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Longo S, Del Chierico F, Scanu M, Toto F, Legramante JM, Rizza S, Putignani L, Federici M. An Investigation of Metabolic Risk Factors and Gut Microbiota in Unexplained Syncope. Biomedicines 2024; 12:264. [PMID: 38397866 PMCID: PMC10886590 DOI: 10.3390/biomedicines12020264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The pathogenesis of many syncopal episodes remains unexplained. Intestinal dysbiosis could be involved in the pathophysiological mechanisms of syncope due to its connection with the central nervous system via the microbiota-gut-brain axis. This pilot study aimed to explore the specific cardiometabolic risk factors and gut microbiota in unexplained syncope (US), compared to other types of syncope, to assess their similarity or verify their different origins. METHODS We studied 86 participants with syncope, who were divided into four groups: an orthostatic syncope group (OH, n = 24), a neuromediated syncope group (NMS, n = 26), a cardiological syncope group (CS, n = 9), and an unexplained syncope group (US, n = 27). We evaluated the anthropometric, clinical, and metabolic characteristics of the four groups; the α- and β-diversity; and the differences in the abundance of the microbial taxa. RESULTS The US group had a lower incidence of systolic hypertension at the first visit and a lower frequency of patients with nocturnal hypertension than the CS group. Compared to the OH and NMS groups, the US group had a higher incidence of carotid plaques and greater carotid intima-media thickness, respectively. The microbiota differed significantly between the US and CS groups, but not between the US group and the OH or NMS group. CONCLUSIONS We observed significant differences in the gut microbiota between CS and US. Future studies are necessary to evaluate the involvement of the gut microbiota in the complex pathogenesis of syncope and whether its analysis could support the interpretation of the pathophysiological mechasnisms underlying some episodes classifiable as US.
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Affiliation(s)
- Susanna Longo
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (S.L.); (J.M.L.); (S.R.)
| | - Federica Del Chierico
- Unit of Human Microbiome, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.D.C.); (M.S.); (F.T.)
| | - Matteo Scanu
- Unit of Human Microbiome, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.D.C.); (M.S.); (F.T.)
| | - Francesca Toto
- Unit of Human Microbiome, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.D.C.); (M.S.); (F.T.)
| | - Jacopo M. Legramante
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (S.L.); (J.M.L.); (S.R.)
| | - Stefano Rizza
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (S.L.); (J.M.L.); (S.R.)
| | - Lorenza Putignani
- Unit of Microbiomics and Unit of Human Microbiome, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; (S.L.); (J.M.L.); (S.R.)
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Torabi P, Hamrefors V, Sutton R, Brignole M, Fedorowski A. Definitive aetiology of unexplained syncope after cardiovascular autonomic tests in a tertiary syncope unit. Europace 2023; 25:euad247. [PMID: 37589189 PMCID: PMC10505743 DOI: 10.1093/europace/euad247] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/24/2023] [Accepted: 08/13/2023] [Indexed: 08/18/2023] Open
Abstract
AIMS Syncope is a common condition with many possible causes, ranging from benign to life-threatening aetiologies. Establishing a diagnosis can be difficult, and specialized syncope units, using cardiovascular autonomic tests (CATs), including a head-up tilt test, can increase the diagnostic yield. However, up to one-fifth of examined patients have inconclusive CAT results. The aim of the present study was to investigate the predictive value of history, and clinical findings for unexplained syncope after CAT and characterize the group with negative results. METHODS AND RESULTS Consecutive syncope patients [n = 2663, 61% women, median age 52 (32-69) years] were evaluated and CAT explained aetiology of syncope in 79% of cases, whereas 21% remained unexplained. Predictors of negative CAT were older age at first syncope (+8% higher odds per 10-year increment, P = 0.042), higher supine heart rate (HR; +12% per 10 b.p.m.; P = 0.003), absence of prodromes (+48%; P < 0.001), hypertension (+45%; P = 0.003), diabetes (+82%; P < 0.001), heart failure (+98%; P = 0.014), and coronary artery disease (+51%; P = 0.027). Compared with vasovagal syncope, patients with negative CAT were older, reported more often the absence of prodromes, and had a higher burden of cardiovascular comorbidities. CONCLUSION A cardiovascular autonomic test established the cause of syncope in 79% of patients evaluated in a syncope unit. Syncope without prodromes and cardiovascular comorbidities were significant predictors of failure to reveal an aetiology from assessment by CAT. These are known risk factors for cardiac syncope and patients with inconclusive CAT warrant further investigation.
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Affiliation(s)
- Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Clinical Physiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milano, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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3
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Dempster KS, Wade TJ, MacNeil AJ, O'Leary DD. Adverse childhood experiences are associated with altered cardiovascular reactivity to head-up tilt in young adults. Am J Physiol Regul Integr Comp Physiol 2023; 324:R425-R434. [PMID: 36693169 DOI: 10.1152/ajpregu.00148.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Adverse childhood experiences (ACEs) are associated with greater prevalence of cardiovascular disease and altered acute stress reactivity. The current study investigated the effect of ACEs on hemodynamic and autonomic responses to orthostatic stress imposed by 60° head-up tilt (HUT) in young adults. Two-hundred twenty-six healthy young adults (age = 22.6 ± 1.5 yr; n = 116 females) without cardiovascular disease participated and had complete data. Participants underwent supine blood pressure (BP), R-R interval (RRI), cardiac output (CO), total peripheral resistance (TPR), and cardiovagal baroreflex sensitivity (cvBRS) testing followed by a transition to 60° HUT where measures were reassessed. Childhood adversity exposures were assessed based on categorical exposure and nonexposure to childhood household dysfunction and maltreatment, and <4 and ≥4 types of ACEs. Significantly greater increases in SBP (P < 0.05), DBP, MAP, and TPR (P < 0.01; all) following 60° HUT were observed in individuals with ≥4 compared with those with <4 types of ACEs. Attenuated decreases in RRI and cvBRS were observed in those with ≥4 types of ACEs (P < 0.05). Experiencing ≥4 types of ACEs was associated with augmented BP and TPR reactivity and a blunted decrease in cvBRS in response to 60° HUT in young adults. Results suggest that a reduced vagal response to orthostatic stress is present in those who have experienced ≥4 types of ACEs that may promote autonomic dysfunction. Future research examining the sympathetic and vagal baroreflex branches is warranted.
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Affiliation(s)
- Kylie S Dempster
- Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada.,Brock-Niagara Centre for Health and Well-Being, St. Catharines, Ontario, Canada
| | - Terrane J Wade
- Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada.,Brock-Niagara Centre for Health and Well-Being, St. Catharines, Ontario, Canada
| | - Adam J MacNeil
- Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Deborah D O'Leary
- Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada.,Brock-Niagara Centre for Health and Well-Being, St. Catharines, Ontario, Canada
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Dani M, Taraborrelli P, Panagopoulos D, Dirksen A, Torocastro M, Sutton R, Lim PB. New horizons in the ageing autonomic nervous system: orthostatic hypotension and supine hypertension. Age Ageing 2022; 51:6653480. [PMID: 35930723 PMCID: PMC9724614 DOI: 10.1093/ageing/afac150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Indexed: 01/25/2023] Open
Abstract
Blood pressure regulation is an automatic, moment-by-moment buffering of the blood pressure in response to physiological changes such as orthostasis, exercise and haemorrhage. This finely orchestrated reflex is called the baroreflex. It is a regulated arc of afferent, central and efferent arms. Multiple physiological changes occur with ageing that can disrupt this reflex, making blood pressure regulation less effective. In addition, multiple changes can occur with ageing-related diseases such as neurodegeneration, atherosclerosis, deconditioning and polypharmacy. These changes commonly result in orthostatic hypotension, hypertension or both, and are consistently associated with multiple adverse outcomes. In this article, we discuss the healthy baroreflex, and physiological and pathophysiological reasons for impaired baroreflex function in older people. We discuss why the common clinical manifestations of orthostatic hypotension and concomitant supine hypertension occur, and strategies for balancing these conflicting priorities. Finally, we discuss strategies for treating them, outlining our practice alongside consensus and expert guidance.
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Affiliation(s)
- Melanie Dani
- Address correspondence to: Melanie Dani, Imperial Syncope Unit, Hammersmith Hospital, London W12 0HS, UK.
| | | | | | - Andreas Dirksen
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Miriam Torocastro
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Phang Boon Lim
- Imperial Syncope Unit, Imperial College Healthcare NHS Trust, London W12 0HS, UK
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Barón-Esquivias G, Quintanilla M, Díaz-Martín AJ, Barón-Solís C, Almeida-González CV, García-Romero C, Paneque I, Rubio-Guerrero C, Rodríguez-Corredor R, Valle-Racero JI, Ordóñez A, Morillo CA. Long-term recurrences and mortality in patients with noncardiac syncope. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:568-575. [PMID: 34969644 DOI: 10.1016/j.rec.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/07/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES There are no in-depth studies of the long-term outcome of patients with syncope after exclusion of cardiac etiology. We therefore analyzed the long-term outcome of this population. METHODS For 147 months, we included all patients with syncope referred to our syncope unit after exclusion of a cardiac cause. RESULTS We included 589 consecutive patients. There were 313 (53.1%) women, and the median age was 52 [34-66] years. Of these, 405 (68.8%) were diagnosed with vasovagal syncope (VVS), 65 (11%) with orthostatic hypotension syncope (OHS), and 119 (20.2%) with syncope of unknown etiology (SUE). During a median follow-up of 52 [28-89] months, 220 (37.4%) had recurrences (21.7% ≥ 2 recurrences), and 39 died (6.6%). Syncope recurred in 41% of patients with VVS, 35.4% with OHS, and 25.2% with SUE (P=.006). In the Cox multivariate analysis, recurrence was correlated with age (P=.002), female sex (P <.0001), and the number of previous episodes (< 5 vs ≥ 5; P <.0001). Death occurred in 15 (3.5%) patients with VVS, 11 (16.9%) with OHS, and 13 (10.9%) with SUE (P=.001). In the multivariate analysis, death was associated with age (P=.0001), diabetes (P=.007), and diagnosis of OHS (P=.026) and SUE (P=.020). CONCLUSIONS In patients with noncardiac syncope, the recurrence rate after 52 months of follow-up was 37.4% and mortality was 6.6% per year. Recurrence was higher in patients with a neuromedial profile and mortality was higher in patients with a nonneuromedial profile.
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Affiliation(s)
- Gonzalo Barón-Esquivias
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain; Unidad Cardiovascular, Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Macarena Quintanilla
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Antonio J Díaz-Martín
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Carmen Barón-Solís
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Carmen V Almeida-González
- Unidad de Metodología, Estadística e Investigación, Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain
| | - Carmen García-Romero
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Inmaculada Paneque
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Carmen Rubio-Guerrero
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Rosario Rodríguez-Corredor
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Juan I Valle-Racero
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Antonio Ordóñez
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain; Unidad Cardiovascular, Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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6
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Barón-Esquivias G, Quintanilla M, Díaz-Martín AJ, Barón-Solís C, Almeida-González CV, García-Romero C, Paneque I, Rubio-Guerrero C, Rodríguez-Corredor R, Valle-Racero JI, Ordóñez A, Morillo CA. Recurrencia y mortalidad a largo plazo de los pacientes con síncope no cardiogénico. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Colburn S, Benditt DG. Age at first syncope: a consideration for assessing probable cause? Eur Heart J 2022; 43:2124-2126. [DOI: 10.1093/eurheartj/ehac122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Shaun Colburn
- Cardiac Arrhythmia Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David G. Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Outcomes of Primary vs. Delayed Strategy of Implanting a Cardiac Monitor for Unexplained Syncope. J Clin Med 2022; 11:jcm11071819. [PMID: 35407427 PMCID: PMC8999882 DOI: 10.3390/jcm11071819] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/16/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023] Open
Abstract
Objective: Implantable cardiac monitors (ILR) have an important role in diagnosing unexplained syncope. However, outcomes of primary vs. delayed ILR implantation after initial syncope evaluation have not been explored. Methods: A total of 1705 patients with unexplained syncope were prospectively enrolled in the SYSTEMA (Syncope Study of Unselected Population in Malmö) cohort. Patients who underwent cardiovascular autonomic testing (CAT) and ILR were grouped into those referred to CAT after ILR implantation (primary ILR) and those in whom ILR was indicated after CAT (post-CAT ILR). Results: One-hundred-and-fifteen patients (6.7%) received ILRs. ILR recipients were older (58 vs. 52 years; p = 0.002), had more syncope recurrences (6 vs. 4; p < 0.001), more traumatic falls (72% vs. 53%; p < 0.001), and less prodrome (40% vs. 55%; p = 0.005) than patients without ILRs. During follow-up ≥16 months after ILR, 67 (58%) had normal sinus rhythm, 10 (8.7%) had sinus arrest, 10 (8.7%) AV-block, 13 (11.3%) atrial fibrillation, 9 (7.8%) supraventricular tachycardia, 4 (3.5%) sinus tachycardia and 2 (1.7%) ventricular tachycardia with clinical symptom reproduction. There were 52 patients (45%) in the primary-ILR group and 63 (55%) in the post-CAT ILR group. Proportions of negative ILR monitoring (17/52 vs. 25/63; p = 0.56) and pacemaker implantations (7/52 vs. 15/63; p = 0.23) did not differ between groups. Baseline ECG conduction disorders predicted pacemaker implantation (n = 11/17; odds ratio:10.6; 95%CI: 3.15−35.3; p < 0.001). CAT was more often positive (73% vs. 40%; p < 0.001) in primary-ILR group. Conclusions: Primary ILR implantation was associated with more positive CAT compared with delayed ILR implantation, but negative monitoring and pacemaker implantations were not different between groups. ECG conduction disorders predicted subsequent pacemaker implantation.
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Sutton R, Ricci F, Fedorowski A. Risk stratification of syncope: Current syncope guidelines and beyond. Auton Neurosci 2022; 238:102929. [PMID: 34968831 DOI: 10.1016/j.autneu.2021.102929] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/27/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
Syncope is an alarming event carrying the possibility of serious outcomes, including sudden cardiac death (SCD). Therefore, immediate risk stratification should be applied whenever syncope occurs, especially in the Emergency Department, where most dramatic presentations occur. It has long been known that short- and long-term syncope prognosis is affected not only by its mechanism but also by presence of concomitant conditions, especially cardiovascular disease. Over the last two decades, several syncope prediction tools have been developed to refine patient stratification and triage patients who need expert in-hospital care from those who may receive nonurgent expert care in the community. However, despite promising results, prognostic tools for syncope remain challenging and often poorly effective. Current European Society of Cardiology syncope guidelines recommend an initial syncope workup based on detailed patient's history, physical examination supine and standing blood pressure, resting ECG, and laboratory tests, including cardiac biomarkers, where appropriate. Subsequent risk stratification based on screening of features aims to identify three groups: high-, intermediate- and low-risk. The first should immediately be hospitalized and appropriately investigated; intermediate group, with recurrent or medium-risk events, requires systematic evaluation by syncope experts; low-risk group, sporadic reflex syncope, merits education about its benign nature, and discharge. Thus, initial syncope risk stratification is crucial as it determines how and by whom syncope patients are managed. This review summarizes the crucial elements of syncope risk stratification, pros and cons of proposed risk evaluation scores, major challenges in initial syncope management, and how risk stratification impacts management of high-risk/recurrent syncope.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, Dept. of Cardiology, Hammersmith Hospital, Du Cane Road, London W12 0HS, United Kingdom
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, Via Luigi Polacchi, 11, 66100 Chieti, Italy; Casa di Cura Villa Serena, Città Sant'Angelo, Italy
| | - Artur Fedorowski
- Dept. of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Stockholm, Sweden.
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11
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Coyte A, Perry R, Papacosta AO, Lennon L, Whincup PH, Wannamethee SG, Ramsay ASE. Social relationships and the risk of incident heart failure: results from a prospective population-based study of older men. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeab045. [PMID: 35036999 PMCID: PMC8755459 DOI: 10.1093/ehjopen/oeab045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/14/2021] [Indexed: 12/21/2022]
Abstract
Abstract
Aims
Limited social relationships, particularly in older adults, have been implicated as a risk factor for cardiovascular disease. However, little is known about the associations between poor social relationships and heart failure incidence.
Methods and results
Prospective study of socially representative men aged 60–79 years drawn from general practices in 24 British towns and followed up for a maximum of 18 years. A total of 3698 participants with no previous diagnosis of heart failure were included. Information on social relationships was based on a combination of marital status, living circumstances, and social contacts with friends and family. These provided information on contact frequency, contact satisfaction, and a social relationship score (low to high) combining frequency and satisfaction with contact. Heart failure included both incidents non-fatal heart failure and death from heart failure. Among 3698 participants, 330 developed heart failure. Men with low compared to high frequency of contact with family and friends had an increased risk of incident heart failure [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.15–2.18]; this remained statistically significant after adjustment for social class, behavioural, and biological risk factors. Low compared to high scores for satisfaction with contacts was associated with increased risk of heart failure (adjusted HR = 1.54; 95% CI 1.14–2.07). Lower social relationship scores (combining frequency and satisfaction with contact) were associated with greater risk of incident heart failure (adjusted HR = 1.38, 95% CI 1.02–1.87). Marital status and living alone were not significantly associated with heart failure.
Conclusion
Weaker social relationships appear to increase the risk of developing heart failure in older age. Further research is needed to investigate pathways underlying these associations and to test whether interventions to strengthen social relationships can reduce the risk of heart failure.
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Affiliation(s)
- Aishah Coyte
- Population Health Science Institute, Newcastle University , Newcastle upon Tyne NE2 4AX, UK
| | - Rachel Perry
- Population Health Science Institute, Newcastle University , Newcastle upon Tyne NE2 4AX, UK
| | - Anna Olia Papacosta
- Department of Primary Care and Population Health, University College , London W6 8RP, UK
| | - Lucy Lennon
- Department of Primary Care and Population Health, University College , London W6 8RP, UK
| | - Peter Hynes Whincup
- Population Health Research Institute, St George’s University of London , London SW17 0RE, UK
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Torabi P, Rivasi G, Hamrefors V, Ungar A, Sutton R, Brignole M, Fedorowski A. OUP accepted manuscript. Eur Heart J 2022; 43:2116-2123. [PMID: 35139180 PMCID: PMC9170473 DOI: 10.1093/eurheartj/ehac017] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/15/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
Aims Methods and results Conclusion
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Affiliation(s)
| | | | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - 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 & Fall Programme, 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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13
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Johansson M, Rogmark C, Sutton R, Fedorowski A, Hamrefors V. Risk of incident fractures in individuals hospitalised due to unexplained syncope and orthostatic hypotension. BMC Med 2021; 19:188. [PMID: 34446019 PMCID: PMC8394111 DOI: 10.1186/s12916-021-02065-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Impaired orthostatic blood pressure response and syncope confer a high risk of falls and trauma. The relationship between a history of unexplained syncope and orthostatic hypotension (OH) with subsequent fractures, however, has not been thoroughly examined. In this study, we aimed to investigate the relationship between previous hospital admissions due to unexplained syncope and OH and incident fractures in a middle-aged population. METHODS We analysed a large population-based prospective cohort of 30,399 middle-aged individuals (age, 57.5 ± 7.6; women, 60.2%). We included individuals hospitalised due to unexplained syncope or OH as the main diagnosis. Multivariable-adjusted Cox regression analysis was applied to assess the impact of unexplained syncope and OH hospitalisations on subsequent incident fractures. RESULTS During a follow-up period of 17.8 + 6.5 years, 8201 (27%) subjects suffered incident fractures. The mean time from baseline and first admission for syncope (n = 493) or OH (n = 406) was 12.6 ± 4.2 years, and the mean age of the first hospitalisation was 74.6 ± 7.4 years. Individuals with incident fractures were older, more likely to be women, and had lower BMI, higher prevalence of prevalent fractures, and family history of fractures. Multivariable-adjusted Cox regression showed an increased risk of incident fractures following hospitalisations due to unexplained syncope (HR 1.20; 95% CI 1.02-1.40; p = 0.025) and OH (HR 1.42; 95% CI 1.21-1.66; p < 0.001) compared with unaffected individuals. CONCLUSIONS Individuals hospitalised due to unexplained syncope and orthostatic hypotension have an increased risk of subsequent fractures. Our findings suggest that such individuals should be clinically assessed for their syncope aetiology, with preventative measures aimed at fall and fracture risk assessment and management.
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Affiliation(s)
- Madeleine Johansson
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden. .,Department of Cardiology, Skåne University Hospital, Malmö, Sweden.
| | - Cecilia Rogmark
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden.,Department of Orthopaedics, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Artur Fedorowski
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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14
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Abstract
Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced age. Indeed, antihypertensive treatment may predispose to orthostatic and post-prandial hypotension, while intensive blood pressure lowering may be responsible for systemic hypotension. Over recent years, systemic and orthostatic hypotension have emerged as important although often neglected risk factors for adverse outcomes, paralleling the widely recognized arterial hypertension. Both hypertension and hypotension are associated with detrimental effects on target organs and survival, thus significantly impacting patients' prognosis, functional autonomy and quality of life. Balancing low and high blood pressure requires accurate diagnostic assessment of blood pressure values and patients' hypotensive susceptibility, which allow for the development of customized treatment strategies based on individual hypo/hypertensive risk profile. The present review illustrates the complex interrelationship between hypotension and hypertension and discusses the relevant prognostic role of these conditions. Additionally, it provides an overview on hypotension detection and treatment in patients with hypertension, focusing on customized diagnostic and therapeutic strategies.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy -
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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15
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Fedorowski A, Pirouzifard M, Sundquist J, Sundquist K, Sutton R, Zöller B. Risk Factors for Syncope Associated With Multigenerational Relatives With a History of Syncope. JAMA Netw Open 2021; 4:e212521. [PMID: 33783519 PMCID: PMC8010588 DOI: 10.1001/jamanetworkopen.2021.2521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Reflex syncope is the major cause of transient loss of consciousness, which affects one-third of the population, but effective treatment for individuals with severe syncope is lacking. Better understanding of reflex syncope predisposition may offer new therapeutic solutions. OBJECTIVES To determine the familial risk of syncope in first-, second-, and third-degree relatives of affected individuals and to explore the role of genes and family environment in reflex syncope. DESIGN, SETTING, AND PARTICIPANTS In this national population-based family cohort study, the Swedish multigeneration register was linked to 3 Swedish nationwide registers: hospital discharge, outpatient care, and primary care registers for the period from 1997 to 2015. Sibling pairs born to Swedish parents between 1948 and 2005 were included. Linkage was also made to half-siblings and cousins. Data analysis was performed from June to October 2020. EXPOSURES Register-based syncope diagnosis among relatives: pairs of twins, siblings, half-siblings, and cousins. MAIN OUTCOMES AND MEASURES Odds ratios for syncope were calculated for relatives (twins, siblings, half-siblings, and cousins) of individuals who had syncope compared with relatives of individuals without syncope for reference. Sensitivity analysis excluding families with definite nonreflex syncope diagnosis was performed. RESULTS Among the study population of 2 694 442 participants, 1 381 453 (51.3%) were male, and the median (interquartile range) age was 32 (22-43) years. The study population consisted of 24 020 twins, 1 546 108 siblings, 264 244 half-siblings, and 1 044 546 cousins. In total, 61 861 (2.30%) unique individuals were diagnosed with syncope. Sixty-two percent (38 226) of the syncope-positive individuals were female. The odds ratio (OR) for syncope was 2.39 (95% CI, 1.61-3.53) for twins, 1.81 (95% CI, 1.71-1.91) for siblings, 1.28 (95% CI, 1.20-1.37) for half-siblings, and 1.13 (95% CI, 1.10-1.17) for cousins of individuals with syncope. The OR was highest among male twins at 5.03 (95% CI, 2.57-9.85). The proportion of syncope-positive individuals was consistently higher in women vs men, regardless of degree of relationship (twins: 346 [2.88%] vs 193 [1.61%]; siblings: 22 111 [2.92%] vs 13 419 [1.70%], half-siblings: 4148 [3.44%] vs 2425 [1.93%], cousins: 14 498 [2.87%] vs 9246 [1.72%]). Exclusion of nonreflex syncope diagnoses did not change syncope risk in affected families. CONCLUSIONS AND RELEVANCE In this Swedish national population-based study, the risk of syncope among relatives of affected individuals was associated with the relationship degree and was strongest in twins and siblings, which suggests that there are genetic components of reflex syncope. Women were more likely to experience syncope independently of family relationship. A better understanding of genetic predisposition to reflex syncope may offer new therapeutic options in severely affected individuals.
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Affiliation(s)
- Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Mirnabi Pirouzifard
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
- Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
- Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California
| | - Richard Sutton
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- National Heart and Lung Institute, Imperial College, Department of Cardiology, London, United Kingdom
| | - Bengt Zöller
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
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16
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Perings C, Wolff C, Wilk A, Witthohn A, Voss R, Rybak K. Do implantable loop recorders impact the survival of patients with recurrent unexplained syncope? J Comp Eff Res 2021; 10:285-294. [PMID: 33499667 DOI: 10.2217/cer-2020-0242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study compares the outcomes of patients who receive an implantable loop recorder (ILR) for unexplained syncope to a control group without the diagnostic device in German claims data. Methods and materials: Patients with ILR were matched to a control group based on prior syncope events, age, gender and Charlson Comorbidity index (CCI). Survival, syncope hospitalizations, treatment and costs were compared. Results/conclusion: Four hundred and twelve ILR patients were matched with controls, mean age was 68, mean CCI was 2.7, 42% females. ILR patients lived on average 1.2 years longer than patients in the control group. Twenty-five percent of ILR patients received a therapeutic device compared with 5% in the control group. ILRs might help to diagnose and treat patients with positive impact on survival.
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Affiliation(s)
- Christian Perings
- Department of Cardiology, St. Marien-Hospital, Altstadtstraße 23, 44534 Lünen, Germany
| | - Claudia Wolff
- Medtronic International Trading Sarl, Route du Molliau 31,1131 Tolochenaz, Switzerland
| | - Adrian Wilk
- Team Gesundheit, Gesellschaft für Gesundheitsmanagement GmbH, Rellinghauser Str. 93, 45128 Essen, Germany
| | | | - Rainer Voss
- Medtronic GmbH, Earl-Bakken-Platz 1, 40670 Meerbusch, Germany
| | - Karin Rybak
- Kardiologische Praxis, Kochstedter Kreisstraße 11, 06847 Dessau-Roßlau, Germany
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17
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Disease network delineates the disease progression profile of cardiovascular diseases. J Biomed Inform 2021; 115:103686. [PMID: 33493631 DOI: 10.1016/j.jbi.2021.103686] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE As Electronic Health Records (EHR) data accumulated explosively in recent years, the tremendous amount of patient clinical data provided opportunities to discover real world evidence. In this study, a graphical disease network, named progressive cardiovascular disease network (progCDN), was built to delineate the progression profiles of cardiovascular diseases (CVD). MATERIALS AND METHODS The EHR data of 14.3 million patients with CVD diagnoses were collected for building disease network and further analysis. We applied a new designed method, progression rates (PR), to calculate the progression relationship among different diagnoses. Based on the disease network outcome, 23 disease progression pair were selected to screen for salient features. RESULTS The network depicted the dominant diseases in CVD development, such as the heart failure and coronary arteriosclerosis. Novel progression relationships were also discovered, such as the progression path from long QT syndrome to major depression. In addition, three age-group progCDNs identified a series of age-associated disease progression paths and important successor diseases with age bias. Furthermore, a list of important features with sufficient abundance and high correlation was extracted for building disease risk models. DISCUSSION The PR method designed for identifying the progression relationship could be widely applied in any EHR database due to its flexibility and robust functionality. Meanwhile, researchers could use the progCDN network to validate or explore novel disease relationships in real world data. CONCLUSION The first-time interrogation of such a huge CVD patients cohort enabled us to explore the general and age-specific disease progression patterns in CVD development.
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18
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Romero-Ortuño R, Martínez-Velilla N, Sutton R, Ungar A, Fedorowski A, Galvin R, Theou O, Davies A, Reilly RB, Claassen J, Kelly ÁM, Ivanov PC. Network Physiology in Aging and Frailty: The Grand Challenge of Physiological Reserve in Older Adults. FRONTIERS IN NETWORK PHYSIOLOGY 2021; 1:712430. [PMID: 36925570 PMCID: PMC10012993 DOI: 10.3389/fnetp.2021.712430] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/25/2021] [Indexed: 12/29/2022]
Affiliation(s)
- Román Romero-Ortuño
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland.,Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland.,Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Nicolás Martínez-Velilla
- Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Public University of Navarra (UPNA), Navarra Health Research Institute (IdisNa), Pamplona, Spain
| | - Richard Sutton
- Faculty of Medicine, Imperial College London, Heart Science, National Heart and Lung Institute, London, United Kingdom
| | - Andrea Ungar
- Geriatric Department, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University and Department of Cardiology, Skåne University Hospital, Malmo, Sweden
| | - Rose Galvin
- Ageing Research Centre, School of Allied Health, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Olga Theou
- Physiotherapy and Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Andrew Davies
- School of Medicine, Trinity College Dublin, University College Dublin and Our Lady's Hospice and Care Services, Dublin, Ireland
| | - Richard B Reilly
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland.,Trinity Centre for Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Jurgen Claassen
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Áine M Kelly
- Discipline of Physiology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Plamen Ch Ivanov
- Keck Laboratory for Network Physiology, Boston University, Boston, MA, United States
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19
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Adlan AM, Eftekhari H, Paul G, Hayat S, Osman F. The Impact of a Nurse-Led Syncope Clinic: Experience from a single UK tertiary center. J Arrhythm 2020; 36:854-862. [PMID: 33024463 PMCID: PMC7532277 DOI: 10.1002/joa3.12420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/30/2020] [Accepted: 08/06/2020] [Indexed: 12/02/2022] Open
Abstract
Background Syncope is a leading cause of hospital admission and is associated with significant morbidity and mortality. Our Syncope Clinic commenced in 2014 and we sought to evaluate its impact on outcomes (1‐yr mortality and syncope re‐hospitalization) in patients discharged following syncope admission. Methods A single‐center study of all consecutive patients discharged with syncope (ICD‐10 R55) between April 2012 and 2017. Patient demographics, comorbidities, hospital stay, syncope re‐hospitalization, and mortality at one‐year were collected. Those subsequently referred and seen in Syncope Clinic were compared with those who were not and predictors of poor outcome were evaluated. Results In total 2950 patients were discharged from hospital with syncope (median age: 73years, 51% male) with 1220 (41%) discharged same‐day; after commencement of Syncope Clinic 231were subsequently reviewed here. Overall mortality was 11%, which was lower in the Syncope Clinic group (3% vs 12%, P < .001). Temporal analysis revealed reduced re‐hospitalization following commencement of Syncope Clinic (2% vs 6%, P = .027). Independent predictors of mortality were increasing age (HR 1.03, 95% CI 1.03‐1.04), AF (HR 1.6, 95% CI 1.2‐2.1), HF (HR 2.2, 95% CI 1.6‐3.0), COPD (HR 1.9, 95% CI 1.4‐2.7), and CHADS2 score ≥ 1 (HR 1.45, 95% CI 1,12‐1.87). Syncope Clinic attendance was associated with reduced mortality (HR 0.3, 95% CI 0.1‐0.6). Conclusions Syncope patients discharged from hospital had reduced 1yr mortality if seen in subsequent Syncope Clinic. Independent predictors of mortality were COPD, HF, AF, and CHADS2 ≥1. Prospective randomized trials of Syncope Clinics are warranted.
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Affiliation(s)
- Ahmed M Adlan
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK
| | - Helen Eftekhari
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK
| | - Geeta Paul
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK
| | - Sajad Hayat
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK.,Department of Adult Cardiology Heart Hospital Hamad Medical Corporation Doha Qatar
| | - Faizel Osman
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK.,University of Warwick (Medical School) Coventry UK
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20
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Wolff C, Petkar S. Burden of recurrent syncope and injuries and the usefulness of implantable cardiac monitors: insights from a nationwide longitudinal cohort analysis. J Comp Eff Res 2020; 9:659-666. [PMID: 32639168 DOI: 10.2217/cer-2020-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The study assesses the burden and costs of recurring unexplained syncope and injuries and the effectiveness of implantable loop recorders. Methods: The English national hospital database (Hospital Episode Statistics) was retrospectively analyzed. Results: 12,002 patients were identified with repeated syncope hospitalizations. 25% of patients were hospitalized at least once again for syncope, 9% of the patients were hospitalized at least once for an injury, causing substantial costs. In the second analysis: 10,902 patients implanted with an implantable cardiac monitor were tracked. By year 3, hospitalizations due to syncope had dropped by 60% versus pre-implantable cardiac monitor (ICM) levels. Conclusion: This study shows a high rate of recurrent syncope admissions and a parallel burden of hospitalizations for injuries. Use of an ICM appears to reduce syncope hospitalizations.
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Affiliation(s)
- Claudia Wolff
- Department of Health Economics, Medtronic, Route du Molliau 31, Tolochenaz 1131, Switzerland
| | - Sanjiv Petkar
- Department of Cardiology, New Cross Hospital, Wolverhampton Rd, Heath Town, Wolverhampton WV10 0QP, UK
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21
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Orthostatic hypotension is associated with new-onset atrial fibrillation: Systemic review and meta-analysis. Indian Heart J 2019; 71:320-327. [PMID: 31779860 PMCID: PMC6890958 DOI: 10.1016/j.ihj.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/02/2019] [Accepted: 07/24/2019] [Indexed: 01/11/2023] Open
Abstract
Introduction Orthostatic hypotension (OH) is common among elderly patients. Its presence may herald severe underlying comorbidities and be associated with a higher risk of mortality. Interestingly, recent studies suggest that OH is associated with new-onset atrial fibrillation (AF). However, a systematic review and meta-analysis of the literature has not been performed. We assessed the association between AF and OH through a systematic review of the literature and a meta-analysis. Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to November 2018. Published prospective or retrospective cohort studies that compared new-onset AF between male patients with and without OH were included. Data from each study were combined using the random-effects, generic inverse-variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. Results Four studies from October 2010 to March 2018 were included in the meta-analysis involving 76,963 subjects (of which 3318 were diagnosed with OH). The presence of OH was associated with new-onset AF (pooled risk ratio 1.48; 95% confidence interval [1.21, 1.81], p?< 0.001; I2 = 69.4%). In hypertensive patients, analysis revealed an association between OH and the occurrence of new-onset AF (OR 1.46; 95% CI [1.27, 1.68], p < 0.001 with I2 = 0). Conclusions OH was associated with new-onset AF up to 1.5-fold compared with those subjects without OH. The interplay between OH and AF is likely bidirectional.
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Min M, Shi T, Sun C, Liang M, Zhang Y, Tian S, Sun Y. The association between orthostatic hypotension and cognition and stroke: a meta-analysis of prospective cohort studies. Blood Press 2019; 29:3-12. [DOI: 10.1080/08037051.2019.1689808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Min Min
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Tingting Shi
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Chenyu Sun
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Mingming Liang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Yun Zhang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Shun Tian
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Yehuan Sun
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, China
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Min M, Shi T, Sun C, Liang M, Zhang Y, Bo G, Sun Y. Orthostatic hypotension and the risk of atrial fibrillation and other cardiovascular diseases: An updated meta-analysis of prospective cohort studies. J Clin Hypertens (Greenwich) 2019; 21:1221-1227. [PMID: 31290595 PMCID: PMC8030411 DOI: 10.1111/jch.13613] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/23/2019] [Accepted: 05/05/2019] [Indexed: 11/27/2022]
Abstract
The relationships between orthostatic hypotension (OH) and some kinds of cardiovascular disease are inconsistent among studies. This updated meta-analysis was conducted in hopes of producing progress on this topic. A systematic database search was performed in electronic databases, including the Chinese Biomedical Database (CBM), PubMed, Web of Science, and the Cochrane Library. Summary hazard ratio (HR) estimates with 95% confidence intervals (CIs) were calculated by a random-effects model. Statistical heterogeneity was assessed with Cochran's Q test and the I2 statistic. From 1462 potentially eligible records, 15 studies met the inclusion criteria. Subjects with OH had a high risk of heart failure (HF) and atrial fibrillation (AF) (pooled HR 1.34, 95% CI 1.17-1.52, P < 0.001 and pooled HR 1.51, 95% CI 1.28-1.79, P < 0.001, respectively). This meta-analysis also showed significant associations between OH and the risks of developing coronary heart disease (CHD) (pooled HR 1.44, 95% CI 1.18-1.75, P < 0.001) and myocardial infarction (MI) (pooled HR 1.52, 95% CI 1.12-2.06, P = 0.008). Our study suggests that OH is positively associated with high risks of HF and AF. Moreover, it may be related to high risks of CHD and MI.
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Affiliation(s)
- Min Min
- Department of Epidemiology and Health Statistics, School of Public HealthAnhui Medical UniversityHefeiChina
| | - Tingting Shi
- Department of Epidemiology and Health Statistics, School of Public HealthAnhui Medical UniversityHefeiChina
| | - Chenyu Sun
- The First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Mingming Liang
- Department of Epidemiology and Health Statistics, School of Public HealthAnhui Medical UniversityHefeiChina
| | - Yun Zhang
- Department of Epidemiology and Health Statistics, School of Public HealthAnhui Medical UniversityHefeiChina
| | - Guang Bo
- Department of Epidemiology and Health Statistics, School of Public HealthAnhui Medical UniversityHefeiChina
| | - Yehuan Sun
- Department of Epidemiology and Health Statistics, School of Public HealthAnhui Medical UniversityHefeiChina
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24
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Abstract
OBJECTIVES Most studies of orthostatic hypotension (OH) have focused on community-dwelling and institutionalized patient populations. Less is known about OH in hospitalized patients. Moreover, a comprehensive review of OH in internal medicine wards has not been published in the English literature. Our purpose is to provide current information regarding OH in internal medicine inpatients. METHODS A comprehensive search of medical databases was performed for potentially relevant articles, using the following keywords: postural or orthostatic hypotension, with the combination of hospitalization or internal medicine. Inclusion criteria were: population of patients hospitalized for acute disorders in internal medicine or geriatric wards with a sample size of ≥50 and publication as an original full-length article in the English language. Data from 14 selected studies are reviewed, including: pathophysiology, evaluation, prevalence, manifestations, risk factors, prognosis, and management. RESULTS OH is a common and often symptomatic disorder in elderly internal medicine patients. The prevalence of OH in this population ranges from 22-75%. There are substantial discrepancies between the studies reviewed regarding definitions and means of evaluating OH. OH in internal medicine wards is largely non-neurogenic and multifactorial. The main predisposing factors for OH are prolonged bed rest, hypertension, and heart failure. OH in internal medicine wards is managed mainly with non-pharmacologic interventions, and is frequently reversible. CONCLUSIONS In internal medicine inpatients, OH warrants attention because this disorder is common, potentially dangerous, and treatable. In the hospital setting, OH should be routinely assessed on ambulation, following the current guidelines for OH definition and meaning.
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Affiliation(s)
- Irma Tzur
- a Department of Internal Medicine "F" , Assaf Harofeh Medical Center , Zerifin , Israel (affiliated to Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel)
| | - Shimon Izhakian
- a Department of Internal Medicine "F" , Assaf Harofeh Medical Center , Zerifin , Israel (affiliated to Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel)
| | - Oleg Gorelik
- a Department of Internal Medicine "F" , Assaf Harofeh Medical Center , Zerifin , Israel (affiliated to Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel)
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25
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Yasa E, Ricci F, Holm H, Persson T, Melander O, Sutton R, Hamrefors V, Fedorowski A. Pacing therapy in the management of unexplained syncope: a tertiary care centre prospective study. Open Heart 2019; 6:e001015. [PMID: 30997138 PMCID: PMC6443123 DOI: 10.1136/openhrt-2019-001015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 12/22/2022] Open
Abstract
Objective Pacemaker (PM) therapy is effective when syncope is associated with bradycardia, but syncope recurrences and fall injuries after PM implantation may occur. We aimed to survey indications and outcomes of PM implantation, following evaluation of unexplained syncope. Methods Among 1666 consecutive unpaced patients investigated in a tertiary syncope unit by carotid-sinus massage (CSM), head-up tilt test (HUT) and ECG monitoring, 106 (6.4%; age, 65 ± 17 years) received a PM. We assessed bradycardia detection methods, PM implantation indications, and explored incidence of recurrent syncope, fall-related fractures and mortality. Results Indications for PM therapy were met in 32/106 patients (30%) by CSM, in 41/106 (39%) by HUT, in 14/106 patients (13%) by implantable loop-recorder (ILR) and in 19/106 (18%) by standard ECG. Sinus arrest with asystole was the predominant PM indication during CSM/HUT and external ECG monitoring, whereas ILR detected proportionally the same numbers o f asystole due to sinus arrest and atrioventricular block. During follow-up (median, 4.3 years), 15 patients (14%) had syncope recurrence, 15 suffered fall-related fractures and 9 died. Neither syncope recurrence nor fall-related fractures were dependent on initial PM indication. The composite endpoint of recurrent syncope/fall-related fracture was associated with treated hypertension (OR 2.45; 95% CI 1.00 to 6.0), reduced glomerular filtration rate (OR 1.63 per 10 mL/min↓; 95% CI 1.22 to 2.19) and atrial fibrillation (OR 3.98; 95% CI 1.11 to 14.3). Recurrent syncope predicted increased mortality (OR 9.20; 95% CI 1.89 to 44.8). Conclusions Cardiovascular autonomic testing and ECG monitoring effectively identify pacing indications in patients with unexplained syncope. After PM implantation, treated hypertension, renal failure and atrial fibrillation predict syncope recurrence and fall-related injury. Recurrent syncope predicts increased mortality.
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Affiliation(s)
- Ekrem Yasa
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Fabrizio Ricci
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Neuroscience, Imaging and Clinical Sciences, Universita degli Studi Gabriele d'Annunzio Chieti e Pescara, Chieti Scalo, Italy
| | - Hannes Holm
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Torbjörn Persson
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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Mol A, Reijnierse EM, Bui Hoang PTS, van Wezel RJ, Meskers CG, Maier AB. Orthostatic hypotension and physical functioning in older adults: A systematic review and meta-analysis. Ageing Res Rev 2018; 48:122-144. [PMID: 30394339 DOI: 10.1016/j.arr.2018.10.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/17/2018] [Accepted: 10/17/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) may negatively affect physical functioning and aggravate morbidities, but existing evidence is contradictory. METHODS MEDLINE (from 1946), PubMed (from 1966) and EMBASE databases (from 1947) were systematically searched for studies on the association of OH and physical functioning in older adults, categorized as: balance, gait characteristics, walking speed, Timed Up and Go time, handgrip strength (HGS), physical frailty, exercise tolerance, physical activity, activities of daily living (ADL), and performance on the Hoehn and Yahr scale (HY) and Unified Parkinson's Disease Rating Scale (UPDRS). Study quality was assessed using the Newcastle Ottawa Scale. RESULTS Forty-two studies were included in the systematic review (29,421 individuals) and 29 studies in the meta-analyses (23,879 individuals). Sixteen out of 42 studies reported a significant association of OH with worse physical functioning. Meta-analysis showed a significant association of OH with impaired balance, ADL performance and HY/UPDRS III performance, but not with gait characteristics, mobility, walking speed, TUG, HGS, physical frailty, exercise tolerance, physical activity and UPDRS II performance. CONCLUSIONS OH was associated with impaired balance, ADL performance and HY/UPDRS III performance, but not with other physical functioning categories. The results suggest that OH interventions could potentially improve some aspects of physical functioning.
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Ricci F, Sutton R, Palermi S, Tana C, Renda G, Gallina S, Melander O, De Caterina R, Fedorowski A. Prognostic significance of noncardiac syncope in the general population: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2018; 29:1641-1647. [PMID: 30106212 DOI: 10.1111/jce.13715] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/04/2018] [Accepted: 08/07/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Cardiac syncope heralds significantly higher mortality compared with syncope due to noncardiac causes or unknown etiology, commonly considered a benign event. A few epidemiologic studies have examined the outcome of noncardiac/unexplained syncope comparing individuals with and without syncope, but with controversial results. We performed a systematic review and meta-analysis to clarify whether history of noncardiac/unexplained syncope is associated with increased all-cause mortality in the general population. METHODS AND RESULTS Our systematic review of the literature published between January 1, 1966, and March 31, 2018 sought prospective, observational, cohort studies reporting summary-level outcome data about all-cause mortality in subjects with history of noncardiac/unexplained syncope compared with syncope-free participants. Adjusted hazard ratios were pooled through inverse variance random-effect meta-analysis to compute the summary effect size. Meta-regression models were performed to explore the effect of age, cardiovascular risk factors, or other potential confounders on the measured effect size. We identified four studies including 287 382 individuals (51.6% men; age, 64 ± 12 years): 38 843 with history of noncardiac/unexplained syncope and 248 539 without history of syncope. The average follow-up was 4.4 years. History of noncardiac/unexplained syncope was associated with higher all-cause mortality (pooled adjusted hazard ratio = 1.13; 95% confidence interval, 1.05 to 1.23). Meta-regression analysis showed a stronger positive relationship proportional to aging and increasing prevalence of diabetes and hypertension. CONCLUSIONS This study-level meta-analysis showed that among older, diabetic and/or hypertensive individuals, history of noncardiac/unexplained syncope, even in the absence of an obvious cardiac etiology, is associated with higher all-cause mortality.
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Affiliation(s)
- Fabrizio Ricci
- Department of Neuroscience and Imaging and Clinical Sciences, Institute for Advanced Biomedical Technologies, G. D'Annunzio University, Chieti, Italy.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Stefano Palermi
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, and Center of Excellence on Aging, CeSI-Met, G. D'Annunzio University, Chieti, Italy
| | - Claudio Tana
- Medicine Geriatric-Rehabilitation Department, Internal Medicine and Critical Subacute Care Unit, University Hospital of Parma, Parma, Italy
| | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, and Center of Excellence on Aging, CeSI-Met, G. D'Annunzio University, Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, and Center of Excellence on Aging, CeSI-Met, G. D'Annunzio University, Chieti, Italy
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Raffaele De Caterina
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, and Center of Excellence on Aging, CeSI-Met, G. D'Annunzio University, Chieti, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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Affiliation(s)
- Josh Waytz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
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Ruwald MH. Syncope and orthostatic hypotension: early markers of cardiac disease in the general population. Heart 2017; 104:456-457. [DOI: 10.1136/heartjnl-2017-312112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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