Long-term follow-up after syncope. A group of 183 patients observed for 5 years

BACKGROUND

To determine the incidence of recurrent syncope and mortality rate in a group of patients hospitalized for syncope.

METHODS

A 5 years follow-up of 183 patients hospitalized for syncope. A collaborative study between the Departments of Cardiology and Neurology.

RESULTS

The etiological diagnosis of syncope was the following: unknown causes 21.86%, cardiovascular causes 72.67%, non-cardiovascular cause 5.46%. The general mortality rate was 26.77% (51.94% in those aged > = 70 years, 8.49% in < 70 years). The mortality rate of syncope of unknown causes was 30% among all patients (61.11% in those aged > = 70 years and 4.54% < 70 years). Syncope of cardiac cause (prevalent arrhythmias) and syncope of iatrogenic cause had a high mortality rate (respectively 63.33% and 42.10%); both in young people (28.53%, 26.53%) and in old people (66.66%, 50%). Syncope of reflex cause has a mortality rate of 5.79% (4/69) among all patients (14.28% in those aged > = 70 years, 3.63 in < 70 years). Age, arterial hypertension, ischemic heart disease and cerebrovascular events are significantly associated with mortality rate. Recurrences were quite common: 24.59% of all patients (45/183); 29/45 syncope (64.44%) were observed in the first year of follow-up with a prevalence for patients with a syncope of reflex cause (26.09%) and for those with a syncope of unknown cause (37.56%). Recurrences were less common among patients with syncope of cardiac cause, however more frequent during the first year of follow-up, with an increased risk of mortality.

CONCLUSIONS

A. The cause of syncope is most frequently established on the basis of history and clinical examination. B. A collaboration between Departments with a common interest for this pathology is recommended. C. Cardiac syncope has the worst prognosis and therefore needs recurrent clinical examinations and prompt treatment. D. Syncope itself is not a risk factor for increased overall and cardiac mortality or cardiovascular events. E. Underlying diseases such as hypertension, ischemic heart diseases, congestive heart failure, cerebrovascular events are the major risk factors for mortality.

[Incidence of carotid atherosclerosis in patients undergoing a coronarographic study. A prospective study of 193 patients]

BACKGROUND

Many studies have identified the interrelationship between carotid artery disease (CD) and coronary artery disease (CAD). The purpose of this study was to evaluate the real incidence of CD, using an echo-duplex technique, in patients hospitalized for diagnostic coronary angiography.

METHODS AND RESULTS

An ultrasound evaluation with echo-duplex of the carotid arteries was performed on 193 consecutive patients (152 males and 41 females) hospitalized for diagnostic coronary arteriography. Patients were divided into three groups: normal coronary angiography, coronary artery with stenosis < 70% (< 50% of left main), coronary artery with stenosis > or = 70% of a vessel (> or = 50% of left main). Carotid arteries were divided into normal arteries, arteries with stenosis < 50%, arteries with stenosis > or = 50% and < 70% and arteries with stenosis > or = 70%. Seventy-one patients had one-vessel disease, 42 had two-vessel disease and 49 had three-vessel disease (10 with left main disease). Out of 193 patients, 86 had CD and of these, 64 had a lumen stenosis < 50% and 22 a lumen stenosis > or = 50%. There was a strong correlation between the degree of carotid lumen stenosis and the extent of CAD. Carotid artery stenosis > or = 50% was present in 12.96% of the patients (21/162) with coronary stenosis > or = 70% of a vessel. In particular, 8.45% (6/71) and 9.52 (4/42) of patients with stenosis of 1 or 2 coronary vessels; 22.45% (11/49) with stenosis of 3 coronary vessels [40% (4/10) when the left main artery was involved].

CONCLUSIONS

Our study confirms the relatively high frequency of CD in patients with CAD and the correlation between the degree of carotid artery stenosis and the extent of CAD. This seems to justify the use of carotid echo-duplex investigation in patients hospitalized for diagnostic coronary angiography and indeed, it is mandatory before coronary revascularization (especially in aorta-coronary bypass).

[Patients with carotid stenosis and clinical history negative for coronary disease. Usefulness of the ergometric test for the identification of ischemic myocardial disease]

BACKGROUND

The purpose of this study was to evaluate, by Stress-Exercise Electrocardiography (SE), the presence of Coronary Artery Disease (CAD) in patients with asymptomatic or symptomatic carotid stenosis, who had no history of myocardial ischemia.

MATERIALS, METHODS AND RESULTS

133 patients with significant carotid stenosis (> = 50%) were consecutively studied according to an established vascular protocol. Of 92 patients with no history of CAD, 3 were excluded, 4 with bilateral carotid occlusion underwent an Echocardiography-Stress Test with Dipyridamole (ED) with negative result. 85 patients underwent a SE. The result was negative in 50 patients, positive in 21. In 14 patients the SE was uncertain so that they underwent an ED or stress thallium-201 myocardial scintigraphy with positive result in 2. No correlation between the degree of carotid stenosis and the positive SE in patients with significant carotid artery atherosclerosis was found.

CONCLUSIONS

Our study demonstrates that about 25% of patients with significant asymptomatic and symptomatic carotid stenosis and no history of CAD had a latent myocardial ischemia and that the screening of these patients with SE is easy, inexpensive and safe and allow us to detect those who need a more active treatment.

[Importance of ischemic heart disease in patients with carotid arteriosclerosis and lower extremity arteriopathy. Results of a prospective study]

OBJECTIVES

Myocardial ischemia (MI) is a frequent cause of morbility and mortality in patients with carotid atherosclerosis (CA) independently of the symptomatology. The objective of our study was the identification of MI through clinical-history or as revealed by the stress test.

METHODS

The study considered a consecutive series of patients with significant CA (stenosis > or = 50%), studied with echo-B mode and Doppler velocity scans chosen from all patients in the diagnostic vascular cerebral laboratory, between May 1992 and January 1994, for a non invasive study of neck arteries. The protocol of the multidisciplinary study included: history of risk factors (RF); neurologic evaluation; peripheral vascular evaluation with Doppler velocity scans; cardiac evaluation, and patients without clinical history of MI underwent a maximal stress test (ST). If there was bilateral carotid occlusion or non-evaluated ST the patients underwent echo-stress with dipyridamole (ED) or myocardial scintigraphy stress test (MS); haematologic tests, CT in patients with symptoms of cerebral ischemia; arteriography of epi-aortic arteries in patients with indication for carotid enderterectomy.

RESULTS

133 patients were studied (age 48-80). Neurologic symptoms were present in 67.67%; of the RF, smoke was present in 62.48%, blood hypertension (BH) in 58.64% and family history in 36.84%. The MI was affirmed in 64 patients (48.12%): in 41 with clinical history, in 23 with ST. Of the 92 patients without clinical history: 4 with bilateral carotid occlusion underwent ED; 3 did not undergo ST, 85 underwent ST with negative results in 50, positive in 21, non-evaluated in 14 who underwent ED or MS with positive results of MI in 2. In 25% (23/92) ST revealed MI without previous history.

CONCLUSIONS

The patients with CA have high incidence of MI and of peripheral artery disease (PAD), in MI could be studied by ST. Age, smoke, BH, contribute substantially to the development of CA. PAD develops similarly to CA. MI is distributed independently of the severity of CA. A patient with CA, whatever his presentation, must be studied to reveal an eventual, latent or silent MI. It is this, in fact, which heavily conditions the prognosis.

[Value of continuous electrocardiographic monitoring of patients with syncope. Results of a prospective study]

AIM

Syncope, a temporary loss of conscience, is a frequent cause for consulting the family doctor or more often being brought to the hospital emergency ward. In order to evaluate the importance of the continuous recording of ECG in the formulation of the diagnosis, the relevant data were extrapolated from more general data in the prospective study.

MATERIAL

A total of 194 patients were enrolled whose diagnosis was divided into three distinct stages. Continuous echographic registration using Holter's method and/or bedside monitoring was included in the 2nd stage and was performed in 134 patients.

RESULTS

102 out of 134 patients (76.11%) showed rhythm alterations: varying degrees of atrio-ventricular block were recorded in 6 patients; supraventricular arrhythmia in 73 cases which were divided according to a modified to a modified version of Lawn's classification. Continuous ECG recording alone proved decisive in formulating a diagnosis in 6 patients (one of which together with echocardiogram): in 2 patients due to the presence of complex ventricular extrasystoles; in 4 due to torsion of the tip, sinusal arrest, cardiac arrest, supraventricular tachycardia with aberrant intraventricular conduction, respectively.

CONCLUSIONS

Especially when standard surface ECG is carried out rapidly following an acute attack, continuous ECG recording is of scant diagnostic value due to the etiological definition of syncope. But due to its moderate cost and non-invasive character it is worth performing in syncopes of suspected cardiogenic etiology with a more severe prognosis.

[Syncope in a general population: etiologic diagnosis and follow-up. Results of a prospective study]

OBJECTIVE

Syncope is a common clinical problem in a general population. A prospective study was performed, in our hospital, to evaluate the incidence of the disease and to standardize the diagnostic and clinical management.

METHODS

194 patients aged 10-92 years were recruited during one year. The diagnostic produce followed the three standard stages: First stage clinical evaluation (a complete history, physical and neurological examination, a base-line laboratory evaluation, a 12-lead electrocardiogram, carotid sinus stimulation); Second stage non invasive investigation (echocardiogram, 24-hour electrocardiographic monitoring, electroencephalography, Doppler echocardiography of epiaortic vessels, head-up tilt test, head CT scan); third stage invasive investigation (electrophysiologic study).

RESULTS

Diagnosis was, sometimes, difficult because of the sporadic and transitory nature of the syncope. The etiological diagnosis were the following: cardiovascular causes 68.55% (cardiac 31.95%, reflex syncope 36.59%). Non-cardiovascular causes 10.82% (metabolic 5.15%, neurologic 3.5%, different 2.06%). Unknown cause 20.61%. Diagnosis was determined at the following stages: ist stage 63.40% (complete history and physical examination alone 4072%), 2nd stage 14.43%, 3rd stage 1.54%. The mean follow-up period was 21.71 +/- 6.22 months. Over this period 17 (8.76) patients died; all aged (> 65 years) end in this aged the incidence is 18.08%. If we look at patients with correct diagnosis of syncope (183 patients) the mortality rate is 8.19% (if we consider those aged > 65 the rate is 17.44%). The mortality rate of cardiac syncope of unknown (28.88% for aged > 65 years). 2 deaths among syncope of unknown cause. 17.48% had 1 or more episodes of recurrent syncope during this follow-up period with little prevalence for patients with syncope of unknown origin. Other major cardiovascular events was 18.03% in all patients with little prevalence for cardiac cause of syncope.

CONCLUSIONS

1) Frequently an accurate history, a physical examination and a standard ECG are enough to formulate a correct diagnosis. 2) Head-up tilt test must be considered in patients with a unknown diagnosis, before starting invasive investigation. 3) Prognosis is dependent on the specific cause. Since cardiac syncope has a serious prognosis, when it is not treated correctly, it can even lead to sudden death.

[The use of dynamic electrocardiographic monitoring in scleroderma patients]

A comparative analysis of arrhythmias by "basal" electrocardiogram (ECG) and by continuous 24-hour Holter electrocardiogram monitoring was performed in 17 patients with systemic sclerosis (16 women and one man). Our study confirms that rhythm disturbances are better detectable using Holter monitoring. In fact, no patients had ventricular arrhythmias detected by ECG; on the contrary, Holter monitoring revealed ventricular arrhythmias in nine patients (53.3%). This method also revealed a ventricular tachycardia, not detected by ECG. In two patients ventricular repolarisation abnormalities without symptoms was revealed.

Nitrendipine once daily compared with nicardipine in the treatment of mild to moderate hypertension

Twenty-four patients with mild to moderate hypertension were randomly assigned to 42 days of treatment with 20 mg of nitrendipine once daily or 20 mg of nicardipine thrice daily. In the nitrendipine-treated and nicardipine-treated patients, respectively, mean resting blood pressure decreased from 163 +/- 12 and 161 +/- 11 mmHg at baseline to 152 +/- 12 and 146 +/- 9 mmHg at six weeks (P less than 0.001). Blood pressures were reduced after one day of treatment, followed by an attenuation of the drug effect. In both treatment groups, blood pressures after cycloergometric, isometric, and cold-pressure tests were significantly lower at six weeks than at baseline; at six weeks, blood pressures were also significantly reduced two hours after drug administration, compared with those at or just before drug administration. It is concluded that nitrendipine taken once daily is safe and effective in the treatment of mild to moderate hypertension.