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Koechlin L, Strebel I, Zimmermann T, Nestelberger T, Walter J, Lopez-Ayala P, Boeddinghaus J, Shrestha S, Arslani K, Stefanelli S, Reuthebuch B, Wussler D, Ratmann PD, Christ M, Badertscher P, Wildi K, Giménez MR, Gualandro DM, Miró Ò, Fuenzalida C, Martin-Sanchez FJ, Kawecki D, Bürgler F, Keller DI, Abächerli R, Reuthebuch O, Eckstein FS, Twerenbold R, Reichlin T, Mueller C. Hyperacute T Wave in the Early Diagnosis of Acute Myocardial Infarction. Ann Emerg Med 2023; 82:194-202. [PMID: 36774205 DOI: 10.1016/j.annemergmed.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/24/2021] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 02/12/2023]
Abstract
STUDY OBJECTIVE The diagnostic performance of T-wave amplitudes for the detection of myocardial infarction is largely unknown. We aimed to address this knowledge gap. METHODS T-wave amplitudes were automatically measured in 12-lead ECGs of patients presenting with acute chest discomfort to the emergency department within a prospective diagnostic multicenter study. The final diagnosis was centrally adjudicated by 2 independent cardiologists. Patients with left ventricular hypertrophy, complete left bundle branch block, or paced ventricular depolarization were excluded. The performance for lead-specific 95th-percentile thresholds were reported as likelihood ratios (lr), specificity, and sensitivity. RESULTS Myocardial infarction was the final diagnosis in 445 (18%) of 2457 patients. In most leads, T-wave amplitudes tended to be greater in patients without myocardial infarction than those with myocardial infarction, and T-wave amplitude exceeding the 95th percentile had positive and negative lr close to 1 or with confidence intervals (CIs) crossing 1. The exceptions were leads III, aVR, and V1, which had positive lrs of 3.8 (95% CI, 2.7 to 5.3), 4.3 (95% CI, 3.1 to 6.0) and 2.0 (95% CI, 1.4 to 2.9), respectively. These leads normally have inverted T waves, so T-wave amplitude exceeding the 95th percentile reflects upright rather than increased-amplitude hyperacute T waves. CONCLUSION Hyperacute T waves, when defined as increased T-wave amplitude exceeding the 95th percentile, did not provide useful information in diagnosing myocardial infarction in this sample.
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Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Ketina Arslani
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Sabrina Stefanelli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Benedikt Reuthebuch
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Division of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Paul David Ratmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Division of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Michael Christ
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Emergency Department, Kantonsspital Luzern, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Cardiology, Medical University of South Carolina, Charleston, United States
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Critical Care Research Group, the Prince Charles Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Cardiology Department, Herzzentrum Leipzig, Germany
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Òscar Miró
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carolina Fuenzalida
- GREAT network; Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network; 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Poland
| | - Franz Bürgler
- Emergency Department, Kantonsspital Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Roger Abächerli
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; Institute of Medical Engineering, Lucerne University of Applied Sciences and Arts, Horw, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network; Department of Cardiology, Inselspital, University Hospital Bern, University of Bern, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University Hospital Basel, University of Basel, Switzerland; GREAT network.
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2
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Boeddinghaus J, Nestelberger T, Koechlin L, Lopez-Ayala P, Wussler D, Mais M, Zwimpfer L, Zimmermann T, Wildi K, Rubini Giménez M, Strebel I, Miró Ò, Martin-Sanchez FJ, Parenica J, Keller DI, Gualandro DM, Nickel CH, Bingisser R, Christ M, Mueller C, Twerenbold R, Puelacher C, Glarner N, Okamura B, Sanchez AY, de Lavallaz JDF, Potlukova E, Freese M, Rentsch K, Buser A, López B, Martinez-Nadal G, Adrada ER, von Eckardstein A, Morawiec B, Kawecki D, Muzyk P, Bürgler F, Geigy N. Association of accompanying dyspnea with diagnosis and outcome of patients presenting with acute chest discomfort. Eur Heart J Acute Cardiovasc Care 2023; 12:283-295. [PMID: 36917461 DOI: 10.1093/ehjacc/zuad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/27/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023]
Abstract
AIM The presence of accompanying dyspnea is routinely assessed and common in patients presenting with acute chest pain/discomfort to the emergency department (ED). We aimed to assess the association of accompanying dyspnea with differential diagnoses, diagnostic work-up and outcome. METHODS We enrolled patients presenting to the ED with chest pain/discomfort. Final diagnoses were adjudicated by independent cardiologists using all information including cardiac imaging. The primary diagnostic endpoint was the final diagnosis. The secondary diagnostic endpoint was the performance of high-sensitivity cardiac troponin (hs-cTn) and the European Society of Cardiology (ESC) 0/1h-algorithms for the diagnosis of myocardial infarction (MI). The prognostic endpoints were cardiovascular and all-cause mortality at two years. RESULTS Among 6045 patients, 2892/6045 (48%) had accompanying dyspnea. The prevalence of ACS in patients with versus without dyspnea was comparable (MI 22.4% vs. 21.9%, p = 0.60, unstable angina 8.7% vs. 7.9%, p = 0.29). In contrast, patients with dyspnea more often had cardiac, non-coronary disease (15.3% vs. 10.2%, p < 0.001). Diagnostic accuracy of hs-cTnT/I concentrations was not affected by the presence of dyspnea (area under the curve 0.89-0.91 in both groups) and the safety of the ESC 0/1h-algorithms was maintained with negative predictive values >99.4%. Accompanying dyspnea was an independent predictor for cardiovascular and all-cause death at two years (Hazard Ratio [HR] 1.813 [95%CI, 1.453-2.261, p < 0.01]). CONCLUSION Accompanying dyspnea was not associated with a higher prevalence of ACS but with cardiac, non-coronary disease. While the safety of the diagnostic work-up was not affected, accompanying dyspnea was an independent predictor for cardiovascular and all-cause death.
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Affiliation(s)
- Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,BHF Centre for Cardiovascular Science, University of Edinburgh, Scotland, United Kingdom
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Cardiac Surgery, University Hospital Basel, University of Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Maximilian Mais
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Luca Zwimpfer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Critical Care Research Group, the Prince Charles Hospital, Brisbane and the University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy.,Leipzig Heart Center, Leipzig, Germany
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
| | - Òscar Miró
- GREAT network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- GREAT network, Rome, Italy.,Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - Jiri Parenica
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Switzerland
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland.,GREAT network, Rome, Italy
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3
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Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, Lopez-Ayala P, Badertscher P, Widmer V, Shrestha S, Strebel I, Glarner N, Diebold M, Miró Ò, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Bilici M, Costabel JP, Kühne M, Breidthardt T, Thiruganasambandamoorthy V, Mueller C, Belkin M, Leu K, Lohrmann J, Boeddinghaus J, Twerenbold R, Koechlin L, Walter JE, Amrein M, Wussler D, Freese M, Puelacher C, Kawecki D, Morawiec B, Salgado E, Martinez-Nadal G, Inostroza CIF, Mandrión JB, Poepping I, Rentsch K, von Eckardstein A, Buser A, Greenslade J, Reichlin T, Bürgler F. International Validation of the Canadian Syncope Risk Score : A Cohort Study. Ann Intern Med 2022; 175:783-794. [PMID: 35467933 DOI: 10.7326/m21-2313] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes not evident during emergency department (ED) evaluation. OBJECTIVE To externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score. DESIGN Prospective cohort study. SETTING Large, international, multicenter study recruiting patients in EDs in 8 countries on 3 continents. PARTICIPANTS Patients with syncope aged 40 years or older presenting to the ED within 12 hours of syncope. MEASUREMENTS Composite outcome of serious clinical plus procedural events (primary outcome) and the primary composite outcome excluding procedural interventions (secondary outcome). RESULTS Among 2283 patients with a mean age of 68 years, the primary composite outcome occurred in 7.2%, and the composite outcome excluding procedural interventions occurred in 3.1% at 30 days. Prognostic performance of the CSRS was good for both 30-day composite outcomes and better compared with the OESIL score (area under the receiver-operating characteristic curve [AUC], 0.85 [95% CI, 0.83 to 0.88] vs. 0.74 [CI, 0.71 to 0.78] and 0.80 [CI, 0.75 to 0.84] vs. 0.69 [CI, 0.64 to 0.75], respectively). Safety of triage, as measured by the frequency of the primary composite outcome in the low-risk group, was higher using the CSRS (19 of 1388 [0.6%]) versus the OESIL score (17 of 1104 [1.5%]). A simplified model including only the clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) variable at ED discharge-a component of the CSRS-achieved similar discrimination as the CSRS (AUC, 0.83 [CI, 0.80 to 0.87] for the primary composite outcome). LIMITATION Unable to disentangle the influence of other CSRS components on clinician classification of syncope at ED discharge. CONCLUSION This international external validation of the CSRS showed good performance in identifying patients at low risk for serious outcomes outside of Canada and superior performance compared with the OESIL score. However, clinician classification of syncope at ED discharge seems to explain much of the performance of the CSRS in this study. The clinical utility of the CSRS remains uncertain. PRIMARY FUNDING SOURCE Swiss National Science Foundation & Swiss Heart Foundation.
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Affiliation(s)
- Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.Z.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.N.)
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil (D.M.G.)
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Velina Widmer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Matthias Diebold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Òscar Miró
- GREAT Network, Rome, Italy, and Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | - Michael Christ
- GREAT Network, Rome, Italy, and Kantonsspital Luzern, Luzern, Switzerland (M.C.)
| | - Louise Cullen
- GREAT Network, Rome, Italy, and Royal Brisbane & Women's Hospital, Herston, Australia (L.C.)
| | - Martin Than
- GREAT Network, Rome, Italy, and Christchurch Hospital, Christchurch, New Zealand (M.T.)
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy, and Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.)
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy, and Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Italy (S.D.S.)
| | - W Frank Peacock
- GREAT Network, Rome, Italy, and Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas (W.F.P.)
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Zürich, Switzerland (D.I.K.)
| | - Murat Bilici
- Department of Orthopedics and Traumatology, University Hospital Basel, University of Basel, Basel, Switzerland (M.B.)
| | | | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.B.)
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
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4
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Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, Strebel I, Badertscher P, Lopez-Ayala P, Widmer V, Freese M, Miró Ò, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Boeddinghaus J, Twerenbold R, Wussler D, Koechlin L, Walter JE, Bürgler F, Geigy N, Kühne M, Reichlin T, Lohrmann J, Mueller C. Incidence, characteristics, determinants, and prognostic impact of recurrent syncope. Europace 2020; 22:1885-1895. [PMID: 33038231 DOI: 10.1093/europace/euaa227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 04/02/2020] [Accepted: 07/17/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS The aim of this study is to characterize recurrent syncope, including sex-specific aspects, and its impact on death and major adverse cardiovascular events (MACE). METHODS AND RESULTS We characterized recurrent syncope in a large international multicentre study, enrolling patients ≥40 years presenting to the emergency department (ED) with a syncopal event within the last 12 h. Syncope aetiology was centrally adjudicated by two independent cardiologists using all information becoming available during syncope work-up and long-term follow-up. Overall, 1790 patients were eligible for this analysis. Incidence of recurrent syncope was 20% [95% confidence interval (CI) 18-22%] within the first 24 months. Patients with an adjudicated final diagnosis of cardiac syncope (hazard ratio (HR) 1.50, 95% CI 1.11-2.01) or syncope with an unknown aetiology even after central adjudication (HR 2.11, 95% CI 1.54-2.89) had an increased risk for syncope recurrence. Least Absolute Shrinkage and Selection Operator regression fit on all patient information available early in the ED identified >3 previous episodes of syncope as the only independent predictor for recurrent syncope (HR 2.13, 95% CI 1.64-2.75). Recurrent syncope carried an increased risk for death (HR 1.87, 95% CI 1.26-2.77) and MACE (HR 2.69, 95% CI 2.02-3.59) over 24 months of follow-up, however, with a time-dependent effect. These findings were confirmed in a sensitivity analysis excluding patients with syncope recurrence or MACE before or during ED evaluation. CONCLUSION Recurrence rates of syncope are substantial and vary depending on syncope aetiology. Importantly, recurrent syncope carries a time-dependent increased risk for death and MACE. TRIAL REGISTRATION BAsel Syncope EvaLuation (BASEL IX, ClinicalTrials.gov registry number NCT01548352).
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Affiliation(s)
- Tobias Zimmermann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Danielle M Gualandro
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Patrick Badertscher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiology, University of Illinois at Chicago, Chicago, IL, USA
| | - Pedro Lopez-Ayala
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Velina Widmer
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Michael Freese
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Òscar Miró
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Michael Christ
- GREAT Network, Rome, Italy.,Emergency Department, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Louise Cullen
- GREAT Network, Rome, Italy.,Emergency & Trauma Centre, Royal Brisbane & Women's Hospital, Herston, Australia
| | - Martin Than
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, Hospital Clínico San Carlos, Madrid, Spain
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy.,Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Roma, Italy
| | - W Frank Peacock
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, Houston, Baylor College of Medicine, TX, USA
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Zürich, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Desiree Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joan E Walter
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Franz Bürgler
- Emergency Department, Kantonsspital Liestal, Liestal, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Liestal, Switzerland
| | - Michael Kühne
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Tobias Reichlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jens Lohrmann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
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Boeddinghaus J, Nestelberger T, Koechlin L, Wussler D, Lopez-Ayala P, Walter JE, Troester V, Ratmann PD, Seidel F, Zimmermann T, Badertscher P, Wildi K, Rubini Giménez M, Potlukova E, Strebel I, Freese M, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller DI, Gualandro DM, Christ M, Twerenbold R, Mueller C, Meier M, Puelacher C, du Fay de Lavallaz J, Kozhuharov N, Rentsch K, Stelzig C, Meissner K, Kulangara C, Hillinger P, Michou E, Flores D, Reichlin T, López B, Fuenzalida C, Adrada ER, Ganovská E, Lohrmann J, Huber J, Steude J, Buser A, von Eckardstein A, Morawiec B, Nowalany-Kozielska E, Muzyk P, Bürgler F, Geigy N. Early Diagnosis of Myocardial Infarction With Point-of-Care High-Sensitivity Cardiac Troponin I. J Am Coll Cardiol 2020; 75:1111-1124. [DOI: 10.1016/j.jacc.2019.12.065] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 10/24/2022]
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