Syncope in the Elderly

European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

Predictors of pacemaker requirement in patients receiving implantable loop recorders for unexplained syncope: A systematic review and meta-analysis

BACKGROUND

Implantable loop recorders (ILRs) are increasingly used to evaluate patients with unexplained syncope. Identification of all predictors of bradycardic syncope and consequent permanent pacemaker (PPM) insertion is of substantial clinical interest as patients in the highest risk category may benefit from upfront pacemaker insertion.

OBJECTIVE

We performed a systematic review and meta-analysis to identify risk predictors for PPM insertion in ILR recipients with unexplained syncope.

METHODS

An electronic database search (MEDLINE, Embase, Scopus, Cochrane) was performed in June 2023. Studies evaluating ILR recipients with unexplained syncope and recording risk factors for eventual PPM insertion were included. A random effects model was used to calculate the pooled odds ratio (OR) for clinical and electrocardiographic characteristics with respect to future PPM requirement.

RESULTS

Eight studies evaluating 1007 ILR recipients were included; 268 patients (26.6%) underwent PPM insertion during study follow-up. PPM recipients were older (mean age, 70.2 ± 15.4 years vs 61.6 ± 19.7 years; P < .001). PR prolongation on baseline electrocardiography was a significant predictor of PPM requirement (pooled OR, 2.91; 95% confidence interval, 1.63-5.20). The presence of distal conduction system disease, encompassing any bundle branch or fascicular block, yielded a pooled OR of 2.88 for PPM insertion (95% confidence interval, 1.53-5.41). Injurious syncope and lack of syncopal prodrome were not significant predictors of PPM insertion. Sinus node dysfunction accounted for 62% of PPM insertions, whereas atrioventricular block accounted for 26%.

CONCLUSION

Approximately one-quarter of ILR recipients for unexplained syncope require eventual PPM insertion. Advancing age, PR prolongation, and distal conduction disease are the strongest predictors for PPM requirement.

Current ED syncope management in Italian hospitals and prospects for optimization: a national survey

To investigate current ED management of patients with syncope in Italy and opportunities for optimization, we carried out a questionnaire survey involving 102 directors of ED facilities in our country, of any complexity level, with 55.9% located in the North, 97% equipped with an ED Observation Unit (EDOU), and 21.8% with an outpatient Syncope Unit (SU). 43.6% of EDs management is not standardized. Clinical judgment and monitoring are the main factors leading management while old age and neuropsychic comorbidities the most hindering it. More than one third of ED facilities treats fewer than half of patients in EDOU. Most of respondents (73.7%) reported an admission rate within 20%, primarily in cardiology, in the case of an established or suspected cardiac etiology of syncope. In most centers, the referral to the general practitioner is the priority path at discharge from ED. Nearly 50% of participants rated syncope management in their own center as sub-optimal. To optimize it, 98% of them believe that is appropriate to implement a standardized approach, with and a large majority focusing on increasing diagnostic yield and safety; other priorities include application of guidelines, implementation of care pathways, enhancement of the role of EDOU, and direct path to the SU. This study highlights that the management of syncope patients in our country requires a further improvement, especially through standardization of pathways and adoption of innovative organizational solutions. Admissions appear to be lower than reported in the literature but this finding must be confirmed by a multicentric study based on direct collection of data.

Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition)

With the deepening of aging in China, the prevalence of diabetes in older people has increased noticeably, and standardized diabetes management is critical for improving clinical outcomes of diabetes in older people. In 2021, the National Center of Gerontology, Chinese Society of Geriatrics, and Diabetes Professional Committee of Chinese Aging Well Association organized experts to write the first guideline for diabetes diagnosis and treatment in older people in China, the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2021 Edition). The guideline emphasizes that older patients with diabetes are a highly heterogeneous group requiring comprehensive assessment and stratified and individualized management strategies. The guideline proposes simple treatments and de-intensified treatment strategies for older patients with diabetes. This edition of the guideline provides clinicians with practical and operable clinical guidance, thus greatly contributing to the comprehensive and full-cycle standardized management of older patients with diabetes in China and promoting the extensive development of clinical and basic research on diabetes in older people and related fields. In the past 3 years, evidence-based medicine for older patients with diabetes and related fields has further advanced, and new treatment concepts, drugs, and technologies have been developed. The guideline editorial committee promptly updated the first edition of the guideline and compiled the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition). More precise management paths for older patients with diabetes are proposed, for achieving continued standardization of the management of older Chinese patients with diabetes and improving their clinical outcomes.

Association between Syncope and the 6-Month Incidence of Ischemic Stroke, Arrhythmia, Brain Tumor, Epilepsy, and Anxiety Disorder

OBJECTIVES

the aim of the present study is to investigate the associations between syncope and subsequent diagnoses of brain tumor, cardiac arrhythmia, stroke/transient ischemic attack (TIA), epilepsy, and anxiety disorder in a large outpatient population in Germany.

METHODS

This retrospective cohort study uses data from the Disease Analyzer database (IQVIA). Adults who received syncope diagnosis from one of 1284 general practices between January 2005 and December 2021 (index date) were included and matched (1:1) to individuals without syncope diagnosis using a propensity score based on age, sex, the number of consultations during the follow-up period (up to 6 months), and defined co-diagnoses documented within 12 months prior to and on the index date. Finally, associations between syncope and subsequent outcome diagnoses were investigated using multivariable logistic regression models.

RESULTS

Data related to 64,016 patients with and 64,016 patients without syncope (mean age 54.5 years, 56.5% female) were available. In total, 6.43% of syncope patients and 2.14% of non-syncope patients were diagnosed with one of the five outcome diagnoses within 6 months of the index date. There was a positive and significant association between syncope and incidences of ischemic stroke/TIA (OR = 2.83, 95% CI = 2.41-3.32), arrhythmia (OR = 3.81, 95% CI = 3.44-4.18), brain tumor (OR = 4.24, 95% CI = 2.50-7.19), epilepsy (OR = 5.52, 95% CI = 4.27-7.14), and anxiety disorder (OR = 1.99, 95% CI = 1.79-2.21).

CONCLUSIONS

Syncope is significantly associated with an increased risk of subsequent ischemic stroke/TIA, cardiac arrhythmia, brain tumor, epilepsy, and anxiety disorder. Nevertheless, the cumulative incidences for all five diagnoses are very low.

Vasovagal syncope: An overview of pathophysiological mechanisms

Syncope is a short-term transient loss of consciousness, characterized by rapid onset and complete spontaneous recovery. According to the 2018 European Society of Cardiology guidelines, three different types of syncope have been identified. However, all forms of syncope share a common final pathophysiological event, global cerebral hypoperfusion, which results from the inability of the circulatory system to maintain blood pressure at the level required to efficiently supply blood to the brain. The vasovagal syncope (VVS) is the most common form of syncope. Although, VVS is generally harmless, its frequent occurrence can negatively affect quality of life and increase the risk of adverse events. The pathophysiological mechanisms underlying VVS remain obscure. The multifaceted nature of VVS presents a veritable challenge to understanding this condition and developing preventative strategies. Thus, the aim of this review was to discuss the factors contributing to the pathogenesis of VVS and provide guidance for future research.

Knowledge and Awareness of Syncope Among General Populations of Makkah Region in Saudi Arabia: A Cross-Sectional Study

Background Syncope is a transient loss of consciousness and postural tone due to global cerebral hypoperfusion which is followed by spontaneous recovery. It is relatively common and increases the risk of subsequent falls and injury. There is scant literature and targeted research on the population's knowledge of syncope. Hence, this study aimed to assess awareness and evaluate the knowledge of syncope among the population of the Makkah region. Methodology An online cross-sectional study was done on 563 participants. A questionnaire was used to collect data about participants' demographics, experiencing syncope in relatives, and knowledge about syncope using case scenarios. Results Females represented 72.6% of the participants and about one third of participants admitted that they had experienced syncope throughout their life. About one-third of participants admitted that they had experienced syncope throughout their life. Most of the study participants (68.9%) showed a good level of knowledge about syncope while 31.1% of them had poor knowledge; the average awareness score was 5.3±1.64. Cardiogenic syncope was the most commonly recognized type of syncope. Furthermore, participants aged between 18 and 35 years and widowed participants demonstrated a good amount of knowledge about syncopal attacks (p<0.001). Conclusions General population of the Makkah region in Saudi Arabia had a sufficient level of knowledge about syncope. Additional studies along with educational programs are needed.

Recurrent syncope in long survivors and its association with geriatric syndromes

Objective

Syncope is a common clinical condition in the elderly, associated with significant morbidity and risk of recurrence. Recurrent syncope causing a repeated reduction in the cerebral blood flow can predispose to progressive neurodegeneration, a decline in overall health and functionality. Hence, this study was conducted to study the common causes of recurrent syncope and its association with various geriatric syndromes.

Methodology

This case-control study recruited 50 cases of recurrent syncope and 50 controls, aged 75 years and older. A detailed history and sequential evaluation for aetiologies of recurrent syncope were done. Cognition, frailty, activities of daily living, depression, and nutrition were assessed using various scales.

Results

Most (80%, 80/100) of the participants were males and the mean age was 80.04 ± 4.3 years. In the syncope group, 42% (21/50) of patients had arrhythmia, and 30% (15/30) had valvular heart disease. Recurrent syncope was significantly associated with lower scores on Montreal cognitive assessment scale (OR: 6.47 P < 0.001), four or more comorbidities (OR: 6.29 P < 0.001), and hearing impairment (OR: 6.21 P < 0.004) on multivariate logistic regression analysis.

Conclusion

Recurrent syncope is significantly associated with cognitive impairment, the presence of four or more comorbidities, and hearing impairment. Conduction abnormality was the most common etiology of recurrent cardiovascular syncope. Structured evaluation and appropriate management of recurrent syncope might reduce the decline in physical, cognitive, and psychological reserve. A follow-up longitudinal study is needed to establish this.

Trauma and syncope: looking beyond the injury

Background

42% of the population experience syncope by the age of 70, accounting for up to 6% of hospital admissions that frequently present as falls. The etiologies of some falls are benign, and others, such as cardiac syncope, are associated with a greater mortality and must be identified.

Methods

This review article aims to bridge the literature gap by providing a comprehensive practice review and critical summary of the current syncope guidance relating to the trauma patient.

Results

The National Institute for Health and Care Excellence, the American College of Cardiology, and European Society of Cardiology published syncope risk stratification guidance. The inclusion of certain high-risk features represented in all three guidelines suggests their significance to identify cardiac syncope including heart failure, abnormal vital signs, syncope during exercise with little to no prodrome, family history of sudden cardiac death, and ECG abnormalities. Of 11 syncope risk stratification scoring systems based on these guidelines, only 2 are externally validated in the emergency department, neither of which are validated for major trauma use. Adherence to thorough history-taking, examination, orthostatic blood pressure recording, and an ECG can diagnose the cause of syncope in up to 50% of patients. ECG findings are 95% to 98% sensitive in the detection of serious adverse outcomes after cardiac syncope and should form part of a standardized syncope trauma assessment. Routine blood testing in trauma is often performed despite evidence that it is neither useful nor cost effective, where the screening of cardiac enzymes and D-dimer rarely influences management.

Discussion

In the absence of a gold-standard clinical test to identify the cause of a syncopal episode, standardized syncope guidelines as described in this review could be incorporated into trauma protocols to analyze high-risk etiologies, improve diagnostic accuracy, reduce unnecessary investigations, and develop an effective and safer management strategy.

The Influence of Age on Cerebral Tissue Oxygenation in Vasovagal Syncope and Orthostatic Hypotension

Age-related physiological impairment increases susceptibility to syncope. We tested the hypotheses that cerebral oxygenation during orthostatic provocation, as well as the level at which syncope occurs, differs according to age. Non-invasive hemodynamic monitoring and cerebral oximetry were applied during a head-up tilt test in 139 patients with vasovagal syncope (mean (SD) 45, (17) years, 60%-female); 121 patients with orthostatic hypotension (61.4 (19.2) years, 49.6%-female); and 82 patients with a negative head-up tilt test (45 (18) years, 61%-female). Group differences in cerebral tissue oxygenation levels and systolic blood pressure were assessed in supine at 3 and 10 min of orthostatic provocation, 30 s before (i.e., presyncopal phase) and during syncope in age groups of <30, 30−60, and >60 years. During the head-up tilt test, cerebral tissue oxygenation at the presyncopal phase decreased with age, both in patients with vasovagal syncope (<30 years: 66.9 ± 6.2, 30−60: 64.5 ± 6.1, >60: 62.2 ± 5.8%; p = 0.009) and orthostatic hypotension (<30: 67.4 ± 4.4, 30−60: 61.6 ± 6.2, >60: 57.5 ± 3.9; p < 0.001). Mean systolic blood pressure at the presyncopal phase did not differ according to age. Cerebral oxygenation prior to syncope in older individuals with vasovagal syncope and orthostatic hypotension is lower compared with younger individuals independently of systolic blood pressure. This suggests that the level of cerebral oxygenation at which syncope is elected is lower in older individuals.

The Syncope-Falls Index: a tool for predicting risk of syncope and complex falls in the older adult based on cumulative health deficits

BACKGROUND

Syncope is aetiologically diverse and associated with adverse outcomes; in older people, there is clinical overlap with complex falls presentations (i.e. recurrent, unexplained and/or injurious).

AIM

To formulate an index to predict future risk of syncope and falls in the Irish longitudinal study on ageing (TILDA).

DESIGN/METHODS

Using the frailty index methodology, we selected, from TILDA Wave 1 (2010), 40 deficits that might increase risk of syncope and falls. This syncope-falls index (SYFI) was applied to TILDA Wave 1 participants aged 65 and over, who were divided into three risk groups (low, intermediate and high) based on SYFI tertiles. Multivariate logistic regression models were used to investigate, controlling for age and sex, how SYFI groups predicted incident syncope, complex falls and simple falls occurring up to Wave 4 of the study (2016).

RESULTS

At Wave 1, there were 3499 participants (mean age 73, 53% women). By Wave 4, of the remaining 2907 participants, 185 (6.4%) had reported new syncope, 1077 (37.0%) complex falls and 218 (7.5%) simple falls. The risk of both syncope and complex falls increased along the SYFI groups (high risk group: odds ratio 1.88 [1.26-2.80], P = 0.002 for syncope; 2.22 [1.82-2.72], P < 0.001 for complex falls). No significant relationship was identified between SYFI and simple falls.

CONCLUSION

The 6-year incidences of falls and syncope were high in this cohort. SYFI could help identify older adults at risk of syncope and complex falls, and thus facilitate early referral to specialist clinics to improve outcomes.

How Should We Approach Syncope in the Emergency Department? Current Perspectives

Syncope is a clinical picture that can affect all age groups and has an important place in admissions to the emergency department. There is an important diagnostic challenge in cases where there are different clinical presentations and patients cannot express the situation clearly. Although the emergency department facilities for the diagnosis of syncope are limited, the diagnosis of many patients can be differentiated from life-threatening conditions with a detailed history and physical examination. High-risk patients should be identified and directed for definitive treatment by emergency medicine physicians. This review contains information about the management of the syncope patient in the emergency department.

An atypical presentation of orthostatic hypotension and falls in an older adult

Introduction

Falls are a significant cause of morbidity and mortality in older adults. Orthostatic hypotension (OH) is very common in this cohort of patients and is a significant risk for falls and associated injuries. We present the case of an 89-year-old female who fell at home, witnessed by her husband. OH was identified during the clinical assessment and considered to be the predominant contributing factor, although the clinical presentation was not associated with classical symptoms.

Case presentation

The patient lost balance while turning away from the kitchen sink; she noted some instability due to a complaint of generalised weakness in both of her legs. No acute medical illness or traumatic injury was identified. A comprehensive history was obtained that identified multiple intrinsic and extrinsic risk factors for falling. The cardiovascular examination was unremarkable except for OH, with a pronounced reduction in systolic blood pressure of 34 mmHg at the three-minute interval and which reproduced some generalised weaknesses in the patient's legs and slight instability. Although classical OH symptoms were not identified, this was considered to be the predominant factor contributing to the fall. A series of recommendations was made to primary and community-based care teams based upon a rapid holistic review; this included a recommendation to review the patient's dual antihypertensive therapy.

Conclusion

It is widely known that OH is a significant risk factor for falls, but asymptomatic or atypical presentations can make diagnosis challenging. Using the correct technique to measure a lying and standing blood pressure, as defined by the Royal College of Physicians, is crucial for accurate diagnosis and subsequent management. Ambulance clinicians are ideally placed to undertake this quick and non-invasive assessment to identify OH in patients that have fallen.

OUP accepted manuscript

Aims

Methods and results

Conclusion

Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation

Brain function critically depends on a close matching between metabolic demands, appropriate delivery of oxygen and nutrients, and removal of cellular waste. This matching requires continuous regulation of cerebral blood flow (CBF), which can be categorized into four broad topics: 1) autoregulation, which describes the response of the cerebrovasculature to changes in perfusion pressure; 2) vascular reactivity to vasoactive stimuli [including carbon dioxide (CO2)]; 3) neurovascular coupling (NVC), i.e., the CBF response to local changes in neural activity (often standardized cognitive stimuli in humans); and 4) endothelium-dependent responses. This review focuses primarily on autoregulation and its clinical implications. To place autoregulation in a more precise context, and to better understand integrated approaches in the cerebral circulation, we also briefly address reactivity to CO2 and NVC. In addition to our focus on effects of perfusion pressure (or blood pressure), we describe the impact of select stimuli on regulation of CBF (i.e., arterial blood gases, cerebral metabolism, neural mechanisms, and specific vascular cells), the interrelationships between these stimuli, and implications for regulation of CBF at the level of large arteries and the microcirculation. We review clinical implications of autoregulation in aging, hypertension, stroke, mild cognitive impairment, anesthesia, and dementias. Finally, we discuss autoregulation in the context of common daily physiological challenges, including changes in posture (e.g., orthostatic hypotension, syncope) and physical activity.

Early standardized clinical judgement for syncope diagnosis in the emergency department

BACKGROUND

The diagnosis of cardiac syncope remains a challenge in the emergency department (ED).

OBJECTIVE

Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score.

METHODS

In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ.

RESULTS

Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy.

CONCLUSION

ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.

Age-related tilt test responses in patients with suspected reflex syncope

AIMS

Tilt testing (TT) is recognized to be a valuable contribution to the diagnosis and the pathophysiology of vasovagal syncope (VVS). This study aimed to assess the influence of age on TT responses by examination of a large patient cohort.

METHODS AND RESULTS

Retrospective data from three experienced European Syncope Units were merged to include 5236 patients investigated for suspected VVS by the Italian TT protocol. Tilt testing-positivity rates and haemodynamics were analysed across age-decade subgroups. Of 5236 investigated patients, 3129 (60%) had a positive TT. Cardioinhibitory responses accounted for 16.5% of positive tests and were more common in younger patients, decreasing from the age of 50-59 years. Vasodepressor (VD) responses accounted for 24.4% of positive tests and prevailed in older patients, starting from the age of 50-59. Mixed responses (59.1% of cases) declined slightly with increasing age. Overall, TT positivity showed a similar age-related trend (P = 0.0001) and was significantly related to baseline systolic blood pressure (P < 0.001). Tilt testing was positive during passive phase in 18% and during nitroglycerine (TNG)-potentiated phase in 82% of cases. Positivity rate of passive phase declined with age (P = 0.001), whereas positivity rate during TNG remained quite stable. The prevalence of cardioinhibitory and VD responses was similar during passive and TNG-potentiated TT, when age-adjusted.

CONCLUSIONS

Age significantly impacts the haemodynamic pattern of TT responses, starting from the age of 50. Conversely, TT phase-passive or TNG-potentiated-does not significantly influence the type of response, when age-adjusted. Vagal hyperactivity dominates in younger patients, older patients show tendency to vasodepression.

Syncope in Commercial Pilots and New Regulatory Guidance

INTRODUCTION: Syncope is both incapacitating and unpredictable, presenting a significant challenge in aircrew assessment. Previous UK Civil Aviation Authority (CAA) guidance lacked transparency and relied heavily on specialist in-house cardiology and neurology opinion. A new algorithm was developed which elaborated and formalized the decision-making process. An analysis of its impact on historic cases was undertaken to ensure it aligned with previous certificatory outcomes.METHODS: The medical literature on syncope and the approaches of other national aviation authorities were reviewed to help inform the development of a new algorithm. Using syncope cases in the CAA database, regulatory outcomes generated using the new algorithm were compared with previous decisions in terms of time off from flying (TOF) and Operational Multi-Crew Limitation (OML) duration.RESULTS: There were 40 historic syncope cases (25 existing certificate holders,15 initial applicants) which were reassessed using the new algorithm. The mean TOF for existing pilots using the new algorithm was 7.1 9.8 (mean SD) vs. 4.2 3.5 mo under the old guidance with an OML duration of 21.4 34.9 vs. 24.5 25.2 mo. One less initial applicant experienced a delay to certification. Four cases with underlying pathology were detected using old and new guidance.DISCUSSION: The reassessment of cases showed no statistically significant difference in TOF and OML duration; this is a positive finding from a regulatory perspective, enabling algorithm-led decision-making with less reliance on in-house expertise. A similar approach may be useful in future updates to other areas of regulatory practice.Anderton RA, Mitchell SJ, ONunain SS. Syncope in commercial pilots and new regulatory guidance. Aerosp Med Hum Perform. 2021; 92(8):642649.

Association between antihypertensive treatment and adverse events: systematic review and meta-analysis

OBJECTIVE

To examine the association between antihypertensive treatment and specific adverse events.

DESIGN

Systematic review and meta-analysis.

ELIGIBILITY CRITERIA

Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up.

INFORMATION SOURCES

Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020.

MAIN OUTCOME MEASURES

The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ2).

RESULTS

Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ2=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ2=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ2=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ2=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ2=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction.

CONCLUSIONS

This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function.

REGISTRATION

PROSPERO CRD42018116860.

The association between dementia severity and hospitalisation profile in a newly assessed clinical cohort: the South London and Maudsley case register

OBJECTIVES

To evaluate the risk and common causes of hospitalisation in patients with newly diagnosed dementia and variation by severity of cognitive impairment.

SETTING

We used data from a large London mental healthcare case register linked to a national hospitalisation database.

PARTICIPANTS

Individuals aged ≥65 years with newly diagnosed dementia with recorded cognitive function and the catchment population within the same geography.

OUTCOME MEASURES

We evaluated the risk and duration of hospitalisation in the year following a dementia diagnosis. In addition we identified the most common causes of hospitalisation and calculated age-standardised and gender-standardised admission ratios by dementia severity (mild/moderate/severe) relative to the catchment population.

RESULTS

Of the 5218 patients with dementia, 2596 (49.8%) were hospitalised in the year following diagnosis. The proportion of individuals with mild, moderate and severe dementia who had a hospital admission was 47.9%, 50.8% and 51.7%, respectively (p= 0.097). Duration of hospital stay increased with dementia severity (median 2 days in mild to 4 days in severe dementia, p 0.0001). After excluding readmissions for the same cause, the most common primary hospitalisation discharge diagnoses among patients with dementia were urinary system disorders, pneumonia and fracture of femur, accounting for 15%, 10% and 6% of admissions, respectively. Overall, patients with dementia were hospitalised 30% more than the catchment population, and this trend was observed for most of the discharge diagnoses evaluated. Standardised admission ratios for urinary and respiratory disorders were higher in those with more severe dementia at diagnosis.

CONCLUSIONS

Individuals with a dementia diagnosis were more likely to be hospitalised than individuals in the catchment population. The length of hospital stay increased with dementia severity. Most of the common causes of hospitalisation were more common than expected relative to the catchment population, but standardised admission ratios only varied by dementia stage for certain groups of conditions.

The Association of Kidney Function and Albuminuria With the Risk and Outcomes of Syncope: A Population-Based Cohort Study

BACKGROUND

The risks and subsequent outcomes of syncope among seniors with chronic kidney disease (CKD) are unclear.

METHODS

We conducted a population-based retrospective cohort study of 272,146 patients ≥ 66 years old, in Ontario, Canada, from April 1, 2006, to March 31, 2016. Using administrative health care databases, we examined the association of estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (ACR) with incident syncope and the association of incident syncope with the composite outcome of myocardial infarction, stroke, and death by levels of eGFR/ACR, using adjusted Cox proportional hazards models.

RESULTS

A total of 15,074 incident syncopal events occurred during the study period. The adjusted risk for syncope was higher with a lower eGFR and higher ACR in a stepwise manner (eGFR 60 to < 90: HR 1.17 [1.09-1.26] vs eGFR < 30: HR 1.67 (1.50-1.87) with eGFR ≥ 90 referent; ACR > 30: HR 1.15 [1.07-1.24] with ACR < 3 referent). Among the 12,710 patients with a first syncope event and 1 year of follow-up, the adjusted risk for the composite outcome was higher with a lower eGFR and higher ACR in a stepwise manner (eGFR 60 to < 90: HR 1.05 [0.90-1.22] vs eGFR < 30: HR 1.62 [1.34-1.96] with eGFR ≥ 90 referent; ACR > 30: HR 1.77 [1.60-1.96], ACR < 3 referent).

CONCLUSIONS

A lower eGFR and higher ACR are associated with a higher risk of a hospital encounter for syncope and of related complications among persons of advanced age.