Andrea Ungar

Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: the EGSYS score

Objective: To develop, in patients referred for syncope to an emergency department (ED), a diagnostic score to identify those patients likely to have a cardiac cause. Design: Prospective cohort study. Setting: ED of 14 general hospitals. Patients: 516 consecutive patients with unexplained syncope. Interventions: Subjects underwent a diagnostic evaluation on adherence to Guidelines of the European Society of Cardiology. The clinical features of syncope were analysed using a standard 52-item form. In a validation cohort of 260 patients the predictive value of symptoms/signs was evaluated, a point score was developed and then validated in a cohort of 256 other patients. Main outcome measurements: Diagnosis of cardiac syncope, mortality. Results: Abnormal ECG and/or heart disease, palpitations before syncope, syncope during effort or in supine position, absence of autonomic prodromes and absence of predisposing and/or precipitating factors were found to be predictors of cardiac syncope. To each variable a score from +4 to –1 was assigned to the magnitude of regression coefficient. A score ⩾3 identified cardiac syncope with a sensitivity of 95%/92% and a specificity of 61%/69% in the derivation and validation cohorts, respectively. During follow-up (mean (SD) 614 (73) days) patients with score ⩾3 had a higher total mortality than patients with a score <3 both in the derivation (17% vs 3%; p<0.001) and in the validation cohort (21% vs 2%; p<0.001). Conclusions: A simple score derived from clinical history can be usefully employed for the triage and management of patients with syncope in an ED.

Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit Results From a Pilot, Randomized Trial

Background— Observational studies suggest that open visiting policies are preferred by most patients and visitors in intensive care units (ICUs), but no randomized trial has compared the safety and health outcomes of unrestrictive (UVP) and restrictive (RVP) visiting policies. The aim of this pilot, randomized trial was to compare the complications associated with UVP (single visitor with frequency and duration chosen by patient) and RVP (single visitor for 30 minutes twice a day). Methods and Results— Two-month sequences of the 2 visiting policies were randomly alternated for 2 years in a 6-bed ICU, with 226 patients enrolled (RVP/UVP, n=115/111). Environmental microbial contamination, septic and cardiovascular complications, emotional profile, and stress hormones response were systematically assessed. Patients admitted during the randomly scheduled periods of UVP received more frequent (3.2±0.2 versus 2.0±0.0 visits per day, mean±SEM) and longer (2.6±0.2 versus 1.0±0.0 h/d) visits (P<0.001 for both comparisons). Despite significantly higher environmental microbial contamination during the UVP periods, septic complications were similar in the 2 periods. The risk of cardiocirculatory complications was 2-fold (odds ratio 2.0; 95% CI, 1.1 to 3.5; P=0.03) in the RVP periods, which were also associated with a nonsignificantly higher mortality rate (5.2% versus 1.8%; P=0.28). The UVP was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. Conclusions— Despite greater environmental microbial contamination, liberalizing visiting hours in ICUs does not increase septic complications, whereas it might reduce cardiovascular complications, possibly through reduced anxiety and more favorable hormonal profile.

Effects of Low Blood Pressure in Cognitively Impaired Elderly Patients Treated With Antihypertensive Drugs

IMPORTANCE The prognostic role of high blood pressure and the aggressiveness of blood pressure lowering in dementia are not well characterized. OBJECTIVE To assess whether office blood pressure, ambulatory blood pressure monitoring, or the use of antihypertensive drugs (AHDs) predict the progression of cognitive decline in patients with overt dementia and mild cognitive impairment (MCI). DESIGN, SETTING, AND PARTICIPANTS Cohort study between June 1, 2009, and December 31, 2012, with a median 9-month follow-up of patients with dementia and MCI in 2 outpatient memory clinics. MAIN OUTCOMES AND MEASURES Cognitive decline, defined as a Mini-Mental State Examination (MMSE) score change between baseline and follow-up. RESULTS We analyzed 172 patients, with a mean (SD) age of 79 (5) years and a mean (SD) MMSE score of 22.1 (4.4). Among them, 68.0% had dementia, 32.0% had MCI, and 69.8% were being treated with AHDs. Patients in the lowest tertile of daytime systolic blood pressure (SBP) (≤ 128 mm Hg) showed a greater MMSE score change (mean [SD], -2.8 [3.8]) compared with patients in the intermediate tertile (129-144 mm Hg) (mean [SD], -0.7 [2.5]; P = .002) and patients in the highest tertile (≥ 145 mm Hg) (mean [SD], -0.7 [3.7]; P = .003). The association was significant in the dementia and MCI subgroups only among patients treated with AHDs. In a multivariable model that included age, baseline MMSE score, and vascular comorbidity score, the interaction term between low daytime SBP tertile and AHD treatment was independently associated with a greater cognitive decline in both subgroups. The association between office SBP and MMSE score change was weaker. Other ambulatory blood pressure monitoring variables were not associated with MMSE score change. CONCLUSIONS AND RELEVANCE Low daytime SBP was independently associated with a greater progression of cognitive decline in older patients with dementia and MCI among those treated with AHDs. Excessive SBP lowering may be harmful for older patients with cognitive impairment. Ambulatory blood pressure monitoring can be useful to help avoid high blood pressure overtreatment in this population.

Diagnosis and Characteristics of Syncope in Older Patients Referred to Geriatric Departments

OBJECTIVES: To test the applicability and safety of a standardized diagnostic algorithm in geriatric departments and to define the prevalence of different causes of syncope in older patients.

Prognostic Stratification of Older Persons Based on Simple Administrative Data: Development and Validation of the “Silver Code,” To Be Used in Emergency Department Triage

BACKGROUND Prognostic stratification of older patients with complex medical problems among those who access the emergency department (ED) may improve the effectiveness of geriatric interventions. Whether such targeting can be performed through simple administrative data is unknown. METHODS We examined the discharge records for 10,913 patients aged 75 years or older admitted during 2005 to the ED of all public hospitals in Florence, Italy. Using information on demographics, drug treatment, previous hospital admissions, and discharge diagnoses, we developed a 1-year mortality prognostic index. The predictive validity of this index was tested in a subsample of patients independent of the subsample used for its original development. Finally, we tested whether patients stratified by the prognostic index had different mortality when admitted to a geriatrics compared with an internal medicine ward. RESULTS In the validation subsample, patients with scores of 4-6, 7-10, and 11+ compared with those with scores less than 4 had hazard ratios (95% confidence interval) for 1-year mortality of, respectively, 1.5 (1.3-1.7), 2.2 (1.3-1.7), and 3.0 (2.6-3.4). Patients in the worse prognostic stratum experienced 33% higher mortality when admitted to an internal medicine compared with a geriatrics ward, although mortality was not significantly affected by the type of ward of admission in all other risk strata. CONCLUSIONS Simple administrative data provide prognostic information on long-term mortality in older patients hospitalized via ED. Patients with worse prognostic index scores appear to benefit from admission in a geriatrics compared with an internal medicine ward.

Prospective multicentre systematic guideline-based management of patients referred to the Syncope Units of general hospitals

AIMS Although an organizational model for syncope management facilities was proposed in the 2004 guidelines of the European Society of Cardiology (ESC), its implementation in clinical practice and its effectiveness are largely unknown. METHODS AND RESULTS This prospective study enrolled 941 consecutive patients referred to the Syncope Units of nine general hospitals from 15 March 2008 to 15 September 2008. A median of 15 patients per month were examined in each unit, but the five older units had a two-fold higher volume of activity than the four newer ones (instituted <1 year before): 23 vs. 12, P = 0.02. These figures give an estimated volume of 163 and 60 patients per 100,000 inhabitants per year, respectively. Referrals: 60% from out-of-hospital services, 11% immediate and 13% delayed referrals from the Emergency Department, and 16% hospitalized patients. A diagnosis was established on initial evaluation in 191 (21%) patients and early by means of 2.9 +/- 1.6 tests in 541 (61%) patients. A likely reflex cause was established in 67%, orthostatic hypotension in 4%, cardiac in 6% and non-syncopal in 5% of the cases. The cause of syncope remained unexplained in 159 (18%) patients, despite a mean of 3.5 +/- 1.8 tests per patient. These latter patients were older, more frequently had structural heart disease or electrocardiographic abnormalities, unpredictable onset of syncope due to the lack of prodromes, and higher OESIL and EGSIS risk scores than the other groups of patients. The mean costs of diagnostic evaluation was 209 euro per outpatient and 1073 euro per inpatient. The median cost of hospital stay was 2990 euro per patient. CONCLUSION We documented the current practice of syncope management in specialized facilities that have adopted the management model proposed by the ESC. The results are useful for those who wish to replicate this model in other hospitals. Syncope remains unexplained during in-hospital evaluation in more complex cases at higher risk.

Early and late outcome of treated patients referred for syncope to emergency department: the EGSYS 2 follow-up study

AIMS We evaluated the early (1 month) and late (2 years) death rate and syncopal relapses of patients referred for syncope to 11 general hospitals emergency departments. Patients were enrolled in the Evaluation of Guidelines in SYncope Study 2 (EGSYS 2) study. The guidelines of the European Society of Cardiology were strictly followed in the management of patients. METHODS AND RESULTS Out of the 465 patients enrolled in the EGSYS 2 study, 398 (86%) underwent a complete follow-up. We excluded 18 patients with non-syncopal attacks. Among the remaining 380 patients, death of any cause occurred in 35 (9.2%). The mean follow-up was 614 +/- 73 days. Six deaths (17% of total) occurred during the first month of follow-up. Patients who died were older, had a higher incidence of structural heart disease and/or abnormal ECG, had injuries related to syncope and higher EGSYS score. Syncope recurred in 63 (16.5%) patients. Syncopal relapses occurred in only one patient during the first month of follow-up. The incidence of syncopal recurrences was unrelated to the mechanism of syncope. No clinical differences were found between patients with or without syncopal recurrence and in patients with EGSYS score < or >or=3. CONCLUSION A peak of cardiovascular mortality but not of syncopal recurrences was observed in patients attending to the emergency department for syncope within the first month. Late unfavourable outcomes were caused by associated cardiovascular diseases rather than by the mechanism of syncope. The causes of syncope did not determine the recurrence rate.

Cardiopulmonary resuscitation of older, inhospital patients : Immediate efficacy and long-term outcome

Objective To determine the independent effect of advancing age on prognosis after cardiopulmonary resuscitation (CPR). Design and Setting Retrospective analysis of clinical records of patients who received CPR in a geriatric department equipped with an intensive care unit. Patients A total of 245 patients (146 men, 99 women; mean age, 70 ± 11 yrs) received CPR. Of these, 221 had a cardiocirculatory arrest (CA) in the intensive care unit and 24 had a CA in the general ward of the department. Acute myocardial infarction was the most frequent admission diagnosis. Interventions CPR according to standard guidelines in all cases. Measurements and Main Results Immediate, short-term (hospital discharge), and long-term (median follow-up, 31.5 months; range, <1–124 months) survival. Older patients had a lower immediate survival (<70 yrs [72/137] 52.6% vs. ≥70 yrs [43/108] 39.4%;p < .05) and, less frequently, ventricular tachycardia/fibrillation (VT/VF) as a cause of CA. VT/VF bore the lowest immediate mortality rate (19/104; 18.3%) as compared with asystole/complete heart block (66/102; 64.7%) or pulseless electrical activity (40/49; 81.6%;p < .001). Acute myocardial infarction, acute heart failure, hypotension, and occurrence of CA in the intensive care unit were also univariate predictors of unfavorable, immediate prognosis. However, in a multiple logistic analysis model, the mechanism of CA (asystole/complete heart block or pulseless electrical activity vs. VT/VF), acute myocardial infarction, heart failure, and hypotension were independent predictors of unfavorable immediate prognosis, whereas advancing age was not. Similarly, after initially successful CPR, short-term survival was independently associated with acute myocardial infarction, hypotension before CA, initial rhythm at CA, and need for mechanical ventilatory support after CPR, but not with age. Long-term survival (42 patients; 17.2% of the original cohort; median survival, 32 months) was also independent of age, whereas it was negatively associated with heart failure. Conclusion Immediate, short- and long-term prognosis after inhospital CPR is independent of age, at least when possible confounders are simultaneously taken into account.

Low Diastolic Ambulatory Blood Pressure Is Associated with Greater All-Cause Mortality in Older Patients with Hypertension

OBJECTIVES: To assess the relationship between office and ambulatory systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP) and total mortality in elderly patients with hypertension.

An Expert Opinion From the European Society of Hypertension–European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects

Two years after the publication of the 2013 guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC),1 the ESH and the European Union Geriatric Medicine Society have created a common working group to examine the management of hypertensive subjects aged >80 years. The general term hypertension in the elderly is not sufficiently accurate because it mixes younger old patients (60–70 years) with the oldest old. Our group believes that the management of hypertension in individuals aged ≥80 years should be specifically addressed. Although arbitrary, this cutoff value identifies a population that is expanding faster than any other age group with a 50% increase of life expectancy during the past 50 years2,3; furthermore, the incidence and prevalence of comorbidities, frailty, and loss of autonomy greatly increases after the age of 80 years4; finally, although there is limited evidence on the management of hypertension in this age group, the latest clinical studies indicate that in these patients, treatment may not be the same as in patients in the lower age strata. The aim of this Working Group was to discuss more in-depth treatment aspects of hypertensive patients aged ≥80 years or older, with special focus on the difficulties and uncertainties posed by very old frail individuals. We focused, in particular, on the following points of the 2013 ESH/ESC guidelines: The 2013 ESH/ESC guidelines1 reported the results of the Hypertension in the Very Elderly Double Blind Trial (HYVET). This showed that in hypertensive patients aged ≥80 years, the administration of the thiazide-like diuretic indapamide supplemented, if necessary, by the angiotensin-converting enzyme inhibitor perindopril led to a significant reduction in the …