Dorota Zyśko

Electrocardiographic characteristics of atrioventricular block induced by tilt testing

AIMS The electrocardiographic (ECG) characteristics of atrioventricular (AV) block during reflex syncope may be unique due to the presence of hypervagotonia. The aim of the present study was to define the ECG characteristics of the AV block induced by neurocardiogenic reflex provoked by tilt testing (TT). METHODS AND RESULTS A series of 31 patients with presumed vasovagal syncope and AV block provoked by TT was studied. The duration of PP and PR interval, AV block grade and type, concomitant arrhythmias, and timing of the AV block occurrence were assessed. The AV block occurred at TT termination in 26 patients, in the recovery in 4 patients, and in both periods in 1 patient. Atrioventricular block was preceded by sinus slowing, and sinus rhythm during AV block was slow and instable. Mobitz I, 2:1 second-degree AV block, and advanced second-degree AV block were recognized in 35.5, 48.4, and 67.8% of patients, respectively. Third-degree AV block was diagnosed in 41.9% of patients. Twenty-one patients had at least two AV block forms. The most prevalent concomitant arrhythmia was junctional escape rhythm (61.3%). CONCLUSION (i) The occurrence of the AV block during neurocardiogenic reaction induced by TT is always preceded by sinus rhythm slowing and usually by PR interval prolongation. (ii) The AV block provoked by TT usually occurs at TT termination, but may occur even in the recovery period in a supine position. Sometimes the AV block may be present both at TT termination and during the recovery period.

Influence of tilt training on activation of the autonomic nervous system in patients with vasovagal syncope.

Objective — Tilt training is a new treatment for vasovagal syncope. Its therapeutic efficacy is thought to be the result of the desensitization of cardiopulmonary receptors, but it could be the influence of the tilt training on the activation of the autonomic nervous system as well. Methods and results — The study group consisted of 24 vasovagal patients (17 women and 7 men) aged 32.5 ± 11.8 years.The diagnostic head-up tilt test was performed according to the Italian protocol with nitroglycerin if necessary. The monitoring head-up tilt test was performed according to the Westminster protocol without provocation, after 1 to 3 months of tilt training. Holter ECG recordings for HRV parameters (time and frequency domain) were obtained from selected 2-min intervals before, during and after the diagnostic and monitoring tilt test. The diagnostic test was positive in the passive phase in 6 and after provocation in 18 patients. During the training period no syncope occurred.Analysing the HRV parameters we demonstrated the following findings: 1. mRR decreases immediately after assumption of a vertical position in both tests (diagnostic and monitoring) but in the diagnostic test its further decrease occurs earlier than in the monitoring test; 2. the absolute power of the HF component is greater in the early phase of tilt after tilt training than in the corresponding period in the diagnostic test. Conclusions — After a longer period of tilt training the activation of the sympathetic nervous system in response to the erect position is diminished.

Increased Content of Resistin in Epicardial Adipose Tissue of Patients with Advanced Coronary Atherosclerosis and History of Myocardial Infarction

OBJECTIVES The aim of the study was to assess whether the plasma level and content of adipokines, in adipose tissue, is associated with a medical history of myocardial infarction. PATIENTS AND METHODS The study group consisted of 33 consecutive patients (12 females, 21 males, aged 68.6 ± 6.8 years) who underwent cardiac bypass surgery. Patients were divided into groups; group 1 presented with a history of myocardial infarction and group 2 presented without a history of myocardial infarction. During cardiac surgery, samples of epicardial adipose tissue, adipose tissue located at internal mammary artery, subcutaneous adipose tissue, and blood samples were taken for further assessment.Significantly higher levels of resistin in adipose tissue from the epicardial tissue were found in group 1 than in group 2: median and interquartile range, respectively, 37.2 (8.9-121.5) ng/g versus 15.0 (7.1-24.1) ng/g; p < 0.049. Multivariate analysis found that previous myocardial infarction was associated with male gender, older age, and higher content of resistin in epicardial adipose tissue. CONCLUSION The resistin content in epicardial adipose tissue in patients with advanced coronary atherosclerosis seems higher in those with a history myocardial infarction. Increased resistin epicardial content seems related to the previous myocardial infarction independent of the other established risk factors such as age and male gender. The importance of paracrine function of adipose pericardial tissue in the occurrence of complications of atherosclerosis merits further investigations.

The risk for syncope and presyncope during surgery in surgeons and nurses.

Background:  Surgeons and nurses are exposed to orthostatic stress.

The Choice of Surgical Specialization by Medical Students and Their Syncopal History

Background The aim of the study was to assess whether medical students’ fainting outside the university or while witnessing surgical procedures and/or autopsies influenced their choice of a specialization. Materials and Methods The study group consisted of 605 medical students (from fourth to sixth year of study) from five medical universities in Poland (325 women, 212 men and 8 responders of an unspecified gender). The median age of subjects studied was 23 years, and the interquartile range was 23–24 years. The students at each university were chosen randomly by the author who worked there and had contact with them. An anonymous questionnaire was developed to gather information regarding demographics, the specialization which each student wanted to choose, the syncope occurrence in the medical history, the syncope and presyncope occurrence during surgery and autopsy as well as the syncopal events’ characteristics. Results The group of 15% of women and 30% of men declared to have pursued the surgical specialization (P<0.001), 29% of women and 56% of men declared the intention to pursue an invasive specialization (P<0.001). As many as 36.0% of women studied and 13.1% of men studied reported syncopal spells outside university (P<0.001). Only 41 students (6.8%) reported that syncope or presyncope in any studied circumstances had an impact on their specialization choice. The multivariate analysis showed that the choice of surgical specialization is related to the male gender and the absence of syncopal spells outside the university. Conclusions Syncopal and presyncopal spells may affect the professional choices of the medical students. The male gender and a lack of syncope occurrence outside operating room are related to the choice of surgical specialization.

The clinical relevance of the duration of loss of consciousness provoked by tilt testing.

Objective — The authors assessed the relationships between the duration of loss of consciousness (dLOC) during tilt testing-induced syncope (TTS) and demographics, medical history as well as tilt testing results. Previous research focused on the relevance of the type of neurocardiogenic reaction during TTS. The importance of dLOC has not been assessed so far. The study was carried out in 274 patients with suspected neurally mediated syncope and total loss of consciousness during tilt testing. Results — The syncope burden, demographics, and data regarding spontaneous syncope or TTS were compared between group 1 with dLOC ≥ 47 seconds and group 2 with dLOC < 47 seconds. Medical history revealed that patients in group 1 had more syncopal spells, more frequent syncope-related traumatic injuries, urine incontinence, jerking movements and typical vasovagal history than in group 2. Moreover, group 1 patients had more frequently a cardioinhibitory type of reaction and a shorter active phase duration. In addition, they manifested more frequent accompanying cerebral hypoperfusion signs and reproduction of symptoms during TTS than patients in group 2. Conclusions — The loss of consciousness during tilt testing-induced syncope differs in terms of duration among patients with neurally mediated syncope.The dLOC during TTS is associated with medical history and tilt-testing data which confirm the vasovagal aetiology of spontaneous events. The longer dLOC suggests deeper cerebral haemodynamic disturbances during either spontaneous or provoked syncope.

Reflex syncope, anxiety level, and family history of cardiovascular disease in young women: case-control study.

AIMS Anxiety is an emotion, which stimulates sympathetic nervous outflow potentially facilitating vasovagal reflex syncope (VVS) but reports on anxiety levels in patients with VVS are sparse. METHODS AND RESULTS We studied anxiety levels in young women (21-40 years) referred for unexplained transient loss of consciousness (TLOC), and age-matched female controls with or without past history of TLOC (≈probable VVS). Referred patients underwent head-up tilt (HUT) according to current ESC Guidelines. State and Trait Anxiety Inventory questionnaire evaluated anxiety levels plus a questionnaire explored risk factors for cardiovascular disease (CVD). Sixty-five of 91 women were diagnosed with VVS on HUT. Among 549 controls, 223 (40.6%) reported at least one episode of TLOC. State-anxiety level in patients with VVS undergoing HUT (42.4 ± 9.3) was higher compared with both controls with (38.3 ± 10.2; P < 0.01) and without past TLOC history (35.9 ± 9.8; P < 0.001). Trait anxiety in patients with VVS (42.7 ± 8.4), and controls with TLOC history (42.4 ± 8.4) was higher compared with controls without TLOC history (39.7 ± 8.5; P < 0.01). In the logistic regression using controls without TLOC as reference, both VVS diagnosis and past history of TLOC were associated with family history of CVD [odds ratio (OR) 2.4, 95% confidence interval (CI), 1.3-4.4; P = 0.007, and 2.3, 1.4-3.6; P = 0.001, respectively], and this association was independent of anxiety level. CONCLUSIONS Trait anxiety and family history of CVD are increased in both young women with VVS and controls with history of TLOC. However, the height of anxiety level does not explain CVD heredity and other mechanisms may link syncope with CVD.

Catheter ablation of cardiac arrhythmias in pregnancy without fluoroscopy: A case control retrospective study

BACKGROUND Cardiac arrhythmias are common in pregnant women. In most cases, they do not require treatment other than rest, electrolyte supplementation and avoidance of strong coffee and tea. Persistent arrhythmia or the ventricular rate running at a high frequency may cause hemodynamic deterioration in the fetus or in both the fetus and the mother. OBJECTIVES The aim of this study was to assess the prevalence and characteristics of arrhythmias in pregnant women who qualified for ablation as well as the feasibility and specific features of these interventions. MATERIAL AND METHODS The study group consisted of 11 pregnant women (16-32 Hbd) aged 31 + 6. The control group consisted of 111 women aged 15-50 years (34 + 10), scheduled for ablation in 2012. The medical records of the selected study and control groups were analyzed and the following data was retrieved: age, the reason the ablation procedure was performed, the ablation duration, the number of radiofrequency applications, the total duration of radiofrequency applications, gravity, and comorbidities. RESULTS In the study group, accessory pathway related arrhythmias or atrial tachycardia (AT) accounted for 62% of cases, whereas in the control group for 32% (p = 0.042). All the procedures in the study group were performed with an electroanatomical system without fluoroscopy. All of the patients, but one, had no recurrence of arrhythmia. There were no complications and no overt effects were noted in the fetus. CONCLUSIONS Ablation of arrhythmias during pregnancy is rare. An experienced surgeon using electroanatomical system is usually able to ablate arrhythmic substrate without the use of X-ray fluoroscopy. The most prevalent causes of arrhythmias in pregnant women requiring ablation are accessory pathway and AT focus.

Tilt testing results are influenced by tilt protocol.

AIMS It is unknown how the return to supine position influences duration of loss of consciousness (LOC) and cardioinhibition during tilt test. METHODS AND RESULTS Retrospective analysis of two datasets containing records of patients who underwent tilt testing for unexplained syncope in two centres was performed. Patients, totalling 1232, were included in the study: 262 in a Swedish centre and 970 patients in a Polish centre. In Sweden, tilt table with tilt-down time (TDT) of 18 s was used (Group II). In Poland, two different tilt tables were used, one of them with TDT of 10 s (Group I, n = 325), and the other with TDT of 47 s (Group III, n = 645). Cardioinhibitory reflex occurred most frequently in Group III, whereas number of pauses >3 s, frequency of very long asystole ≥30 s, and the total duration of pauses >3 s demonstrated a trend to increase from Group I to III. Duration of LOC in Groups II and III was significantly longer compared with Group I (32.0 and 33.7 s vs. 16.4 s). In the multivariate-adjusted regression model, cardioinhibitory reflex was predicted by tilt-table model (odds ratio per model with increasing TDT: 1.40; 95% confidence interval, 1.19-1.64; P < 0.0001), whereas LOC duration was longer with increasing TDT (P < 0.0001) and age (P < 0.0001). CONCLUSION Longer TDT during induced vasovagal syncope increases the prevalence of cardioinhibitory reflex and prolongs the duration of LOC. Tilt-down time does not affect asystolic pause duration but delay may lead to occurrence of multiple pauses, higher frequency of very long asystole, and longer total asystole duration.

The study of the Polish version of the Questionnaire for the Assessment of Disgust Sensitivity (QADS)

AIM Disgust is one of the principal emotions, typically triggered by a variety of biological and social stimuli. Several questionnaire tools have been used to assess disgust. The aim of the study was to assess psychometric properties of the Polish version of the Questionnaire for the Assessment of Disgust Sensitivity (QADS), adapted from the tool prepared by the German researchers. METHODS Eight hundred twenty subjects (631, 77% females and 189, 23% males) aged 18-69 (mean - 28 years) participated in the study. There are 3 subscale in the questionnaire: Core Disgust, Animal Reminder and Contamination. The tool consists of 37 items, the intensity of feeling of disgust is assessed based on 5-point Likert scale. RESULTS Confirmatory factor analysis confirmed the adequacy of grouping of items in the three subscales: Core Disgust, Animal-Reminder, and Contamination-Interpersonal. In our sample, females had higher levels of disgust than males. Several other psychometric variables - high degree of correlations between the subscales, and high reliability -were in agreement with parameters of the original version. The Polish version compared favourably with the original, with Cronbachs alpha of 0.94 for the whole questionnaire and 0.85 - 0.90 for the subscales. CONCLUSIONS The psychometric properties of the Polish version of QADS are sufficient to recommend this tool for diagnostic and research use.