Utility of telemetry in syncope admissions

Introduction

Syncope is a major cause of emergency room visits and admission to telemetry units however, prior studies have shown conflicting evidence for the necessity for a telemetry admission. Our current 2017 ACC/AHA/HRS guidelines recommend telemetry admissions for syncope evaluation when cardiac etiology is suspected.

Purpose

The purpose of this study is to investigate whether there are any differences in telemetry events in patients with a cardiac syncope versus non-cardiac/unspecified and to determine any correlation between the number of cardiac risk factors in patients with cardiac syncope versus non-cardiac etiology to predict those who would benefit most from telemetry.

Methods

Our retrospective study included 574 patients admitted to the cardiac telemetry unit between February 2017 and February 2020 at our metropolitan tertiary care centre, further grouped into: cardiac, non-cardiac, or unspecified syncope. Cardiac syncope included aetiologies such as arrhythmias, pulmonary hypertension, Long QTc, device malfunction etc. The non-cardiac syncope group included aetiologies such as orthostatic and reflex mediated. Thirteen cardiac risk factors were summed from the 2009 ESC syncope guidelines. These included HFrEF, elevated BNP, anemia, abnormal ECG, family history of sudden cardiac death or MI, age above 65, male gender, structural heart disease, abnormal vitals on presentation, history of sudden cardiac death, no prodrome prior to syncope and chest pain.

Results

Of the 574 patients, 102 patients (17.7%) had a cardiac etiology, 405 patients (70.5%) had a non-cardiac etiology and 67 patients (11.6%) had unspecified etiology for syncope. Overall, 47% of the cardiac group, 16% of the non-cardiac group, and 12% of the unspecified group had telemetry events. There was a statistically significant difference in the number of patients with telemetry events among the three syncope groups, p<0.0001. The odds of patients with cardiac syncope having telemetry events were 4.0 times greater than those with non-cardiac syncope and 6.3 time higher than those with unspecified syncope.

The average number of risk factors were: 4 (±1.7) (cardiac), 3±1.6 (non-cardiac), and 3±1.7 (unspecified). Linear regression model showed the number of risk factors to be 19% and 15% lower in the non-cardiac and unspecified groups compared to the cardiac group. There was no association between any of the individual risk factors and the presence of telemetry event.

Conclusions

Our study demonstrates that those with cardiac syncope tend to have more cardiac risk factors and more telemetry events relative to their non-cardiac syncope counterparts. While patients with cardiac risk factors have on average a higher cardiac risk factor profile, it is not clinically significant enough to determine who would benefit from telemetry versus who would not.

Funding Acknowledgement

Type of funding sources: None.

MP14: UTILIZATION OF THE INVASIVE CARDIAC LABORATORY FOR IMMEDIATE CARDIAC CATHETERIZATION: A QUALITY IMPROVEMENT PROJECT

Purpose of Study

Immediate cardiac catheterization is indicated for patients presenting with ST elevation (STE) myocardial infarction, and door-to-balloon time should be <90 min. Patients with non-ST elevation myocardial infarction (NSTEMI) can often be stabilized with medication, and only require urgent invasive evaluation if there is persistent chest pain(despite medical therapy) or hemodynamic or electrical instability. Immediate cardiac catheterization for patients presenting to the ER with chest pain is available in many hospitals, but it involves a large investment of resources which need to be properly utilized. This study evaluated patients sent for urgent invasive evaluation to determine how the facility is utilized.

Abstract MP14 Table 1

STE+STE−≥90%2910≤90% 4 7

Methods Used

In a retrospective chart review, charts from all STEMI code patients presenting between the dates 1/1/15–9/1/15 were studied. The presenting EKG was evaluated to determine whether STE criteria (as per ACC guidelines) were met. The charts were reviewed for angiographic data to determine whether there was ≥90% stenosis of a coronary artery (≥90%) or not (≤90%). Clinical parameters were studied to determine if there were any differences between the groups.

Summary of Results

The study group included 50 patients who went to the cardiology catheterization lab emergently secondary to an indication of STE; 33/50 (66%) patients met guideline criteria for ST elevation (STE+) while 17/50 (34%) did not (STE−). In the STE+ group, 29/33 (88%) had ≥90% occlusion of a coronary artery, while 10/17 (59%) in the STE-group had this degree of stenosis. The sensitivity and specificity of STE for ≥90% coronary artery occlusion on angiography was 74% and 64% respectively. The PPV of STE for >90% stenosis was 88%, while the NPV was 41%.

Conclusions

Significant STE in the proper clinical situation is a Class 1 indication for immediate coronary catheterization. However, 34% referred for immediate catheterization in this study did not meet ACC criteria for STEMI. Although a significant % in the NSTEMI group had ≥90% stenosis, urgent catheterization is only indicated in this group when there is a clinical parameter which dictates the necessity of immediate evaluation.

Comparison of two calcium blockers on hemodynamics, left ventricular mass, and coronary vasodilatory in advanced hypertension

Dihydropyridine and nondihydropyridine calcium channel blockers (CCB) differ in pharmacologic characteristics. Few clinical studies distinguish effects of CCB as monotherapy. We conducted a comprehensive comparison of two CCB on patients with moderate to severe hypertension. Thirty patients with pretreatment diastolic blood pressures > or = 100 mm Hg were randomly assigned to either nifedipine-GITS or verapamil-SR. Dose titration achieved a diastolic blood pressure of < or = 95 mm Hg or a decrease of > or = 15 mm Hg over 4 weeks. Clinic blood pressure (BP), 24-h ambulatory BP, exercise BP, left ventricular mass, systolic and diastolic function by echocardiography, and coronary flow reserve by split-dose thallium-201 imaging with adenosine were assessed at baseline, end of titration, 3 months and 6 months of treatment. Plasma renin activity, atrial natriuretic peptide, norepinephrine, and epinephrine were assayed. Both drugs caused similar reductions in clinic and 24-h ambulatory BP and similar reductions in left ventricular mass index. Compared to nifedipine-GITS, verapamil-SR produced a significantly lower resting and peak exercise heart rate. Nifedipine-GITS elicited a lower peak exercise systolic BP. At end titration nifedipine-GITS produced lower plasma atrial natriuretic peptide levels, no longer apparent by 6 months. Plasma norepinephrine was lower with verapamil-SR, also at end titration and at 3 months, but not at 6 months. Plasma epinephrine and plasma renin activity were unchanged by either drug. There was no difference for systolic or diastolic left ventricular function or coronary flow reserve between the two treatments. Once daily nifedipine-GITS and verapamil-SR are equally effective for reduction of arterial pressure in moderate to severe hypertension. Differences in their hemodynamic profiles and neurohormonal responses are consistent with preclinical pharmacologic characteristics. The clinical implications of their similarities and differences remain to be fully evaluated in outcome studies.

Effects of fire fighting uniform (modern, modified modern, and traditional) design changes on exercise duration in New York City Firefighters

Fire departments have replaced traditional uniforms with modern, more thermal protective gear. Although the new uniforms afford superior burn protection, they may reduce work time. Our purpose was to determine if exercise time was (1) reduced by wearing the modern versus traditional uniform, and (2) increased by a design change to a modified modern uniform (T-shirt and short pants rather than a shirt and long pants under the outer uniform). Male firefighters (n = 23; age 27 to 59) performed a maximum exercise test in gym clothes (maximal oxygen consumption = 46 +/- 9 ml/kg/min) and then returned on separate days to exercise using a moderately high intensity, constant work rate treadmill protocol while wearing fire fighting breathing apparatus and each of three uniforms. Firefighters exceeded anaerobic threshold by 1 minute and eventually reached or exceeded maximum heart rate and maximal oxygen consumption. Exercise time in modern (15 +/- 3 min) was significantly less than in traditional (18 +/- 5 min) uniform. Exercise time in modified modern (17 +/- 5 min) was significantly greater than in modern and not significantly different than in traditional uniforms. The rate of change in oxygen consumption and water loss were significantly affected by uniform type, with faster rates in modern compared with modified modern or traditional uniforms. These findings show the impact that design changes have on energy demands and exercise duration.

Hemodynamic compromise secondary to a mediastinal bronchogenic cyst

Bronchogenic cysts are not commonly the cause of severe symptoms, and often present only as an abnormality on chest roentgenogram. We report an unusual patient with a mediastinal bronchogenic cyst associated with rapid hemodynamic deterioration secondary to compression of vital structures.

Naloxone-responsive hypotension in a patient with an ACTH-secreting tumor

We report a case in which hypotension was corrected by the administration of naloxone in a patient with an ACTH-secreting mediastinal tumor. According to previous reports, reversal of hypotension would not be expected in patients with suppressed central ACTH secretion. The implications of this patient's response on the possible mechanisms for naloxone's action in reversing septic shock are discussed.