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Wang S, Peng Y, Wang Y, Li F, Xu Y, Zheng H, Yuan H, Hu C, Liao D, Cai H, Zhang J, Li W, Ding Y, Zhang W, Xue X, Liu X, Zhu L, Liu D, Kang M, Liu L, Chu W, Li X, Luo X, Zou R, Wang C. Relationship between syncopal symptoms and head-up tilt test modes. Cardiol Young 2024:1-6. [PMID: 38577783 DOI: 10.1017/s1047951124000726] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
OBJECTIVE Head-up tilt test (HUTT) is an important tool in the diagnosis of pediatric vasovagal syncope. This research will explore the relationship between syncopal symptoms and HUTT modes in pediatric vasovagal syncope. METHODS A retrospective analysis was performed on the clinical data of 2513 children aged 3-18 years, who were diagnosed with vasovagal syncope, from Jan. 2001 to Dec. 2021 due to unexplained syncope or pre-syncope. The average age was 11.76 ± 2.83 years, including 1124 males and 1389 females. The patients were divided into the basic head-up tilt test (BHUT) group (596 patients) and the sublingual nitroglycerine head-up tilt test (SNHUT) group (1917 patients) according to the mode of positive HUTT at the time of confirmed pediatric vasovagal syncope. RESULTS (1) Baseline characteristics: Age, height, weight, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and composition ratio of syncope at baseline status were higher in the BHUT group than in the SNHUT group (all P < 0.05). (2) Univariate analysis: Age, height, weight, HR, SBP, DBP, and syncope were potential risk factors for BHUT positive (all P < 0.05). (3) Multivariate analysis: syncope was an independent risk factor for BHUT positive, with a probability increase of 121% compared to pre-syncope (P<0.001). CONCLUSION The probability of BHUT positivity was significantly higher than SNHUT in pediatric vasovagal syncope with previous syncopal episodes.
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Affiliation(s)
- Shuo Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yali Peng
- Section of Science and Education, The First People's Hospital of Changde City, Changde, China
| | - Yuwen Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fang Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi Xu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Huifen Zheng
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Shenzhen People's Hospital, Shenzhen, China
| | - Heli Yuan
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Chunyan Hu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, The Second Affiliated Hospital, University of South China, Hengyang, China
| | - Donglei Liao
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hong Cai
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Juan Zhang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wen Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yiyi Ding
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, The First People's Hospital of Changde City, Changde, China
| | - Wenhua Zhang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, The Third Hospital of Changsha, Changsha, China
| | - Xiaohong Xue
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Hunan Want Want Hospital, Changsha, China
| | - Xiaoyan Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Changsha Central Hospital, University of South China, Changsha, China
| | - Liping Zhu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Neonatology, Changsha Central Hospital, University of South China, Changsha, China
| | - Deyu Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Hunan Lixian People's Hospital, Changde, China
| | - Meihua Kang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Weijia Pediatric Hospital, Changsha, China
| | - Liping Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatric Cardiology, Hunan People's Hospital/First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Weihong Chu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Xiaoming Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Jieyang People's Hospital, Jieyang, China
| | - Xuemei Luo
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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Pachon-M JC, Pachon-M EI, Pachon CTC, Santillana-P TG, Lobo TJ, Pachon-M JC, Higuti C, Zerpa-A JC, Pachon MZC, Ortencio FA, Osorio TG, Peixoto LA. Long-term outcomes of cardioneuroablation with and without extra-cardiac vagal stimulation confirmation in severe cardioinhibitory neurocardiogenic syncope. J Cardiovasc Electrophysiol 2024; 35:641-650. [PMID: 38240356 DOI: 10.1111/jce.16188] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Cardioneuroablation (CNA) is a novel therapeutic approach for functional bradyarrhythmias, specifically neurocardiogenic syncope or atrial fibrillation, achieved through endocardial radiofrequency catheter ablation of vagal innervation, obviating the need for pacemaker implantation. Originating in the nineties, the first series of CNA procedures was published in 2005. Extra-cardiac vagal stimulation (ECVS) is employed as a direct method for stepwise denervation control during CNA. OBJECTIVE This study aimed to compare the long-term follow-up outcomes of patients with severe cardioinhibitory syncope undergoing CNA with and without denervation confirmation via ECVS. METHOD A cohort of 48 patients, predominantly female (56.3%), suffering from recurrent syncope (5.1 ± 2.5 episodes annually) that remained unresponsive to clinical and pharmacological interventions, underwent CNA, divided into two groups: ECVS and NoECVS, consisting of 34 and 14 cases, respectively. ECVS procedures were conducted with and without atrial pacing. RESULTS Demographic characteristics, left atrial size, and ejection fraction displayed no statistically significant differences between the groups. Follow-up duration was comparable, with 29.1 ± 15 months for the ECVS group and 31.9 ± 20 months for the NoECVS group (p = .24). Notably, syncope recurrence was significantly lower in the ECVS group (two cases vs. four cases, Log Rank p = .04). Moreover, the Hazard ratio revealed a fivefold higher risk of syncope recurrence in the NoECVS group. CONCLUSION This study demonstrates that concluding CNA with denervation confirmation via ECVS yields a higher success rate and a substantially reduced risk of syncope recurrence compared to procedures without ECVS confirmation.
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Affiliation(s)
- Jose Carlos Pachon-M
- Sao Paulo University, Sao Paulo, Brazil
- Sao Paulo Heart Hospital, Sao Paulo, Brazil
| | - Enrique I Pachon-M
- Sao Paulo University, Sao Paulo, Brazil
- Sao Paulo Heart Hospital, Sao Paulo, Brazil
| | | | | | | | - Juan C Pachon-M
- Sao Paulo University, Sao Paulo, Brazil
- Sao Paulo Heart Hospital, Sao Paulo, Brazil
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Kautzner J. Do we have a clear end-point for cardioneuroablation? J Cardiovasc Electrophysiol 2024; 35:651-653. [PMID: 38556798 DOI: 10.1111/jce.16265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/17/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Karliński MA, Grabowski M, Kempa M, Farkowski MM, Sławek J, Rejdak K, Mitkowski P, Hryniewiecki T, Słowik A. Expert opinion of the Heart Rhythm Association of the Polish Cardiac Society and the Polish Neurological Society on evidence-driven implementation of implantable loop recorders in Poland. Kardiol Pol 2024; 82:353-359. [PMID: 38493471 DOI: 10.33963/v.phj.99401] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/28/2024] [Indexed: 03/19/2024]
Abstract
Implantable loop recorders (ILR) are considered increasingly helpful in diagnosing cardio-neurological conditions, especially if arrhythmic events are of high clinical importance but are unlikely to be captured by standard methods of electrocardiogram recording due to the low frequency of events and short duration of a single event. The compelling evidence from randomized trials and observational studies strongly supports ILR utilization in patients after cryptogenic stroke or transient ischemic attack and in patients with recurrent transient loss of consciousness of unknown origin. These two groups of patients are expected to gain the most from initiating ILR-driven clinically effective management strategies. Stroke or transient ischemic attack survivors with detected subclinical atrial fibrillation can be switched from antiplatelets to anticoagulants, whilst patients with recurrent syncope may avoid severe injuries and/or substantial impairment of their quality of life. This joint opinion of the Heart Rhythm Association of the Polish Cardiac Society and experts from the Polish Neurological Society summarizes the up-to-date rationale for using ILR in everyday clinical practice and describes the road map for implementing this technology in Poland. Special emphasis is placed on the most recent guidelines issued by both cardiological and neurological scientific societies.
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Affiliation(s)
- Michał A Karliński
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warszawa, Poland.
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Maciej Kempa
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdansk, Gdańsk, Poland
| | - Michał M Farkowski
- Department of Cardiology, Ministry of Interior and Administration National Medical Institute, Warszawa, Poland
| | - Jarosław Sławek
- Department of Neurological-Psychiatric Nursing, Faculty of Health Sciences, Medical University of Gdansk and Neurology Stroke Department, St. Adalbert Hospital, Gdańsk, Poland
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Przemysław Mitkowski
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Tomasz Hryniewiecki
- Department of Valvular Heart Disease, National Institute of Cardiology, Warszawa, Poland
| | - Agnieszka Słowik
- Department of Neurology, Jagiellonian University, Kraków, Poland
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Wu S, Chen Z, Gao Y, Shu S, Chen F, Wu Y, Dai Y, Zhang S, Chen K. Development and Validation of a Novel Predictive Model for the Early Differentiation of Cardiac and Non-Cardiac Syncope. Int J Gen Med 2024; 17:841-853. [PMID: 38463438 PMCID: PMC10924787 DOI: 10.2147/ijgm.s454521] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/26/2024] [Indexed: 03/12/2024] Open
Abstract
Background The diagnosis of cardiac syncope remains a challenge. This study sought to develop and validate a diagnostic model for the early identification of individuals likely to have a cardiac cause. Methods 877 syncope patients with a determined cause were retrospectively enrolled at a tertiary heart center. They were randomly divided into the training set and validation set at a 7:3 ratio. We analyzed the demographic information, medical history, laboratory tests, electrocardiogram, and echocardiogram by the least absolute shrinkage and selection operator (LASSO) regression for selection of key features. Then a multivariable logistic regression analysis was performed to identify independent predictors and construct a diagnostic model. The receiver operating characteristic curves, area under the curve (AUC), calibration curves, and decision curve analysis were used to evaluate the predictive accuracy and clinical value of this nomogram. Results Five independent predictors for cardiac syncope were selected: BMI (OR 1.088; 95% CI 1.022-1.158; P =0.008), chest symptoms preceding syncope (OR 5.251; 95% CI 3.326-8.288; P <0.001), logarithmic NT-proBNP (OR 1.463; 95% CI 1.240-1.727; P <0.001), left ventricular ejection fraction (OR 0.940; 95% CI 0.908-0.973; P <0.001), and abnormal electrocardiogram (OR 6.171; 95% CI 3.966-9.600; P <0.001). Subsequently, a nomogram based on a multivariate logistic regression model was developed and validated, yielding AUC of 0.873 (95% CI 0.845-0.902) and 0.856 (95% CI 0.809-0.903), respectively. The calibration curves showcased the nomogram's reasonable calibration, and the decision curve analysis demonstrated good clinical utility. Conclusion A diagnostic tool providing individualized probability predictions for cardiac syncope was developed and validated, which may potentially serve as an effective tool to facilitate early identification of such patients.
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Affiliation(s)
- Sijin Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Zhongli Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Gao
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Songren Shu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Feng Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Ying Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Dai
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Shu Zhang
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Keping Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Poon D, Muthukumar B, Pang YL. Assessing postural hypotension in a UK District General Hospital. J R Coll Physicians Edinb 2024; 54:106-107. [PMID: 38456284 DOI: 10.1177/14782715241238785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Affiliation(s)
- Dennis Poon
- King's Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, UK
| | | | - Yik Lam Pang
- King's Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, UK
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van Zanten S, Sutton R, Hamrefors V, Fedorowski A, de Lange FJ. Tilt table testing, methodology and practical insights for the clinic. Clin Physiol Funct Imaging 2024; 44:119-130. [PMID: 37839043 DOI: 10.1111/cpf.12859] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value.
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Affiliation(s)
- Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Kamel I, Dietzius H, Magee T, Esteghamati S. A Case of Rapidly Growing Tricuspid Valve Papillary Fibroelastoma Presenting With Syncope. Cureus 2024; 16:e55510. [PMID: 38444927 PMCID: PMC10912823 DOI: 10.7759/cureus.55510] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2024] [Indexed: 03/07/2024] Open
Abstract
Cardio-oncology, at the intersection of cardiovascular diseases, oncological conditions, and treatments, presents unique challenges in medical care. This abstract highlights a case involving a 60-year-old male presenting with syncope at work; the workup revealed a rapidly growing tricuspid valve papillary fibroelastoma (PFE), emphasizing diagnostic approaches, management strategies, and clinical implications. The diagnostic investigation, including blood cultures, transthoracic echocardiogram, transesophageal echocardiogram, and cardiac MRI, confirmed the diagnosis of tricuspid valve PFE. A multidisciplinary approach led to a shared decision with the patient to opt for serial monitoring. Syncope was attributed to dehydration. This case underscores the complexities of managing cardiovascular conditions in the context of oncology and the importance of collaborative decision-making in patient care.
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Affiliation(s)
- Ibrahim Kamel
- Internal Medicine, Tufts Medical Center, Boston, USA
- Internal Medicine, Steward Carney Hospital, Dorchester, USA
| | | | - Toni Magee
- Cardiology, Steward Carney Hospital, Dorchester, USA
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Covino S, Russo V. False-positive alarms in patients with implantable loop recorder followed by remote monitoring: A systematic review. Pacing Clin Electrophysiol 2024; 47:406-416. [PMID: 38341627 DOI: 10.1111/pace.14941] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/15/2023] [Accepted: 01/23/2024] [Indexed: 02/12/2024]
Abstract
Remote Monitoring (RM) has been shown to provide useful information about arrhythmic events in patients with implantable loop recorders (ILRs), however there is few and conflicting data about the false positive (FP) alarms burden and characteristics among ILR recipients. The aim of the present systematic review was to evaluate incidence and characteristics of FP alarms among ILR patients followed by RM. We developed a systematic research in Embase, MEDLINE and PubMed databases and selected all papers focused on false positive ILR transmissions published from June 1, 2013 to June 1, 2023. Case reports, meeting summaries, posters and simple reviews were excluded. Twelve reports were finally selected, including five prospective and seven retrospective studies. Information about population characteristics, device type and setting, overall transmissions and FP alarms and any adopted strategies to reduce them were extracted from an overall population of 3.305 patients. FP alarms were 59.7% of the overall remote transmissions and were found in 1/5 of the analyzed population. FP alarms for atrial fibrillation were the most common cause of false transmissions and were mainly due to premature atrial and ventricular complexes. No clinical predictors of FP alarms were identified, except for nonparasternal ILR implantation site. Since the overload work due to FP alarms might reduce the benefit of remote monitoring of ILR patients, the device optimization is an important step until an help from machine-learning algorithms is available.
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Affiliation(s)
- Simona Covino
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
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Bjelic M, Goldenberg I, Younis A, Chen AY, Huang DT, Yoruk A, Aktas MK, Rosero S, Cutter K, McNitt S, Sotoodehnia N, Kudenchuk PJ, Rea TD, Arking DE, Zareba W, Ackerman MJ, Goldenberg I. Risk Prediction in Male Adolescents With Congenital Long QT Syndrome: Implications for Sex-Specific Risk Stratification in Potassium Channel-Mediated Long QT Syndrome. J Am Heart Assoc 2024; 13:e028902. [PMID: 38240206 DOI: 10.1161/jaha.122.028902] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 07/06/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Sex-specific risk management may improve outcomes in congenital long QT syndrome (LQTS). We recently developed a prediction score for cardiac events (CEs) and life-threatening events (LTEs) in postadolescent women with LQTS. In the present study, we aimed to develop personalized risk estimates for the burden of CEs and LTEs in male adolescents with potassium channel-mediated LQTS. METHODS AND RESULTS The prognostic model was derived from the LQTS Registry headquartered in Rochester, NY, comprising 611 LQT1 or LQT2 male adolescents from age 10 through 20 years, using the following variables: genotype/mutation location, QTc-specific thresholds, history of syncope, and β-blocker therapy. Anderson-Gill modeling was performed for the end point of CE burden (total number of syncope, aborted cardiac arrest, and appropriate defibrillator shocks). The applicability of the CE prediction model was tested for the end point of the first LTE (excluding syncope and adding sudden cardiac death) using Cox modeling. A total of 270 CEs occurred during follow-up. The genotype-phenotype risk prediction model identified low-, intermediate-, and high-risk groups, comprising 74%, 14%, and 12% of the study population, respectively. Compared with the low-risk group, high-risk male subjects experienced a pronounced 5.2-fold increased risk of recurrent CEs (P<0.001), whereas intermediate-risk patients had a 2.1-fold (P=0.004) increased risk . At age 20 years, the low-, intermediate-, and high-risk adolescent male patients had on average 0.3, 0.6, and 1.4 CEs per person, respectively. Corresponding 10-year adjusted probabilities for a first LTE were 2%, 6%, and 8%. CONCLUSIONS Personalized genotype-phenotype risk estimates can be used to guide sex-specific management in male adolescents with potassium channel-mediated LQTS.
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Affiliation(s)
- Milica Bjelic
- Clinical Cardiovascular Research Center, Division of Cardiology University of Rochester Medical Center Rochester NY USA
- Department of Anesthesiology St. Elizabeth's Medical Center Boston University School of Medicine Boston MA USA
| | - Ido Goldenberg
- Clinical Cardiovascular Research Center, Division of Cardiology University of Rochester Medical Center Rochester NY USA
- Department of Medicine, Rochester Regional Health Rochester NY USA
| | - Arwa Younis
- Clinical Cardiovascular Research Center, Division of Cardiology University of Rochester Medical Center Rochester NY USA
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland OH USA
| | - Anita Y Chen
- Department of Biostatistics and Computational Biology University of Rochester Medical Center Rochester NY USA
| | - David T Huang
- Department of Medicine, Division of Cardiology University of Rochester Medical Center Rochester NY USA
| | - Ayhan Yoruk
- Division of Cardiology The University of California, San Francisco Medical Center San Francisco CA USA
| | - Mehmet K Aktas
- Department of Medicine, Division of Cardiology University of Rochester Medical Center Rochester NY USA
| | - Spencer Rosero
- Department of Medicine, Division of Cardiology University of Rochester Medical Center Rochester NY USA
| | - Kristina Cutter
- Clinical Cardiovascular Research Center, Division of Cardiology University of Rochester Medical Center Rochester NY USA
| | - Scott McNitt
- Clinical Cardiovascular Research Center, Division of Cardiology University of Rochester Medical Center Rochester NY USA
| | - Nona Sotoodehnia
- Department of Medicine, Division of Cardiology University of Washington Seattle WA USA
| | | | - Thomas D Rea
- Department of Medicine University of Washington Seattle WA USA
| | - Dan E Arking
- The McKusick-Nathans Institute, Department of Genetic Medicine John Hopkins University School of Medicine Baltimore MD USA
| | - Wojciech Zareba
- Clinical Cardiovascular Research Center, Division of Cardiology University of Rochester Medical Center Rochester NY USA
| | - Michael J Ackerman
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics Laboratory Mayo Clinic Rochester MN USA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center, Division of Cardiology University of Rochester Medical Center Rochester NY USA
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Acehan F, Karsavuranoğlu B, Kalkan C, Aslan M, Altiparmak E, Ates I. Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding. J Emerg Med 2024; 66:64-73. [PMID: 38267298 DOI: 10.1016/j.jemermed.2023.08.016] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/31/2023] [Accepted: 08/31/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention. OBJECTIVE The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department. METHODS Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis. RESULTS Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103). CONCLUSIONS Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.
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Affiliation(s)
- Fatih Acehan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey.
| | | | - Cagdas Kalkan
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Meryem Aslan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Emin Altiparmak
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
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12
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Jansen S, van der Velde N. Syncope in older adults: challenges, approach and treatment. Age Ageing 2024; 53:afad245. [PMID: 38331395 DOI: 10.1093/ageing/afad245] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Indexed: 02/10/2024] Open
Abstract
Syncope can have devastating consequences, resulting in injuries, accidents or even death. In our ageing society, the subsequent healthcare usage, such as emergency room presentations, surgeries and hospital admissions, forms a significant and growing socioeconomic burden. Causes of syncope in the older adult include orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, structural cardiac abnormalities, cardiac arrhythmias and conduction abnormalities. As stated in the recently published World Falls Guidelines, syncope in older adults often presents as falls, which is either due to amnesia for loss of consciousness, or pre-syncope leading to a fall, especially in those prone to falls with several other risk-factors for falls present. This difference in presentation can hinder the recognition of syncope. In patients with unexplained falls, or in whom the history comprises red flags for potential syncope, special attention to (pre)syncope is therefore warranted. When syncope is mistaken for other causes of a transient loss of consciousness, such as epileptic seizures, or when syncope presents as falls, patients are often referred to multiple specialists, which may in turn lead to excessive and unnecessary diagnostic testing and costs. Specialist services that are able to provide a comprehensive assessment can improve diagnostic yield and minimise diagnostic testing, thus improving patient satisfaction. Comprehensive assessment also leads to reduced length of hospital stay. Increasingly, geriatricians are involved in the assessment of syncope in the older patient, especially given the overlap with falls. Therefore, awareness of causes of syncope, as well as state-of-the-art assessment and treatment, is of great importance.
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Affiliation(s)
- Sofie Jansen
- Internal Medicine, Section of Geriatric Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Internal Medicine, Section of Geriatric Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
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13
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Yang G, Lei Y, Xin M, Xu W, Zhao G, Jin X, Piao M, Li X, Cheng XW. Recurrent syncope driven by unique-variant angina pectoris. Clin Case Rep 2024; 12:e8460. [PMID: 38314185 PMCID: PMC10834378 DOI: 10.1002/ccr3.8460] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/23/2023] [Accepted: 01/13/2024] [Indexed: 02/06/2024] Open
Abstract
The patient's vasospastic variant angina manifested as syncope with asymptomatic ischemic episodes, and repeated 24-h dynamic electrocardiogram and coronary angiography examinations combined with coronary provocation spasm tests were necessary for its diagnosis and management.
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Affiliation(s)
- Guang Yang
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
| | - Yanna Lei
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
| | - Minglong Xin
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
| | - Wenhu Xu
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
| | - Guangxian Zhao
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
| | - Xueying Jin
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
| | - Meina Piao
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
| | - Xiang Li
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
| | - Xian Wu Cheng
- Department of Cardiology and Hypertension, Jilin Provincial Key Laboratory of Stress and Cardiovascular DiseaseYanbian University HospitalYanjiJilinChina
- Key Laboratory of Natural Medicines of the Changbai Mountain, Ministry of EducationYanbian UniversityYanjiJilinChina
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14
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Habecker BA. Identifying vagal sensory neurons driving the Bezold-Jarisch reflex. Trends Neurosci 2024; 47:90-91. [PMID: 38030510 PMCID: PMC10922441 DOI: 10.1016/j.tins.2023.11.007] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023]
Abstract
Homeostatic reflexes are crucial for life, but the subpopulations of sensory neurons that stimulate these reflexes are largely unknown. A recent paper from Lovelace, Ma, and colleagues identified a population of sensory neurons in the cardiac ventricle that underlies the Bezold-Jarisch reflex and triggers syncope (fainting).
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Affiliation(s)
- Beth A Habecker
- Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, Portland, OR 97239, USA; Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR 97239, USA.
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15
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Al Khateeb AQ, Suthar PP, Bhabad S. MRI Findings Reflecting Ongoing Cardiac Arrest While Being on an MRI Scanner. Cureus 2024; 16:e54608. [PMID: 38523963 PMCID: PMC10959468 DOI: 10.7759/cureus.54608] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Sudden cardiac arrest (SCA) is the abrupt loss of cardiac function that results in acute cardiovascular collapse and subsequent decreased or loss of various organ perfusion. Here, we present an interesting case of a 58-year-old man who developed abnormal brain MRI findings reflecting ongoing cardiac arrest due to pulseless electric activity (PEA) during an MRI scan. To our knowledge, this is the first case describing the MRI findings of ongoing cardiac arrest due to PEA. Our case is unique in imaging findings, which are not routinely encountered in day-to-day practice. This case raised awareness among the readers.
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Affiliation(s)
- Abdallah Q Al Khateeb
- Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, USA
| | - Pokhraj P Suthar
- Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, USA
| | - Sudeep Bhabad
- Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, USA
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Finkler BS, Sant'Anna R, Pinos J, Zanotta DB, Moreira TC, de Jesus FDB, Batista PD, da Rocha HG, de Lima BA, Saffi MAL, de Lima GG, Kruse M, Leiria TLL. Prognosis of programmed ventricular stimulation in adult patients with syncope of unexplained origin: A historical cohort. J Arrhythm 2024; 40:124-130. [PMID: 38333395 PMCID: PMC10848573 DOI: 10.1002/joa3.12953] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/06/2023] [Accepted: 10/24/2023] [Indexed: 02/10/2024] Open
Abstract
Background Programmed ventricular stimulation (PVS) during electrophysiological study (EPS), is a globally accepted tool for risk stratification of sudden cardiac death (SCD) in some specific clinical situations. The aim of this study was to evaluate the prognosis of ventricular arrhythmia induction in a cohort of patients with syncope of undetermined origin (SUO). Methods This is a historical cohort study in a population of patients with SUO referred for EPS between the years 2008-2021. In this interval, 575 patients underwent the procedure. Results Patients with induced ventricular arrhythmias had a higher occurrence of structural heart disease (36.7% vs. 76.5%), ischemic heart disease (28.2 vs. 57.1%), heart failure (15.5% vs. 34.4%), and lower left ventricular ejection fraction (59.16% vs. 47.51%), when compared to the outcome with a negative study. PVS triggered ventricular arrhythmias in 98 patients, 62 monomorphic and 36 polymorphic. During a median follow-up of 37.6 months, 100 deaths occurred. Only the induction of sustained ventricular arrhythmias showed a significant association with the primary outcome (all-cause mortality) with a p value <.001. After the performance of EPS, 142 patients underwent cardioverter-defibrillator (ICD) implantation. At study follow-up, 30 patients had therapies by the device. Only the induction of sustained monomorphic ventricular arrhythmia showed statistically significant association with appropriate therapies by the device (p = .012). Conclusion In patients with SUO, the induction of sustained monomorphic ventricular arrhythmia after programmed ventricular pacing is related to a worse prognosis, with a higher incidence of mortality and appropriate therapies by the ICD.
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Affiliation(s)
- Bruno Schaaf Finkler
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
| | - Roberto Sant'Anna
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
| | - Javier Pinos
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
| | - Danilo Barros Zanotta
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
| | - Thiago Camargo Moreira
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
| | | | - Pedro Dutra Batista
- Universidade Federal de Ciências da Saúde de Porto AlegrePorto AlegreRSBrazil
| | | | - Barbara Adelmann de Lima
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
| | | | - Gustavo Glotz de Lima
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
| | - Marcelo Kruse
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
| | - Tiago Luiz Luz Leiria
- Instituto de Cardiologia do Rio Grande, do Sul, Fundação Universitária de CardiologiaPorto AlegreRSBrazil
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Choi NH, Hong J, Moak JP. Cardioneuroablation for pediatric patients with functional sinus node dysfunction and paroxysmal atrioventricular block. J Cardiovasc Electrophysiol 2024; 35:221-229. [PMID: 38038245 DOI: 10.1111/jce.16145] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Severe transitory episodes of bradycardia with subsequent syncope in children are common, and generally portend a benign prognosis. Rarely, patients may experience prolonged asystolic episodes secondary to significant sinus pauses (SP) or paroxysmal atrioventricular block (AVB). Cardioneuroablation (CNA) is a catheter-based intervention, used to identify and ablate the epicardial ganglionated plexi (GP), which results in disruption of the vagal-mediated parasympathetic input to the sinus and atrioventricular node. OBJECTIVE Describe the methodology and role of CNA for treatment of pediatric patients with functional AVB or SP. METHODS This is a single-center, case series study. Patients with SP or AVB, 21 years of age or younger, who underwent CNA between 2015 and 2021 were included. CNA was performed via anatomically guided and high-frequency stimulation methods. RESULTS Six patients were included. The median age was 18.9 years (range 12.3-20.9 years), 33% female. Two patients had prolonged SP, two had paroxysmal AVB, and two had both SP and AVB. Four patients had prior syncope. The median longest pause was 8.9 s (range 3.9-16.8) with 11 total documented pauses (range 2-231) during the 6 months pre-CNA. Post-CNA, the median longest pause was 1.3 s (range 0.8-2.2) with one documented SP after termination of atrial tachycardia at the 3-month follow-up. At 6 months, the median longest pause was 1.1 s (0.8-1.3) with 0 documented pauses. No patients had syncope post-CNA. CONCLUSION CNA may be an effective alternative to pacemaker implantation in pediatric patients with syncope or significant symptoms secondary to functional SP or AVB.
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Affiliation(s)
- Nak Hyun Choi
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
- Division of Cardiology, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Jeff Hong
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Jeffrey P Moak
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
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18
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Chen W, Wu Y, Hsu Y, Hsu J, Tseng H, Chen C, Chiang M, Hsiao J, Chin S, Huang Y, Lei M. Comparison of continuous 24-hour and 14-day ECG monitoring for the detection of cardiac arrhythmias in patients with ischemic stroke or syncope. Clin Cardiol 2024; 47:e24247. [PMID: 38450794 PMCID: PMC10918718 DOI: 10.1002/clc.24247] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Previous studies show that using 12-lead electrocardiogram (ECG) or 24-h ECG monitor for the detection of cardiac arrhythmia events in patients with stroke or syncope is ineffective. HYPOTHESIS The 14-day continuous ECG patch has higher detection rates of arrhythmias compared with conventional 24-h ECG monitoring in patients with ischemic stroke or syncope. METHODS This cross-sectional study of patients with newly diagnosed ischemic stroke or syncope received a 24-h ECG monitoring and 14-day continuous cardiac monitoring patch and the arrhythmia events were measured. RESULTS This study enrolled 83 patients with ischemic stroke or syncope. The detection rate of composite cardiac arrhythmias was significantly higher for the 14-day ECG patch than 24-h Holter monitor (69.9% vs. 21.7%, p = .006). In patients with ischemic stroke, the detection rates of cardiac arrhythmias were 63.4% for supraventricular tachycardia (SVT), 7% for ventricular tachycardia (VT), 5.6% for atrial fibrillation (AF), 4.2% for atrioventricular block (AVB), and 1.4% for pause by 14-day ECG patch, respectively. The significant difference in arrhythmic detection rates were found for SVT (45.8%), AF (6%), pause (1.2%), AVB (2.4%), and VT (9.6%) by 14-day ECG patch but not by 24-h Holter monitor in patients with ischemic stroke or syncope. CONCLUSIONS A 14-day ECG patch can be used on patients with ischemic stroke or syncope for the early detection of AF or other cardiac arrhythmia events. The patch can be helpful for physicians in planning medical or mechanical interventions of patients with ischemic stroke and occult AF.
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Affiliation(s)
- Wei‐Cheng Chen
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - Yu‐Lin Wu
- Post‐Baccalaureate Program in Nursing, College of NursingTaipei Medical UniversityTaipeiTaiwan
| | - Yu‐Cheng Hsu
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - Jen‐Te Hsu
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - Hung‐Pin Tseng
- Division of Neurology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - Chao‐Chin Chen
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - Meng‐Hsiu Chiang
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - Ju‐Feng Hsiao
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - See‐Khong Chin
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - Ying‐Li Huang
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
| | - Meng‐Huan Lei
- Division of Cardiology, Department of Internal MedicineLo‐Tung Poh‐Ai HospitalLuodongTaiwan
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Martone AM, Parrini I, Ciciarello F, Galluzzo V, Cacciatore S, Massaro C, Giordano R, Giani T, Landi G, Gulizia MM, Colivicchi F, Gabrielli D, Oliva F, Zuccalà G. Recent Advances and Future Directions in Syncope Management: A Comprehensive Narrative Review. J Clin Med 2024; 13:727. [PMID: 38337421 PMCID: PMC10856004 DOI: 10.3390/jcm13030727] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Syncope is a highly prevalent clinical condition characterized by a rapid, complete, and brief loss of consciousness, followed by full recovery caused by cerebral hypoperfusion. This symptom carries significance, as its potential underlying causes may involve the heart, blood pressure, or brain, leading to a spectrum of consequences, from sudden death to compromised quality of life. Various factors contribute to syncope, and adhering to a precise diagnostic pathway can enhance diagnostic accuracy and treatment effectiveness. A standardized initial assessment, risk stratification, and appropriate test identification facilitate determining the underlying cause in the majority of cases. New technologies, including artificial intelligence and smart devices, may have the potential to reshape syncope management into a proactive, personalized, and data-centric model, ultimately enhancing patient outcomes and quality of life. This review addresses key aspects of syncope management, including pathogenesis, current diagnostic testing options, treatments, and considerations in the geriatric population.
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Affiliation(s)
- Anna Maria Martone
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Iris Parrini
- Department of Cardiology, Mauriziano Hospital, Largo Filippo Turati, 62, 10128 Turin, Italy
| | - Francesca Ciciarello
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | - Vincenzo Galluzzo
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | - Stefano Cacciatore
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Claudia Massaro
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Rossella Giordano
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Tommaso Giani
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Giovanni Landi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | | | - Furio Colivicchi
- Division of Cardiology, San Filippo Neri Hospital-ASL Roma 1, Via Giovanni Martinotti, 20, 00135 Rome, Italy;
| | - Domenico Gabrielli
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy;
| | - Fabrizio Oliva
- “A. De Gasperis” Cardiovascular Department, Division of Cardiology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, 3, 20162 Milan, Italy;
| | - Giuseppe Zuccalà
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
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Benditt DG, Goldstein M. Aging and Susceptibility to Cardioinhibitory Response in Vasovagal Syncope: A Physiological or Methodological Issue? JACC Clin Electrophysiol 2024:S2405-500X(24)00014-8. [PMID: 38385915 DOI: 10.1016/j.jacep.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/01/2024] [Indexed: 02/23/2024]
Affiliation(s)
- David G Benditt
- Cardiac Arrhythmia Center, University of Minnesota, Minneapolis, Minnesota, USA.
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Kojo K, Morikawa T, Kikawa T, Sasaki K, Suyama Y, Shimizu T. Diagnostic Dilemma of Syncope: Esophageal Hiatal Hernia and High-risk Bundle-branch Block. Intern Med 2024; 63:83-86. [PMID: 37197958 PMCID: PMC10824654 DOI: 10.2169/internalmedicine.1569-23] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/16/2023] [Indexed: 05/19/2023] Open
Abstract
We herein report a complicated case of recurrent syncope accompanying bundle branch block and hiatal hernia of the esophagus. An 83-year-old woman presented with syncope. Echocardiography visualized the left atrium compressed by an esophageal hiatal hernia, which had potential to decrease the cardiac output. Although she underwent esophageal repair surgery, two months after the surgery, she presented to the emergency department again with complaints of syncope. At the return visit, her face was pale and her pulse rate was 30 beats per minute. Electrocardiography showed complete atrioventricular block. On reviewing the patient's previous electrocardiography findings, we found a record of trifascicular block. This case illustrates the importance of predicting atrioventricular blocks in patients with high-risk bundle-branch blocks. Keeping in mind high-risk bundle-branch blocks will help clinicians avoid anchoring bias due to a striking image masquerading as the true diagnosis.
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Affiliation(s)
- Kenshiro Kojo
- Department of General Medicine, Nara City Hospital, Japan
| | - Toru Morikawa
- Department of General Medicine, Nara City Hospital, Japan
| | - Tomoko Kikawa
- Department of Cardiovascular Medicine, Nara City Hospital, Japan
| | - Kantaro Sasaki
- Department of General Medicine, Nara City Hospital, Japan
| | | | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Japan
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Cutler MJ, Eckhardt LL, Kaufman ES, Arbelo E, Behr ER, Brugada P, Cerrone M, Crotti L, deAsmundis C, Gollob MH, Horie M, Huang DT, Krahn AD, London B, Lubitz SA, Mackall JA, Nademanee K, Perez MV, Probst V, Roden DM, Sacher F, Sarquella-Brugada G, Scheinman MM, Shimizu W, Shoemaker B, Sy RW, Watanabe A, Wilde AAM. Clinical Management of Brugada Syndrome: Commentary From the Experts. Circ Arrhythm Electrophysiol 2024; 17:e012072. [PMID: 38099441 PMCID: PMC10824563 DOI: 10.1161/circep.123.012072] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
Although there is consensus on the management of patients with Brugada Syndrome with high risk for sudden cardiac arrest, asymptomatic or intermediate-risk patients present clinical management challenges. This document explores the management opinions of experts throughout the world for patients with Brugada Syndrome who do not fit guideline recommendations. Four real-world clinical scenarios were presented with commentary from small expert groups for each case. All authors voted on case-specific questions to evaluate the level of consensus among the entire group in nuanced diagnostic and management decisions relevant to each case. Points of agreement, points of controversy, and gaps in knowledge are highlighted.
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Affiliation(s)
- Michael J Cutler
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT (M.J.C.)
| | - Lee L Eckhardt
- Cellular and Molecular Arrhythmia Research Program, Division of CVM, Department of Medicine, University of Wisconsin-Madison (L.L.E.)
| | - Elizabeth S Kaufman
- Heart and Vascular Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (E.S.K.)
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona (E.A.)
- Centro de Investigacion Biomedica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid (E.A.)
- IDIBAPS, Institut d'Investigacio August Pi I Sunyer, Barcelona, Spain (E.A.)
| | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Cardiology Section, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust (E.R.B.)
- Mayo Clinic Healthcare, London, United Kingdom (E.R.B.)
| | - Pedro Brugada
- Cardiovascular Division, UZ Brussel-VUB, Belgium (P.B.)
- Arrhythmia Unit, Helicopteros Sanitarios Hospital (HSH), Puerto Banús, Marbella, Malaga, Spain (P.B.)
| | - Marina Cerrone
- New York Univ Grossman School of Medicine, Leon H. Charney Division of Cardiology (M.C.)
| | - Lia Crotti
- Department of Medicine and Surgery, University of Milano-Bicocca (L.C.)
- Istituto Auxologico Italiano IRCCS, Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Milan, Italy (L.C.)
| | - Carlo deAsmundis
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (C.D.)
| | - Michael H Gollob
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Canada (M.H.G.)
| | - Minoru Horie
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Ohtsu, Japan (M.H.)
| | | | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, Canada (A.D.K.)
| | - Barry London
- Division of Cardiovascular Medicine, Department of Internal Medicine and Abboud Cardiovascular Research Center, University of Iowa Carver College of Medicine, Iowa City (B.L.)
| | - Steven A Lubitz
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston (S.A.L.)
| | - Judith A Mackall
- Department of Medicine, Division of Cardiology, University Hospitals Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH (J.A.M.)
| | - Koonlawee Nademanee
- Center of Excellence in Arrhythmia Research, Department of Medicine, Faculty of Medicine, Chulalongkorn University (K.N.)
- Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital, Bangkok, Thailand (K.N.)
| | - Marco V Perez
- Stanford Center for Inherited Cardiovascular Diseases, Stanford University, CA (M.V.P.)
| | - Vincent Probst
- Université Nantes, CHU Nantes, CNRS, INSERM, Service de Cardiologie, l'institut du thorax, Nantes, France (V.P.)
| | - Dan M Roden
- Departments of Medicine, Pharmacology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN (D.M.R.)
| | - Frederic Sacher
- Arrhythmia Department, Bordeaux University Hospital, IHU LIRYC, Pessac, France (F.S.)
| | - Georgia Sarquella-Brugada
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Universitat de Barcelona (G.S.-B.)
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain (G.S.-B.)
| | - Melvin M Scheinman
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California-San Francisco (M.M.S.)
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (W.S.)
| | - Benjamin Shoemaker
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.S.)
| | - Raymond W Sy
- Faculty of Medicine and Heath, The University of Sydney (R.W.S.)
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (R.W.S.)
| | - Atsuyuki Watanabe
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Japan (A.W.)
| | - Arthur A M Wilde
- Department of Cardiology, University of Amsterdam (A.A.M.W.)
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands (A.A.M.W.)
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23
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Sun Q, Xie Z, Wang F, Guo J, Yan X. Case report of a child with long QT syndrome type 14 caused by CALM1 gene mutation and literature review. Mol Genet Genomic Med 2024; 12:e2287. [PMID: 37905352 PMCID: PMC10767591 DOI: 10.1002/mgg3.2287] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/24/2023] [Accepted: 09/07/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE To analyze the clinical and genetic characteristics of a patient with long QT syndrome type 14 (long QT syndrome-14, LQT14, OMIM # 616247) caused by a de novo CALM1 mutation. METHODS The clinical data of the patient were collected, next-generation sequencing technology was used to determine the exome gene sequence of the patient, and the suspected pathogenic locus was verified by Sanger sequencing. RESULTS A 5-year and 9-month-old girl was admitted to the hospital due to a syncopal episode. During the attack, the main symptoms were loss of consciousness, cyanosis of the face and lips, and weakness of limbs. The child had multiple seizures in the past, all of which occurred after emotional excitement and activity. She was diagnosed with epilepsy for more than 3 years, but the effect of antiepileptic treatment was not satisfactory. The electrocardiogram was normal in the past. A month ago, convulsions occurred again after exercise, and the electrocardiogram showed QTc 496 ms. The treadmill test showed a significant prolongation of QTc after exercise, and the genetic results suggested a new heterozygous variant of CALM1, c.395A>G; p. (Asp132Gly). Consequently, she was diagnosed with LQT14 and treated with propranolol. During a follow-up of 15 months, there were no seizures or syncope. CONCLUSIONS This patient had multiple episodes of convulsions or syncope after emotional stimulation or activity, with intermittent prolongation of the QTc on routine ECG, marked prolongation of the QTc after exercise, and T-wave alternans, which differed from the LQT14 phenotype caused by the previous CALM1 mutation.
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Affiliation(s)
- Qiqing Sun
- Department of CardiologyChildren's Hospital Affiliated to Zhengzhou University, Zhengzhou Hospital of Beijing Children's HospitalZhengzhouChina
| | - Zhenhua Xie
- Henan Key Laboratory of Pediatric Inherited and Metabolic DiseasesChildren's Hospital Affiliated to Zhengzhou University, Zhengzhou Hospital of Beijing Children's HospitalZhengzhouChina
| | - Fangjie Wang
- Department of CardiologyChildren's Hospital Affiliated to Zhengzhou University, Zhengzhou Hospital of Beijing Children's HospitalZhengzhouChina
| | - Jun Guo
- Beijing Key Laboratory for Genetics of Birth DefectsBeijing Pediatric Research Institute, MOE Key Laboratory of Major Diseases in Children, Capital Medical University, Center of Rare Diseases, National Center for Children's Health, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Xiaochen Yan
- Department of CardiologyChildren's Hospital Affiliated to Zhengzhou University, Zhengzhou Hospital of Beijing Children's HospitalZhengzhouChina
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24
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Chandrashekhar H, Arman S, Khan J, Kalladka M. Lymphoma masquerading as jaw pain, headache, and syncope: A case report. J Am Dent Assoc 2024; 155:79-88. [PMID: 37389534 DOI: 10.1016/j.adaj.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/04/2023] [Accepted: 03/22/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Lymphomas of parapharyngeal space often have complex manifestations, posing a diagnostic dilemma for clinicians. CASE DESCRIPTION A 64-year-old man sought treatment for a 4-month history of unresolving right-sided headache and jaw pain associated with syncope, all of which started with a toothache. Since the onset of pain, the patient had undergone multiple diagnostic tests with various specialists, with no pain relief. A detailed clinical and radiologic examination by an orofacial pain specialist revealed diffuse large B-cell lymphoma in the parapharynx. PRACTICAL IMPLICATIONS A thorough knowledge of the head and neck anatomy helps in identifying the pathophysiology of complex orofacial pain manifestations, which assists in early diagnosis and treatment.
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25
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AlHazmi H, Bahadur AY, AlAhmadi K, Bahadur OY. Syncope: Atypical Presentation of Diaphragmatic Hernia. Cureus 2024; 16:e51715. [PMID: 38318536 PMCID: PMC10838808 DOI: 10.7759/cureus.51715] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/07/2024] Open
Abstract
In this case report, we describe a rare presentation of diaphragmatic hernia in a pediatric patient presenting with syncope. Congenital diaphragmatic hernia (CDH) is a developmental discontinuity of the diaphragm that causes the abdominal viscera to herniate into the thoracic cavity. It is usually diagnosed shortly after birth and is often associated with pulmonary hypoplasia and pulmonary hypertension, causing life-threatening conditions, or it could be completely asymptomatic. Syncope is induced by various conditions such as cerebrovascular disease, arrhythmia, hypoglycemia, anemia, epilepsy, and autonomic nervous disorder.
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Affiliation(s)
- Hazem AlHazmi
- Pediatric Emergency Medicine, King Abdulaziz Medical City Jeddah, Jeddah, SAU
| | | | | | - Ola Y Bahadur
- Medicine and Surgery, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Jeddah, SAU
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26
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Ma Y, Zhang Y, Coresh J, Viswanathan A, Sullivan KJ, Walker KA, Liu C, Lipsitz LA, Selvin E, Sharrett AR, Gottesman RF, Blacker D, Hofman A, Windham BG, Juraschek SP. Orthostatic Blood Pressure Change, Dizziness, and Risk of Dementia in the ARIC Study. Hypertension 2024; 81:96-106. [PMID: 37869909 PMCID: PMC10843561 DOI: 10.1161/hypertensionaha.123.21438] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/14/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Abnormal orthostatic blood pressure (BP) regulation may result in cerebral hypoperfusion and brain ischemia and contribute to dementia. It may also manifest as early symptoms of the neurodegenerative process associated with dementia. The relationship between the magnitude and timing of orthostatic BP responses and dementia risk is not fully understood. METHODS We conducted a prospective cohort analysis of the associations of orthostatic BP changes and self-reported orthostatic dizziness with the risk of dementia in the Atherosclerosis Risk in Communities study (ARIC). We calculated changes in BP from the supine to the standing position at 5 measurements taken within 2 minutes after standing during the baseline visit (1987-1989). The primary outcome was adjudicated dementia ascertained through 2019. RESULTS Among 11 644 participants (mean [SD] age, 54.5 [5.7] years; 54.1% women; 25.9% Black), 2303 dementia cases were identified during a median follow-up of 25.9 years. Large decreases in systolic BP from the supine to standing position measured at the first 2 measurements ≈30 and 50 seconds after standing, but not afterward, were associated with orthostatic dizziness and a higher risk of dementia. Comparing a decrease in systolic BP of ≤-20 or >-20 to -10 mm Hg to stable systolic BP (>-10 to 10 mm Hg) at the first measurement, the adjusted hazard ratios were 1.22 (95% CI, 1.01-1.47) and 1.10 (95% CI, 0.97-1.25), respectively. CONCLUSIONS Abnormal orthostatic BP regulation, especially abrupt drops in BP within the first minute, might be early risk markers for the development of dementia. Transient early orthostatic hypotension warrants more attention in clinical settings.
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Affiliation(s)
- Yuan Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Yiwen Zhang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Josef Coresh
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, USA
| | - Kevin J. Sullivan
- Memory Impairment and Neurogenerative Dementia Center, University of Mississippi Medical Center, Jackson, MS USA
| | - Keenan A. Walker
- Intramural Research Program of the National Institute on Aging, NIH, Baltimore, Maryland, USA
| | - Chelsea Liu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Lewis A. Lipsitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, and Hebrew Senior Life Hinda and Arthur Marcus Institute for Aging Research, Boston, USA
| | - Elizabeth Selvin
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - A. Richey Sharrett
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rebecca F. Gottesman
- National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland, USA
| | - Deborah Blacker
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Albert Hofman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - B. Gwen Windham
- Memory Impairment and Neurogenerative Dementia Center, University of Mississippi Medical Center, Jackson, MS USA
| | - Stephen P Juraschek
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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27
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Dipaola F, Gatti M, Menè R, Shiffer D, Giaj Levra A, Solbiati M, Villa P, Costantino G, Furlan R. A Hybrid Model for 30-Day Syncope Prognosis Prediction in the Emergency Department. J Pers Med 2023; 14:4. [PMID: 38276219 PMCID: PMC10817569 DOI: 10.3390/jpm14010004] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 01/27/2024] Open
Abstract
Syncope is a challenging problem in the emergency department (ED) as the available risk prediction tools have suboptimal predictive performances. Predictive models based on machine learning (ML) are promising tools whose application in the context of syncope remains underexplored. The aim of the present study was to develop and compare the performance of ML-based models in predicting the risk of clinically significant outcomes in patients presenting to the ED for syncope. We enrolled 266 consecutive patients (age 73, IQR 58-83; 52% males) admitted for syncope at three tertiary centers. We collected demographic and clinical information as well as the occurrence of clinically significant outcomes at a 30-day telephone follow-up. We implemented an XGBoost model based on the best-performing candidate predictors. Subsequently, we integrated the XGboost predictors with knowledge-based rules. The obtained hybrid model outperformed the XGboost model (AUC = 0.81 vs. 0.73, p < 0.001) with acceptable calibration. In conclusion, we developed an ML-based model characterized by a commendable capability to predict adverse events within 30 days post-syncope evaluation in the ED. This model relies solely on clinical data routinely collected during a patient's initial syncope evaluation, thus obviating the need for laboratory tests or syncope experienced clinical judgment.
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Affiliation(s)
- Franca Dipaola
- Internal Medicine, Syncope Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy;
| | | | - Roberto Menè
- Department of Medicine and Surgery, University of Milano-Bicocca, 20100 Milan, Italy;
| | - Dana Shiffer
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy;
| | | | - Monica Solbiati
- Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, 20100 Milan, Italy; (M.S.); (G.C.)
| | - Paolo Villa
- Emergency Medicine Unit, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, 20100 Milan, Italy;
| | - Giorgio Costantino
- Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, 20100 Milan, Italy; (M.S.); (G.C.)
| | - Raffaello Furlan
- Internal Medicine, Syncope Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy;
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28
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Brignole M, Groppelli A, Russo V, Fedorowski A, van Dijk G, Alboni P. The Rate of Asystolic Reflex Syncope Is Not Influenced by Age. JACC Clin Electrophysiol 2023:S2405-500X(23)00901-5. [PMID: 38243997 DOI: 10.1016/j.jacep.2023.11.021] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND The head-up tilt test (HUT) and other evidence suggest that the vagal effect on the heart decreases with age. OBJECTIVES The main aim of the study was to assess whether this age effect also affects the rate of asystole in spontaneous reflex syncope (RS). METHOD We performed an analysis of pooled individual data from 4 studies that recruited patients ≥40 years of age affected by certain or suspected RS who received an implantable loop recorder (ILR) and reported follow-up data on syncope recurrence. We assessed the presence of asystolic syncope of >3 seconds or nonsyncopal asystole of >6 seconds recorded by ILR and compared the findings to tilt test results on the same patients. RESULTS A total of 1,046 patients received ILR because of unexplained syncope. Of these, 201 (19.2%) had a documentation of an asystolic event of 10-second (Q1-Q3: 6- to 15-second) duration. They were subdivided in 3 age tertiles: ≤60 years (n = 64), 61 to 72 years (n = 72), and ≥73 years (n = 65). The rate of asystolic events was similar in the 3 subgroups (50.1%, 50.1%, and 49.2%, respectively; P = 0.99). Conversely, the rate of asystolic syncope induced during HUT (performed in 169 of 201) was greatly age dependent (31.0%, 12.1%, and 11.1% in increasing age tertiles, respectively; P = 0.009). CONCLUSIONS The rate of the spontaneous asystolic form of RS documented by ILR is constant at any age >40 years. Conversely, the rate of asystolic syncope induced by HUT is higher in younger patients and decreases with age. The contrasting results between spontaneous and tilt-induced events cast doubt on the concept that asystole in RS is less common in older patients.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milan, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milan, Italy.
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Monaldi Hospital, Naples, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Solna, Sweden; Department of Medicine, Karolinska Institute, Solna, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Paolo Alboni
- Section of Cardiology, Ospedale Privato Quisisana, Ferrara, Italy
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29
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Tan NY, Giudicessi JR, Harvey JR, Asirvatham SJ, Siontis KC. Sinus arrest in a p.Arg160X-DSP-positive patient without evidence of desmoplakin-mediated cardiomyopathy: a case report. Front Cardiovasc Med 2023; 10:1328898. [PMID: 38169814 PMCID: PMC10758468 DOI: 10.3389/fcvm.2023.1328898] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
Background Pathogenic/Likely pathogenic variants in DSP-encoded desmoplakin are strongly associated with arrhythmogenic cardiomyopathy (ACM). However, their contribution towards sinus node dysfunction has not been well-delineated. Case summary A 74-year-old man with a pathogenic variant of DSP-encoded desmoplakin (c.478C >T; p.Arg160X) but no evidence of ACM presented with one episode of syncope in the setting of a gastrointestinal illness. Workup including echocardiography, cardiac magnetic resonance imaging, and Holter monitor did not show evidence of ACM or significant arrhythmias. One month later, he experienced several closely-spaced episodes of syncope associated with long sinus pauses and sinus arrest documented on telemetry. He underwent urgent dual chamber pacemaker implantation, during which a ventricular programmed stimulation study was performed and was negative for sustained ventricular arrhythmias. His syncopal episodes resolved and he had no recurrent events on three-month follow-up. Discussion As highlighted here, DSP-encoded desmoplakin pathogenic/Likely pathogenic variants may contribute to isolated sinus node dysfunction. This clinical link should be further explored in larger studies involving patients with DSP variants.
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Russo V, Covino S, De Pasquale V, Parente E, Comune A, Rago A, Papa AA, Ammendola E, Spadaro Guerra A, Napoli P, Golino P, Nigro G. Remote monitoring of implantable cardiac monitors in patients with unexplained syncope: Predictors of false-positive alert episodes. Pacing Clin Electrophysiol 2023; 46:1500-1508. [PMID: 37885375 DOI: 10.1111/pace.14851] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/03/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Remote monitoring is recommended for patients with implantable cardiac monitors (ICMs), but compared to other cardiac implantable devices, ICMs are less accurate and transmit a higher number of alerts. OBJECTIVE The aim of this study was to investigate the predictors of false-positive (FP) arrhythmic alerts in patients with unexplained syncope who were implanted with ICM and followed by an automatic remote monitoring system. METHODS We retrospectively evaluated all consecutive patients who received a long-sensing vector ICM for unexplained syncope between January 2019 to September 2021 at our Syncope Unit. The primary endpoint was the incidence of the first FP episode. The secondary endpoints included assessing the incidence of FP episodes for all types of algorhythms and indentifying the reasons for the misdetection of these episodes. RESULTS Among 105 patients (44.8% males, median age 51 years), 51 (48.6%) transmitted at least one FP alert during a median follow-up of 301 days. The presence of pre-ventricular complexes (PVCs) on the resting electrocardiogram was the only clinical characteristic associated with an increased risk of FP alerts (adjusted Hazard ratio [HR] 5.76 [2.66-12.4], p = 0.010). The other significant device-related variables were a low-frequency filter at 0.05 Hz versus the default 0.5 Hz (adjusted HR 3.82 [1.38-10.5], p = 0.010) and the R-wave amplitude (adjusted HR 0.35 [0.13-0.99], p = 0.049). CONCLUSION Patients who have PVCs are at higher risk of inappropriate ICM activations. To reduce the occurrence of FP alerts, it may be beneficial to target a large R-wave amplitude during device insertion and avoid programming a low-frequency filter at 0.05 Hz.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Simona Covino
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Valentina De Pasquale
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Andrea Antonio Papa
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Ernesto Ammendola
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | | | - Paola Napoli
- Clinical Research Unit, Biotronik Italia S.p.A., Milan, Italy
| | - Paolo Golino
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
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31
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Alhazmi L. Reversibility of Sinus Bradycardia-Induced Syncope Resulting From Low-Voltage Electrical Injury: A Case Report. Cureus 2023; 15:e50509. [PMID: 38222168 PMCID: PMC10787379 DOI: 10.7759/cureus.50509] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/16/2024] Open
Abstract
Electric shocks pose a serious threat to public health. The heart is among the organs that are most commonly impacted. Electrical harm can cause a number of potentially fatal heart conditions, including asystole, ventricular fibrillation, and myocardial rupture. Some patients had sinus bradycardia diagnosed at the time of admission. In this case report, we describe a 43-year-old male patient who had an electrical injury that resulted in syncope and sinus bradycardia. After 24 hours of cardiac monitoring, the patient was found to not require a pacemaker. This suggests that patients with symptomatic sinus bradycardia should have cardiac monitoring. If, after 24 hours, cardiac monitoring revealed no new episodes of sinus bradycardia and the patient remained asymptomatic, the patient is unlikely to require a pacemaker. There are differing guidelines and suggestions regarding the supervision of patients following electrical damage, and further study in this area is necessary to enable the unification of guidelines.
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Affiliation(s)
- Luai Alhazmi
- Department of Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
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Eltawansy S, Klei L, Imburgio S, Decker M, Udongwo N, Alrefaee A, Mararenko A, Lamarche N. Apical Hypertrophic Cardiomyopathy: A Fatal yet Underappreciated Variant of Hypertrophic Cardiomyopathy. Cureus 2023; 15:e51345. [PMID: 38288204 PMCID: PMC10824511 DOI: 10.7759/cureus.51345] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 01/31/2024] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a group of diseases affecting the left ventricle heart muscle that share a common feature of left ventricular hypertrophy without associated cardiac or systemic disorder. It was found to have a genetic basis with autosomal dominant mutations in the sarcomeric protein genes. Apical HCM is a rare subtype and underappreciated variant of HCM that primarily affects the apex of the heart. Apical HCM is dissimilar to classic HCM, with more challenges in diagnosis and inconsistent clinical course than other types. We report a case of a 91-year-old female who presented with a syncopal episode. Workup revealed atypical nonclassic features. Her transthoracic echocardiogram revealed a "spade-like" configuration of the left ventricular cavity at end-diastole consistent with apical hypertrophic cardiomyopathy. The remaining of her workup was consistent with the apical hypertrophic cardiomyopathy as a reason for the syncopal episode on presentation. Apical HCM is a distinct form of HCM that requires more attention among clinicians. In our case, the patient ended up having an implantable cardioverter defibrillator (ICD) for secondary prevention and a prescription of a beta blocker with a good outcome in her case.
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Affiliation(s)
- Sherif Eltawansy
- Internal Medicine, Jersey Shore University Medical Center, Neptune Township, USA
| | - Lauren Klei
- Internal Medicine, Jersey Shore University Medical Center, Neptune Township, USA
| | - Steven Imburgio
- Internal Medicine, Jersey Shore University Medical Center, Neptune Township, USA
| | - Megan Decker
- Internal Medicine, Jersey Shore University Medical Center, Neptune Township, USA
| | - Ndausung Udongwo
- Internal Medicine, Jersey Shore University Medical Center, Neptune Township, USA
| | - Anas Alrefaee
- Cardiology, Jersey Shore University Medical Center, Neptune Township, USA
| | - Anton Mararenko
- Internal Medicine, Jersey Shore University Medical Center, Neptune Township, USA
| | - Nelson Lamarche
- Cardiology, Jersey Shore University Medical Center, Neptune Township, USA
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Orenshtein S, Sheiner E, Sergienko R, Wainstock T. Syncope in pregnancy, immediate pregnancy outcomes, and offspring long-term neurologic health. Am J Obstet Gynecol MFM 2023; 5:101190. [PMID: 37838012 DOI: 10.1016/j.ajogmf.2023.101190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/03/2023] [Revised: 09/26/2023] [Accepted: 10/09/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND There are limited data regarding the perinatal consequences of maternal syncope during pregnancy, and even less is known about the potential long-term effect on offspring health. OBJECTIVE This study aimed to examine perinatal outcomes as well as long-term offspring neurologic morbidity associated with prenatal maternal syncope, and the possible differential effect by trimester of first syncope episode. STUDY DESIGN A retrospective cohort study was conducted, including all singleton deliveries occurring between 1991 and 2021 at a large tertiary medical center. Multivariable analyses were applied to study the associations between prenatal maternal syncope and various perinatal outcomes as well as offspring neurologic morbidity up to the age of 18 years, while adjusting for clinically relevant factors. Analyses were further conducted by trimester of first syncope episode. RESULTS The study population included 232,475 pregnancies, 774 (0.3%) were affected by maternal syncope, which most frequently first occurred during the second trimester (44.5%), followed by the first trimester (31.8%) and finally the third trimester (27.7%). Maternal syncope was independently associated with increased risk for intrauterine growth restriction (adjusted odds ratio, 1.52; 95% confidence interval, 1.01-2.29), which appeared to be mainly driven by first trimester syncope occurrence; as well as with increased risk for cesarean delivery (adjusted odds ratio, 1.33; 95% confidence interval, 1.10-1.61), and for long-term offspring neurologic morbidity (adjusted hazard ratio, 1.79; 95% confidence interval, 1.65-2.08), regardless of the trimester of syncope occurrence. CONCLUSION Prenatal maternal syncope is an independent risk factor for intrauterine growth restriction, cesarean delivery, and for long-term offspring neurologic morbidity.
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Affiliation(s)
- Shani Orenshtein
- Faculty of Health Sciences, Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Ms Orenshtein, Mr Sergienko, and Dr Wainstock).
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Prof Sheiner)
| | - Ruslan Sergienko
- Faculty of Health Sciences, Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Ms Orenshtein, Mr Sergienko, and Dr Wainstock)
| | - Tamar Wainstock
- Faculty of Health Sciences, Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Ms Orenshtein, Mr Sergienko, and Dr Wainstock)
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Huang J, Ahmed I, Balogun A, Hamid K. Niacin-Induced Syncope in a Middle-Aged Male: When an Over-the-Counter Vitamin Goes Wrong. Cureus 2023; 15:e50454. [PMID: 38222212 PMCID: PMC10786186 DOI: 10.7759/cureus.50454] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 01/16/2024] Open
Abstract
Niacin is an essential vitamin with lipid-modifying properties. It is readily available in many over-the-counter (OTC) supplements. However, the use of niacin can lead to undesirable adverse reactions, including flushing, nausea, hyperglycemia, etc. Here, we present a rare case of niacin-induced syncope caused by a sudden increase in dosage in a middle-aged male. Extensive history, examination, and cardiovascular investigation were obtained to rule out various common etiologies of syncope. We also discuss the utility of niacin as a nutritional supplement, as most individuals obtain sufficient niacin intake from foods and beverages. As a treatment for dyslipidemia, niacin no longer exhibits cardiovascular benefits in the contemporary statin era. We argue that an additional niacin supplement is both unnecessary and potentially harmful. Therefore, niacin supplementation should be cautiously taken with no additional health benefits and frequent deleterious effects.
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Affiliation(s)
- Jiannan Huang
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Ibrahim Ahmed
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Ayodeji Balogun
- Hospital Medicine, University of South Dakota Sanford Medical Center, Sioux Falls, USA
| | - Khizar Hamid
- Pulmonary Disease and Critical Care Medicine, Corewell Health East, Royal Oak, USA
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Schembri L, Vangaveti V, Mallett A. Diagnostic utility and outcomes of inpatient investigations for syncope in a regional setting. Intern Med J 2023; 53:2208-2215. [PMID: 36645299 DOI: 10.1111/imj.16019] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 01/07/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Syncope is a common presentation to the emergency department with a wide spectrum of aetiology. The identification of the underlying cause can be diagnostically challenging, as are the choice of investigations and the decision for inpatient versus outpatient disposition. AIMS This study aimed to evaluate the aetiology of syncope as documented, the diagnostic yield of inpatient investigations and outcomes for adult patients admitted for syncope. METHODS A single-centred, retrospective cohort study was conducted in adult patients admitted for syncope within a 2-year period. A total of 386 patients were identified after exclusion. Information regarding syncope aetiology, investigations and outcomes were established via chart review of electronic records. RESULTS The most common cause of syncope was neural-mediated (43%), followed by orthostatic (36.5%) and cardiogenic (20.5%). The investigations performed in order of frequency included: telemetry electrocardiogram (ECG) (75.4%), computed tomography head non-contrast (58.8%), transthoracic echocardiogram (TTE) (20.2%), computed tomography pulmonary angiogram (CTPA) (6.5%), MR brain (3.9%), electroencephalogram (1.3%) and carotid ultrasound (0.3%). Telemetry ECG, TTE and CTPA led to the diagnosis of syncope in a minority of patients only. As a result, 17.5% of patients had a new intervention on discharge, 5.4% were readmitted for syncope and 9.6% of patients died. CONCLUSIONS In the context of the inpatient evaluation of syncope, this study supports the use of telemetry ECG and TTE. Neuroimaging demonstrates a low diagnostic yield for the cause of syncope, but it may have a role to play in excluding other pathologies. Our study does not support the routine use of CTPA, EEG or carotid ultrasound in the evaluation of syncope.
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Affiliation(s)
- Laura Schembri
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Townsville University Hospital, Douglas, Queensland, Australia
| | - Venkat Vangaveti
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Townsville University Hospital, Douglas, Queensland, Australia
| | - Andrew Mallett
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Townsville University Hospital, Douglas, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
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Doundoulakis I, Tsiachris D, Kordalis A, Koliastasis L, Soulaidopoulos S, Arsenos P, Xintarakou A, Bartsioka LI, Dilaveris P, Vlachopoulos C, Sideris S, Tsioufis K, Gatzoulis KA. Management of Patients With Unexplained Syncope: Derivation and Validation of a Simplified 2-Step Diagnostic Approach. J Am Heart Assoc 2023; 12:e031659. [PMID: 37982260 PMCID: PMC10727290 DOI: 10.1161/jaha.123.031659] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/19/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The aim of this study was to develop a structured 2-step approach, based on noninvasive diagnostic criteria, that led to an electrophysiology study in patients with unexplained syncope. METHODS AND RESULTS Two independent cohorts were used: the derivation cohort with 665 patients based on electronic health record data to develop our 2-step diagnostic approach, and the validation cohort based on 160 prospectively screened patients, presenting with unexplained syncope episodes. Noninvasive electrocardiographic and imaging markers and an electrophysiology study-based invasive assessment were combined. A positive diagnostic approach according to our study's prespecified criteria resulted in a decision to proceed with a permanent pacemaker/implantable cardioverter-defibrillator. The primary end point was the time until the event of recurrent syncope (syncope-free survival). Number needed to treat was calculated for patients with a positive diagnostic approach. The number of patients with unexplained syncope and borderline sinus bradycardia needed to treat was 5, and the number of patients with unexplained syncope and bundle branch block needed to treat was 3 over a mean follow-up of ≈4 years. After the structured 2-step approach, the primary outcome occurred in 14 of 82 (17.1%) with a pacemaker/implantable cardioverter-defibrillator and 19 of 57 (33%) with a negative approach, with a mean follow-up of ≈2.5 years (29.29±12.58 months, P=0.03). CONCLUSIONS The low number needed to treat in the derivation cohort and the low percentage of syncope recurrence in the validation cohort supports the proposed 2-step electrophysiology-inclusive algorithm as a potentially low-cost, 1-day, structured tool for these patients.
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Affiliation(s)
- Ioannis Doundoulakis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Dimitris Tsiachris
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Athanasios Kordalis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Leonidas Koliastasis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Stergios Soulaidopoulos
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Petros Arsenos
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Anastasia Xintarakou
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Lamprini Iro Bartsioka
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Polychronis Dilaveris
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Charalambos Vlachopoulos
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Skevos Sideris
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Konstantinos Tsioufis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
| | - Konstantinos A. Gatzoulis
- First Department of CardiologyNational and Kapodistrian University, Hippokration General HospitalAthensGreece
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Ahuja M, Siddhpuria S, Karimi A, Lewis K, Wong E, Lee J, Reppas-Rindlisbacher C, Sood E, Gabor C, Patterson C. Cholinesterase inhibitors and falls, syncope and injuries in patients with cognitive impairment: a systematic review and meta-analysis. Age Ageing 2023; 52:afad205. [PMID: 37993407 DOI: 10.1093/ageing/afad205] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Cholinesterase inhibitors are commonly used to treat patients with neurocognitive disorders, who often have an elevated risk of falling. Effective use of these medications requires a thoughtful assessment of risks and benefits. OBJECTIVE To provide an update on previous reviews and determine the association between cholinesterase inhibitors and falls, syncope, fracture and accidental injuries in patients with neurocognitive disorders. METHODS Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature and AgeLine were systematically searched through March 2023 to identify all randomised controlled trials of cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in patients with cognitive impairment. Corresponding authors were contacted for additional data necessary for meta-analysis. Inclusion criteria consisted of adults ≥19 years, with a diagnosis of dementia, Parkinson's disease, mild cognitive impairment or traumatic brain injury. Data were extracted in duplicate for the aforementioned primary outcomes and all outcomes were analysed using random-effects meta-analysis. RESULTS Fifty three studies (30 donepezil, 14 galantamine, 9 rivastigmine) were included providing data on 25, 399 patients. Cholinesterase inhibitors, compared to placebo, were associated with reduced risk of falls (risk ratio [RR] 0.84 [95% confidence interval [CI] = 0.73-0.96, P = 0.009]) and increased risk of syncope (RR 1.50 [95% CI = 1.02-2.21, P = 0.04]). There was no association with accidental injuries or fractures. CONCLUSION In patients with neurocognitive disorders, cholinesterase inhibitors were associated with decreased risk of falls, increased risk of syncope and no association with accidental trauma or fractures. These findings will help clinicians better evaluate risks and benefits of cholinesterase inhibitors.
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Affiliation(s)
- Manan Ahuja
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shailee Siddhpuria
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arian Karimi
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Kaitlin Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Eric Wong
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Justin Lee
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Emma Sood
- Faculty of Science, Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Ontario, Canada
| | | | - Christopher Patterson
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Canada
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Sfairopoulos D, Konstantinou CS, Korantzopoulos P. Syncope in the setting of trifascicular block and retrograde concealed conduction: A case report. Med Int (Lond) 2023; 3:64. [PMID: 38099149 PMCID: PMC10719962 DOI: 10.3892/mi.2023.124] [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] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023]
Abstract
In clinical practice, the accurate diagnosis of the causes of syncope is often challenging and demanding. Moreover, certain rare electrocardiographic phenomena may complicate the diagnostic workup, leading to imprecise diagnoses. The present study briefly describes the case of an 82-year-old male patient with ischemic cardiomyopathy who suffered syncopal episodes in the setting of trifascicular block. The 12-lead electrocardiogram revealed premature ventricular contractions and non-conducted P waves due to the phenomenon of retrograde concealed conduction. Following the exclusion of myocardial ischemia, an electrophysiological study yielded abnormal results and a biventricular pacemaker was implanted. Although retrograde concealed conduction is considered a benign phenomenon caused by the transient modification of antegrade atrioventricular conduction characteristics, further meticulous investigation is required in patients with concomitant baseline conduction abnormalities and/or structural heart disease.
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Affiliation(s)
- Dimitrios Sfairopoulos
- First Department of Cardiology, University of Ioannina Faculty of Medicine, 45110 Ioannina, Greece
| | - Christos S. Konstantinou
- First Department of Cardiology, University of Ioannina Faculty of Medicine, 45110 Ioannina, Greece
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Earle WB, Kondo JK, Kendrick KN, Turkson-Ocran RA, Ngo L, Cluett JL, Mukamal KJ, Daya Malek N, Selvin E, Lutsey PL, Coresh J, Juraschek SP. Association of Supine Hypertension Versus Standing Hypotension With Adverse Events Among Middle-Aged Adults. Hypertension 2023; 80:2437-2446. [PMID: 37646155 PMCID: PMC10640713 DOI: 10.1161/hypertensionaha.123.21215] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Management of orthostatic hypotension (OH) prioritizes prevention of standing hypotension, sometimes at the expense of supine hypertension. It is unclear whether supine hypertension is associated with adverse outcomes relative to standing hypotension. OBJECTIVES To compare the long-term clinical consequences of supine hypertension and standing hypotension among middle-aged adults with and without OH. METHODS The ARIC study (Atherosclerosis Risk in Communities) measured supine and standing blood pressure (BP) in adults aged 45 to 64 years, without neurogenic OH, between 1987 and 1989. We defined OH as a positional drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg, supine hypertension as supine BP≥140/≥90 mm Hg, and standing hypotension as standing BP≤105/≤65 mm Hg. Participants were followed for >30 years. We used Cox regression models to examine associations with cardiovascular disease events, all-cause mortality, falls, and syncope. RESULTS Of 12 489 participants (55% female, 26% Black, mean age 54 years, SD 6), 4.4% had OH. Among those without OH (N=11 943), 19% had supine hypertension and 21% had standing hypotension, while among those with OH (N=546), 58% had supine hypertension and 38% had standing hypotension. Associations with outcomes did not differ by OH status (P-interactions >0.25). Supine hypertension was associated with heart failure (hazard ratio, 1.83 [95% CI, 1.68-1.99]), falls (hazard ratio, 1.12 [95% CI, 1.02-1.22]), and all-cause mortality (hazard ratio, 1.45 [95% CI, 1.37-1.54]), while standing hypotension was only significantly associated with mortality (hazard ratio, 1.06 [95% CI, 1.00-1.14]). CONCLUSIONS Supine hypertension was associated with higher risk of adverse events than standing hypotension, regardless of OH status. This challenges conventional OH management, which prioritizes standing hypotension over supine hypertension.
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Affiliation(s)
- William B Earle
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Jordan K Kondo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Karla N Kendrick
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Ruth-Alma Turkson-Ocran
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Jennifer L Cluett
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Natalie Daya Malek
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (P.L.L.)
| | - Josef Coresh
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
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Neshige S, Ohno N, Maruyama H. Attacks With Urinary Incontinence Without Convulsions: Complete Atrioventricular Block Mimicking an Epileptic Seizure. Cureus 2023; 15:e49552. [PMID: 38156189 PMCID: PMC10753645 DOI: 10.7759/cureus.49552] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Differentiating between syncope and epileptic seizures can be challenging when a specific medical history is not available. We herein report a 70s man who exhibited recurrent, brief unresponsiveness while at rest on five occasions over a year. While there were no convulsions, the patient consistently reported urinary incontinence. These events were preceded by an epigastric rising sensation without chest symptoms, suggesting a possible diagnosis of temporal lobe epilepsy, and subsequent EEG revealed temporal semi-rhythmic delta activity. In contrast, the ECG revealed a left bundle branch block, while the initial Holter ECG showed no abnormalities. However, subsequent follow-up examinations revealed a complete atrioventricular block necessitating permanent pacemaker implantation. It is important to exercise caution in the interpretation of EEG findings. Moreover, instances of 'urinary incontinence without convulsion' may indicate non-epileptic events.
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Affiliation(s)
- Shuichiro Neshige
- Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, JPN
| | - Narumi Ohno
- Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, JPN
| | - Hirofumi Maruyama
- Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, JPN
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El Hunjul GN, Cazzaniga J, Navarro Gonzalez J, Quinonez J, Ruxmohan S, Fahs A. A Case of Takayasu's Arteritis Presenting With Acute Middle Cerebral Artery Stroke Managed With Aortic-Common Carotid Artery (CCA) Bypass Surgery. Cureus 2023; 15:e48166. [PMID: 38046774 PMCID: PMC10693388 DOI: 10.7759/cureus.48166] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
Takayasu's arteritis (TA) is a rare inflammatory disorder that affects large arteries, particularly the aorta and its main branches. TA is also known as a pulseless disease because it diminishes blood flow to the limbs and organs. The patient was a 17-year-old female whose prior medical history included a diagnosis of TA. She had been experiencing multiple syncopal episodes up to three times daily, lasting 10 seconds each. She was being managed outpatient with immunologic therapy and warfarin. She initially presented to a children's hospital with abdominal pain and an asymmetrical smile and was found to have a ruptured ovarian cyst. This case demonstrated that life-threatening complications of TA can occur as a result of otherwise unrelated and common circumstances. The patient was managed medically and then proceeded to surgery. The case further highlights the multidisciplinary team approach between medical and surgical specialties and weighing the risks and benefits of complications for the patient's long-term care. Early diagnosis and prompt initiation of appropriate therapy are essential for better outcomes. Clinicians should be aware of the nonspecific symptoms of TA and consider it in the differential diagnosis of young patients presenting with systemic symptoms and arterial insufficiency. The initial presentation of middle cerebral artery stroke in young women has been documented in prior literature, but most published cases present the medical management of the disease. Our patient's case was unique because medical management was insufficient, with surgical management pursued due to persistent symptomatic hypotension. The inciting event of this case, an ovarian rupture with retroperitoneal hemorrhage, represents a unique burden to watershed infarctions in this patient group. Further research is needed to understand the pathogenesis of TA better and to develop more effective treatment strategies for this challenging disease.
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Affiliation(s)
| | - Juliana Cazzaniga
- Neurology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | | | - Jonathan Quinonez
- Osteopathic Medicine/Neurology, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
- Addiction Medicine, Brandon Regional Hospital, Brandon, USA
| | - Samir Ruxmohan
- Neurocritical Care, University of Texas (UT) Southwestern Medical Center, Dallas, USA
| | - Abrahim Fahs
- Addiction Medicine, Brandon Regional Hospital, Brandon, USA
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Kawji MM. Alternating right and left bundle branch block during a treadmill stress test. J Electrocardiol 2023; 81:1-3. [PMID: 37453272 DOI: 10.1016/j.jelectrocard.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/12/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Mazen M Kawji
- OSF Cardiovascular Institute, Peoria, IL, United States of America; Saint Elizabeth Medical Center, Ottawa, IL, United States of America.
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Kondo JK, Earle WB, Turkson-Ocran RAN, Ngo LH, Cluett JL, Lipsitz LA, Daya NR, Selvin E, Lutsey PL, Coresh J, Windham BG, Kendrick KN, Juraschek SP. Standing Blood Pressure and Risk of Falls, Syncope, Coronary Heart Disease, and Mortality. Am J Hypertens 2023; 36:593-601. [PMID: 37458702 PMCID: PMC11003466 DOI: 10.1093/ajh/hpad064] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/05/2023] [Accepted: 07/13/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND ACC/AHA guidelines caution against the use of antihypertensive therapy in the setting of low standing systolic BP (SBP) < 110 mm Hg due to unclear benefits. METHODS The Atherosclerosis Risk in Communities (ARIC) Study measured supine and standing SBP in adults aged 45-64 years between 1987 and 1989. We used Cox regression to evaluate the associations of low standing SBP (<110 mm Hg) with risk of falls, syncope, coronary heart disease (CHD), and mortality through December 31, 2019. Falls and syncope were ascertained by hospitalization and outpatient claims; CHD events were adjudicated. Associations were examined overall and in strata of hypertension stage, 10-year atherosclerotic cardiovascular disease (ASCVD) risk, age, and sex. RESULTS Among 12,467 adults followed a median of 24 years (mean age at enrollment 54.1 ± 5.8 years, 55% women, 26% Black adults), 3,000 (24%) had a standing SBP < 110 mm Hg. A standing SBP < 110 mm Hg compared to standing SBP ≥ 110 mm Hg was not significantly associated with falls or syncope, and was associated with a lower risk of CHD events and mortality with HRs of 1.02 (95% CI 0.94, 1.11), 1.02 (0.93, 1.11), 0.88 (0.80, 0.97), and 0.91 (0.86, 0.97), respectively. There were no clinically meaningful differences when stratified by hypertension stage, 10-year ASCVD risk, age, and sex. CONCLUSIONS In this community-based population, low standing SBP was common and not significantly associated with falls or syncope, but was associated with a lower risk of CHD and mortality. These findings do not support screening for low standing BP as a risk factor for adverse events.
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Affiliation(s)
| | - William B Earle
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ruth-Alma N Turkson-Ocran
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Long H Ngo
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jennifer L Cluett
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Lewis A Lipsitz
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Natalie R Daya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Beverly Gwen Windham
- Department of Medicine, Division of Geriatric Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Karla N Kendrick
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Winchester Hospital, Beth Israel Lahey Health, Woburn, MA, USA
| | - Stephen P Juraschek
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Fernandes SIL, Carvalho MHA, Santos ICT, Palma AFM, Faim DRO, Dias JMO, Borges IR, Martins HAF, Pires AMGS. Characterisation and long-term follow-up of children with Brugada syndrome: experience from a tertiary paediatric referral centre. Cardiol Young 2023; 33:2028-2033. [PMID: 36510790 DOI: 10.1017/s1047951122003894] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIMS Brugada syndrome is an inherited condition, which typically presents in young adults. It can also be diagnosed in children, but data in this group remain scarce. This study aims to describe the clinical features, management, and follow-up of children with personal or family history of Brugada syndrome. METHODS Retrospective study of consecutive patients with Brugada history followed up in a tertiary paediatric referral centre between 2009 and 2021. Patients were assessed according to the phenotype: positive (with variable genotype) or negative (with positive genotype). RESULTS Thirty patients were included (mean age at diagnosis 7 ± 6 years, 53% male). Within the positive phenotype (n = 16), 81% were male, and 88% had spontaneous type 1 ECG pattern. A genetic test was performed in 88% and was positive in 57%. Fourteen patients had a negative phenotype-positive genotype, 79% female, all diagnosed during family screening; 43% mentioned family history of sudden cardiac death. Although most of the patients were asymptomatic, the prevalence of rhythm/conduction disturbances was not negligible, particularly if a positive phenotype. No clinically significant events were reported in the negative phenotype patients. Three patients were hospitalised due to an arrhythmic cause, all in patients with a positive phenotype. CONCLUSION In our study, the documentation of rhythm and conduction disturbances was not infrequent, especially in patients with a positive phenotype. Despite the significant family history, phenotype negative patients had no relevant events during follow-up. Nevertheless, the management of these patients is not clear cut, and a personalised therapeutic strategy with close follow-up is essential.
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Affiliation(s)
| | - Maria H A Carvalho
- Department of Paediatric Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Isabel C T Santos
- Department of Paediatric Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Andreia F M Palma
- Department of Paediatric Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Diogo R O Faim
- Department of Paediatric Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - João M O Dias
- Department of Paediatric Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Izidro R Borges
- Department of Paediatric Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | | | - António M G S Pires
- Department of Paediatric Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
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45
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Norrish G, Kadirrajah V, Field E, Dady K, Tollit J, McLeod K, McGowan R, Cervi E, Kaski JP. Childhood Hypertrophic Cardiomyopathy Caused by Beta-Myosin Heavy Chain Variants Is Associated With a More Obstructive but Less Arrhythmogenic Phenotype Than Myosin-Binding Protein C Disease. Circ Genom Precis Med 2023; 16:483-485. [PMID: 37387224 DOI: 10.1161/circgen.123.004118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Affiliation(s)
- Gabrielle Norrish
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., K.D., J.T., E.C., J.P.K.)
- Institute of Cardiovascular Science, University College London, United Kingdom (G.N., V.K., E.F., J.T., E.C., J.P.K.)
| | - Vidthya Kadirrajah
- Institute of Cardiovascular Science, University College London, United Kingdom (G.N., V.K., E.F., J.T., E.C., J.P.K.)
| | - Ella Field
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., K.D., J.T., E.C., J.P.K.)
- Institute of Cardiovascular Science, University College London, United Kingdom (G.N., V.K., E.F., J.T., E.C., J.P.K.)
| | - Kathleen Dady
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., K.D., J.T., E.C., J.P.K.)
| | - Jennifer Tollit
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., K.D., J.T., E.C., J.P.K.)
- Institute of Cardiovascular Science, University College London, United Kingdom (G.N., V.K., E.F., J.T., E.C., J.P.K.)
| | - Karen McLeod
- Department of Pediatric Cardiology, Royal Hospital for Children, Glasgow, United Kingdom (KML)
| | - Ruth McGowan
- West of Scotland Centre for Genomic Medicine, Glasgow, United Kingdom (R.M.G.)
| | - Elena Cervi
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., K.D., J.T., E.C., J.P.K.)
- Institute of Cardiovascular Science, University College London, United Kingdom (G.N., V.K., E.F., J.T., E.C., J.P.K.)
| | - Juan Pablo Kaski
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., K.D., J.T., E.C., J.P.K.)
- Institute of Cardiovascular Science, University College London, United Kingdom (G.N., V.K., E.F., J.T., E.C., J.P.K.)
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46
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Chaudhary AJ, Qureshi MH, El Sharu H, Prostak J. An Interesting Case of Recurrent Postprandial Cardiogenic Syncope Caused by Type III Hiatal Hernia. Cureus 2023; 15:e47791. [PMID: 38021578 PMCID: PMC10676567 DOI: 10.7759/cureus.47791] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Patients with syncope often present a diagnostic challenge due to the diverse causes of this condition. While a careful assessment can identify the underlying cause in many cases, syncope can arise from a variety of sources, including structural anomalies. Among these, hiatal hernia (HH) is a relatively common yet unusual condition associated with syncope. HH involves the protrusion of abdominal organs into the mediastinum through the diaphragmatic esophageal hiatus, with types III and IV being capable of causing cardiac problems. We report a case of a 92-year-old patient with a known HH history who experienced recurrent syncope episodes triggered by heavy meals. Extensive evaluation ruled out cardiac and neurological causes. Imaging revealed a large HH compressing the left atrium. Despite being an infrequent occurrence, such cases highlight the potential for atrial compression-induced syncope, which can be effectively managed with proton pump inhibitors and lifestyle modifications, as demonstrated by our patient's positive outcome.
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Affiliation(s)
| | | | - Husam El Sharu
- Internal Medicine, East Carolina University, Greenville, USA
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47
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Stec S, Wileczek A, Reichert A, Śledź J, Kosior J, Jagielski D, Polewczyk A, Zając M, Kutarski A, Karbarz D, Zyśko D, Nowarski Ł, Stodółkiewicz-Nowarska E. Shared Decision Making and Cardioneuroablation Allow Discontinuation of Permanent Pacing in Patients with Vagally Mediated Bradycardia. J Cardiovasc Dev Dis 2023; 10:392. [PMID: 37754821 PMCID: PMC10532162 DOI: 10.3390/jcdd10090392] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Safe discontinuation of pacemaker therapy for vagally mediated bradycardia is a dilemma. The aim of the study was to present the outcomes of a proposed diagnostic and therapeutic process aimed at discontinuing or not restoring pacemaker therapy (PPM) in patients with vagally mediated bradycardia. METHODS The study group consisted of two subgroups of patients with suspected vagally mediated bradycardia who were considered to have PPM discontinued or not to restore their PPM if cardioneuroablation (CNA) would successfully treat their bradycardia. A group of 3 patients had just their pacemaker explanted but reimplantation was suggested, and 17 patients had preexisting pacemakers implanted. An invasive electrophysiology study was performed. If EPS was negative, extracardiac vagal nerve stimulation (ECVS) was performed. Then, patients with positive ECVS received CNA. Patients with an implanted pacemaker had it programmed to pace at the lowest possible rate. After the observational period and control EPS including ECVS, redo-CNA was performed if pauses were induced. The decision to explant the pacemaker was obtained based on shared decision making (SDM). RESULTS After initial clinical and electrophysiological evaluation, 17 patients were deemed eligible for CNA (which was then performed). During the observational period after the initial CNA, all 17 patients were clinically asymptomatic. The subsequent invasive evaluation with ECVS resulted in pause induction in seven (41%) patients, and these patients underwent redo-CNA. Then, SDM resulted in the discontinuation of pacemaker therapy or a decision to not perform pacemaker reimplantation in all the patients after CAN. The pacemaker was explanted in 12 patients post-CNA, while in 2 patients explantation was postponed. During a median follow-up of 18 (IQR: 8-22) months, recurrent syncope did not occur in the CNA recipients. CONCLUSIONS Pacemaker therapy in patients with vagally mediated bradycardia could be discontinued safely after CNA.
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Affiliation(s)
- Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Antoni Wileczek
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Agnieszka Reichert
- Department of Invasive Cardiology, County Specialistic Hospital, 37-450 Stalowa Wola, Poland
| | - Janusz Śledź
- El-Medica, EP-NETWORK, 26-110 Skarzysko-Kamienna, Poland
| | - Jarosław Kosior
- Department of Cardiology, Masovian Specialist Hospital, 26-617 Radom, Poland
| | - Dariusz Jagielski
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, 50-981 Wroclaw, Poland
- Faculty of Medicine, Wrocław University of Science and Technology, 50-370 Wroclaw, Poland
| | - Anna Polewczyk
- Department of Physiology, Pathophysiology and Clinical Immunology, Institute of Medical Sciences, Jan Kochanowski University, 25-369 Kielce, Poland
- Department of Cardiac Surgery, Świętokrzyskie Center of Cardiology, 25-736 Kielce, Poland
| | - Magdalena Zając
- Department of Special Pedagogy and Speech Therapy, Kazimierz Wielki University, 85-064 Bydgoszcz, Poland
| | - Andrzej Kutarski
- Department of Cardiology, Medical University, 20-059 Lublin, Poland
| | | | - Dorota Zyśko
- Department of Emergency Medicine, Wrocław Medical University, 50-367 Wroclaw, Poland
| | - Łukasz Nowarski
- Vascular Surgery Department, The Brothers of Saint John of God Hospital, 31-061 Krakow, Poland
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48
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Pasini E, Michelucci R. The Heart and Seizures: Friends or Enemies? J Clin Med 2023; 12:5805. [PMID: 37762746 PMCID: PMC10532013 DOI: 10.3390/jcm12185805] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
The heart and seizures are closely linked by an indissoluble relationship that finds its basis in the cerebral limbic circuit whose mechanisms remain largely obscure. The differential diagnosis between seizures and syncopes has always been a cornerstone of the collaboration between cardiologists and neurologists and is renewed as a field of great interest for multidisciplinary collaboration in the era of the diffusion of prolonged telemonitoring units. The occurrence of ictal or post-ictal arrhythmias is currently a cause of great scientific debate with respect to the role and risks that these complications can generate (including sudden unexpected death in epilepsy). Furthermore, the study of epileptic seizures and the arrhythmological complications they cause (during and after seizures) also allows us to unravel the mechanisms that link them. Finally, intercritical arrhythmias may represent great potential in terms of the prevention of cardiological risk in epileptic patients as well as in the possible prediction of the seizures themselves. In this paper, we review the pertaining literature on this subject and propose a scheme of classification of the cases of arrhythmia temporally connected to seizures.
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49
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Breda D, Ferreira S, Colino M, Cerqueira É, Amado I. Recurrent Syncope Related to Carotid Compression in Eagle Syndrome: A Case Report. Cureus 2023; 15:e45134. [PMID: 37842484 PMCID: PMC10569899 DOI: 10.7759/cureus.45134] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2023] [Indexed: 10/17/2023] Open
Abstract
Eagle syndrome is a rare disease characterised by symptoms associated with an elongated styloid process or calcification of the stylohyoid and stylomandibular ligament. Symptoms associated with Eagle Syndrome include orofacial and cervical pain, dysphagia, and pharyngeal foreign body sensation. Additionally, it can present with cerebrovascular symptoms due to the compression of adjacent neurovascular structures within the vicinity of the styloid process during rotation and extension of the neck. This report presents the case of a 33-year-old male with bilateral elongated styloid processes in whom the only symptom referred was recurrent syncope. The diagnosis was made years after the initial complaints and after several observations and imagings performed by different specialities. Surgical resection of the elongated process by the cervical approach was the treatment of choice. In patients with cerebrovascular symptoms, principally those induced by positional changes of the neck, Eagle syndrome should be considered in the differential diagnosis.
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Affiliation(s)
- Diana Breda
- Maxillofacial Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Sandra Ferreira
- Maxillofacial Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Margarida Colino
- Maxillofacial Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Érica Cerqueira
- Maxillofacial Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Isabel Amado
- Maxillofacial Surgery Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
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50
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Bhatia RT, Finocchiaro G, Westaby J, Chatrath N, Behr ER, Papadakis M, Sharma S, Sheppard MN. Myocarditis and Sudden Cardiac Death in the Community: Clinical and Pathological Insights From a National Registry in the United Kingdom. Circ Arrhythm Electrophysiol 2023; 16:e012129. [PMID: 37565354 PMCID: PMC10615359 DOI: 10.1161/circep.123.012129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Affiliation(s)
- Raghav T. Bhatia
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom (R.T.B., G.F., J.W., N.C., E.R.B., M.P., S.S., M.N.S.)
- Hull University Teaching Hospitals NHS Trust, Kingston-upon-Hull, United Kingdom (R.T.B.)
| | - Gherardo Finocchiaro
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom (R.T.B., G.F., J.W., N.C., E.R.B., M.P., S.S., M.N.S.)
| | - Joseph Westaby
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom (R.T.B., G.F., J.W., N.C., E.R.B., M.P., S.S., M.N.S.)
- Cardiovascular Pathology Department, St George’s, University of London, United Kingdom (J.W., M.N.S.)
| | - Nikhil Chatrath
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom (R.T.B., G.F., J.W., N.C., E.R.B., M.P., S.S., M.N.S.)
| | - Elijah R. Behr
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom (R.T.B., G.F., J.W., N.C., E.R.B., M.P., S.S., M.N.S.)
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom (R.T.B., G.F., J.W., N.C., E.R.B., M.P., S.S., M.N.S.)
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom (R.T.B., G.F., J.W., N.C., E.R.B., M.P., S.S., M.N.S.)
| | - Mary N. Sheppard
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom (R.T.B., G.F., J.W., N.C., E.R.B., M.P., S.S., M.N.S.)
- Cardiovascular Pathology Department, St George’s, University of London, United Kingdom (J.W., M.N.S.)
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