Recent Updates and Technological Developments in Evaluating Cardiac Syncope in the Emergency Department

Syncope is a commonly encountered problem in the emergency department (ED), accounting for approximately 3% of presenting complaints. Clinical assessment of syncope can be challenging due to the diverse range of conditions that can precipitate the symptom. Annual mortality for patients presenting with syncope ranges from 0-12%, and if the syncope is secondary to a cardiac cause, then this figure rises to 18-33%. In ED, it is paramount to accurately identify those presenting with syncope, especially patients with an underlying cardiac aetiology, initiate appropriate management, and refer them for further investigations. In 2018, the European Society of Cardiology (ESC) updated its guidelines with regard to diagnosing and managing patients with syncope. We highlight recent developments and considerations in various components of the workup, such as history, physical examination, investigations, risk stratification, and novel biomarkers, since the establishment of the 2018 ESC guidelines. We further discuss the emerging role of artificial intelligence in diagnosing cardiac syncope and postulate how wearable technology may transform evaluating cardiac syncope in ED.

The Indications and Findings at Colonoscopy in a Tertiary Hospital in North-Central Nigeria: A Seven-Year Review

BACKGROUND

Colonoscopy is an invaluable tool used in the diagnosis of colorectal diseases. It is also useful in the prevention and treatment of some of these diseases. The knowledge of the prevailing colorectal diseases is key to planning for prevention.

OBJECTIVES

This study aimed at determining the spectra of indications and findings at colonoscopy in a tertiary health facility.

METHODS

This was a hospital-based cross-sectional study of all patients who underwent colonoscopy between March 2013 and February 2020. The patients' biodata, indications and findings at colonoscopy were retrieved from the Endoscopy Register.

RESULTS

A total of 385 colonoscopy reports were included in the analysis. The age of the patients ranged from 14 to 95 years with a mean age (standard deviation) of 55.9 (15.4) years. There were 219 (57.0%) males and 166 (43.0%) females. The commonest indication for colonoscopy was haematochezia 150 (38.9%) followed by suspected colorectal malignancy 98 (25.5%), abdominal pain 28 (7.3%), altered bowel habit 21 (5.5%), constipation 20 (5.2%), chronic diarrhoea 19 (4.9%), surveillance/ screening 16 (4.2%), occult bleeding and anal pain 7 (1.8%) each, and others 19 (4.9%). The colonoscopy findings were normal findings 116 (30.1%), haemorrhoids 127 (32.9%), colorectal polyps 70 (18.2%), diverticulosis 46 (11.9%), rectal tumour 43 (11.2%), colonic tumour 32 (8.3%), colitis 23 (5.9%), angiodysplasias 6 (1.6), others 12 (3.1%). The findings were not mutually exclusive. Our diagnostic yield was 69.9%.

CONCLUSION

The commonest indication and diagnosis for colonoscopy were haematochezia and haemorrhoids respectively. Our diagnostic yield was 69.9%.

Recurrent Infective Endocarditis with Mycotic Aneurysm - Imaging Modalities for the Detection of an Infective Focus

Staphylococcus aureus bacteremia (SAB) and infective endocarditis (IE) are infections associated with considerable morbidity, requiring prompt accurate diagnosis and treatment. We present a case of a 58-year-old male patient with four episodes of recurrent symptomatic SAB treated for IE, but without positive findings on transthoracic echocardiography, transesophageal echocardiography, and fluorodeoxyglucose-positron emission tomography (FDG-PET). On the last admission, FDG-PET showed increased uptake in the right atrial appendage, and white blood cell single-photon emission computerized tomography (WBC-SPECT) was able to identify the infective focus as IE of the aortic valve. CT of the thorax also identified an associated mycotic aneurysm of the right coronary sinus. He was subsequently treated with mechanical aortic prosthesis and right coronary sinus plasty, and his symptoms did not recur till 2 years postcardiothoracic surgery. This case report demonstrates the emergence of nuclear cardiovascular imaging modalities in the diagnostic workup of IE and the utility of FDG-PET and WBC-SPECT in the identification of the infective focus. Patients with possible IE from the modified Duke criteria should be considered for FDG-PET or WBC-SPECT to enhance sensitivity. Peripheral mycotic aneurysms are a common complication of left-sided IE, which can present late into the disease process, and aortic imaging should be considered in patients with recurrent endocarditis to identify this.

Right sided heart failure secondary to hypereosinophilic cardiomyopathy - clinical manifestation and diagnostic pathway

Hypereosinophilic cardiomyopathy is a rare restrictive cardiomyopathy which often presents with left-sided heart failure. We present an interesting case of a 58-year-old male patient with known hypereosinophillic syndrome who had presented with congestive cardiac failure with predominant features of right-sided volume overload. Cardiac magnetic resonance imaging confirmed the diagnosis by demonstrating obliteration of the right ventricular apex and endocardial-delayed gadolinium enhancement at the mid-septal and inferior segment, at both the right ventricular and left ventricular apical region, consistent with fibrosis. He was successfully treated with intravenous diuretics to good effect.

This case report demonstrates a rare clinical presentation of right ventricle involvement in hypereosinophilic cardiomyopathy and the current pathway for diagnosis with the favoured emergence of cardiac magnetic resonance imaging. All patients with hypereosinophilic syndrome should be closely monitored for signs of cardiac involvement, as early treatment carries a better prognosis.

Vasospasm induced myocardial ischaemia secondary to sumatriptan use

Certain medications have been implicated in causing acute myocardial infarctions (AMI). Sumatriptan, a medication usually prescribed for acute migraine and cluster headaches has been documented as potentially causing coronary vasospasm, thereby leading to MI. This is usually seen in patients with strong risk factors for coronary artery disease (CAD) or in those with established CAD. Most cases thus far have been reported in patients using the subcutaneous preparation of sumatriptan. Here, we present a case of a patient without prior risk factors for CAD and angiographically unremarkable coronary arteries who presented with evidence of an AMI after oral sumatriptan use for migraines.