS AND METHODS We retrospectively evaluated all consecutive patients who underwent NTG-potentiated HUTT for VVS. The study population was dichotomized into classical and non-classical VVS. RESULTS A total of 1285 VVS patients (45± 19.1 years; 49.6% male) were enrolled: 627 (48.8%) had a history of classical VVS and 658 (51.2%) of non-classical VVS. HUTT was positive in 866 (67.4%) patients. The positivity rate was significantly higher in patients with classical compared to those with non-classical VVS (81.5% vs 54%; P< 0.0001). Cardioinhibitory response showed similar total positivity rate (27.6% vs 31%; P= 0.17), but higher relative prevalence among positive tests (57.7% vs 33.9%, P< 0.0001) in patients with non-classical VVS. At multivariable analysis, classical reflex syncope, male sex, history of traumatic syncope and use of diuretics were independent predictors of HUTT positivity. CONCLUSION The clinical presentation of syncope influences the overall HUTT positivity rate and the type of responses. Cardioinhibitory response and traumatic syncope are more likely in patients with non-classical VVS.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy.
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Nunzia Laezza
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Paolo Golino
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
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28
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de Jong JSY, van Zanten S, Thijs RD, van Rossum IA, Harms MPM, de Groot JR, Sutton R, de Lange FJ. Syncope Diagnosis at Referral to a Tertiary Syncope Unit: An in-Depth Analysis of the FAST II. J Clin Med 2023; 12:2562. [PMID: 37048646 PMCID: PMC10095278 DOI: 10.3390/jcm12072562] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVE A substantial number of patients with a transient loss of consciousness (T-LOC) are referred to a tertiary syncope unit without a diagnosis. This study investigates the final diagnoses reached in patients who, on referral, were undiagnosed or inaccurately diagnosed in secondary care. METHODS This study is an in-depth analysis of the recently published Fainting Assessment Study II, a prospective cohort study in a tertiary syncope unit. The diagnosis at the tertiary syncope unit was established after history taking (phase 1), following autonomic function tests (phase 2), and confirming after critical follow-up of 1.5-2 years, with the adjudicated diagnosis (phase 3) by a multidisciplinary committee. Diagnoses suggested by the referring physician were considered the phase 0 diagnosis. We determined the accuracy of the phase 0 diagnosis by comparing this with the phase 3 diagnosis. RESULTS 51% (134/264) of patients had no diagnosis upon referral (phase 0), the remaining 49% (130/264) carried a diagnosis, but 80% (104/130) considered their condition unexplained. Of the patients undiagnosed at referral, three major causes of T-LOC were revealed: reflex syncope (69%), initial orthostatic hypotension (20%) and psychogenic pseudosyncope (13%) (sum > 100% due to cases with multiple causes). Referral diagnoses were either inaccurate or incomplete in 65% of the patients and were mainly altered at tertiary care assessment to reflex syncope, initial orthostatic hypotension or psychogenic pseudosyncope. A diagnosis of cardiac syncope at referral proved wrong in 17/18 patients. CONCLUSIONS Syncope patients diagnosed or undiagnosed in primary and secondary care and referred to a syncope unit mostly suffer from reflex syncope, initial orthostatic hypotension or psychogenic pseudosyncope. These causes of T-LOC do not necessarily require ancillary tests, but can be diagnosed by careful history-taking. Besides access to a network of specialized syncope units, simple interventions, such as guideline-based structured evaluation, proper risk-stratification and critical follow-up may reduce diagnostic delay and improve diagnostic accuracy for syncope.
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Affiliation(s)
- Jelle S. Y. de Jong
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, 2625 AD Delft, The Netherlands
| | - Roland D. Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands
- Department of Neurology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| | - Ineke A. van Rossum
- Department of Neurology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| | - Mark P. M. Harms
- Department of Internal and Emergency Medicine, University Medical Centre Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Joris R. de Groot
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital Campus, Imperial College, London SW7 6LY, UK
| | - Frederik J. de Lange
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Duval GT, Schott AM, Rolland Y, Gautier J, Blain H, Duque G, Annweiler C. Orthostatic hypotension and neurocognitive disorders in older women: Results from the EPIDOS cohort study. PLoS One 2023; 18:e0281634. [PMID: 36827394 PMCID: PMC9955614 DOI: 10.1371/journal.pone.0281634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 01/27/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Although it is well-admitted that cardiovascular health affects cognition, the association between orthostatic hypotension (OH) and cognition remains unclear. The objectives of the present study were i) to determine among the EPIDOS cohort (EPIdémiologie de l'OStéoporose) whether OH was cross-sectionally associated with cognitive impairment at baseline, and ii) whether baseline OH could predict incident cognitive decline after 7 years of follow-up. METHODS Systolic and Diastolic Blood Pressure (SBP and DBP) changes while standing (ie, ΔSBP and ΔDBP, in %) were measured at baseline among 2,715 community-dwelling older women aged 75 years and older using no antihypertensive drugs from the French EPIDOS cohort. OH was defined as a decrease in SBP ≥20 mmHg and/or a decrease in DBP ≥10 mmHg within 3 min after standing. Cognitive impairment was defined as a Short Portable Mental Status Questionnaire (SPMSQ) score <8 (/10). Among those without cognitive impairment at baseline, a possible incident onset of cognitive decline was then sought after 7 years of follow-up among 257 participants. RESULTS Baseline ΔSBP was associated with baseline cognitive impairment (adjusted OR = 1.01, p = 0.047), but not with incident onset of cognitive decline after 7 years (adjusted OR = 0.98, p = 0.371). Neither baseline OH nor baseline ΔDBP were associated with cognitive impairment neither at baseline (p = 0.426 and p = 0.325 respectively) nor after 7 years (p = 0.180 and p = 0.345 respectively). CONCLUSIONS SBP drop while standing, but neither OH per se nor DBP drop while standing, was associated with baseline cognitive impairment in older women. The relationship between OH and cognitive impairment appears more complex than previously expected.
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Affiliation(s)
- Guillaume T. Duval
- Department of Geriatric Medicine, University Memory Center, Research Center on Autonomy and Longevity (CeRAL), Angers University Hospital, Angers, France
- School of Medicine and UPRES EA 4638, University of Angers, Angers, France
- * E-mail:
| | - Anne-Marie Schott
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle de Santé Publique, Service de Recherche et D’épidémiologie Cliniques, Lyon, France
| | - Yves Rolland
- Department of Geriatrics, Toulouse University Hospital, INSERM U1027, University of Toulouse III, Toulouse, France
| | - Jennifer Gautier
- Department of Geriatric Medicine, University Memory Center, Research Center on Autonomy and Longevity (CeRAL), Angers University Hospital, Angers, France
| | - Hubert Blain
- Department of Internal Medicine and Geriatrics, Montpellier University Hospital, University of Montpellier 1, Montpellier, France
| | - Gustavo Duque
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St. Albans, Victoria, Australia
- Department of Medicine, Melbourne Medical School–Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia
| | - Cedric Annweiler
- Department of Geriatric Medicine, University Memory Center, Research Center on Autonomy and Longevity (CeRAL), Angers University Hospital, Angers, France
- School of Medicine and UPRES EA 4638, University of Angers, Angers, France
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
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Russo V, Parente E, Groppelli A, Rivasi G, Tomaino M, Gargaro A, Giacopelli D, Ungar A, Parati G, Fedorowski A, Sutton R, van Dijk JG, Brignole M. Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology. Europace 2023; 25:263-269. [PMID: 36796797 PMCID: PMC10103574 DOI: 10.1093/europace/euac154] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
This review addresses tilt-testing methodology by searching the literature which reports timing of asystole and loss of consciousness (LOC). Despite the Italian protocol being the most widely adopted, its stipulations are not always followed to the letter of the European Society of Cardiology guidelines. The discrepancies permit reassessment of the incidence of asystole when tilt-down is early, impending syncope, compared with late, established LOC. Asystole is uncommon with early tilt down and diminishes with increasing age. However, if LOC is established as test-end, asystole is more common, and it is age-independent. Thus, the implications are that asystole is commonly under-diagnosed by early tilt-down. The prevalence of asystolic responses observed using the Italian protocol with a rigorous tilt down time is numerically close to that observed during spontaneous attacks by electrocardiogram loop recorder. Recently, tilt-testing has been questioned as to its validity but, in selection of pacemaker therapy in older highly symptomatic vasovagal syncope patients, the occurrence of asystole has been shown to be an effective guide for treatment. The use of head-up tilt test as an indication for cardiac pacing therapy requires pursuing the test until complete LOC. This review offers explanations for the findings and their applicability to practice. A novel interpretation is offered to explain why pacing induced earlier may combat vasodepression by raising the heart rate when sufficient blood remains in the heart.
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Affiliation(s)
- Vincenzo Russo
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Erika Parente
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Marco Tomaino
- Ospedale Generale Regionale, Via Lorenz Böhler, 5, 39100 Bolzano, Italy
| | - Alessio Gargaro
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Daniele Giacopelli
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
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Brignole M, Rivasi G, Fedorowski A, Ståhlberg M, Groppelli A, Ungar A. Tests for the identification of reflex syncope mechanism. Expert Rev Med Devices 2023; 20:109-119. [PMID: 36814102 DOI: 10.1080/17434440.2023.2174428] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Treatment efficacy of reflex syncope is mainly related to the mechanism underlying syncope rather than its etiology or clinical presentation. The predominant mechanism underlying reflex syncope can be assigned to hypotensive or to bradycardic phenotypes. AREAS COVERED Methodology and diagnostic criteria of the most useful tests for the identification of hypotensive and bradycardic phenotypes are discussed. Diagnostic tests for the hypotensive phenotype include office blood pressure measurement with active standing test, home, and wearable blood pressure monitoring, 24-h ambulatory blood pressure monitoring and tilt table test. Diagnostic tests for the bradycardic phenotype include carotid sinus massage, tilt table test and prolonged ECG monitoring. EXPERT OPINION In reflex syncope, the documentation of bradycardia/asystole during a syncopal episode does not rule out the possibility that a preceding or parallel hypotensive reflex plays an important role. Similarly, even when a hypotensive mechanism is established, the possibility of an associated cardioinhibitory reflex should be investigated. Investigating the mechanism of reflex syncope is mandatory in patients with severe recurrent episodes, with the final aim to develop a personalized treatment strategy. Recent trials have demonstrated the benefits of personalized mechanism-based therapy, thus highlighting the importance of a comprehensive assessment of the mechanisms underlying syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Marcus Ståhlberg
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Antonella Groppelli
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Stec S, Jankowska-Polańska B, Jagielski D, Wileczek A, Josiak K, Śledź J, Reichert A, Kustroń A, Zyśko D, Skonieczny B, Fedorowski A, Ratajska A, Zając M, Hering D, Wąsek W, Stodółkiewicz-Nowarska E. Rationale and design of SAN.OK randomized clinical trial and registry: Comparison of the effects of evidence-based pacemaker therapy and cardioneuroablation in sinus node dysfunction. Cardiol J 2022; 29:1031-1036. [PMID: 36385604 PMCID: PMC9788751 DOI: 10.5603/cj.a2022.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/10/2022] [Accepted: 10/31/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, Sanok, Poland,Elmedica, EP-Network, SKA, Poland
| | | | - Dariusz Jagielski
- Department of Cardiology, Center for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | - Antoni Wileczek
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, Sanok, Poland,Elmedica, EP-Network, SKA, Poland
| | - Krystian Josiak
- Department of Cardiology, Center for Heart Diseases, 4th Military Hospital, Wroclaw, Poland,Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | | | | | - Dorota Zyśko
- Department of Cardiology, Center for Heart Diseases, 4th Military Hospital, Wroclaw, Poland,Department of Emergency Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Bartosz Skonieczny
- Department of Cardiology, Center for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Anna Ratajska
- Psychological Therapeutic and Research Center, University Hospital No. 2, Bydgoszcz, Poland,Department of Humanization, Medicine and Sexology, Institute of Health Sciences, University of Zielona Gora, Poland
| | - Magdalena Zając
- Department of Pedagogy, University of Kazimierz Wielki, Bydgoszcz, Poland
| | - Dagmara Hering
- Department of Hyper tension and Diabetology, Medical University of Gdansk, Poland
| | - Wojciech Wąsek
- Department of Internal Medicine, Institute of Health Sciences, College of Medical Sciences, Rzeszow University, Poland
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Kim DH, Park JY, Kim SY, Lee NM, Yi DY, Yun SW, Lim IS, Chae SA. Awareness of postural orthostatic tachycardia syndrome is required in adolescent syncope. Medicine (Baltimore) 2022; 101:e31513. [PMID: 36397456 PMCID: PMC9666125 DOI: 10.1097/md.0000000000031513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We investigated head-up tilt test (HUTT) results across age-groups in syncope/presyncope patients to establish pediatric postural orthostatic tachycardia syndrome (POTS) characteristics. We retrospectively reviewed syncope patients' medical records. Adolescents were defined as 10 to 19 years old, adults as 20 to 59 years old, and older individuals as ≥60 years old. From HUTT results, we determined POTS prevalence and differences among the age-groups. We included 147 adolescents, 269 adults, and 123 older patients. Seventy (13.0%) patients (61.4% females; median age: 20 [17-25] years) were diagnosed with POTS. The syndrome was more prevalent among adolescents (33 [22.4%]) than adults (37 [13.8%]), and was absent among older individuals. Affected adolescents had significantly lower resting diastolic blood pressure (DBP) and heart rate (HR), and converted to maximum HR more rapidly than adolescents without the syndrome during the passive phase. Adolescents with POTS demonstrated several unique characteristics compared to adults with and adolescents without this syndrome. POTS may be underrecognized among syncope and presyncope patients, among which 22.4% of adolescents were diagnosed with the syndrome. POTS should be considered when evaluating syncope patients.
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Affiliation(s)
- Dong Hyun Kim
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Ji Young Park
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Su Yeong Kim
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Na Mi Lee
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Dae Yong Yi
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Sin Weon Yun
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - In Seok Lim
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Soo Ahn Chae
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
- *Correspondence: Soo Ahn Chae, Department of Pediatrics, Chung-Ang University Hospital, 102, Heukseok-ro, Dongjak-gu, Seoul 06973, Republic of Korea (e-mail: )
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Effects of long-acting bronchodilators on cardiac autonomic control in COPD. Respir Med Res 2022; 82:100968. [DOI: 10.1016/j.resmer.2022.100968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/25/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022]
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Loh GOC, Wong EYL, Tan YTF, Wee HC, Ng RS, Syed HK, Kok Khiang P. Simple and high sample throughput LC/ESI-MS/MS method for bioequivalence study of prazosin, a drug with risk of orthostatic hypotension. Drug Dev Ind Pharm 2022; 48:470-479. [DOI: 10.1080/03639045.2022.2125985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Gabriel Onn Cit Loh
- Bioxis Sdn. Bhd. PMT 1241, Jalan Perindustrian Bukit Minyak 8, Taman Perindustrian Bukit Minyak, 14100 Simpang Ampat, Penang, Malaysia
| | - Emily Yii Ling Wong
- Bioxis Sdn. Bhd. PMT 1241, Jalan Perindustrian Bukit Minyak 8, Taman Perindustrian Bukit Minyak, 14100 Simpang Ampat, Penang, Malaysia
| | - Yvonne Tze Fung Tan
- Bioxis Sdn. Bhd. PMT 1241, Jalan Perindustrian Bukit Minyak 8, Taman Perindustrian Bukit Minyak, 14100 Simpang Ampat, Penang, Malaysia
| | - Hong Chin Wee
- Clinical Research Centre, Hospital Pulau Pinang, Jalan Residensi, 10990 Georgetown, Penang, Malaysia
| | - Ru Shing Ng
- Clinical Research Centre, Hospital Pulau Pinang, Jalan Residensi, 10990 Georgetown, Penang, Malaysia
| | - Haroon Khalid Syed
- Department of Pharmaceutics, Faculty of Pharmaceutical Sciences, Government College University, Faisalabad 38000, Pakistan
| | - Peh Kok Khiang
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Minden, Penang, Malaysia
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Vasovagal Syncope Is Associated with Variants in Genes Involved in Neurohumoral Signaling Pathways. Genes (Basel) 2022; 13:genes13091653. [PMID: 36140820 PMCID: PMC9498630 DOI: 10.3390/genes13091653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022] Open
Abstract
Vasovagal syncope (VVS) is the most common cause of sudden loss of consciousness. VVS results from cerebral hypoperfusion, due to abnormal autonomic control of blood circulation, leading to arterial hypotension. It is a complex disease, and its development is largely associated with genetic susceptibility. Since abnormal neurohumoral regulation plays an important role in VVS development, we analyzed the association of VVS with polymorphic variants of ADRA1A, ADRB1, HTR1A, ADORA2A, COMT, and NOS3 genes, the products of which are involved in neurohumoral signaling, in patients with a confirmed VVS diagnosis (157 subjects) and individuals without a history of syncope (161 subjects). We were able to identify the associations between VVS and alleles/genotypes ADRA1A rs1048101, ADRB1 rs1801253, ADORA2A rs5751876, and COMT rs4680, as well as NOS3 rs2070744 in biallelic combination with COMT rs4680. Thus, we are the first to observe, within a single study, the role of the genes that encode α- and β-adrenergic receptors, catechol-O-methyltransferase, adenosine receptors and nitric oxide synthase in VVS development. These findings demonstrate that the genes involved in neurohumoral signaling pathways contribute to the formation of a genetic susceptibility to VVS.
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Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
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Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Tao C, Cui Y, Zhang C, Liu X, Zhang Q, Liu P, Wang Y, Du J, Jin H. Clinical Efficacy of Empirical Therapy in Children with Vasovagal Syncope. CHILDREN 2022; 9:children9071065. [PMID: 35884049 PMCID: PMC9315970 DOI: 10.3390/children9071065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022]
Abstract
(1) Background: This case-control study was designed to assess the efficacy of empiric treatment for vasovagal syncope in children; (2) Methods: We retrospectively enrolled 181 children with vasovagal syncope from the Department of Pediatrics of Peking University First Hospital. The participants were categorized into four groups, based on the empiric treatment received: conventional treatment, including health education and orthostatic training; conventional treatment plus oral rehydration salts; conventional treatment plus metoprolol; conventional treatment plus midodrine hydrochloride. Patients were followed up to evaluate the syncopal or presyncopal recurrence. Kaplan–Meier curves were drawn to explore the syncopal or presyncopal recurrence in children, and the differences were compared among the groups using a log-rank test; (3) Results: Among the 181 children with vasovagal syncope, 11 were lost to follow-up. The median time of follow-up was 20 (8, 42) months. The Kaplan–Meier survival curve showed no significant difference in syncopal or presyncopal recurrence in children treated with different empiric options according to a log-rank test (χ2 = 1.328, p = 0.723); (4) Conclusions: The efficacy of unselected empiric therapy of vasovagal syncope in children was limited, and the individualized therapies merit further studies.
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Affiliation(s)
- Chunyan Tao
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
- Department of Genetics and Endocrinology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Yaxi Cui
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Xueqin Liu
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Qingyou Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Ping Liu
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Yuli Wang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
- Correspondence: ; Tel.: +86-10-83573165
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Lisboa da Silva RMF, Oliveira PML, Tonelli HAF, Alves Meira ZM, Mota CDCC. Neurally Mediated Syncope in Children and Adolescents: An Updated Narrative Review. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2205110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Syncope presents a proportion of up to 25% among children and adolescents and accounts for 0.9% of emergency room visits. Its most frequent aetiology is neurally mediated syncope, which includes vasovagal syncope and orthostatic hypotension. Up to 70% of the paediatric population with reflex syncope is female. There are usually precipitating factors and prodromes. This mini-review will discuss the particularities of the clinical presentation, diagnosis, modified Calgary score, indications and accuracy of the head-up tilt test, classification, and pathophysiology in four sequential phases. Prognostic data and the non-pharmacological and pharmacological approaches will also be reviewed and differences regarding reflex syncope in adults will be discussed.
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Syncope without prodromes is associated with excessive plasma release of adenosine at the time of syncope during head-up tilt table test. Int J Cardiol 2022; 363:43-48. [PMID: 35716941 DOI: 10.1016/j.ijcard.2022.06.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/29/2022] [Accepted: 06/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND In syncopal patients without underlying structural disease, we sought to investigate the association of Adenosine Plasma Levels (ADP) with the clinical presentation of neurally mediated syncope (NMS) and the outcomes of Head-Up Tilt Table Test (HUTT) and Adenosine test (ADT). METHODS We studied 124 patients with different clinical types of NMS, i.e., Vasovagal (VVS, n=58), non-prodromes (NPS, n=18), or situational syncope (SS, n=48), using a standard protocol including HUTT and ADT. During HUTT, ADP was measured in the supine position, at table tilting and in syncope. RESULTS Baseline ADP did not differ among groups. ADP at syncope were higher in NPS (n=5) compared to VVS (n=20): 0.23 vs. 0.12 μΜ, p=0.03, and SS (n=22): 0.04 μΜ, p=0.02. In NPS, ADP increased from supine to syncope (n=5): 0.15 vs. 0.23 μΜ, p=0.04. In VVS, ADP increased only from supine to tilt position: 0.11 vs. 0.14 μΜ, p=0.02. In SS, ADP did not change during HUTT. In positive vasodepressor HUTT, ADP increased from supine to tilt position (p=0.002) and at syncope (p=0.01). In SS, 20.0% exhibited cardioinhibitory HUTT vs. 6.8% in other forms of syncope (p=0.04). In SS, 22.9% manifested positive ADT vs 6.6% in other types of syncope (p=0.012). CONCLUSION The subset of NPS patients with positive HUTT, show excessive ADP release at the time of syncope. This may explain the lack of prodromes in this form of syncope. Such observations contribute to the understanding of distinct profiles of clinical forms of syncope and may differentiate the management approach accordingly.
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Canakci ME, Sevik OE, Acar N. How Should We Approach Syncope in the Emergency Department? Current Perspectives. Open Access Emerg Med 2022; 14:299-309. [PMID: 35789812 PMCID: PMC9249662 DOI: 10.2147/oaem.s247023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/10/2022] [Indexed: 11/23/2022] Open
Abstract
Syncope is a clinical picture that can affect all age groups and has an important place in admissions to the emergency department. There is an important diagnostic challenge in cases where there are different clinical presentations and patients cannot express the situation clearly. Although the emergency department facilities for the diagnosis of syncope are limited, the diagnosis of many patients can be differentiated from life-threatening conditions with a detailed history and physical examination. High-risk patients should be identified and directed for definitive treatment by emergency medicine physicians. This review contains information about the management of the syncope patient in the emergency department.
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Affiliation(s)
- Mustafa Emin Canakci
- Emergency Department, Eskisehir Osmangazi University, Eskisehir, Turkey
- Correspondence: Mustafa Emin Canakci, Emergency Department, Eskisehir Osmangazi University, Prof. Dr. Nabi Avcı Boulevard, No: 4, Meselik, Odunpazarı, Eskisehir, 26040, Turkey, Tel +902222392979 – 5607, Email
| | - Omer Erdem Sevik
- Emergency Department, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Nurdan Acar
- Emergency Department, Eskisehir Osmangazi University, Eskisehir, Turkey
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Polverino P, Ajčević M, Catalan M, Bertolotti C, Furlanis G, Marsich A, Buoite Stella A, Accardo A, Manganotti P. Comprehensive telemedicine solution for remote monitoring of Parkinson's disease patients with orthostatic hypotension during COVID-19 pandemic. Neurol Sci 2022; 43:3479-3487. [PMID: 35301614 PMCID: PMC8930064 DOI: 10.1007/s10072-022-05972-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/21/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Orthostatic hypotension (OH) represents a frequent but under-recognized phenomenon in Parkinson's disease (PD). During COVID-19 pandemic, Information and Communication Technologies (ICT) have become pivotal in the management of chronic diseases like PD, not only to assess motor impairment, but also for vital signs monitoring. This pilot study aimed to propose a real-time remote home-monitoring system and protocol for PD patients with OH. METHODS Vital parameters were acquired by wireless devices and transmitted to an ICT platform, providing data and smart notifications to the healthcare provider through an interactive web portal. Eight patients with idiopathic PD and OH underwent 5-day monitoring. Data about OH episodes, therapeutic interventions, impact on daily activities, and patient satisfaction were collected and analyzed. RESULTS The proposed solution allowed the identification of 65 OH episodes and subsequent medical interventions. Thirty-five episodes were asymptomatic, especially in the postprandial and in the afternoon recordings. Systolic-blood-pressure (SBP) and diastolic-blood-pressure (DBP) were significantly lower in symptomatic episodes, while the pressure drops resulted significantly higher in presence of symptoms. High usability and patient satisfaction scores were observed. CONCLUSION The proposed home-monitoring system and protocol have proved to provide useful information and to allow prompt interventions in the management of PD patients with OH during COVID-19 pandemic.
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Affiliation(s)
- Paola Polverino
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447-34149, Trieste, Italy
| | - Miloš Ajčević
- Department of Engineering and Architecture, University of Trieste, Via A. Valerio, 10-34127, Trieste, Italy
| | - Mauro Catalan
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447-34149, Trieste, Italy
| | - Claudio Bertolotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447-34149, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447-34149, Trieste, Italy
| | | | - Alex Buoite Stella
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447-34149, Trieste, Italy
| | - Agostino Accardo
- Department of Engineering and Architecture, University of Trieste, Via A. Valerio, 10-34127, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447-34149, Trieste, Italy.
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Uppoor RB, Patel K. Syncope: Diagnostic Yield of Various Clinical Investigations. Cureus 2022; 14:e23596. [PMID: 35505734 PMCID: PMC9053362 DOI: 10.7759/cureus.23596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/21/2022] Open
Abstract
Objective: The present study was designed to evaluate the clinical profile of patients with syncope and the usefulness of various tests to reach a diagnosis of syncope and its etiology. Methods: This was a cross-sectional, observational study that enrolled 90 consecutive patients (aged ≥ 12 years) who presented with syncope. Detailed information was obtained from each enrolled patient on history and physical examination. All patients underwent electrocardiography (ECG) and echocardiographic examination. Other specific tests were also performed based on the findings from medical history, physical examination, ECG, and echocardiography findings. Results: Among 90 patients with syncope, 45% were males, and age distribution showed a bimodal distribution with two peaks. A total of 67% and 5% of patients had past history of syncope and injury due to syncope, respectively. Of the patients, 38% underwent Holter monitoring, 79 (87%) underwent head-up tilt table test (HUTT) test, 8% underwent treadmill test, 36% underwent CT/MRI of the brain, 25% underwent electroencephalography, 40% underwent carotid sinus massage, 7% underwent coronary angiography, 3% underwent electrophysiological study, and 3% of patients underwent carotid Doppler ultrasound. The commonly noted syncope was vasovagal/neutrally mediated syncope (68%). However, the etiology of syncope could not be determined in six (7%) patients. Conclusion: This study concluded that the initial evaluation of patients with syncope should focus on history, physical examination, and ECG examination. Information obtained from such basic evaluations should be used to guide the selection of further high yield tests to reduce the cost of evaluation and for appropriate workup for the diagnosis of syncope.
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Yuan P, Li X, Tao C, Du X, Zhang C, Du J, Huang Y, Liao Y. Poincaré Plot Can Be a Useful Tool to Select Potential Responders to Metoprolol Therapy in Children with Vasovagal Syncope. Int J Gen Med 2022; 15:2681-2693. [PMID: 35300141 PMCID: PMC8922042 DOI: 10.2147/ijgm.s352928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Piaoliu Yuan
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xueying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Chunyan Tao
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xiaojuan Du
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, People’s Republic of China
| | - Yaqian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
- Correspondence: Ying Liao; Yaqian Huang, Department of Pediatrics, Peking University First Hospital, Xi-An Men Street No. 1, West District, Beijing, 100034, People’s Republic of China, Tel +8610-83573238; +8610-83575807, Fax +8610-66530532, Email ;
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Numeroso F, Mossini G, Grieco I, Bergamin M, Maggio M, Lippi G, Cervellin G. Incidence and predictive factors of acute diseases in patients with syncope: the ESCAPE study. Intern Emerg Med 2022; 17:215-221. [PMID: 33735415 PMCID: PMC7971406 DOI: 10.1007/s11739-021-02678-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 02/15/2021] [Indexed: 11/01/2022]
Abstract
According to the 2018 ESC guidelines, emergency physicians shall primarily aim to identify syncopal episodes associated with an underlying acute principal disease. Therefore, in this study, we aimed to assess the incidence of syncope associated with acute principal diseases (APDs) and to identify predictive factors reflecting the presence of these underlying conditions. We retrospectively evaluated all patients presenting with syncope during a 6-month period to the local emergency department, collecting incidence of syncopal cases associated with APDs, personal information, clinical features, and laboratory abnormalities, which were compared between syncopal patients with or without APDs. A syncope-associated APD could be diagnosed in 346/1279 patients (27.1%). In the majority of cases, the cause was a non-cardiovascular acute condition (67%), mostly non-life-threatening such as infectious diseases (34.4%) and acute diseases with pain, fluid loss or hypotension (23.7%). Severe acute cardiovascular conditions were less frequent (4.2%). Cardiogenic syncope, no previous history of syncopal episodes, not full agreement with typical clinical features of syncope, alterations of vital parameters, and laboratory abnormalities were also found to be independently associated with syncope-associated APDs. Syncope may be frequently associated with APDs of varying severity, though mostly non-clinically threatening, thus confirming that this condition shall be considered a symptom and not a disease. Emergency physicians should hence be first engaged in troubleshooting an underlying pathology when facing patients with syncope, for timely identifying patients at higher risk of short-term adverse events and reducing inappropriate admissions and diagnostic investigations, especially in the presence of hypotensive syncope elicited by non-severe concurrent conditions.
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Affiliation(s)
- Filippo Numeroso
- Emergency Department, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy.
| | - Gianluigi Mossini
- Emergency Department, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Ilaria Grieco
- Postgraduate School of Gerontology, University of Parma, Via Università 12, 43121, Parma, Italy
| | - Marina Bergamin
- Postgraduate School of Gerontology, University of Parma, Via Università 12, 43121, Parma, Italy
| | - Marcello Maggio
- Emergency Department, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, Department of Neuroscience, Biomedicine and Movement, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Gianfranco Cervellin
- Academy of Emergency Medicine and Care (AcEMC), Via Maugeri 10, 27100, Pavia, Italy
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Hatoum T, Sheldon RS. Syncope and the aging patient: Navigating the challenges. Auton Neurosci 2021; 237:102919. [PMID: 34856496 DOI: 10.1016/j.autneu.2021.102919] [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: 07/19/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
Syncope in the elderly patient is a common presentation and the most common causes are usually non-cardiac. Older adults however are more challenging dilemmas as their presentation is complicated by co-morbidities, mainly cardiovascular and neurodegenerative disorders. Frailty and cognitive impairment add to the ambiguity of the presentation, and polypharmacy is often a major modifiable contributing factor. Vasovagal syncope is a common presentation throughout life even as we age. It has a favorable prognosis and conservative management usually suffices. Vasovagal syncope in this population may be misdiagnosed as accidental falls and is frequently associated with injury, as is carotid sinus syndrome. The initial approach to these patients entails a detailed history and physical examination including a comprehensive medication history, orthostatic vital signs, and a 12-lead electrocardiogram. Further cardiac and neuroimaging rarely helps, unless directed by specific clinical findings. Head-up tilt testing and carotid sinus massage retain their diagnostic accuracy and safety in the elderly, and implantable loop recorders provide important information in many elderly patients with unexplained falls and syncope. The starting point in management of this population with non-cardiac syncope is attempting to withdraw unnecessary vasoactive and psychotropic medications. Non-pharmacologic and pharmacologic therapy for syncope in the elderly has limited efficacy and safety concerns. In selected patients, pacemaker therapy might offer symptomatic relief despite lack of efficacy when vasodepression is prominent. An approach focused on primary care with targeted specialist referral seems a safe and effective strategy.
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Affiliation(s)
- Tarek Hatoum
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
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Post-Acute Sequelae of COVID-19 and Cardiovascular Autonomic Dysfunction: What Do We Know? J Cardiovasc Dev Dis 2021; 8:jcdd8110156. [PMID: 34821709 PMCID: PMC8621226 DOI: 10.3390/jcdd8110156] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
Post-acute sequelae of SARS-CoV-2 (PASC), or long COVID syndrome, is emerging as a major health issue in patients with previous SARS-CoV-2 infection. Symptoms commonly experienced by patients include fatigue, palpitations, chest pain, dyspnea, reduced exercise tolerance, and “brain fog”. Additionally, symptoms of orthostatic intolerance and syncope suggest the involvement of the autonomic nervous system. Signs of cardiovascular autonomic dysfunction appear to be common in PASC and are similar to those observed in postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. In this review, we report on the epidemiology of PASC, discuss current evidence and possible mechanisms underpinning the dysregulation of the autonomic nervous system, and suggest nonpharmacological and pharmacological interventions to treat and relieve symptoms of PASC-associated dysautonomia.
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Hussain S, Raza Z, Kumar TVV, Goswami N. Diagnosing Neurally Mediated Syncope Using Classification Techniques. J Clin Med 2021; 10:jcm10215016. [PMID: 34768538 PMCID: PMC8584937 DOI: 10.3390/jcm10215016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Syncope is a medical condition resulting in the spontaneous transient loss of consciousness and postural tone with spontaneous recovery. The diagnosis of syncope is a challenging task, as similar types of symptoms are observed in seizures, vertigo, stroke, coma, etc. The advent of Healthcare 4.0, which facilitates the usage of artificial intelligence and big data, has been widely used for diagnosing various diseases based on past historical data. In this paper, classification-based machine learning is used to diagnose syncope based on data collected through a head-up tilt test carried out in a purely clinical setting. This work is concerned with the use of classification techniques for diagnosing neurally mediated syncope triggered by a number of neurocardiogenic or cardiac-related factors. Experimental results show the effectiveness of using classification-based machine learning techniques for an early diagnosis and proactive treatment of neurally mediated syncope.
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Affiliation(s)
- Shahadat Hussain
- School of Computer and Systems Sciences, Jawaharlal Nehru University, New Delhi 110067, India; (S.H.); (T.V.V.K.)
| | - Zahid Raza
- School of Computer and Systems Sciences, Jawaharlal Nehru University, New Delhi 110067, India; (S.H.); (T.V.V.K.)
- Correspondence:
| | - T V Vijay Kumar
- School of Computer and Systems Sciences, Jawaharlal Nehru University, New Delhi 110067, India; (S.H.); (T.V.V.K.)
| | - Nandu Goswami
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, 8036 Graz, Austria;
- Department of Health Sciences, Alma Mater Europea Maribor, 2000 Maribor, Slovenia
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van Dijk JG, van Rossum IA, Thijs RD. The pathophysiology of vasovagal syncope: Novel insights. Auton Neurosci 2021; 236:102899. [PMID: 34688189 DOI: 10.1016/j.autneu.2021.102899] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 12/16/2022]
Abstract
The pathophysiology of vasovagal syncope (VVS) is reviewed, focusing on hemodynamic aspects. Much more is known about orthostatic than about emotional VVS, probably because the former can be studied using a tilt table test (TTT). Recent advances made it possible to quantify the relative contributions of the three factors that control blood pressure: heart rate (HR), stroke volume (SV) and total peripheral resistance (TPR). Orthostatic VVS starts with venous pooling, reflected in a decrease of SV. This is followed by cardioinhibition (CI), which is a decrease of HR that accelerates the ongoing decrease of BP, making the start of CI a literal as well as fundamental turning point. The role of hormonal and other humoral factors, respiration and of psychological influences is reviewed in short, leading to the conclusion that a multidisciplinary approach to the study of the pathophysiology of VVS may yield new insights.
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Affiliation(s)
- J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Ineke A van Rossum
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands
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