Holter ECG for Syncope Evaluation in the Internal Medicine Department-Choosing the Right Patients

Association of Cardiovascular Risk Factors With Major and Minor Electrocardiographic Abnormalities: A Report From the Cross-Sectional Phase of Tehran Cohort Study

Background and Aims

In the current study, we aimed to identify the association between major and minor electrocardiographic abnormalities and cardiovascular risk factors.

Methods

We used the Tehran cohort study baseline data, an ongoing multidisciplinary, longitudinal study designed to identify cardiovascular disease risk factors in the adult population of Tehran. The electrocardiograms (ECGs) of 7630 Iranian adults aged 35 years and above were analyzed. ECG abnormalities were categorized into major or minor groups based on their clinical importance. Results were obtained by multivariable logistic regression and are expressed as odds ratios (ORs).

Results

A total of 756 (9.9%) participants had major ECG abnormalities, while minor abnormalities were detected in 2526 (33.1%). Males comprised 45.8% of the total population, and 41.8% of them had minor abnormalities. Individuals with older age, diabetes (OR = 1.35; 95% CI: 1.11-1.64), and hypertension (OR = 2.21; 95% CI: 1.82-2.68) had an increased risk of major ECG abnormalities. In contrast, intermediate (OR = 0.69; 95% CI: 0.57-0.84) and high physical activity levels (OR = 0.66; 95% CI: 0.51-0.86) were associated with a lower prevalence of major abnormalities. Male sex, older age, hypertension, and current smoking were also associated with an increased prevalence of ECG abnormalities combined (major or minor).

Conclusion

Major and minor ECG abnormalities are linked with important cardiovascular risk factors such as diabetes and hypertension. Since these abnormalities have been associated with poor outcomes, screening patients with cardiovascular risk factors with an ECG may distinguish high-risk individuals who require appropriate care and follow-up.

Predicting the Outcomes of Inpatient Cardiac Evaluation for Syncope Using Validated Risk Scores

BACKGROUND

Validated syncope risk scores were aimed to predict a cardiac etiology and are mainly used in the decision of hospital admission. Whether these scores could also predict the outcomes of inpatient cardiac evaluation is unknown and was the subject of our study.

METHODS

This was an observational study including consecutive patients admitted for syncope evaluation. All patients completed prolonged electrocardiogram monitoring and an echocardiography before discharge. The area under the receiver-operating characteristic curve (AUC) was used to evaluate the ability of validated risk scores to predict positive inpatient findings. Subsequently, a multivariate regression was performed to identify independent predictors for positive cardiac evaluation, which were then incorporated into the best predictive risk scores.

RESULTS

Three hundred ninety-seven patients were included, 56 (14%) with a positive inpatient cardiac evaluation. The Osservatorio Epidemiologico sulla Sincope Lazio and Canadian Syncope Risk Score achieved the largest AUC (0.701, 95% confidence interval [CI] 0.63-0.77 and 0.694, 95% CI 0.62-0.77, respectively). Yet, all scores provided relatively high sensitivity with low specificity. Multivariate regression revealed age ≥75 (adjusted odds ratio 3.50, 95% CI 1.5-7.9) and abnormal cardiac auscultation (adjusted odds ratio 4.79, 95% CI 2.5-9.1) to be independent predictors. Incorporating these factors led to a significantly higher prediction ability of the Osservatorio Epidemiologico sulla Sincope Lazio (AUC of 0.787, P < .01) and Canadian Syncope Risk Score (AUC 0.778, P < .01) modified scores.

CONCLUSIONS

Current syncope risk scores provide limited prediction ability for the outcomes of inpatient cardiac syncope work-up. One should specifically consider age > 75 years and either cardiac murmur or irregular heart rate on examination very significant in implying a cardiac etiology for syncope. Although these factors may be obvious, current risk scores can be interpreted in such a fashion that ignores the importance of findings extracted from a good history and physical examination.

Predictive value of isolated very low QRS voltage in tilt-table test for neurally mediated syncope

Objective

The cause of syncope is generally determined based on clinical manifestations. There has been little discussion about the value of electrocardiograms for diagnosing neurally mediated syncope. The aim of this study was to test the predictive value of the isolated very low QRS voltage in tilt-table testing for suspected neurally mediated syncope in a Chinese population.

Methods

This retrospective study enrolled patients with suspected neurally mediated syncope. Tilt-table testing was a part of the diagnostic examination. Each patient underwent echocardiography and electrocardiogram. isolated very low QRS voltage referred to a voltage of ⩽0.3 mV for the QRS complex in an isolated frontal lead or ⩽0.7 mV for the QRS complex in an isolated precordial lead.

Results

In total, 157 patients were included in the tilt-table testing positive group, and 242 patients were included in the tilt-table testing negative group. Compared with the testing negative group, the testing positive group had more patients with isolated very low QRS voltage in the frontal leads (p < 0.001). Moreover, for patients with isolated very low QRS voltage in the precordial leads, no significant difference was noted between the testing positive group and testing negative group (p = 0.289). Isolated very low QRS voltage in the frontal leads demonstrated 84.08% sensitivity and 74.38% specificity for a positive tilt-table testing response. The area under the curve of isolated very low QRS voltage for a positive tilt-table testing response in frontal leads was 0.806 (p < 0.0001).

Conclusion

In patients with suspected neurally mediated syncope, isolated very low QRS voltage in the frontal leads is a parameter that can predict a positive tilt-table testing response. The presence of isolated very low QRS voltage in frontal leads can serve as a parameter for evaluating syncope patients.

Enhancing Comprehensive Assessments in Chronic Heart Failure Caused by Ischemic Heart Disease: The Diagnostic Utility of Holter ECG Parameters

Background and Objectives: Chronic heart failure (CHF) caused by ischemic heart disease (IHD) is the leading cause of death worldwide and presents significant health challenges. Effective management of IHD requires prevention, early detection, and treatment to improve patient outcomes. This study aims to expand the diagnostic utility of various 24 h Holter ECG parameters, such as T-wave alternans (TWA), late ventricular potentials (LVPs), and heart rate variability (HRV) in patients with CHF caused by IHD. Additionally, we seek to explore the association between these parameters and other comorbid conditions affecting the prognosis of CHF patients. Materials and Methods: We conducted a prospective case-control study with 150 patients divided into two subgroups: 100 patients with CHF caused by IHD, and 50 patients in the control group. Data included medical history, physical examination, laboratory tests, echocardiography, and 24 h Holter monitoring. Results: Our comparative analysis demonstrated that both TWA and LVPs were significantly higher in patients with CHF compared to the control group (p < 0.01), indicating increased myocardial electrical vulnerability in CHF patients. Both time and frequency-domain HRV parameters were significantly lower in the CHF group. However, the ratio of NN50 to the total count of NN intervals (PNN50) showed a borderline significance (p = 0.06). While the low-frequency (LF) domain was significantly lower in CHF patients, the high-frequency (HF) domain did not differ significantly between groups. Acceleration and deceleration capacities were also significantly altered in CHF patients. Categorizing CHF patients by left ventricular ejection fraction (LVEF) revealed that the mean of the 5-min normal-to-normal intervals over the complete recording (SDNN Index) was significantly higher in patients with LVEF ≥ 50% compared to those with CHF with reduced EF and CHF with mildly reduced EF (p < 0.001), whereas the other HRV parameters showed no significant differences among the groups. Conclusions: Holter ECG parameters can become a reliable tool in the assessment of patients with CHF. The integration of multiple Holter ECG parameters, such as TWA, LVPs, and HRV, can significantly enhance the diagnostic assessment of CHF caused by IHD. This comprehensive approach allows for a more nuanced understanding of the patient's condition and potential outcomes.

Recent Advances and Future Directions in Syncope Management: A Comprehensive Narrative Review

Syncope is a highly prevalent clinical condition characterized by a rapid, complete, and brief loss of consciousness, followed by full recovery caused by cerebral hypoperfusion. This symptom carries significance, as its potential underlying causes may involve the heart, blood pressure, or brain, leading to a spectrum of consequences, from sudden death to compromised quality of life. Various factors contribute to syncope, and adhering to a precise diagnostic pathway can enhance diagnostic accuracy and treatment effectiveness. A standardized initial assessment, risk stratification, and appropriate test identification facilitate determining the underlying cause in the majority of cases. New technologies, including artificial intelligence and smart devices, may have the potential to reshape syncope management into a proactive, personalized, and data-centric model, ultimately enhancing patient outcomes and quality of life. This review addresses key aspects of syncope management, including pathogenesis, current diagnostic testing options, treatments, and considerations in the geriatric population.

An old diagnostic tool for new indications: inpatient Holter ECG for conditions other than syncope or stroke

Holter electrocardiography (ECG) assists in the diagnosis of arrhythmias. Its use in the inpatient setting has been described solely for the evaluation of stroke and syncope. Our aim was to assess its diagnostic value for other conditions in the internal medicine department. We included all hospitalized patients between 2018 and 2021 in a tertiary referral center. The primary outcome was a diagnostic Holter recording a new arrhythmia that led to a change in treatment. Overall, 289 patients completed a 24-h inpatient Holter ECG for conditions other than syncope or stroke, with 39 (13%) diagnostic findings. The highest diagnostic value was found in patients admitted for pre-syncope (19%), palpitations (18%), and unexplained heart failure exacerbation/dyspnea (17%). A low diagnostic yield was found for the evaluation of chest pain (5%). Heart failure with preserved ejection fraction (adjusted OR 2.3, 95% CI 1.1-5.4, p = 0.04), and baseline ECG with either a bundle branch block (AOR 4.2, 95% CI 1.9-9.2, p < 0.01) or atrioventricular block (first or second degree, AOR 5, 95% CI 2.04-12.3, p < 0.01) were among the independent predictors for a diagnostic test. Inpatient Holter ECG monitoring may have value as a diagnostic tool for selected patients with conditions other than syncope or stroke.

The Prevalence of and Predisposing Factors for Late Atrial Arrhythmias after Transcatheter Closure of Secundum Atrial Septal Defects in Children

BACKGROUND

A 24 h Holter study in children after transcatheter secundum ASD (ASD II) closure was conducted to detect the prevalence of defects and/or device-related late atrial arrhythmias (LAAs). ASD II closure with an Amplatzer septal occluder (ASO) is an established procedure. Little is known about LAAs after device implantation.

METHODS

The eligible participants were children who had undergone ASO implantation, with a follow-up of ≥5 years, as well as one pre- and at least one post-procedural Holter ECG.

RESULTS

In total, 161 patients (mean age: 6.2 ± 4.3 years), with a mean follow-up of 12.9 ± 3.1 years (range 5-19), were included. A median of four Holter ECGs per patient were available. LAAs occurred before intervention in four patients (2.5%), and it was peri-interventional in four patients (2.5%), sustained in three patients (1.9%), and developed in three patients (1.9%). In patients with pre- and peri-interventional LAAs, the Qp/Qs ratio was higher (6.4 ± 3.9 vs. non-AA: 2.0 ± 1.1 (p = 0.002)) and the IAS/ASO ratio was lower (1.18 ± 0.27 vs. non-AA: 1.7 ± 0.4 (p < 0.001)). The patients with LAAs differed from those without LAAs in their Qp/Qs (6.8 ± 3.5 vs. 2.0 ± 1.3; p < 0.0001) and IAS/ASO ratios (1.14 ± 0.19 vs. 1.73 ± 0.45; p < 0.001). The patients with LAAs had a Qp/Qs ratio ≥2.94:1, and those who developed LAAs had an IAS/ASO ratio <1.15.

CONCLUSIONS

LAAs occurred in 1.9% of patients and were sustained in another 1.9% of patients but persisted in those with large shunt defects and large occluders in relation to the atrial septal length. The predisposing factors for LAAs after ASD closure were a high Qp/Qs ratio, pre-existing atrial arrhythmias, and a low IAS/ASO ratio.