Franco Giada

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.

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.

Comparison of diagnostic accuracy of sublingual Nitroglycerin test and low-dose Isoproterenol test in patients with unexplained syncope

Despite the widespread use of head-up tilt testing as a means for diagnosing vasovagal syncope, standardization of test methodology remains a controversial issue. The aim of this study was to compare the diagnostic value of head-up tilt testing potentiated with sublingual nitroglycerin with that of head-up tilt testing potentiated with low-dose isoproterenol. For this purpose, 71 patients with unexplained syncope (mean age 43 years) and 30 asymptomatic controls were studied. All underwent the sublingual nitroglycerin and low-dose isoproterenol tests on separate days in a randomized fashion. The protocol of the 2 tests was similar and consisted of 2 phases. Initially, subjects were tilted at 60 degrees for 20 minutes without medication; then, if syncope did not occur, patients and controls received sublingual nitroglycerin (300 microg) or low-dose intravenous isoproterenol (mean infusion rate 1.3 +/- 0.5 microg/min) and continued to be tilted at 60 degrees for a further 20 minutes. During the sublingual nitroglycerin test, a positive response (syncope associated with sudden hypotension and bradycardia) occurred in 35 patients (49%), a negative response in 36 (51%), and drug intolerance in none (0%). During the low-dose isoproterenol test, these percentages were 41%, 59%, and 6%, respectively. A concordant response was observed in 53 cases (75%). Among controls, 3 subjects (10%) had a positive response to the sublingual nitroglycerin test and 4 (13%) to the low-dose isoproterenol test. It is concluded that sublingual nitroglycerin and low-dose isoproterenol are equivalent tests for evaluating patients with unexplained syncope. The sublingual nitroglycerin test, however, is simpler, better tolerated, and safer than the low-dose isoproterenol test and, thus, more suitable for routine clinical use.

Orthostatic Hypotension As Cause of Syncope in Patients Older Than 65 Years Admitted to Emergency Departments for Transient Loss of Consciousness

BACKGROUND Syncope due to orthostatic hypotension (OH) refers to loss of consciousness caused by hypotension induced by the upright position; it is an important risk factor for fall-related physical injuries, especially in the elderly adults. We evaluated the prevalence of OH syncope and the clinical characteristics of patients older than 65 years with syncope due to OH in the Evaluation of Guidelines in Syncope Study 2 group population. METHODS Two hundred fifty nine patients older than 65 years consecutively admitted to the emergency department because of loss of consciousness in a period of a month were submitted to a standardized protocol approved by the European Task Force for the diagnosis of syncope; all the patients were studied by a trained physician who interacted with a central supervisor as the management of syncope was concerned, using a decision-making software. RESULTS Prevalence of OH syncope was 12.4%. Patients with OH syncope were more likely to be affected by Parkinsons disease and by other neurological diseases. ST changes and longer values of QTc were found in OH syncope group, and they took a greater number of diuretics, nitrates, and digoxin. In multivariate analysis, Parkinsons disease (p = .001) and use of nitrates (p = .001) and diuretics (p = .020) were independently related to OH syncope. CONCLUSIONS In patients older than 65 years, Parkinsons disease and neurological comorbidity are strictly related to OH syncope. Moreover, this study suggests the independent link between OH syncope and the use of vasoactive drugs, identifying the majority of cases as adverse drug reaction, a preventable risk factor for syncope and falls in the older population.

Reproducibility of head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope

Head-up tilt testing (HUTT) potentiated with sublingual nitroglycerin has gained acceptance as means of diagnosing neurally mediated syncope. To evaluate the reproducibility of HUTT potentiated with sublingual nitroglycerin, 48 patients with unexplained syncope prospectively underwent 2 consecutive tests 1 to 28 days apart. The initial test ended in syncope in 34 patients (71%). In 9 patients (19%) the test was positive during the drug-free phase, whereas 25 patients (52%) had syncope after nitroglycerin administration. Of these 34 patients with an initial positive test result, 27 (79%) had a reproducible outcome on repeat testing. Of 12 patients (25%) with an initial negative test result, 10 (83%) had a reproducible outcome on repeat testing. Of 2 patients (4%) with a first test ending in exaggerated response, both had a negative repeat test response. The overall reproducibility of sublingual nitroglycerin tilt-table testing was 77%. In a group of 23 patients with both positive tests, 19 (83%) had the same response modality (2 vasodepressor, 4 cardioinhibitory, 13 mixed response). In the same group of patients, individual trough heart rates correlated well with each other between tests. Finally, in the 27 patients with both positive tests, intrapatient time of onset of symptoms did not significantly correlate between tests. Thus, in patients with syncope of unknown origin, HUTT potentiated with sublingual nitroglycerin provides an adequate reproducibility when repeated on different days.

Effectiveness of remote monitoring in the management of syncope and palpitations

AIMS Recently, the remote transmission of data detected by implantable loop recorders (ILRs) has become available. The aim of this study was to evaluate effectiveness and acceptance of remote monitoring in the clinical management of syncope and palpitations in patients with ILR. METHODS AND RESULTS Consecutive patients implanted with ILR (Reveal DX/XT Medtronic, Inc.) and followed up by means of remote monitoring (CareLink(®)) were included. The patients were requested to transmit the data stored in the ILR every week, via the CareLink system, or more frequently during the first period. Patient acceptance of ILR was evaluated by means of a questionnaire concerning physical and mental components. Forty-seven patients (27 males, average age 64 ± 19 years) were enrolled and followed up for 20 ± 13 weeks. Thirty-two patients (68%) had at least one ECG recording of a true relevant event. The mean time from ILR implantation to the first true relevant ECG was 28 ± 49 days, which was 71 ± 17 days less than in the clinical practice of 3-monthly in-office follow-up examinations. Thirty-eight patients (81%) had at least one false arrhythmic event, mainly false asystole and false fast ventricular tachycardia. In the absence of Carelink transmission, at least one episode of memory saturation of ILR would have occurred in 21 patients (45%) that would have limited the diagnostic yield. Patient compliance was good even though one-fifth had some minor psychological concern regarding the ILR implant. CareLink was well accepted and judged easy to use. CONCLUSION Remote monitoring enhances the diagnostic effectiveness of Reveal, limiting the risk of memory saturation due to the high number of false detections and reducing the time to diagnosis. Both ILR and CareLink were well accepted and well tolerated by the patients, as they were considered useful.

Cardiovascular adaptations to endurance training and detraining in young and older athletes

In order to evaluate the influence of aging on cardiovascular adaptations to endurance training and detraining, 12 young (range 19-25 years) and 12 older (range 50-65 years) male cyclists were examined during the training and after 2 months of detraining. Twelve young and 12 older healthy sedentary males matched for age and body surface area were used as control groups. Each subject underwent a maximal exercise test using a cycle-ergometer in order to measure maximum oxygen consumption, an M-mode and 2D echocardiography in order to assess left ventricle morphology and systolic function, and a Doppler echocardiography for evaluating the diastolic filling pattern. During the training period both groups of athletes showed higher values of maximum oxygen consumption, left ventricular wall thicknesses, end-diastolic diameter and volume, as well as left ventricular mass, than their control subjects; in the older subjects the adaptation of the heart to aerobic training seems to be obtained mainly through a higher increase in left ventricular diastolic filling. In both groups no significant modifications in the ejection fraction and diastolic function parameters were recorded. After the detraining period the wall thicknesses decreased only in young athletes, while left ventricular mass and end-diastolic diameter and volume reduced only in older athletes. In conclusion, training and detraining induced nearly similar left ventricular morphological modifications in the two age groups, even though greater in the older athletes with respect to the ventricular mass and volume. No relevant differences were observed in the Doppler filling pattern between athletes and sedentary controls.

Exercise prescription for the prevention and treatment of cardiovascular diseases: part II.

Epidemiological, clinical and laboratory studies have provided definitive evidence that physical activity is able to improve fitness and reduce cardiovascular morbidity and mortality. Moreover, physical exercise also seems to significantly reduce the risk of developing other chronic diseases such as obesity, osteoporosis, diabetes, tumours and depression. Promoting physical activity in the general population is therefore one of the primary objectives of our healthcare institutions. Although the benefits of an active lifestyle have been demonstrated by numerous scientific data, only a few numbers of Italians and Europeans take up regular physical exercise. To promote physical activity, both in the general population and in subjects affected by cardiovascular diseases, the Italian Federation of Sports Medicine, the Italian Society of Sports Cardiology, the Italian Association of Hospital Cardiologists, the Italian Society of Cardiology, the Italian Association of Out-of-Hospital Cardiologists and the Italian Group of Cardiac Rehabilitation have promoted the constitution of a Task Force made up of experts in the fields of sports cardiology. The document produced by the Task Force is intended for healthcare professionals and deals with the role of physical activity in the prevention and treatment of cardiovascular diseases. It examines the beneficial effects of physical activity on the cardiovascular system, while analysing the possible risks involved and how they can be avoided. The rational principles underlying the prescription of physical activity in the cardiologic setting are described, as are the modalities for prescribing such activity.

Prevention of Syncope through Permanent Cardiac Pacing in Patients with Bifascicular Block and Syncope of Unexplained Origin: The PRESS Study

Background—Syncope in patients with bifascicular block (BFB) is a common event whose causes might be difficult to assess. Methods and Results—Prevention of syncope through permanent cardiac pacing in patients with bifascicular block (PRESS) is a multicenter, prospective, randomized, single-blinded study designed to demonstrate a reduction in symptomatic events in patients with bifascicular block and syncope of undetermined origin implanted with permanent pacemaker. Device programming mode (NASPE/BPEG code) at DDD with a lower rate of 60 ppm is compared with backup pacing at DDI with a lower rate of 30 ppm. The end point consisted of (1) syncope, (2) symptomatic presyncopal episodes associated with a device intervention (ventricular pacing), and (3) symptomatic episodes associated with intermittent or permanent atrioventricular block (any degree). One hundred one patients were enrolled and randomized. Primary end point events at 2 years were observed in 23 patients, with a significant lower incidence in the study group (hazard ratio, 0.32; 95% confidence interval [CI], 0.10–0.96; P=0.042). Reduction of any symptoms, associated or not with device intervention, was superior in DDD60 compared with DDI30 (hazard ratio, 0.4; 95% confidence interval, 0.25–0.78; P=0.0053). Fourteen patients developed other rhythm diseases and met class I indication for pacing. The annual incidence of rhythm disease development was 7.4%. Conclusions—In patients with bifascicular block and syncope of undetermined origin, the use of a dual chamber pacemaker programmed to DDD60 led to a significant reduction of syncope or symptomatic events associated with a cardioinhibitory origin, compared with DDI30 programming. Symptoms associated with a new onset of rhythm disease were found in 15% of the population at 2 years.