Geriatric Syncope and Cardiovascular Risk in the Emergency Department

Association of adenylate cyclase activity in vasopressor-type neurally mediated syncope based on the α2b-AR gene

Neurally mediated syncope (NMS) arises from a neural reflex; however, its underlying cause remains unknown. Previous research has shown that variations in the Gi-α signal transduction rate led to changes in adenylate cyclase (AC) activity levels. Thus, we hypothesized that these fluctuations in AC activity could contribute to NMS. This study aimed to investigate the receptor genes associated with glutamate (Glu) repeat polymorphism sites Glu12 and Glu9 in the α2B-AR gene. A total of 50 patients with vasodepressor-type (VT)-NMS and 20 healthy volunteers were included in this study. We assessed AC activity levels and blood pressure responses during the head-up tilt (HUT) test and conducted a Glu repeat polymorphism analysis to explore its potential association with NMS. Our findings showed significantly higher AC activity in patients with the Glu12/12 homotype than healthy volunteers across all four HUT test points. Conversely, patients with the Glu9/12 heterotype exhibited a significant difference only 10 min after the test initiation, suggesting a pronounced activation effect of the β2-AR Gs-α subunit in these individuals. Both genotypes displayed the greatest blood pressure fluctuations under 70° tilt stress, with patients with Glu12/12 showing consistent cardiac load and higher values than those with Glu9/12 at two points. Notably, the frequency of NMS onset within 20 min during the tilt test varied, with one Glu12/12 patient and seven Glu9/12 patients experiencing syncope. Additionally, patients with the Glu9/12 heterotype were found to have a higher risk of syncope after prolonged standing compared to those with the Glu12/12 homotype. These results suggest that patients with the Glu12/12 homotype exhibit elevated AC activity levels, which may help increase blood pressure to prevent syncope. This study underscores that variations in AC activity among different gene types could influence the frequency of NMS onset during standing.

Triggers, Risk Factors, and the Prevalence of Syncope Among Domestic Hajj Pilgrims, 2023: A Cross-Sectional Study

BACKGROUND

Syncope and other transient loss of consciousness episodes in crowded and unfamiliar environments may lead to major health hazards. Despite numerous publications, data on syncope among Hajj pilgrims in Makkah is lacking.

OBJECTIVES

To identify the triggers, risk factors, and prevalence of syncope and other transient loss of consciousness episodes among domestic pilgrims.

METHODOLOGY

This cross-sectional study included a convenient sample of domestic pilgrims who performed Hajj in July 2023 using an online Google Forms questionnaire (Alphabet Inc., Mountain View, CA).

RESULTS

Out of 388 participants, 69 (18.1%) reported a history of syncope during the Hajj pilgrimage. Among these, 57 (82.6%) reported complete loss of consciousness, and 56 (81.2%) noted warning symptoms preceding the episode. The syncopal attack occurred once in 49 respondents (71%). Several triggers for syncope were identified, with sudden standing from a sitting position being the most prevalent (100%). Additional co-triggers were crowding (n=43; 62.3%), stressful conditions (n=30; 43.2%), prolonged standing (n=21; 30.4%), and walking (n=11; 15.9%). Traumatic injuries were reported in 33 (47.8%) as a result of syncope. Standing for long periods of time on the day of Arafat (Arafat standing) emerged as the most common triggering situation (n=48; 69.6%). There were multiple medical factors contributing to syncopal episodes; the most common medical explanations were heat exhaustion (n=48; 69.6%), dehydration (n=24; 34.8%), over-exertion (n=48; 69.6%), low blood sugar (n=10; 14.5%), and low blood pressure (n=17; 24.6%). Significant predictors were the presence of cardiac disease (odd ratio (OR) 7.6, 95% confidence interval (CI) 2.71-21.45, p<0.001), anemia (OR 2.5, 95% CI 1.01-6.09, p=0.049), previous syncope (OR 2.5, 95% CI 1.02-6.27, p=0.049, and family history of syncope (OR 10.1, 95% CI 2.08-49.32, p=0.004).

CONCLUSION

Syncope during the domestic Hajj pilgrimage is frequent, especially on the day of Arafat, and carries the risk of traumatic injury. People with previous episodes of syncope and comorbidities, especially cardiac patients and those who have a family history of syncope, are particularly prone to this risk. Healthcare should focus on at-risk patients, particularly on critical pilgrimage days, and increase pilgrims' awareness about triggers of syncope including sudden and prolonged standing, exertion, and heat exposure.

Role of Biomarkers in the Prediction of Serious Adverse Events after Syncope in Prehospital Assessment: A Multi-Center Observational Study

Syncope is defined as the nontraumatic, transient loss of awareness of rapid onset, short duration and with complete spontaneous recovery, and accounts for 1%–3% of all visits to the emergency department. The objective of this study was to evaluate the predictive capacity of the National Early Warning Score 2 (NEWS2) and prehospital lactate (pLA), individually and combined, at the prehospital level to detect patients with syncope at risk of early mortality (within 48 h) in the hospital environment. A prospective, multicenter cohort study without intervention was carried out on syncope patients aged over 18 who were given advanced life support and taken to the hospital. Our study included a total of 361 cases. Early mortality affected 21 patients (5.8%). The combined score formed by the NEWS2 and the pLA (NEWS2-L) obtained an AUC of 0.948 (95% CI: 0.88–1) and an odds ratio of 86.25 (95% CI: 11.36–645.57), which is significantly higher than that obtained by the NEWS2 or pLA in isolation (p = 0.018). The NEWS2-L can help stratify the risk in patients with syncope treated in the prehospital setting, with only the standard measurement of physiological parameters and pLA.

Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study

BACKGROUND

Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope.

METHODS

We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs.

RESULTS

The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18).

CONCLUSIONS

In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes.