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Brignole M, Deharo JC, Menozzi C, Moya A, Sutton R, Tomaino M, Ungar A. The benefit of pacemaker therapy in patients with neurally mediated syncope and documented asystole: a meta-analysis of implantable loop recorder studies. Europace 2017; 20:1362-1366. [DOI: 10.1093/europace/eux321] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/12/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michele Brignole
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Via Don Bobbio 25, Lavagna, Italy
| | - Jean Claude Deharo
- Department of Cardiology, Hopital La Timone Adultes, 264 Rue Saint-Pierre, Marseille cedex 5, France
| | - Carlo Menozzi
- Department of Cardiology, Arcispedale S. Maria Nuova, Viale Risorgimento 80, Reggio Emilia, Italy
| | - Angel Moya
- Department of Cardiology, Hospital Universitario Vall d’Hebron, Paseo valle d'Ebron 119-129, Barcelona, Spain
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College, South Kensington Campus, London, UK
| | - Marco Tomaino
- Department of Cardiology, Ospedale di Bolzano, Via Lorenz Bohler 5, Bolzano, Italy
| | - Andrea Ungar
- Department of Cardiology, University of Florence, AOU Careggi, Viale Pieraccini 6, Florence, Italy
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Abstract
In part I of this study, we found that the classical studies on vasovagal syncope, conducted in fit young subjects, overstated vasodilatation as the dominant hypotensive mechanism. Since 1980, blood pressure and cardiac output have been measured continuously using noninvasive methods during tilt, mainly in patients with recurrent syncope, including women and the elderly. This has allowed us to analyze in more detail the complex sequence of hemodynamic changes leading up to syncope in the laboratory. All tilt-sensitive patients appear to progress through 4 phases: (1) early stabilization, (2) circulatory instability, (3) terminal hypotension, and (4) recovery. The physiology responsible for each phase is discussed. Although the order of phases is consistent, the time spent in each phase may vary. In teenagers and young adults, progressive hypotension during phases 2 and 3 can be driven by vasodilatation or falling cardiac output. The fall in cardiac output is secondary to a progressive decrease in stroke volume because blood is pooled in the splanchnic veins. In adults a fall in cardiac output is the dominant hypotensive mechanism because systemic vascular resistance always remains above baseline levels.
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Affiliation(s)
- David L Jardine
- Department of General Medicine, Christchurch Hospital, University of Otago, Christchurch, New Zealand.
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Michele Brignole
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands; Department of Internal Medicine III, Technical University Dresden, Dresden, Germany
| | - Richard Sutton
- National Heart and Lung institute, Imperial College, London, United Kingdom
| | - Julian Stewart
- Departments of Pediatrics, Physiology, and Medicine, New York Medical College, Valhalla, New York
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Perrin T, Guieu R, Koutbi L, Franceschi F, Hourdain J, Brignole M, Deharo JC. Theophylline as an adjunct to control malignant ventricular arrhythmia associated with early repolarization. Pacing Clin Electrophysiol 2017; 41:444-446. [PMID: 29148059 DOI: 10.1111/pace.13240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 11/26/2022]
Abstract
Early repolarization (ER) has been associated with an increased risk of sudden cardiac arrest. Interestingly, ventricular arrhythmias seem to be triggered by parasympathetic stimulation. In the present case report, we describe complete control of highly frequent malignant ventricular arrhythmias after adding theophylline to ineffective oral hydroquinidine and high-rate pacing in a patient suffering from malignant ER. We hypothesize that the theophylline-mediated enhanced beta-adrenergic stimulation could reduce the transmural myocardial voltage discrepancy by increasing the inward ICa,L current.
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Affiliation(s)
- Tilman Perrin
- Service de Cardiologie-Rythmologie, CHU la Timone, Marseille, France
| | - Regis Guieu
- Service de Biochimie, CHU la Timone, Marseille, France.,AMU, UMR MD2, Faculté de Médecine Nord, Marseille, France
| | - Linda Koutbi
- Service de Cardiologie-Rythmologie, CHU la Timone, Marseille, France
| | - Frédéric Franceschi
- Service de Cardiologie-Rythmologie, CHU la Timone, Marseille, France.,AMU, UMR MD2, Faculté de Médecine Nord, Marseille, France
| | - Jérôme Hourdain
- Service de Cardiologie-Rythmologie, CHU la Timone, Marseille, France
| | | | - Jean-Claude Deharo
- Service de Cardiologie-Rythmologie, CHU la Timone, Marseille, France.,AMU, UMR MD2, Faculté de Médecine Nord, Marseille, France
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Oddone D, Solari D, Nangah R, Arena G, Mureddu R, Giorgi D, Sitta N, Bottoni N, Senatore G, Giaccardi M, Giammaria M, Themistoclakis S, Laffi M, Cipolla E, Di Lorenzo F, Carpi R, Brignole M. Optimization of coronary sinus lead placement targeted to the longest right-to-left delay in patients undergoing cardiac resynchronization therapy: The Optimal Pacing SITE 2 (OPSITE 2) acute study and protocol. Pacing Clin Electrophysiol 2017; 40:1350-1357. [DOI: 10.1111/pace.13212] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/19/2017] [Accepted: 10/01/2017] [Indexed: 11/27/2022]
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Reek S, Burri H, Roberts PR, Perings C, Epstein AE, Klein HU, Lip G, Gorenek B, Sticherling C, Fauchier L, Goette A, Jung W, Vos MA, Brignole M, Elsner C, Dan GA, Marin F, Boriani G, Lane D, Blomström-Lundqvist C, Savelieva I. The wearable cardioverter-defibrillator: current technology and evolving indications. Europace 2017; 19:335-345. [PMID: 27702851 DOI: 10.1093/europace/euw180] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The wearable cardioverter-defibrillator has been available for over a decade and now is frequently prescribed for patients deemed at high arrhythmic risk in whom the underlying pathology is potentially reversible or who are awaiting an implantable cardioverter-defibrillator. The use of the wearable cardioverter-defibrillator is included in the new 2015 ESC guidelines for the management of ventricular arrhythmias and prevention of sudden cardiac death. The present review provides insight into the current technology and an overview of this approach.
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Affiliation(s)
- Sven Reek
- Electrophysiology Service, Hirslanden Klinik Aarau, Aarau, Switzerland.,Rhythmologie Aargau, Rain 34, CH-5000 Aarau, Switzerland
| | - Haran Burri
- Cardiology Service, University Hospital of Geneva, Geneva, Switzerland
| | - Paul R Roberts
- Cardiac Rhythm Management, University Hospital Southampton, Southampton, UK
| | | | - Andrew E Epstein
- Cardiovascular Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Helmut U Klein
- University of Rochester Medical Center, Heart Research Follow up Program, Rochester, NY, USA
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Rafanelli M, Rivasi G, Solari D, Tesi F, Ceccofiglio A, Sacco F, Venzo S, Giannini I, Brignole M, Ungar A. 073_16760 Predictors of Syncopal Recurrence after Cardiac Pacing in Patients with Carotid Sinus Syndrome. JACC Clin Electrophysiol 2017. [DOI: 10.1016/j.jacep.2017.09.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sheldon R, Talajic M, Becker G, Essebag V, Sultan O, Ritchie D, Rose S, Morillo C, Krahn A, Brignole M, Maxey C. SYNCOPE: PACING VERSUS RECORDING IN THE LATER YEARS. A RANDOMIZED PRAGMATIC CLINICAL TRIAL OF STRATEGIES OF PERMANENT PACEMAKER VERSUS IMPLANTABLE CARDIAC MONITOR IN OLDER PATIENTS WITH SYNCOPE. Can J Cardiol 2017. [DOI: 10.1016/j.cjca.2017.07.285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Introduction The purpose of this study was to assess the clinical and financial outcomes of a novel outreach syncope clinic. Methods We compared the clinical outcome of the Faint and Fall Clinic at the American Center (January-June 2016) with that of the University of Wisconsin Health and Clinics Faint and Fall Clinic (January 2013-December 2014). The American Center-Faint and Fall Clinic is run solely by a nurse practitioner, assisted by online faint-decision software and consultancy of a faint specialist through video-conferencing. Results Five hundred and twenty-eight consecutive patients were seen at the University of Wisconsin Hospital and Clinics-Faint and Fall Clinic and 68 patients at the American Center-Faint and Fall Clinic. The patients' clinical characteristics were similar except for a lower age in the American Center patients (45 ± 18 vs 51 ± 22, p = 0.03). Overall, a diagnosis was made within 45 days in 70% (95% confidence interval 66-74%) of the University of Wisconsin Hospital and Clinics patients and 69% (95% confidence interval 58-80%) of the American Center patients, ( p = 0.9). A mean of 3.0 ± 1.6 tests per patient was used in the University of Wisconsin Hospital and Clinics group compared to 1.5 ± 0.8 tests per patient in the American Center group, p = 0.001. Over the six-month study period, the total revenue at the American Center was US$152,597 (contribution margin of US$122,393 plus professional revenue of US$30,204). The total cost of the nurse practitioner including benefits was US$66,662 ((US$98,466 salary/year + 35.4% benefits)/2). Total revenue minus expenses resulted in a net profit of US$85,935. Discussion A nurse practitioner-run outreach syncope-clinic equipped with online faint-decision software and consultancy of a faint specialist through vedio-conferencing is feasible and financially self-sustainable. It allows the dissemination of standardized high-quality syncope care to patients who have no immediate access to a tertiary teaching hospital.
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Affiliation(s)
- Mohamed H Hamdan
- 1 Division of Cardiovascular Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Kathleen E Walsh
- 1 Division of Cardiovascular Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Jamie Key
- 1 Division of Cardiovascular Medicine, University of Wisconsin, Madison, Wisconsin, USA
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Gorenek B, Bax J, Boriani G, Chen SA, Dagres N, Glotzer TV, Healey JS, Israel CW, Kudaiberdieva G, Levin LÅ, Lip GYH, Martin D, Okumura K, Svendsen JH, Tse HF, Botto GL, Sticherling C, Linde C, Kutyifa V, Bernat R, Scherr D, Lau CP, Iturralde P, Morin DP, Savelieva I, Lip G, Gorenek B, Sticherling C, Fauchier L, Goette A, Jung W, Vos MA, Brignole M, Elsner C, Dan GA, Marin F, Boriani G, Lane D, Lundqvist CB, Savelieva I. Device-detected subclinical atrial tachyarrhythmias: definition, implications and management—an European Heart Rhythm Association (EHRA) consensus document, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2017; 19:1556-1578. [DOI: 10.1093/europace/eux163] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/04/2017] [Indexed: 01/03/2023] Open
Affiliation(s)
| | - Jeroen Bax
- Leiden University Medical Center (Lumc), Leiden, the Netherlands
| | - Giuseppe Boriani
- Cardiology Department, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
| | - Shih-Ann Chen
- Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Electrophysiology, University Leipzig – Heart Center, Leipzig, Germany
| | - Taya V Glotzer
- Hackensack University Medical Center, Hackensack, NJ, USA
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - David Martin
- Lahey Hospital and Medical Center, Burlington, MA, USA
| | | | | | - Hung-Fat Tse
- Cardiology Division, Department of Medicine; The University of Hong Kong, Hong Kong
| | | | | | | | | | | | | | | | | | - Daniel P Morin
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, USA
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Brignole M, Tomaino M, Aerts A, Ammirati F, Ayala-Paredes FA, Deharo JC, Del Rosso A, Hamdan MH, Lunati M, Moya A, Gargaro A. Erratum to Benefit of dual-chamber pacing with Closed Loop Stimulation in tilt-induced cardio-inhibitory reflex syncope (BIOSync trial): study protocol for a randomized controlled trial. Trials 2017; 18:269. [PMID: 28595588 PMCID: PMC5465450 DOI: 10.1186/s13063-017-1988-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/17/2017] [Indexed: 12/05/2022] Open
Affiliation(s)
- Michele Brignole
- Ospedali del Tigullio, Arrhythmologic Centre, Department of Cardiology, Via Don Bobbio, 25, 16033, Lavagna, GE, Italy.
| | | | | | | | | | | | | | | | | | - Angel Moya
- University Hospital Vall d'Hebròn, Barcelona, Spain
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112
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Aste M, Capellini C, Schiappacasse E, Devoto G, Brignole M. Ventricular fibrillation and long-QT syndrome due to panhypopituitarism. J Cardiovasc Med (Hagerstown) 2017; 18:833-834. [PMID: 28562421 DOI: 10.2459/jcm.0000000000000531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Milena Aste
- aDepartment of Cardiology bDepartment of Radiology cDepartment of Neurology dDepartment of Biochemistry, Ospedali del Tigullio, Lavagna, Italy
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113
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Abstract
Current literature reveals three types of paroxysmal atrioventricular block (AVB) that can cause syncope: Intrinsic paroxysmal atrioventricular block is due to an intrinsic disease of the AV conduction system; this type of "cardiac syncope" is also called Stokes-Adams attack; Extrinsic vagal paroxysmal atrioventricular block is linked to the effect of the parasympathetic nervous system on cardiac conduction and is one of the mechanisms involved in "reflex syncope." Extrinsic idiopathic paroxysmal atrioventricular block is associated with low levels of endogenous adenosine and is supposed to be one of the mechanisms involved in "low-adenosine syncope." These three types of paroxysmal AVB present different clinical and electrocardiographic features. Additionally, the efficacy of cardiac pacing and theophylline therapy to prevent syncopal recurrences is also different for these three types of AVB.
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Affiliation(s)
- Milena Aste
- Arrhythmology Center, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy
| | - Michele Brignole
- Arrhythmology Center, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy
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114
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Brignole M, Tomaino M, Aerts A, Ammirati F, Ayala-Paredes FA, Deharo JC, Del Rosso A, Hamdan MH, Lunati M, Moya A, Gargaro A. Benefit of dual-chamber pacing with Closed Loop Stimulation in tilt-induced cardio-inhibitory reflex syncope (BIOSync trial): study protocol for a randomized controlled trial. Trials 2017; 18:208. [PMID: 28472974 PMCID: PMC5415949 DOI: 10.1186/s13063-017-1941-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 04/11/2017] [Indexed: 12/04/2022] Open
Abstract
Background The efficacy of dual-chamber cardiac pacing in neuro-mediated reflex syncope with a cardio-inhibitory response to the Tilt-Table test (TT) has not been definitively assessed so far. The lack of reproducibility of results from previous studies may be partially explained by discrepancies in subject selection and some weaknesses in design and methods. The European Society of Cardiology (ESC) has set a class IIb indication to pacemaker implantation in this population recommending further research. Methods/design The BIOSync study is a multicenter, patient- and outcome-assessor-blind, randomized, parallel-arm, placebo-controlled trial with the objective of assessing the clinical benefit of cardiac pacing in patients with frequently recurrent reflex syncope, suspected (but not proven) to be triggered by asystolic pauses as showing a VASIS 2B response to the TT (>3-s pause regardless of blood pressure drop). The primary and secondary endpoints are time to first post-implantation recurrence of syncope or the combination of pre-syncope or syncope, respectively. One hundred and twenty-eight consenting patients will be 1:1 randomized to dual-chamber cardiac pacing ‘on’ or ‘off’ after pacemaker implantation, and followed up until the first adjudicated primary endpoint event for a maximum of 2 years. The so-called Closed Loop Stimulation function on top of dual-chamber pacing is the pacing mode selected in the study active arm. Participating patients are asked to self-report syncopal symptoms at least every 3 months with self-administered questionnaires addressed to an independent Adjudication Committee. Patients and members of the Adjudicating Committee are blinded to randomization. The study is designed to detect a 40% relative reduction in the 2-year incidence of syncopal recurrences with 80% statistical power. Discussion The BIOSync study is designed to definitively assess the benefit of pacing against placebo in reflex syncope patients with a cardio-inhibitory response to the TT. The study will also provide important information on the efficiency of the TT in appropriately selecting reflex syncope patients for cardiac pacing. Trial registration ClinicalTrials.gov, identifier: NCT02324920 (27 October 2016, date last accessed). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1941-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michele Brignole
- Ospedali del Tigullio, Arrhythmologic Centre, Department of Cardiology, Via Don Bobbio, 25, 16033, Lavagna, GE, Italy.
| | | | | | | | | | | | | | | | | | - Angel Moya
- University Hospital Vall d'Hebròn, Barcelona, Spain
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Brignole M, Guieu R, Tomaino M, Iori M, Ungar A, Bertolone C, Unterhuber M, Bottoni N, Tesi F, Claude Deharo J. Mechanism of syncope without prodromes with normal heart and normal electrocardiogram. Heart Rhythm 2017; 14:234-239. [DOI: 10.1016/j.hrthm.2016.08.046] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Indexed: 12/22/2022]
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Solari D, Tesi F, Unterhuber M, Gaggioli G, Ungar A, Tomaino M, Brignole M. Stop vasodepressor drugs in reflex syncope: a randomised controlled trial. Heart 2016; 103:449-455. [DOI: 10.1136/heartjnl-2016-309865] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/19/2016] [Accepted: 08/30/2016] [Indexed: 01/12/2023] Open
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Donateo P, Bottoni N, Oddone D, Quartieri F, Iori M, Maggi R, Brignole M. Long-Term Results After Single and Multiple Procedures of Ablation of Ventricular Tachycardia. J Cardiovasc Electrophysiol 2016; 27:1319-1324. [PMID: 27489134 DOI: 10.1111/jce.13061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/08/2016] [Accepted: 08/02/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The aim of this study was to assess long-term results after single and multiple procedures of catheter ablation of ventricular tachycardia (VT). While it is generally accepted that multiple procedures are sometimes necessary in order to achieve long-term clinical success, the literature on this issue displays wide variability. METHODS We assessed the outcome of 160 consecutive patients who underwent 214 ablation procedures in the period 2008 to May 2015: 93 had overt structural heart disease (SHD) (previous myocardial infarction in 74 cases) and 67 had no SHD. RESULTS After the first procedure, the 1-year actuarial recurrence rates were 25% in patients with SHD and 5% in those without. However, recurrences increased progressively after the first year, reaching 46% and 35%, respectively, at 5 years. Overall, VT recurred in 35/93 (38%) patients with SHD and 22/67 (33%) patients without. Redo (1 to 4) procedures were performed in 28 (20%) patients with SHD and 18 (27%) patients without. After the last procedure, the 1-year actuarial recurrence rates were 5% in patients with SHD and 7% in those without, and the corresponding rates at 5 years were 23% and 7%. During follow-up, 21 patients died (all in the SHD group): no death was related to VT recurrence. CONCLUSIONS During long-term follow-up, VT frequently recurs after the first procedure, both in patients with SHD and in those without; multiple procedures are needed in order to increase the success rate.
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Affiliation(s)
- Paolo Donateo
- Arrhythmology Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Nicola Bottoni
- Arrhythmology Centre, Department of Cardiology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Daniele Oddone
- Arrhythmology Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Fabio Quartieri
- Arrhythmology Centre, Department of Cardiology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Matteo Iori
- Arrhythmology Centre, Department of Cardiology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Roberto Maggi
- Arrhythmology Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Michele Brignole
- Arrhythmology Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
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Locati ET, Moya A, Oliveira M, Tanner H, Willems R, Lunati M, Brignole M. External prolonged electrocardiogram monitoring in unexplained syncope and palpitations: results of the SYNARR-Flash study. Europace 2016; 18:1265-72. [PMID: 26519025 PMCID: PMC4974630 DOI: 10.1093/europace/euv311] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/18/2015] [Indexed: 12/15/2022] Open
Abstract
AIMS SYNARR-Flash study (Monitoring of SYNcopes and/or sustained palpitations of suspected ARRhythmic origin) is an international, multicentre, observational, prospective trial designed to evaluate the role of external 4-week electrocardiogram (ECG) monitoring in clinical work-up of unexplained syncope and/or sustained palpitations of suspected arrhythmic origin. METHODS AND RESULTS Consecutive patients were enrolled within 1 month after unexplained syncope or palpitations (index event) after being discharged from emergency room or hospitalization without a conclusive diagnosis. A 4-week ECG monitoring was obtained by external high-capacity loop recorder (SpiderFlash-T(®), Sorin) storing patient-activated and auto-triggered tracings. Diagnostic monitorings included (i) conclusive events with reoccurrence of syncope or palpitation with concomitant ECG recording (with/without arrhythmias) and (ii) events with asymptomatic predefined significant arrhythmias (sustained supraventricular or ventricular tachycardia, advanced atrio-ventricular block, sinus bradycardia <30 b.p.m., pauses >6 s). SYNARR-Flash study enrolled 395 patients (57.7% females, 56.9 ± 18.7 years, 28.1% with syncope, and 71.9% with palpitations) from 10 European centres. For syncope, the 4-week diagnostic yield was 24.5%, and predictors of diagnostic events were early start of recording (0-15 vs. >15 days after index event) (OR 6.2, 95% CI 1.3-29.6, P = 0.021) and previous history of supraventricular arrhythmias (OR 3.6, 95% CI 1.4-9.7, P = 0.018). For palpitations, the 4-week diagnostic yield was 71.6% and predictors of diagnostic events were history of recurrent palpitations (P < 0.001) and early start of recording (P = 0.001). CONCLUSION The 4-week external ECG monitoring can be considered as first-line tool in the diagnostic work-up of syncope and palpitation. Early recorder use, history of supraventricular arrhythmia, and frequent previous events increased the likelihood of diagnostic events during the 4-week external ECG monitoring.
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Affiliation(s)
- E T Locati
- Department of Cardiovascular-Cardiology 3, Electrophysiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, Milano 20162, Italy
| | - A Moya
- Univeristy Hospital Vall d'Hebron, Barcelona, Spain University Hospital QuironDexeus, Barcelona, Spain
| | | | | | | | - M Lunati
- Department of Cardiovascular-Cardiology 3, Electrophysiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, Milano 20162, Italy
| | - M Brignole
- Lavagna Hospital, Lavagna, Genova, Italy
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Casagranda I, Brignole M, Cencetti S, Cervellin G, Costantino G, Furlan R, Mossini G, Numeroso F, Pesenti Campagnoni M, Pinna Parpaglia P, Rafanelli M, Ungar A. Management of transient loss of consciousness of suspected syncopal cause, after the initial evaluation in the Emergency Department. Emerg Care J 2016. [DOI: 10.4081/ecj.2016.6046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The recommendations enclosed in the present document have been developed by a group of experts appointed by the <em>Gruppo Multidisciplinare per lo Studio della Sincope</em> (Multidisciplinary Group for the Study of Syncope; GIMSI) and Academy of Emergency Medicine and Care (AcEMC). The aim is to define the diagnostic pathway and the management of patients referred to the Emergency Department (ED) for transient loss of consciousness of suspected syncopal cause, which is still unexplained after the initial evaluation. The risk stratification enables the physician to admit, discharge or monitor shortly the patient in the intensive short-stay Syncope Observation Unit (SOU). There are three risk levels of life-threatening events or serious complications (low, moderate, high). Low risk patients can be discharged, while high risk ones should be monitored and treated properly in case of worsening. Moderate risk patients should undergo clinical and instrumental monitoring in SOU, inside the ED. In all these three cases, patients can be subsequently referred to the Syncope Unit for further diagnostic investigations.
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Chaddha A, Wenzke KE, Brignole M, Wasmund SL, Page RL, Hamdan MH. The Role of the Baroreflex in Tilt Table Testing: Outcome and Type of Response. JACC Clin Electrophysiol 2016; 2:812-817. [PMID: 29759765 DOI: 10.1016/j.jacep.2016.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/29/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The purpose of this study was to better understand the role of the baroreflex in tilt-induced vasovagal syncope (VVS). BACKGROUND The role of the baroreflex in tilt-induced VVS remains controversial. The authors hypothesized that: 1) patients with positive tilt table test (TTT) results have greater baroreflex gain (BRG) compared with patients with negative TTT results; and 2) patients with tilt-induced asystole have greater BRG compared with patients without asystole. METHODS Using the sequence method, BRG measurements were obtained in 438 consecutive patients undergoing TTT. Two hundred sixty-eight patients (61%) had positive TTT results (mean age 50 ± 21 years; 34% men), and 170 patients (39%) had negative TTT results (mean age 48 ± 21 years; 35% men). RESULTS Mean BRG was significantly higher in patients with positive TTT results compared with those with negative TTT results (12.9 ± 6.0 ms/mm Hg vs. 11.5 ± 6.0 ms/mm Hg; p = 0.01). Among the 268 patients with positive TTT results, 23 (9%) had more than 3 s of asystole (mean age 37 ± 17; 30% men), and 245 patients had a mixed vasodepressor or cardioinhibitory response without asystole (mean age 51 ± 17 years; 34% men). Mean BRG was greater in patients with tilt-induced asystole (>3 s) compared with patients without asystole (15.3 ± 5.9 ms/mm Hg vs. 12.7 ± 5.9 ms/mm Hg; p = 0.03). CONCLUSIONS The results of this study demonstrate that baseline BRG was higher in patients with positive TTT results compared with those with negative TTT results, with greater values noted in patients with tilt-induced asystole (>3 s) compared with those without asystole.
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Affiliation(s)
- Ashish Chaddha
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin E Wenzke
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Michele Brignole
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Stephen L Wasmund
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Richard L Page
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mohamed H Hamdan
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Chaddha A, Rafanelli M, Brignole M, Sutton R, Wenzke KE, Wasmund SL, Page RL, Hamdan MH. The pathophysiologic mechanisms associated with hypotensive susceptibility. Clin Auton Res 2016; 26:261-8. [PMID: 27324399 DOI: 10.1007/s10286-016-0362-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/13/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Patients with vasovagal syncope (VVS) and positive tilt table test (TTT) were not found to benefit from pacing in the ISSUE-3 trial despite the presence of spontaneous asystole during monitoring. "Hypotensive susceptibility" unmasked by TTT was reported as a possible explanation. The purpose of this study was to assess the pathophysiologic mechanisms associated with hypotensive susceptibility. METHODS 366 consecutive patients with the diagnosis of VVS who also had TTT were identified. Baroreflex gain (BRG) in addition to blood pressure (BP) and heart rate (HR) responses during the first 20 min of TTT were analyzed and compared between patients with positive TTT (n = 275, 75 %) and negative TTT (n = 91, 25 %). RESULTS The mean BRG was similar between the groups (12.5 ± 6.3 versus 12.4 ± 6.3 ms/mmHg, p = 0.72); however, an age-dependent decrease was noted (17.6 ± 4.8, 15.0 ± 6.0, 10.6 ± 4.2, 10.3 ± 6.4 and 9.9 ± 8.5 ms/mmHg for patients <21, 21-40, 41-60, 61-80 and >80 years old, respectively; p < 0.001). In addition, we saw a main effect of age on the type of response with a greater prevalence of a vasodepressor response in older subjects (p < 0.001). During the first 20 min of TTT, BP was similar in patients with tilt-positive VVS when compared with patients with tilt-negative VVS; however, HR was significantly lower. CONCLUSION BRG is similar in tilt-positive VVS patients when compared with tilt-negative VVS patients. An age-dependent decrease in BRG was noted with a higher prevalence of a vasodepressor response seen in older patients. The clinical significance of the blunted HR response in tilt-positive VVS remains to be determined.
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Affiliation(s)
- Ashish Chaddha
- Division of Cardiovascular Medicine, School of Medicine and Public Health, University of Wisconsin, H4/534 Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792-3248, USA
| | - Martina Rafanelli
- Geriatric Cardiology and Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College, London, UK
| | - Kevin E Wenzke
- Division of Cardiovascular Medicine, School of Medicine and Public Health, University of Wisconsin, H4/534 Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792-3248, USA
| | - Stephen L Wasmund
- Division of Cardiovascular Medicine, School of Medicine and Public Health, University of Wisconsin, H4/534 Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792-3248, USA
| | - Richard L Page
- Division of Cardiovascular Medicine, School of Medicine and Public Health, University of Wisconsin, H4/534 Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792-3248, USA
| | - Mohamed H Hamdan
- Division of Cardiovascular Medicine, School of Medicine and Public Health, University of Wisconsin, H4/534 Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792-3248, USA.
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Brignole M, Solari D, Iori M, Bottoni N, Guieu R, Deharo JC. Efficacy of theophylline in patients affected by low adenosine syncope. Heart Rhythm 2016; 13:1151-1154. [DOI: 10.1016/j.hrthm.2015.12.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Indexed: 11/27/2022]
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Abstract
Syncope due to idiopathic AV block is characterized by: 1) ECG documentation (usually by means of prolonged ECG monitoring) of paroxysmal complete AV block with one or multiple consecutive pauses, without P-P cycle lengthening or PR interval prolongation, not triggered by atrial or ventricular premature beats nor by rate variations; 2) long history of recurrent syncope without prodromes; 3) absence of cardiac and ECG abnormalities; 4) absence of progression to persistent forms of AV block; 5) efficacy of cardiac pacing therapy. The patients affected by idiopathic AV block have low baseline adenosine plasma level values and show an increased susceptibility to exogenous adenosine. The APL value of the patients with idiopathic AV block is much lower than patients affected by vasovagal syncope who have high adenosine values.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Via Don Bobbio 25, Lavagna 16033, Italy.
| | - Jean-Claude Deharo
- Department of Cardiology, Timone University Hospital, 264, rue Saint Pierre 13385, Marseille, France
| | - Regis Guieu
- Laboratory of Biochemistry and Molecular Biology, Timone University Hospital, Unité Mixte de Recherche Ministere de la Defense, Aix Marseille Université, Boulevard P Dramard, Marseille 13015, France
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Aste M, Oddone D, Donateo P, Solano A, Maggi R, Croci F, Solari D, Brignole M. Syncope in patients paced for atrioventricular block. Europace 2016; 18:1735-1739. [DOI: 10.1093/europace/euv425] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/18/2015] [Indexed: 11/15/2022] Open
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Fromonot J, Chaumet G, Gavarry O, Rostain JC, Lucciano M, Joulia F, Brignole M, Deharo JC, Guieu R, Boussuges A. Hyperoxia Improves Hemodynamic Status During Head-up Tilt Testing in Healthy Volunteers: A Randomized Study. Medicine (Baltimore) 2016; 95:e2876. [PMID: 26937921 PMCID: PMC4779018 DOI: 10.1097/md.0000000000002876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Head-up tilt test is useful for exploring neurally mediated syncope. Adenosine is an ATP derivative implicated in cardiovascular disturbances that occur during head-up tilt test. The aim of the present study was to investigate the impact of hyperoxia on adenosine plasma level and on hemodynamic changes induced by head-up tilt testing.Seventeen healthy male volunteers (mean age 35 ± 11 years) were included in the study. The experiment consisted of 2 head-up tilt tests, 1 session with subjects breathing, through a mask, medical air (FiO2 = 21%) and 1 session with administration of pure oxygen (FiO2 = 100%) in double-blind manner. Investigations included continuous monitoring of hemodynamic data and measurement of plasma adenosine levels.No presyncope or syncope was found in 15 of the 17 volunteers. In these subjects, a slight decrease in systolic blood pressure was recorded during orthostatic stress performed under medical air exposure. In contrast, hyperoxia led to increased systolic blood pressure during orthostatic stress when compared with medical air. Furthermore, mean adenosine plasma levels decreased during hyperoxic exposure before (0.31 ± 0.08 μM) and during head-up tilt test (0.33 ± 0.09 μM) when compared with baseline (0.6 ± 0.1 μM). Adenosine plasma level was unchanged during medical air exposure at rest (0.6 ± 0.1 μM), and slightly decreased during orthostatic stress. In 2 volunteers, the head-up tilt test induced a loss of consciousness when breathing air. In these subjects, adenosine plasma level increased during orthostatic stress. In contrast, during hyperoxic exposure, the head-up tilt test did not induce presyncope or syncope. In these 2 volunteers, biological study demonstrated a decrease in adenosine plasma level at both baseline and during orthostatic stress for hyperoxic exposure compared with medical air.These results suggest that hyperoxia was able to increase blood pressure during head-up tilt test via a decrease in plasma adenosine concentration. Our results also suggest that adenosine receptor antagonists are worth trying in neurocardiogenic syncope.
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Affiliation(s)
- Julien Fromonot
- From the UMR-MD2, Dysoxie Suractivité, Institut de Recherche Biomédicale des Armées (IRBA) & Aix-Marseille Université, Faculté de Médecine Nord, Marseille, France (JF, GC, J-CR, FJ, J-CD, RG, AB); Laboratoire HandiBio EA 4322, Université du Sud Toulon Var, La Garde, France (OG); Laboratoire de biomécanique appliquée, Aix Marseille Université, Faculté de Médecine Nord, Marseille, France (ML); and Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy (MB)
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Brignole M, Arabia F, Ammirati F, Tomaino M, Quartieri F, Rafanelli M, Del Rosso A, Rita Vecchi M, Russo V, Gaggioli G. Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study. Europace 2015; 18:1427-33. [DOI: 10.1093/europace/euv343] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/07/2015] [Indexed: 11/12/2022] Open
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Wieling W, Jardine DL, de Lange FJ, Brignole M, Nielsen HB, Stewart J, Sutton R. Cardiac output and vasodilation in the vasovagal response: An analysis of the classic papers. Heart Rhythm 2015; 13:798-805. [PMID: 26598322 DOI: 10.1016/j.hrthm.2015.11.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Indexed: 11/17/2022]
Abstract
The simple faint is secondary to hypotension and bradycardia resulting in transient loss of consciousness. According to Ohm's law applied to the circulation, BP = SVR × CO, hypotension can result from a decrease in systemic vascular resistance (SVR), cardiac output (CO), or both. It is important to understand that when blood pressure (BP) is falling, SVR and CO do not change reciprocally as they do in the steady state. In 1932, Lewis, assuming that decreased SVR alone accounted for hypotension, defined "the vasovagal response" along pathophysiologic lines to denote the association of vasodilation with vagal-induced bradycardia in simple faint. Studies performed by Barcroft and Sharpey-Schafer between 1940 and 1950 used volume-based plethysmography to demonstrate major forearm vasodilation during extreme hypotension and concluded that the main mechanism for hypotension was vasodilation. Plethysmographic measurements were intermittent and not frequent enough to capture rapid changes in blood flow during progressive hypotension. However, later investigations by Weissler, Murray, and Stevens performed between 1950 and 1970 used invasive beat-to-beat BP measurements and more frequent measurements of CO using the Fick principle. They demonstrated that CO significantly fell before syncope, and little vasodilation occurred until very late in the vasovagal reaction Thus, since the 1970s, decreasing cardiac output rather than vasodilation has been regarded as the principal mechanism for the hypotension of vasovagal syncope.
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Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - David L Jardine
- Department of Medicine, Christchurch School of Medicine, University of Otago, Otago, New Zealand
| | - Frederik J de Lange
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Michele Brignole
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy
| | - Henning B Nielsen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Julian Stewart
- Departments of Pediatrics, Physiology and Medicine, New York Medical College, Valhalla, New York
| | - Richard Sutton
- National Heart & Lung institute, Imperial College, London, United Kingdom
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Costantino G, Sun BC, Barbic F, Bossi I, Casazza G, Dipaola F, McDermott D, Quinn J, Reed MJ, Sheldon RS, Solbiati M, Thiruganasambandamoorthy V, Beach D, Bodemer N, Brignole M, Casagranda I, Del Rosso A, Duca P, Falavigna G, Grossman SA, Ippoliti R, Krahn AD, Montano N, Morillo CA, Olshansky B, Raj SR, Ruwald MH, Sarasin FP, Shen WK, Stiell I, Ungar A, Gert van Dijk J, van Dijk N, Wieling W, Furlan R. Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in the emergency department. Eur Heart J 2015; 37:1493-8. [PMID: 26242712 DOI: 10.1093/eurheartj/ehv378] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/21/2015] [Indexed: 02/01/2023] Open
Affiliation(s)
- Giorgio Costantino
- Dipartimento di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Portland, Italy
| | - Benjamin C Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Franca Barbic
- BIOMETRA Department - Humanitas Research Hospital, Università degli Studi di Milano, Rozzano, MI, Italy
| | - Ilaria Bossi
- Emergency Medicine Department, S. Anna Hospital, Como, Italy
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences 'L. Sacco', Università degli Studi di Milano, Milan, Italy
| | - Franca Dipaola
- BIOMETRA Department - Humanitas Research Hospital, Università degli Studi di Milano, Rozzano, MI, Italy
| | - Daniel McDermott
- School of Medicine, University of California- San Francisco, San Francisco, CA, USA
| | - James Quinn
- Division of Emergency Medicine, Stanford University, Stanford, CA, USA
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert S Sheldon
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada
| | - Monica Solbiati
- Dipartimento di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Portland, Italy
| | | | | | | | | | - Ivo Casagranda
- Department of Emergency Medicine, Ospedale di Alessandria, Alessandria, Italy
| | - Attilio Del Rosso
- Electrophysiology Unit, Cardiology Division, Department of Medicine, Ospedale S. Giuseppe, Empoli, Italy
| | - Piergiorgio Duca
- Department of Biomedical and Clinical Sciences 'L. Sacco', Università degli Studi di Milano, Milan, Italy
| | | | - Shamai A Grossman
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Nicola Montano
- Dipartimento di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Portland, Italy
| | - Carlos A Morillo
- McMaster University, Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Medical Center, Iowa City, IA, USA
| | - Satish R Raj
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Martin H Ruwald
- Division of Cardiology, Gentofte Hospital, Copenhagen, Denmark
| | - Francois P Sarasin
- Division of Emergency Medicine, Hopital Cantonal, University of Geneva Medical School, Geneva, Switzerland
| | | | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Andrea Ungar
- Syncope Unit, Geriatric Medicine and Cardiology, Careggi University Hospital, Firenze, Italy
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nynke van Dijk
- Department of General Practice/Family Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Raffaello Furlan
- BIOMETRA Department - Humanitas Research Hospital, Università degli Studi di Milano, Rozzano, MI, Italy
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Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. ACTA ACUST UNITED AC 2015; 67:58. [PMID: 24774265 DOI: 10.1016/j.rec.2013.11.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/04/2013] [Indexed: 10/25/2022]
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Kenny RA, Brignole M, Dan GA, Deharo JC, van Dijk JG, Doherty C, Hamdan M, Moya A, Parry SW, Sutton R, Ungar A, Wieling W. Syncope Unit: rationale and requirement--the European Heart Rhythm Association position statement endorsed by the Heart Rhythm Society. Europace 2015; 17:1325-40. [PMID: 26108809 DOI: 10.1093/europace/euv115] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ungar A, Tesi F, Chisciotti VM, Pepe G, Vanni S, Grifoni S, Balzi D, Rafanelli M, Marchionni N, Brignole M. Assessment of a structured management pathway for patients referred to the Emergency Department for syncope: results in a tertiary hospital. Europace 2015; 18:457-62. [DOI: 10.1093/europace/euv106] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 03/18/2015] [Indexed: 11/15/2022] Open
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Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, Raj SR, Krahn AD, Morillo CA, Stewart JM, Sutton R, Sandroni P, Friday KJ, Hachul DT, Cohen MI, Lau DH, Mayuga KA, Moak JP, Sandhu RK, Kanjwal K. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm 2015; 12:e41-63. [PMID: 25980576 DOI: 10.1016/j.hrthm.2015.03.029] [Citation(s) in RCA: 557] [Impact Index Per Article: 61.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Indexed: 01/14/2023]
Affiliation(s)
| | | | | | | | | | | | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Alberta, Canada; Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Carlos A Morillo
- Department of Medicine, Cardiology Division, McMaster University Population Health Research Institute, Hamilton, Canada
| | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Karen J Friday
- (13)Stanford University School of Medicine, Stanford, California
| | | | - Mitchell I Cohen
- Phoenix Children's Hospital, University of Arizona School of Medicine-Phoenix, Arizona Pediatric Cardiology/Mednax, Phoenix, Arizona
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide; Department of Cardiology, Royal Adelaide Hospital; and South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Jeffrey P Moak
- Children's National Medical Center, Washington, District of Columbia
| | - Roopinder K Sandhu
- University of Alberta, Department of Medicine, Division of Cardiology, Alberta, Canada
| | - Khalil Kanjwal
- Michigan Cardiovascular Institute, Central Michigan University, Saginaw, Michigan
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Brignole M, Ammirati F, Arabia F, Quartieri F, Tomaino M, Ungar A, Lunati M, Russo V, Del Rosso A, Gaggioli G. Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes. Eur Heart J 2015; 36:1529-35. [PMID: 25825044 DOI: 10.1093/eurheartj/ehv069] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 03/02/2015] [Indexed: 12/17/2022] Open
Abstract
AIMS Opinions differ regarding the effectiveness of cardiac pacing in patients affected by reflex syncope. We assessed a standardized guideline-based algorithm in different forms of reflex syncope. METHODS AND RESULTS In this prospective, multi-centre, observational study, patients aged >40 years, affected by severe unpredictable recurrent reflex syncopes, underwent carotid sinus massage (CSM), followed by tilt testing (TT) if CSM was negative, followed by implantation of an implantable loop recorder (ILR) if TT was negative. Those who had an asystolic response to one of these tests received a dual-chamber pacemaker. POPULATION 253 patients, mean age 70 ± 12 years, median 4 (3-6) syncopes, 89% without or with short prodromes. Of these patients, 120 (47%) received a pacemaker and 106 were followed up for a mean of 13 ± 7 months: syncope recurred in 10 (9%). The recurrence rate was similar in 61 CSM+ (11%), 30 TT+ (7%), and 15 ILR+ (7%) patients. The actuarial total syncope recurrence rate was 9% (95% confidence interval (CI), 6-12) at 1 year and 15% (95% CI, 10-20) at 2 years and was significantly lower than that observed in the group of 124 patients with non-diagnostic tests who had received an ILR: i.e. 22% (95% CI, 18-26) at 1 year and 37% (95% CI, 30-43) at 2 years (P = 0.004). CONCLUSION About half of older patients with severe recurrent syncopes without prodromes have an asystolic reflex for which cardiac pacing goes along with a low recurrence rate. The study supports the clinical utility of the algorithm for the selection of candidates to cardiac pacing in everyday clinical practice. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Unique identifier: NCT01509534.
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Affiliation(s)
- Michele Brignole
- Arrhythmology Centre, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy
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136
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Maggi R, Rafanelli M, Ceccofiglio A, Solari D, Brignole M, Ungar A. Additional diagnostic value of implantable loop recorder in patients with initial diagnosis of real or apparent transient loss of consciousness of uncertain origin [Europace 201416: 1226–1230]. Europace 2014; 17:1847. [DOI: 10.1093/europace/euu308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bottoni N, Bertaglia E, Donateo P, Quartieri F, Iori M, Maggi R, Zoppo F, Brandolino G, Brignole M. Long-term clinical outcome of patients who failed catheter ablation of atrial fibrillation. Europace 2014; 17:403-8. [DOI: 10.1093/europace/euu229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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138
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Sutton R, Brignole M. Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis. Eur Heart J 2014; 35:2211-2212. [DOI: 10.1093/eurheartj/ehu255] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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139
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Brignole M, Occhetta E, Grazia Bongiorni M, Proclemer A, Favale S, Gasparini M, Accardi F, Valsecchi S. Decline of defibrillation testing in the clinical practice: an 8-year nation-wide assessment. Europace 2014; 16:1103-4. [DOI: 10.1093/europace/euu135] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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140
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Sun BC, Costantino G, Barbic F, Bossi I, Casazza G, Dipaola F, McDermott D, Quinn J, Reed M, Sheldon RS, Solbiati M, Thiruganasambandamoorthy V, Krahn AD, Beach D, Bodemer N, Brignole M, Casagranda I, Duca P, Falavigna G, Ippoliti R, Montano N, Olshansky B, Raj SR, Ruwald MH, Shen WK, Stiell I, Ungar A, van Dijk JG, van Dijk N, Wieling W, Furlan R. Priorities for emergency department syncope research. Ann Emerg Med 2014; 64:649-55.e2. [PMID: 24882667 DOI: 10.1016/j.annemergmed.2014.04.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/01/2014] [Accepted: 04/07/2014] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVES There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research. METHODS We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process. RESULTS There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management. CONCLUSION We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED.
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Affiliation(s)
- Benjamin C Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR.
| | - Giorgio Costantino
- Division of Medicine and Pathophysiology, Università degli Studi di Milano, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Franca Barbic
- BIOMETRA Department-Humanitas Clinical and Research Center, Rozzano (MI), Università degli Studi di Milano, Milan, Italy
| | - Ilaria Bossi
- Emergency Medicine Department, S. Anna Hospital, Como, Italy
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Franca Dipaola
- BIOMETRA Department-Humanitas Clinical and Research Center, Rozzano (MI), Università degli Studi di Milano, Milan, Italy
| | - Daniel McDermott
- School of Medicine, University of California-San Francisco, San Francisco, CA
| | - James Quinn
- Division of Emergency Medicine, Stanford University, Stanford, CA
| | - Matthew Reed
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, United Kingdom
| | - Robert S Sheldon
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada
| | - Monica Solbiati
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | | | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | | | | | | | | | - Piergiorgio Duca
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | | | | | - Nicola Montano
- Division of Medicine and Pathophysiology, Università degli Studi di Milano, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Medical Center, Iowa City, IA
| | - Satish R Raj
- Departments of Medicine and Pharmacology, Vanderbilt University, Nashville, TN
| | - Martin H Ruwald
- Division of Cardiology, Gentofte Hospital, Copenhagen, Denmark
| | | | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Andrea Ungar
- Division of Geriatrics, Ospedale Careggi, Firenze, Italy
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Nynke van Dijk
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Raffaello Furlan
- BIOMETRA Department-Humanitas Clinical and Research Center, Rozzano (MI), Università degli Studi di Milano, Milan, Italy
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141
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Solari D, Maggi R, Oddone D, Solano A, Croci F, Donateo P, Wieling W, Brignole M. Assessment of the Vasodepressor Reflex in Carotid Sinus Syndrome. Circ Arrhythm Electrophysiol 2014; 7:505-10. [DOI: 10.1161/circep.113.001093] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Diana Solari
- From the Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Lavagna, Italy (D.S., R.M., D.O., A.S., F.C., P.D., M.B.); and Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands (W.W.)
| | - Roberto Maggi
- From the Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Lavagna, Italy (D.S., R.M., D.O., A.S., F.C., P.D., M.B.); and Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands (W.W.)
| | - Daniele Oddone
- From the Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Lavagna, Italy (D.S., R.M., D.O., A.S., F.C., P.D., M.B.); and Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands (W.W.)
| | - Alberto Solano
- From the Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Lavagna, Italy (D.S., R.M., D.O., A.S., F.C., P.D., M.B.); and Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands (W.W.)
| | - Francesco Croci
- From the Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Lavagna, Italy (D.S., R.M., D.O., A.S., F.C., P.D., M.B.); and Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands (W.W.)
| | - Paolo Donateo
- From the Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Lavagna, Italy (D.S., R.M., D.O., A.S., F.C., P.D., M.B.); and Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands (W.W.)
| | - Wouter Wieling
- From the Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Lavagna, Italy (D.S., R.M., D.O., A.S., F.C., P.D., M.B.); and Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands (W.W.)
| | - Michele Brignole
- From the Department of Cardiology, Arrhythmologic Center, Ospedali del Tigullio, Lavagna, Italy (D.S., R.M., D.O., A.S., F.C., P.D., M.B.); and Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands (W.W.)
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Joulia F, Coulange M, Desplantes A, Barberon B, Kipson N, Gerolami V, Jammes Y, Kerbaul F, Née L, Fromonot J, Bruzzese L, Michelet P, Boussuges A, Brignole M, Deharo JC, Guieu R. Purinergic profile of fainting divers is different from patients with vasovagal syncope. Int J Cardiol 2014; 174:741-3. [PMID: 24798778 DOI: 10.1016/j.ijcard.2014.04.090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Fabrice Joulia
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France; Toulon University, France
| | - Mathieu Coulange
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France; Department of Hyperbaric Medicine, Sainte Marguerite Hospital, Marseille, France
| | - Agnalys Desplantes
- Department of Hyperbaric Medicine, Sainte Marguerite Hospital, Marseille, France
| | - Bruno Barberon
- Department of Hyperbaric Medicine, Sainte Marguerite Hospital, Marseille, France
| | - Nathalie Kipson
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France
| | - V Gerolami
- Laboratoire de Biologie Moléculaire, Hôpital de la Conception, AP-HM, France
| | - Yves Jammes
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France
| | - François Kerbaul
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France
| | - Laetitia Née
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France; Department of Intensive Care, AP-HM, France
| | - Julien Fromonot
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France
| | - Laurie Bruzzese
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France
| | - Pierre Michelet
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France; Department of Emergency Medicine, AP-HM, France
| | - Alain Boussuges
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France
| | | | - Jean-Claude Deharo
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France; Department of Cardiology, Timone University Hospital, Marseille, France
| | - Régis Guieu
- UMR MD2, AMU, Faculty of Medicine, Marseille, France; IRBA, France; Laboratory of Biochemistry, Timone University Hospital, AP-HM, France.
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Maggi R, Rafanelli M, Ceccofiglio A, Solari D, Brignole M, Ungar A. Additional diagnostic value of implantable loop recorder in patients with initial diagnosis of real or apparent transient loss of consciousness of uncertain origin. Europace 2014; 16:1226-30. [DOI: 10.1093/europace/euu051] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, Køber L, Lip GY, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Rønnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, McDonagh T, Sechtem U, Bonet LA, Avraamides P, Ben Lamin HA, Brignole M, Coca A, Cowburn P, Dargie H, Elliott P, Flachskampf FA, Guida GF, Hardman S, Iung B, Merkely B, Mueller C, Nanas JN, Nielsen OW, Ørn S, Parissis JT, Ponikowski P. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur J Heart Fail 2014; 14:803-69. [PMID: 22828712 DOI: 10.1093/eurjhf/hfs105] [Citation(s) in RCA: 1818] [Impact Index Per Article: 181.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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145
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Sutton R, Ungar A, Sgobino P, Russo V, Massa R, Melissano D, Beiras X, Bottoni N, Ebert HH, Francese M, Jorfida M, Giuli S, Moya A, Andresen D, Brignole M. Cardiac pacing in patients with neurally mediated syncope and documented asystole: effectiveness analysis from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3) Registry. Europace 2014; 16:595-9. [PMID: 24406537 DOI: 10.1093/europace/eut323] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS The randomized, double-blind Third International Study on Syncope of Uncertain Etiology (ISSUE-3) showed that dual-chamber permanent pacing was effective in reducing the recurrence of syncope in patients ≥ 40 years with severe asystolic, probably neurally mediated syncope (NMS), documented by implantable loop recorder (ILR). Analysis in ISSUE-3 was performed according to the intention-to-treat principle. In the present study, we performed an on-treatment analysis, which included additionally those non-randomized patients followed up in the ISSUE registry to evaluate in a better manner the effectiveness of cardiac pacing therapy. METHODS AND RESULTS Initially, 504 patients received an ILR, 162 (32%) patients had a diagnosis consistent with NMS within a mean observation period of 15 ± 11 months: 99 (19%) patients had documentation of syncope with ≥ 3 s asystole or ≥ 6 s asystole without syncope. Sixty patients affected by asystolic NMS received cardiac pacing therapy and 86 (33 asystolic and 53 non-asystolic NMS) were untreated; 16 patients were lost to follow-up. Paced and unpaced groups had similar clinical characteristics. During subsequent follow-up, syncope recurred in 10 paced (17%) and in 40 non-paced (46%) patients. At 21 months, the estimated product-limit syncope recurrence rates were 27% [95% confidence interval (CI) 15-47] and 54% (95% CI 43-67), respectively (P = 0.01). With cardiac pacing, the risk of recurrence was reduced by 57% (hazard ratio = 0.43, 95% CI = 0.2-0.8). Complications of pacemaker therapy were haemothorax at implantation in one patient and lead dislodgement that required correction in two patients. CONCLUSION Permanent cardiac pacing is effective in reducing recurrence of syncope in patients ≥ 40 years with severe asystolic possible NMS with a few complications. The study shows that 61% of patients with a diagnosis of NMS made by ILR received a pacemaker but 5.1 ILRs had to be implanted to find one patient who finally had a pacemaker implanted.
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Affiliation(s)
- Richard Sutton
- Department of Cardiology, St. Mary's Hospital, Imperial College Healthcare NHS Trust, W2 1NY London, UK
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Brignole M, Donateo P, Tomaino M, Massa R, Iori M, Beiras X, Moya A, Kus T, Deharo JC, Giuli S, Gentili A, Sutton R. Benefit of pacemaker therapy in patients with presumed neurally mediated syncope and documented asystole is greater when tilt test is negative: an analysis from the third International Study on Syncope of Uncertain Etiology (ISSUE-3). Circ Arrhythm Electrophysiol 2013; 7:10-6. [PMID: 24336948 DOI: 10.1161/circep.113.001103] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In the Third International Study on Syncope of Uncertain Etiology (ISSUE-3), cardiac pacing was effective in reducing recurrence of syncope in patients with presumed neurally mediated syncope (NMS) and documented asystole but syncope still recurred in 25% of them at 2 years. We have investigated the role of tilt testing (TT) in predicting recurrences. METHODS AND RESULTS In 136 patients enrolled in the ISSUE-3, TT was positive in 76 and negative in 60. An asystolic response predicted a similar asystolic form during implantable loop recorder monitoring, with a positive predictive value of 86%. The corresponding values were 48% in patients with non-asystolic TT and 58% in patients with negative TT (P=0.001 versus asystolic TT). Fifty-two patients (26 TT+ and 26 TT-) with asystolic neurally mediated syncope received a pacemaker. Syncope recurred in 8 TT+ and in 1 TT- patients. At 21 months, the estimated product-limit syncope recurrence rates were 55% and 5%, respectively (P=0.004). The TT+ recurrence rate was similar to that seen in 45 untreated patients (control group), which was 64% (P=0.75). The recurrence rate was similar between 14 patients with asystolic and 12 with non-asystolic responses during TT (P=0.53). CONCLUSIONS Cardiac pacing was effective in neurally mediated syncope patients with documented asystolic episodes in whom TT was negative; conversely, there was insufficient evidence of efficacy from this data set in patients with a positive TT even when spontaneous asystole was documented. Present observations are unexpected and need to be confirmed by other studies. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01463358.
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Botto GL, Capucci A, Raviele A, Boriani G, Brignole M, Calò L, Calvi V, De Ponti R, De Simone A, Delise P, Di Biase M, Lombardi F, Lunati M, Santomauro M, Senni M, Stabile G, Themistoclakis S, Tritto M, Volpe M. [Appropriateness criteria for the treatment of atrial fibrillation with dronedarone: practical issues. An Italian cardiologists' expert opinion]. G Ital Cardiol (Rome) 2013; 14:773-83. [PMID: 24326640 DOI: 10.1714/1360.15090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Antiarrhythmic agents are among the therapeutic options available for the treatment of atrial fibrillation when a rhythm control strategy is required. Although their efficacy seems to be generally comparable to that of nonpharmacological interventions, the use of these agents remains controversial. In particular, among this class of drugs, the use of dronedarone in clinical practice is a matter of debate. In this paper, the authors aimed to address these issues, involving a team of expert cardiologists who discussed about the potential use of dronedarone in different clinical scenarios. The RAND/UCLA appropriateness method was used to develop appropriateness measures for the optimal management of patients treated with dronedarone, by combining the best available scientific evidence with the collective judgment of experts. To this purpose, a group of experts was identified and asked to rate the benefit-to-harm ratio of 52 clinical scenarios. Each indication was classified as "appropriate", "uncertain" or "inappropriate" in accordance with the panelists' median score. The classification of each scenario has led to the development of several recommendations for clinical practice. The use of dronedarone for the management of paroxysmal and persistent atrial fibrillation has evolved over time: this antiarrhythmic drug appears to be useful not only in monitoring symptoms, but also in reducing hospitalization and mortality rates in patients with atrial fibrillation.
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Ungar A, Sgobino P, Russo V, Vitale E, Sutton R, Melissano D, Beiras X, Bottoni N, Ebert HH, Gulizia M, Jorfida M, Moya A, Andresen D, Grovale N, Brignole M. Diagnosis of neurally mediated syncope at initial evaluation and with tilt table testing compared with that revealed by prolonged ECG monitoring. An analysis from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3). Heart 2013; 99:1825-31. [DOI: 10.1136/heartjnl-2013-304399] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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149
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Joulia F, Coulange M, Lemaitre F, Costalat G, Franceschi F, Gariboldi V, Nee L, Fromonot J, Bruzzese L, Gravier G, Kipson N, Jammes Y, Boussuges A, Brignole M, Deharo JC, Guieu R. Plasma adenosine release is associated with bradycardia and transient loss of consciousness during experimental breath-hold diving. Int J Cardiol 2013; 168:e138-41. [DOI: 10.1016/j.ijcard.2013.08.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 08/09/2013] [Accepted: 08/18/2013] [Indexed: 11/28/2022]
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Brignole M. Reply to the letter of Claas P. Naehle, MD 'Necessary clarifications and minor corrections: Letter to the Editor regarding "2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy"'. Europace 2013; 15:1533. [DOI: 10.1093/europace/eut269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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