Antonio Raviele

Management of syncope referred urgently to general hospitals with and without syncope units

OBJECTIVEnWe tested the hypothesis that management of patients with syncope admitted urgently to a general hospital may be influenced by the presence of an in-hospital structured syncope unit.nnnBACKGROUNDnThe management of syncope is not standardized. Methods We compared six hospitals equipped with a syncope unit organized inside the department of cardiology with six matched hospitals without such facilities. The study enroled all consecutive patients referred to the emergency room from 5 November 2001 to 7 December 2001 who were affected by transient loss of consciousness as their principal symptom.nnnRESULTSnThere were 279 patients in the syncope unit hospitals and 274 in the control hospitals. In the study group, 30 (11%) patients were referred to the syncope unit for evaluation. In the study group, 12% fewer patients were hospitalized (43 vs 49%, not significant) and 8% fewer tests were performed (3.3+/-2.2 vs 3.6+/-2.2 per patient, not significant). In particular, the study group patients underwent fewer basic laboratory tests (75 vs 86%, P=0.002), fewer brain-imaging examinations (17 vs 24%, P=0.05), fewer echocardiograms (11 vs 16%, P=0.04), more carotid sinus massage (13 vs 8%, P=0.03) and more tilt testing (8 vs 1%, P=0.000). In the study group, there was a +56% rate of final diagnosis of neurally mediated syncope (56 vs 36%, P=0.000).nnnCONCLUSIONnAlthough only a minority of patients admitted as an emergency are referred to the syncope unit, overall management is substantially affected. It is speculated that the use of a standardized approach, such as that typically adopted in the syncope unit, is able to influence overall practice in the hospital.

Should We Switch Patients Who Appear to Be Optimally Anticoagulated on Warfarin to DOACs

T wo different types of oral anticoagulants (OACs) are currently available to reduce the risk of stroke/systemic embolism (SE) in patients with atrial fibrillation (AF): vitamin K antagonists (VKAs) and direct OACs (DOACs) (1). The VKAs, for example, warfarin, are the traditional OACs, and until 2009, were the only class of OACs available. VKAs are very effective in preventing thromboembolic events in patients with AF. In a meta-analysis of 6 randomized controlled trials (RCTs) of these drugs, adjusted-dose warfarin reduced the risk of stroke by 64% and the risk of all-cause mortality by 26% in comparison with placebo or no treatment (2). However, VKA therapy has several limitations, such as unpredictable response, narrow therapeutic window, slow onset/offset of action, numerous food– drug interactions, numerous drug–drug interactions, and warfarin resistance, which make it difficult to implement in clinical practice. Moreover, it requires routine coagulation monitoring and frequent dose adjustments, resulting in substantial risk and inconvenience. This explains the low use and the high discontinuation rate of warfarin in the real world, as well as the inadequate level of anticoagulation reached in many patients. Developed in recent years, DOACs are new compounds that directly inhibit thrombin or the activated factor X. In 4 large RCTs, these drugs were compared with warfarin for stroke prevention in >71,000 patients. A meta-analysis of these trials showed that DOACs significantly reduced stroke/SE by 19% and all-cause mortality by 10% in comparison with

Combined Use of Subcutaneous ICD and Pacemakers: The Beginning of a New Era?

The implantable cardioverter defibrillator (ICD) is a firmly established therapy for primary and secondary prevention of sudden cardiac death. Since the first human implantation in 1980, significant advances in ICD technology have been made. Modern transvenous ICDs are miniaturized pectoral devices connected to one or more leads inserted into the venous circulation, and are capable not only of defibrillation but also of pacing and cardiac resynchronization therapy (CRT). Despite continuous technological advances and the proven efficacy of the transvenous ICD, the implantation of these devices continues to carry a non-negligible risk of acute and long-term complications, which are essentially attributable to the endovascular lead(s). Overall, 2.8% to 3.6% of transvenous ICD recipients suffer some lead-related adverse event, such as pneumothorax, hemothorax, pericardial effusion and tamponade, or lead dislodgement during hospitalization for implantation.1 Moreover, lead-related adverse events after hospitalization occur in <0.1 to 6.4% of ICD patients during 2to 70-month follow-up; these include central vein thrombosis and occlusion, tricuspid valve insufficiency, systemic infections and endocarditis, and lead malfunction due to insulation defects or lead fractures, with consequent inappropriate/ineffective therapies and recall/withdrawal of the malfunctioning lead from the market.1 The array of devices that defibrillate the heart has expanded in recent years to include the subcutaneous implantable cardioverter-defibrillator (S-ICD). Introduced in Europe in 2009, the first-generation S-ICD was FDA approved in the United States in September 2012 and the second-generation (EmblemTM, Boston Scientific, Marlborough, MA, USA) in March 2015. The S-ICD consists of a pulse generator implanted in the left mid-axillary line at the fifth intercostal space and an extravascular lead tunneled in the subcutaneous space from the lateral pocket medially to the xiphoid process and then cephalad to the sternum-manubrium just to the left (or right) of the parasternal margin. The subcutaneous lead is equipped with two sensing electrodes separated by an 8-cm shock coil, the proximal electrode usually being placed at the xiphoid process and the distal one at the sterno-manubrium level; this lead has

Role of Loop Recorder and Pacemaker Implantation in Vasovagal Syncope

Given that vasovagal syncope is characterized by a benign prognosis, therapy should be aimed at preventing associated trauma and improving the quality of life rather than prolonging life expectancy. Therefore, according to the European guidelines, only selected patients have to be specifically treated: those suffering from highly recurrent vasovagal syncope, individuals in whom syncope onset is not preceded by prodromal symptoms or recognized triggers, patients suffering from associated severe trauma, and persons engaged in risky jobs.

Criteri di appropriatezza nel trattamento della fibrillazione atriale con dronedarone: Aspetti pratici. L'Opinione di un gruppo di esperti cardiologi Italiani

Antiarrhythmic agents are among the therapeutic options available for the treatment of atrial fibrillation when a rhythm control strategy is required. Although their efficacy seems to be generally comparable to that of nonpharmacological interventions, the use of these agents remains controversial. In particular, among this class of drugs, the use of dronedarone in clinical practice is a matter of debate. In this paper, the authors aimed to address these issues, involving a team of expert cardiologists who discussed about the potential use of dronedarone in different clinical scenarios. The RAND/UCLA appropriateness method was used to develop appropriateness measures for the optimal management of patients treated with dronedarone, by combining the best available scientific evidence with the collective judgment of experts. To this purpose, a group of experts was identified and asked to rate the benefit-to-harm ratio of 52 clinical scenarios. Each indication was classified as appropriate, uncertain or inappropriate in accordance with the panelists median score. The classification of each scenario has led to the development of several recommendations for clinical practice. The use of dronedarone for the management of paroxysmal and persistent atrial fibrillation has evolved over time: this antiarrhythmic drug appears to be useful not only in monitoring symptoms, but also in reducing hospitalization and mortality rates in patients with atrial fibrillation.

Restoring sinus rhythm: a novel antihypertensive therapy?

Hypertension and atrial fibrillation (AF) are 2 common clinical disorders that often coexist. According to epidemiological studies, a significant proportion of hypertensive patients (approximately 10%) have AF.1 Likewise, hypertension is very frequent in AF patients, being found in up to 65% of cases.2 Moreover, patients with concomitant hypertension and AF have an increased risk (2–3 times higher) of cardiovascular events, in particular of all-cause mortality, cardiovascular mortality, stroke, and congestive heart failure.3,4 Because of this potentially dangerous relationship, it is essential in clinical practice to implement preventive measures to avoid AF in hypertensive patients and to lower adequately blood pressure in AF patients.