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Pronk AC, Wang L, van Poelgeest EP, Leeflang MMG, Daams JG, Hoekstra AG, van der Velde N. The impact of cardiovascular diagnostics and treatments on fall risk in older adults: a scoping review and evidence map. GeroScience 2024; 46:153-169. [PMID: 37864713 PMCID: PMC10828261 DOI: 10.1007/s11357-023-00974-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/07/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND We aimed to summarize the published evidence on the fall risk reducing potential of cardiovascular diagnostics and treatments in older adults. METHODS Design: scoping review and evidence map. DATA SOURCES Medline and Embase. ELIGIBILITY CRITERIA all available published evidence; Key search concepts: "older adults," "cardiovascular evaluation," "cardiovascular intervention," and "falls." Studies reporting on fall risk reducing effect of the diagnostic/treatment were included in the evidence map. Studies that investigated cardiovascular diagnostics or treatments within the context of falls, but without reporting a fall-related outcome, were included in the scoping review for qualitative synthesis. RESULTS Two articles on cardiovascular diagnostics and eight articles on cardiovascular treatments were included in the evidence map. Six out of ten studies concerned pacemaker intervention of which one meta-analyses that included randomized controlled trials with contradictory results. A combined cardiovascular assessment/evaluation (one study) and pharmacotherapy in orthostatic hypotension (one study) showed fall reducing potential. The scoping review contained 40 articles on cardiovascular diagnostics and one on cardiovascular treatments. It provides an extensive overview of several diagnostics (e.g., orthostatic blood pressure measurements, heart rhythm assessment) useful in fall prevention. Also, diagnostics were identified, that could potentially provide added value in fall prevention (e.g., blood pressure variability and head turning). CONCLUSION Although the majority of studies showed a reduction in falls after the intervention, the total amount of evidence regarding the effect of cardiovascular diagnostics/treatments on falls is small. Our findings can be used to optimize fall prevention strategies and develop an evidence-based fall prevention care pathway. Adhering to the World guidelines on fall prevention recommendations, it is crucial to undertake a standardized assessment of cardiovascular risk factors, followed by supplementary testing and corresponding interventions, as effective components of fall prevention strategies. In addition, accompanying diagnostics such as blood pressure variability and head turning can be of added value.
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Affiliation(s)
- Anouschka C Pronk
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Liping Wang
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Eveline P van Poelgeest
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands.
| | - Mariska M G Leeflang
- Department of Epidemiology and Data Science Section of Methodology, Amsterdam University Medical Centres, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Joost G Daams
- Medical Library, University of Amsterdam, Amsterdam, The Netherlands
| | - Alfons G Hoekstra
- Computational Science Lab, Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
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Clemmensen SLK, Kragholm K, Tayal B, Torp-Pedersen C, Kold S, Søgaard P, Riahi S. Risk of pacemaker implantation after femur fracture in patients with and without a history syncope: a Danish nationwide registry-based follow-up study. J Geriatr Cardiol 2022; 19:712-718. [PMID: 36284681 PMCID: PMC9548056 DOI: 10.11909/j.issn.1671-5411.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND It has previously been described that fall-associated injuries including fractures are commonly observed among patients with bradyarrhythmia. However, knowledge on the risk of pacemaker implantation after admission due to femur fracture from large population-based epidemiologic data is lacking. Therefore, we investigated the risk of pacemaker implantation following femur fracture in patients with and without a history of previous syncope. METHODS All patients with femur fracture between 2005-2017 were identified using the Danish Nationwide Patient Registry. Among these, patients already having a pacemaker were excluded. Primary outcome was one-year risk of pacemaker implantation and secondary outcome was one-year all-cause mortality. Multivariable logistic regression was used to obtain absolute and relative risks of the study endpoint in relation to patients with versus without history of syncope and standardized to the age, sex, selected comorbidity and pharmacotherapy distribution of all patients. RESULTS Of 93,093 patients with femur fracture, 5508 (5.9%) had a history of syncope within five years. Patients with prior syncope were slightly older (84 vs. 83 years), more often male (33.6% vs. 29.4%), and had more often comorbidities relative to those without history of syncope. All-cause mortality was significantly higher among those with previous history of syncope compared to those without previous syncope (29.9% vs. 28.6%, P = 0.021). The relative mortality risk was 1.05 (95% CI: 1.01-1.09, P = 0.021). A total of 695 (0.8%) patients underwent pacemaker implantation within 5 years following femur fracture, and a significantly higher proportion of patients with syncope had a pacemaker implanted within one year (1.6% vs. 0.7%, P < 0.001; relative risk, 2.01 [95% CI: 1.55-2.46]). CONCLUSIONS In patients with femur fracture, a history of syncope was significantly associated with a higher one-year risk of pacemaker implantation.
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Affiliation(s)
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Bhupendar Tayal
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Kold
- Department of Orthopedics, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
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Sanghvi MM, Jones DM, Kalindjian J, Monkhouse C, Providencia R, Schilling RJ, Ahluwalia N, Earley MJ, Finlay M. The utility of implantable loop recorders (ILR) in patient management: an age and indication stratified study in the outpatient-implant era. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:770-777. [PMID: 34601557 DOI: 10.1093/ehjqcco/qcab071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/30/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Implantable loop recorders (ILR) are now routinely implanted for long-term cardiac monitoring in the clinic setting. This study examined the real-world performance of these devices, focusing on the management decision changes made in response to ILR-recorded data. METHODS AND RESULTS This was a single centre, prospective observational study of consecutive patients undergoing ILR implantation. All patients who underwent implantation of a Medtronic Reveal LINQ device from September 2017 to June 2019 at Barts Heart Centre were included.501 patients were included. 302 (60%) patients underwent ILR implantation for an indication of pre-syncope/syncope, 96 (19%) for palpitations, 72 (14%) for atrial fibrillation (AF) detection with a history of cryptogenic stroke and 31 (6%) for patients deemed to be high risk of serious cardiac arrhythmia.The primary outcome of this study was that an ILR-derived diagnosis altered management in 110 (22%) of patients. Secondary outcomes concerned sub-group analyses by indication: in patients who presented with syncope/presyncope, a change in management resulting from ILR data was positively associated with age (HR: 1.04 [95%CI 1.02-1.06]; p < 0.001) and negatively associated with a normal ECG at baseline (HR 0.54 [0.31-0.93]; p = 0.03). Few patients (1/57, 2%) aged < 40 years in this group underwent device implantation, compared to 19/62 patients (31%) aged 75 years and over (p = 0.0024). 22/183 (12%) of patients in the 40-74 age range had a device implanted.In patients who underwent ILR insertion following cryptogenic stroke, 13/72 patients (18%) had AF detected leading to a decision to commence anticoagulation. CONCLUSION These results inform the utility of ILR in the clinical setting. Diagnoses provided by ILR that lead to changes in management are rare in patients under age 40, particularly following syncope, presyncope or palpitations. In older patients new diagnoses are frequently made and trigger important changes in treatment.
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Affiliation(s)
- Mihir M Sanghvi
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE.,William Harvey Heart Centre, Queen Mary University of London, Charterhouse Square, London, EC1A 6BQ
| | - Daniel M Jones
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE
| | - Jeremy Kalindjian
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE
| | | | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE
| | - Richard J Schilling
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE
| | - Nikhil Ahluwalia
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE
| | - Mark J Earley
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE
| | - Malcolm Finlay
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE.,William Harvey Heart Centre, Queen Mary University of London, Charterhouse Square, London, EC1A 6BQ
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Luiting S, Jansen S, Seppälä LJ, Daams JG, van der Velde N. Effectiveness of Cardiovascular Evaluations and Interventions on Fall Risk: A Scoping Review. J Nutr Health Aging 2019; 23:330-337. [PMID: 30932131 PMCID: PMC6507528 DOI: 10.1007/s12603-019-1165-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/12/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Cardiovascular abnormalities are consistently associated with fall risk in older people. However, little research has been done to assess the effect of cardiovascular interventions on fall risk. The aim of this scoping review is to explore the current literature on the effectiveness of cardiovascular evaluations and interventions in reducing fall risk in older people. DESIGN Scoping review. DATA SOURCES Medline, Cochrane Library, and WHO ICTRP Search Portal were systematically searched. SELECTION CRITERIA Randomized controlled trials (RCTs) and intervention studies of community-dwelling adults aged ≥50 years or with a mean age of >60 years that assessed the effect of a cardiovascular assessment and interventions in reducing fall risk. Key search concepts were "falls" and "aged", and terms for different cardiovascular evaluations and interventions were included. The Cochrane Checklist for risk of bias and the ROBINS-I tool were used to assess the quality of the studies. RESULTS Seven studies were included. The majority showed a reduction in falls after cardiovascular evaluation and intervention. Two out of four studies that focused on carotid sinus hypersensitivity (CSH) as a modifiable cardiovascular risk factor for falls, showed a significant reduction in falls after pacemaker implantation. Two studies that looked at sinus node dysfunction (SND) both showed a significant reduction in falls after pacemaker implantation. One study showed that 33% of the patients experienced a fall after cardiovascular evaluation and intervention, whereas all patients fell before assessment. CONCLUSIONS The majority of the included studies showed a reduction in falls after the intervention. However, the number of published papers regarding the effect of cardiovascular assessment and interventions on falls is small. A standardized assessment of cardiovascular risk factors may be essential in preventing falls in older adults and could consequently reduce injuries, loss of quality of life, deaths, and fall-related expenditures.
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Affiliation(s)
- S Luiting
- Nathalie van der Velde, PhD, Amsterdam University Medical Center, Department of Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam 1105AZ, the Netherlands, Tel. nr: +31 20-5665991, e-mail:
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Sutton R. Carotid sinus syndrome: Progress in understanding and management. Glob Cardiol Sci Pract 2014; 2014:1-8. [PMID: 25405171 PMCID: PMC4220427 DOI: 10.5339/gcsp.2014.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 05/28/2014] [Indexed: 12/19/2022] Open
Abstract
Carotid sinus syndrome (CSS) is a disease of the autonomic nervous system presenting with syncope, especially in older males who often have cardiovascular disease. The aetiology is unknown and epidemiological data is limited. Forty new patients/million population have been estimated to require pacing for CSS and these patients represent ∼9% of those presenting syncope to a specialist facility. CSS is defined as a response to carotid sinus massage (CSM) that includes reproduction of spontaneous symptoms. Cardioinhibitory CSS shows 3s asystole on CSM and vasodepressor CSS shows >50 mmHg fall in blood pressure (BP), there are mixed forms. The methodology of CSM requires correct massage in the supine and upright with continuous ECG and BP. Assessment of the vasodepressor component implies the ‘method of symptoms’ using atropine to prevent asystole. Carotid sinus hypersensitivity (CSH) is a related condition where CSM is positive in an asymptomatic patient. CSH cannot be assumed to respond to pacing. CSS patients present syncope with little or no warning. If no cause is revealed by the initial evaluation, CSM should be considered in all patients >40 years. CSM carries a small risk of thromboembolism. Therapy for cardioinhibitory CSS is dual chamber pacing, which is most effective in patients with a negative tilt test. Syncope recurrence is ∼20% in 5 years in paced patients. Therapy for the vasodepressor component of CSS, as pure vasodepression or mixed, where tilt testing will likely be positive, is often unrewarding: alternative therapeutic measures may be needed including discontinuation/reduction of hypotensive drugs.
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Affiliation(s)
- Richard Sutton
- Emeritus Professor of Clinical Cardiology, National Heart & Lung Institute, Imperial College, London, UK
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Daccarett M, Brignole M, Malasana GR, Sherwood RP, Jetter TL, Hamdan MH. Underevaluation of Cardiovascular Risk Factors in Patients With Nonaccidental Falls. J Prim Care Community Health 2011; 2:173-80. [DOI: 10.1177/2150131911405212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The incidence of adult patients with falls seeking medical assistance in the Salt Lake City area, Utah, is 28,000 per million adult inhabitants. Objective: We sought to evaluate the prevalence of cardiovascular risk assessment and cardiovascular abnormalities in patients presenting with nonaccidental falls at the University of Utah hospital and its affiliated clinics. Methods: We conducted a search of all patients in the University of Utah patient database as well as 9 affiliated primary care and family practice clinics in Utah who were evaluated for a “fall” during October 2009. We analyzed the records of 338 patients who had a fall within the previous 3 months. Nonaccidental falls were defined as falls unrelated to a contact incident or “slip or trip.” Results: Nonaccidental falls occurred in 81 (24%) patients, 39 of these being ≥65 years old. Cardiovascular risk assessment and specifically orthostatic testing were evaluated in 40% and 3% of the patients, respectively. In patients ≥65 years old, the prevalence of cardiovascular risk assessment, orthostatic testing, and carotid sinus massage were equally low at 56%, 5%, and 0%, respectively. Cardiovascular abnormalities were present in 17 (21%) patients, with 9 of them being referred for cardiac evaluation. Conclusion: Our results highlight the inconsistent assessment of potential cardiovascular risk factors in patients with nonaccidental falls, supporting the adoption of a standardized approach in these patients.
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Affiliation(s)
| | - Michele Brignole
- University of Utah Medical Center, Salt Lake City, UT, USA
- Ospedali del Tigullio, Lavagna, Italy
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Brignole M, Menozzi C. The natural history of carotid sinus syncope and the effect of cardiac pacing. Europace 2011; 13:462-4. [DOI: 10.1093/europace/euq516] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Lopes R, Goncalves A, Campos J, Frutuoso C, Silva A, Touguinha C, Freitas J, Maciel MJ. The role of pacemaker in hypersensitive carotid sinus syndrome. Europace 2010; 13:572-5. [DOI: 10.1093/europace/euq455] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abstract
Falls and syncope are among the leading causes for which older patients seek hospital admissions. The prevalence of unexplained or nonaccidental falls is high in this group. The clinical spectrum of falls and syncope has been shown to overlap significantly in the elderly. Carotid sinus syndrome and vasovagal syncope, the two common examples of neurally mediated syncope (NMS), have been increasingly recognised as important attributable causes for unexplained falls and syncope. However, in clinical practice NMS is not widely investigated as a cause of fall and is likely to be underdiagnosed.
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Affiliation(s)
- M Anpalahan
- Department of General Medicine, Western Health and Osteoporosis Clinic, Northern Health, Melbourne, Victoria, Australia.
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Parry SW, Steen N, Baptist M, Fiaschi KA, Parry O, Kenny RA. Cerebral autoregulation is impaired in cardioinhibitory carotid sinus syndrome. Heart 2006; 92:792-7. [PMID: 16449521 PMCID: PMC1860657 DOI: 10.1136/hrt.2004.053348] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To compare changes in cerebral autoregulation in response to controlled, lower body negative pressure-induced hypotension in patients with carotid sinus syndrome (CSS) and case controls. DESIGN Prospective case controlled study. SETTING Secondary and tertiary referral falls and syncope service. PATIENTS 17 consecutive patients with CSS and 11 asymptomatic controls. INTERVENTIONS Hypotension insufficient to cause syncope induced by lower body negative pressure (minimum 30 mm Hg fall in systolic blood pressure (SBP)) during concomitant transcranial Doppler ultrasonography. MAIN OUTCOME MEASURES Cerebral autoregulation (systolic, diastolic and mean middle cerebral arterial blood flow velocities and cerebrovascular resistance) with continuous end-tidal carbon dioxide and haemodynamic monitoring. RESULTS Cerebral autoregulatory indices differed significantly between patients with CSS and controls. Systolic, diastolic and middle cerebral arterial blood flow velocities were, respectively, 9.2 m/s (95% confidence interval (CI) 2.9 to 15.4 m/s), 4.7 m/s (95% CI 1.5 to 7.9 m/s) and 6.9 m/s (95% CI 2.5 to 11.4 m/s) slower in patients with CSS. Cerebrovascular resistance was significantly greater in patients with CSS than in controls at SBP nadir and suction release; differences were 0.9 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s) and 0.8 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s), respectively. End-tidal carbon dioxide and systemic haemodynamic variables were similar for patients and controls at baseline and during lower body negative pressure. CONCLUSIONS Cerebral autoregulation is altered in patients with CSS. This difference may have aetiological implications in the differential presentation with falls and drop attacks rather than syncope.
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Affiliation(s)
- S W Parry
- Cardiovascular Investigation Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
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Parry SW, Steen IN, Baptist M, Kenny RA. Amnesia for Loss of Consciousness in Carotid Sinus Syndrome. J Am Coll Cardiol 2005; 45:1840-3. [PMID: 15936616 DOI: 10.1016/j.jacc.2005.02.060] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2004] [Revised: 02/10/2005] [Accepted: 02/14/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The goal of this study was to compare the clinical characteristics of patients with carotid sinus syndrome who presented with falls with those who presented with syncope. BACKGROUND Carotid sinus syndrome presents with both falls and syncope. The reasons for this differential presentation are unknown, but amnesia for loss of consciousness may be the underlying cause. METHODS Two groups of 34 consecutive patients with carotid sinus syndrome as the sole cause of falls and syncope were recruited. Cognitive function and clinical characteristics were compared between the two groups. RESULTS Syncopal subjects with carotid sinus syndrome were more likely to be older males (18 [53%] vs. 7 [21%] years; p = 0.006) with a longer duration of symptoms (27.9 vs. 13.3 months; p = 0.009) and more soft tissue injuries (19 [56%] vs. 9 [26%]; p = 0.03). Duration of asystole during carotid sinus massage was similar in both groups (5.1 vs. 5.4 s; p = 0.42), but witnessed amnesia for loss of consciousness was more frequent in fallers than those with syncope (21 [95%] vs. 4 [12%]; p < 0.001). Clinical characteristics and cognitive function were otherwise similar in both groups. CONCLUSIONS Patients with carotid sinus syndrome have similar rates of witnessed loss of consciousness during laboratory testing regardless of symptoms. However, those presenting with falls are far less likely to perceive any disturbance of consciousness than those with syncope, showing for the first time the manner in which such patients manifest symptoms. Cognitive impairment does not explain the amnesia for loss of consciousness seen in fallers with carotid sinus syndrome.
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Affiliation(s)
- Steve W Parry
- Falls and Syncope Service and Institute for Ageing and Health, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom.
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Abstract
OBJECTIVES To investigate the causes of recurrent drop attacks in older patients with a comprehensive battery of investigations in the largest series reported to date. DESIGN Observational with mean followup of 18 months. SETTING Inner city emergency department and tertiary facility in Newcastle upon Tyne, United Kingdom. PARTICIPANTS Ninety-three consecutive patients aged 55 and older with three or more drop attacks in the 6 months before evaluation. METHODS Subjects underwent a comprehensive diagnostic evaluation, with particular attention to traditional (e.g., gait and balance abnormalities, medications) and more recently identified (e.g., carotid sinus hypersensitivity) risk factors for drop attacks. RESULTS Subjects tended to be older (mean age+/-standard deviation 77.4+/-9.0) and female (70; 75%) and to have a mean of 10.4 drop attacks before evaluation. Fifty-three (57%) had suffered soft tissue injuries needing medical attention and 32 (34%) fractures secondary to drop attacks. An attributable diagnosis was achieved in all but nine subjects (90%). Cardiovascular diagnoses (49; 53%) were most commonly implicated, with neurological (27; 29%) and gait and balance abnormalities (17; 18%) and drug-related causes (11; 12%) providing the majority of the remaining diagnoses. CONCLUSION Drop attacks in older subjects are associated with high levels of morbidity and healthcare resource utilization. Attributable diagnoses are achievable in the majority of cases with a systematic investigative approach. The high diagnostic yield more than justifies the approach described.
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Abstract
This article reviews the recent literature about carotid sinus syndrome. It looks principally at the various ways in which it may present, the limited knowledge of its pathophysiology, and the role of carotid sinus massage in the investigation of carotid sinus syndrome.
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Affiliation(s)
- Mark Mallet
- Medical Assessment Unit, Royal United Hospital, Bath BA1 3NG
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Abstract
Monitoring devices are an important adjunct to the clinical assessment of patients who experience falls. The use of these devices should be guided by the clinical history, a physical assessment, and routine investigations. Quantitative measures of postural sway should be used in conjunction with clinical measures to provide a more accurate assessment of gait and balance. Assessment of blood pressure changes during the investigation of neurocardiovascular causes of syncope and falls in older adults should be performed with noninvasive digital photoplethysmographic devices, so long as their appropriate use and limitations are applied and understood. Only minimal information can be gained from short-term heart rate and rhythm monitoring in patients with infrequent symptoms. The usefulness of long-term ECG monitoring (with both external and implantable recorders) is well established for the diagnosis of unexplained syncope but requires further assessment in older individuals who experience falls. Twenty-four-hour measurements of ambulatory blood pressure generally are not diagnostically helpful in patients who experience falls or syncope but do have a role in the monitoring of therapeutic interventions.
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Affiliation(s)
- Colette M Seifer
- Cardiovascular Investigation Unit, Institute for the Health of the Elderly, University of Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, United Kingdom
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Abstract
Atrial fibrillation is an extremely rare cause of falls and syncope in the elderly. The routine use of ambulatory ECG monitoring to search for atrial fibrillation in elderly patients who fall is not recommended. Among elderly patients with atrial fibrillation who fall, short pauses of less than 3 seconds are nonspecific and are as common in patients who fall as they are in those who do not. Furthermore, most pauses are not associated with symptoms. Although the decision to implant a pacemaker for extremely long pauses is often straightforward, the decision to implant a pacemaker in patients who fall and who have short pauses ideally should be made after symptoms clearly have been associated with the dysrhythmia. This type of symptom-rhythm correlation is extremely valuable and often requires long-term ambulatory monitoring with external or internal (implanted) event or loop recorders. Among the growing population of elderly persons with chronic atrial fibrillation, oral anticoagulant therapy has been shown to have significant benefit and is underused, particularly in frail residents of long-term care facilities. The published literature does not support the commonly held belief that a patient's propensity to fall is an important factor in determining optimal antithrombotic therapy. Demographic shifts in the worldwide population continue to alter the practice of medicine, which is being influenced increasingly by the health care needs of the expanding elderly population. Additional research is needed to clarify the relationship between atrial fibrillation and falls in the elderly.
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Affiliation(s)
- Mathew S Maurer
- Division of Cardiology, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY 10032, USA
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Abstract
The prevalence and incidence of syncope increases with advancing years due to age related physiological changes in the neurocardiovascular, endocrine and renal systems. Cardiovascular syncope can present as falls because of amnesia for loss of consciousness or postural instability due to hypotension. Drop attacks or non accidental falls should thus be investigated for causes of syncope. The most common causes of neurally mediated syncope in older adults are carotid sinus syndrome, orthostatic hypotension and vasovagal syncope.
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Affiliation(s)
- Rose Anne Kenny
- Department of Medicine (Geriatrics), Cardiovascular Investigation Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK.
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Abstract
There is a high prevalence of cardiovascular disorders among elderly patients with recurrent falls or syncope, and cardiovascular causes are implicated in a significant proportion of three cases. Common cardiovascular causes of falls and syncope include carotid sinus syndrome, vasovagal episodes, sick sinus syndrome, and atrioventricular block. A comprehensive history and physical examination supplemented by electrocardiographic monitoring, carotid sinus massage, and tilt-table testing in appropriately selected patients form the basis of the diagnostic evaluation to exclude a significant cardiovascular disorder. Patients with documented symptomatic bradycardia often benefit from pacemaker implantation, as evidenced by a reduction in recurrent events and improved quality of life. Although dual-chamber pacemakers, particularly those with rate responsiveness, provide more physiologic pacing than single-chamber ventricular devices, the superiority of dual-chamber pacemakers in reducing major clinical events has not been demonstrated. The efficacy of an aggressive evaluation and patient-management strategy that includes pacemaker implantation for elderly patients with recurrent falls has been validated only by one prospective clinical trial; however, available data are compelling. For a variety of cardiovascular conditions, permanent pacemaker implantation has a demonstrated efficacy to prevent symptoms that arise from transient hypotension and decreased cerebral perfusion. The implication of these data is that many falls may be preventable through permanent pacemaker implantation in appropriately selected patients.
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Affiliation(s)
- Mitchell N Faddis
- Clinical Cardiac Electrophysiology Unit, Washington University School of Medicine, Cardiology, Box 8086, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
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Society AG, Society G, Of AA, On Falls Prevention OSP. Guideline for the Prevention of Falls in Older Persons. J Am Geriatr Soc 2001. [DOI: 10.1046/j.1532-5415.2001.49115.x] [Citation(s) in RCA: 1339] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Parry SW, Richardson DA, O'Shea D, Sen B, Kenny RA. Diagnosis of carotid sinus hypersensitivity in older adults: carotid sinus massage in the upright position is essential. Heart 2000; 83:22-3. [PMID: 10618329 PMCID: PMC1729247 DOI: 10.1136/heart.83.1.22] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess the diagnostic value of supine and upright carotid sinus massage in elderly patients. DESIGN Prospective controlled cohort study. SETTING Three inner city accident and emergency departments and a dedicated syncope facility. PATIENTS 1375 consecutive patients aged > 55 years presenting with unexplained syncope and drop attacks; 25 healthy controls. INTERVENTIONS Bilateral supine carotid sinus massage, repeated in the 70 degrees head up tilt position if the initial supine test was not diagnostic of cardioinhibitory and mixed carotid sinus hypersensitivity. MAIN OUTCOME MEASURES Diagnosis of cardioinhibitory or mixed carotid sinus hypersensitivity; clinical characteristics of supine v upright positive groups. RESULTS 226 patients were excluded for contraindications to carotid sinus massage. Of 1149 patients undergoing massage, 223 (19%) had cardioinhibitory or mixed carotid sinus hypersensitivity; 70 (31%) of these had a positive response to massage with head up tilt following negative supine massage (95% confidence interval, 25.3% to 37.5%). None of the healthy controls showed carotid sinus hypersensitivity on erect or supine massage. The initially positive supine test had 74% specificity and 100% sensitivity; these were both 100% for the upright positive test. The clinical characteristics of the supine v upright positive subgroups were similar. CONCLUSIONS The diagnosis of carotid sinus hypersensitivity amenable to treatment by pacing may be missed in one third of cases if only supine massage is performed. Massage should be done routinely in the head up tilt position if the initial supine test is negative.
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Affiliation(s)
- S W Parry
- Cardiovascular Investigation Unit, Institute for the Health of the Elderly, University of Newcastle Upon Tyne, NE1 4LP, UK.
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Abstract
Indications for permanent pacemakers have expanded in recent years. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for implantation of cardiac pacemakers were recently updated and now include several of the newer indications. Greatest interest about newer applications of pacemaker therapy focuses on hypertrophic obstructive cardiomyopathy, dilated cardiomyopathy, and pacing for the prevention of atrial fibrillation. Pacing for neurocardiogenic syncope remains controversial despite emerging data. Pacing for long QT syndrome, pacing after cardiac transplantation, and pacing for hemodynamic improvement in the occasional patient with first-degree atrioventricular block and hemodynamic compromise also warrant attention. Available clinical data are discussed in the context of the recent ACC and AHA guidelines.
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Affiliation(s)
- D L Hayes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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