Steve W. Parry

The Newcastle protocols for head-up tilt table testing in the diagnosis of vasovagal syncope, carotid sinus hypersensitivity, and related disorders

Head-up tilt table testing had been used as an investigative tool in the pathophysiology of orthostatic stress for more than 50 years,1 before the initial demonstration of its utility in the diagnosis of unexplained syncope.2 The Westminster groups landmark study found that 67% of patients with otherwise unexplained syncope demonstrated a vasovagal reaction during head-up tilt, compared to only 10% of healthy controls.2 Head-up tilt table testing has since evolved into the diagnostic test of choice in vasovagal syncope and related disorders, but there are still wide variations in the protocols used in various centres, hampering not only the clinical utility of the test but the adequate assessment of research activity in the field. The following protocols are based on the available evidence and our experience in this field and, as such, provide a practical and standardised approach. They are intended for use by cardiologists and other physicians with an interest in this topic, and hence assume some prior knowledge of the procedure. A more detailed description and justification for the protocols is readily available.3 4 Head-up tilt table testing should be considered in patients with recurrent syncope or presyncope, or in high risk patients with a history of a single syncopal episode (for example, those suffering serious injury during syncope or those experiencing syncope while driving) where no other cause for symptoms is suggested by initial history, examination or cardiovascular and neurological investigations. Tilt table testing may also be useful in the assessment of elderly patients with recurrent, unexplained falls.5 The head-up tilt table test may also have a role in the differential diagnosis of convulsive syncope,5-7 orthostatic hypotension,8 the postural orthostatic tachycardia syndrome,9 psychogenic10 and hyperventilation11 12 syncope, and carotid sinus hypersensitivity.13-15 The Newcastle protocol for carotid …

Falls and confidence related quality of life outcome measures in an older British cohort

Falls are common in older subjects and result in loss of confidence and independence. The Falls Efficacy Scale (FES) and the Activities-specific Balance Confidence scale (ABC) were developed in North America to quantify these entities, but contain idiom unfamiliar to an older British population. Neither has been validated in the UK. The FES and the ABC were modified for use within British culture and the internal consistency and test-retest reliability of the modified scales (FES-UK and ABC-UK) assessed. A total of 193 consecutive, ambulant, new, and return patients (n=119; 62%) and their friends and relatives (“visitors”, n=74; 38%) were tested on both scales, while the last 60 subjects were retested within one week. Internal reliability was excellent for both scales (Cronbachs alpha 0.97 (FES-UK), and 0.98 (ABC-UK)). Test-retest reliability was good for both scales, though superior for the ABC-UK (intraclass correlation coefficient 0.58 (FES-UK), 0.89 (ABC-UK)). There was evidence to suggest that the ABC-UK was better than the FES-UK at distinguishing between older patients and younger patients (‖t ABC‖ = 4.4; ‖t FES‖ = 2.3); and between fallers and non-fallers (‖t ABC‖ = 8.7; ‖t FES‖ = 5.0) where the t statistics are based on the comparison of two independent samples. The ABC-UK and FES-UK are both reliable and valid measures for the assessment of falls and balance related confidence in older adults. However, better test-retest reliability and more robust differentiation of subgroups in whom falls related quality of life would be expected to be different make the ABC-UK the current instrument of choice in assessing this entity in older British subjects.

Diagnosis of carotid sinus hypersensitivity in older adults: carotid sinus massage in the upright position is essential

OBJECTIVE To assess the diagnostic value of supine and upright carotid sinus massage in elderly patients. DESIGN Prospective controlled cohort study. SETTING Three inner city accident and emergency departments and a dedicated syncope facility. PATIENTS 1375 consecutive patients aged > 55 years presenting with unexplained syncope and drop attacks; 25 healthy controls. INTERVENTIONS Bilateral supine carotid sinus massage, repeated in the 70° head up tilt position if the initial supine test was not diagnostic of cardioinhibitory and mixed carotid sinus hypersensitivity. MAIN OUTCOME MEASURES Diagnosis of cardioinhibitory or mixed carotid sinus hypersensitivity; clinical characteristics of supine v upright positive groups. RESULTS 226 patients were excluded for contraindications to carotid sinus massage. Of 1149 patients undergoing massage, 223 (19%) had cardioinhibitory or mixed carotid sinus hypersensitivity; 70 (31%) of these had a positive response to massage with head up tilt following negative supine massage (95% confidence interval, 25.3% to 37.5%). None of the healthy controls showed carotid sinus hypersensitivity on erect or supine massage. The initially positive supine test had 74% specificity and 100% sensitivity; these were both 100% for the upright positive test. The clinical characteristics of the supine v upright positive subgroups were similar. CONCLUSIONS The diagnosis of carotid sinus hypersensitivity amenable to treatment by pacing may be missed in one third of cases if only supine massage is performed. Massage should be done routinely in the head up tilt position if the initial supine test is negative.

Pacing in elderly recurrent fallers with carotid sinus hypersensitivity: a randomised, double-blind, placebo controlled crossover trial

Objectives: While carotid sinus syndrome (CSS) is traditionally defined by the association of carotid sinus hypersensitivity (CSH) with syncope, uncertainty remains over the role, if any, of complex pacing in patients with CSH and unexplained or recurrent falls. We sought to clarify the role of dual chamber pacing in this patient group in the first placebo-controlled study in CSH. Design: Randomised, double-blind, crossover, placebo-controlled trial. Setting: Specialist falls and syncope facility. Patients: Consecutive subjects aged over 55 years with CSH as the sole attributable cause of three or more unexplained falls in the 6 months preceding enrolment. Intervention: Dual-chamber permanent pacing with rate-drop response programming. The pacemaker was switched on (DDD/RDR) or off (ODO (placebo)) for 6 months, then crossed over to the alternate mode for a further 6 months, in randomised, double-blind fashion. Main outcome measure: The primary outcome measure was number of falls in paced and non-paced modes. Results: Twenty-five of 34 subjects (mean 76.8 years (SD 9.0), 27 (79%) female) recruited completed the study. Pacing intervention had no effect on number of falls (4.04 (9.54) in DDD/RDR mode, 3.48 (7.22) in ODO; relative risk of falling in ODO mode 0.82, 95% CI 0.62 to 1.10). Conclusion: Permanent pacing intervention had no effect on fall rates in older patients with CSH. Further work is urgently needed to clarify the role, if any, of complex pacing in this patient group.

Vasovagal Syncope in the Older Patient

Vasovagal syncope (VVS) has been diagnosed with increasing frequency in older patients since the head-up tilt-table test (HUT) was described over 2 decades ago. The incidence and prevalence of VVS in this age group remains unknown. Older individuals are more likely to display a dysautonomic hemodynamic pattern with a predominantly hypotensive response during HUT. The positivity rates to passive and isoprotenerol-provoked HUT are reduced with age, but positivity rates for glyceryl-trinitrate-induced HUT are comparable with younger subjects. Few studies into treatment strategies have included older subjects. This is a review of the existing literature on the epidemiology, clinical characteristics, diagnostic tools, and treatment strategies for VVS in older patients, highlighting important areas for future research.

The history of diagnosing carotid sinus hypersensitivity: why are the current criteria too sensitive?

The carotid sinus syndrome and carotid sinus hypersensitivity (CSH) are closely related disorders. The first is characterized by syncope triggered by manipulation of the carotid sinus in daily life (e.g. shaving). According to the current European Society of Cardiology guidelines, CSH is diagnosed when carotid sinus massage elicits ≥3 s asystole, a fall in systolic blood pressure of ≥50 mmHg, or both, with symptoms. The question is, however, whether symptoms can be expected when these criteria are met. Although they are widely accepted, we will show that their basis is primarily in arbitrary clinical observations and that in the original publications the link between classification and clinical symptoms was often dubious. The current criteria for CSH are thus too sensitive, explaining the reported high prevalence of CSH in the general older population. The review will conclude with suggesting a stricter set of criteria for CSH that should be evaluated in future studies.

Drop Attacks in Older Adults: Systematic Assessment Has a High Diagnostic Yield

Objectives: To investigate the causes of recurrent drop attacks in older patients with a comprehensive battery of investigations in the largest series reported to date.Objectives: To investigate the causes of recurrent drop attacks in older patients with a comprehensive battery of investigations in the largest series reported to date. Design: Observational with mean followup of 18 months. Setting: Inner city emergency department and tertiary facility in Newcastle upon Tyne, United Kingdom. Participants: Ninety-three consecutive patients aged 55 and older with three or more drop attacks in the 6 months before evaluation. Methods: Subjects underwent a comprehensive diagnostic evaluation, with particular attention to traditional (e.g., gait and balance abnormalities, medications) and more recently identified (e.g., carotid sinus hypersensitivity) risk factors for drop attacks. Results: Subjects tended to be older (mean age±standard deviation 77.4±9.0) and female (70; 75%) and to have a mean of 10.4 drop attacks before evaluation. Fifty-three (57%) had suffered soft tissue injuries needing medical attention and 32 (34%) fractures secondary to drop attacks. An attributable diagnosis was achieved in all but nine subjects (90%). Cardiovascular diagnoses (49; 53%) were most commonly implicated, with neurological (27; 29%) and gait and balance abnormalities (17; 18%) and drug-related causes (11; 12%) providing the majority of the remaining diagnoses. Conclusion: Drop attacks in older subjects are associated with high levels of morbidity and healthcare resource utilization. Attributable diagnoses are achievable in the majority of cases with a systematic investigative approach. The high diagnostic yield more than justifies the approach described.

White matter changes in late-life depression: A diffusion tensor imaging study

BACKGROUND Numerous studies have revealed white matter abnormalities in late-life depression (LLD). The objective was to investigate the integrity of white matter tracts in subjects with LLD compared to similar aged healthy individuals using diffusion tensor imaging (DTI). METHODS Sixty eight subjects (30 healthy individuals, 38 depressed) underwent DTI on a 3T scanner following clinical and cognitive assessment. An automated tract-based spatial statistics (TBSS) method was used to derive estimates of fractional anisotropy (FA) and mean diffusivity (MD) for each subject. Group effects and correlations with clinical features on DTI parameters were examined. RESULTS Compared to controls, uncorrected maps revealed patients with LLD exhibited lower FA in frontal, temporal and midbrain regions relative to older healthy subjects (p<0.05). However, using corrected maps no significant differences were observed in LLD patients in FA and MD parameters (p<0.05, family-wise error corrected for multiple comparisons). Regression analyses revealed no significant relationship between DTI parameters and current depressive symptoms in LLD (p>0.05, uncorrected and corrected). CONCLUSIONS Findings are suggestive of loss of integrity in white matter fibres within frontal, temporal and midbrain regions, increasing the evidence that implicates disruptions to the limbic-orbitofrontal networks in the pathogenesis of LLD. However, as results did not survive strict control for multiple comparisons, they should be considered tentative and replication in larger cohorts is needed.

Syncope Unit: rationale and requirement – the European Heart Rhythm Association position statement endorsed by the Heart Rhythm Society

The European Society of Cardiology (ESC) has played an important role in advancing our understanding of the causes, optimal investigation, and management of syncope through publication of practice guidelines in 2001, 2004, and 2009.1–3 The 2009 ESC guidelines recommend the establishment of formal Syncope Units (SUs)—either virtual or physical site within a hospital or clinic facility—with access to syncope specialists and specialized equipment.3 In response, this position statement by the European Heart Rhythm Association (EHRA) endorsed by the Heart Rhythm Society (HRS) offers a pragmatic approach to the rationale and requirement for an SU, based on specialist consensus, existing practice and scientific evidence (see Appendix). The panel consists of specialists who have experience in developing and leading such units representing cardiology, geriatric and general internal medicine, neurology, and emergency medicine. This document is addressed to physicians and others in administration, who are interested in establishing an SU in their hospital, so that they can meet the standards proposed by ESC-EHRA-HRS.1–3 ### Definition of syncope and transient loss of consciousness Syncope is a transient loss of consciousness (T-LOC) due to transient global cerebral hypoperfusion, and is characterized by rapid onset, short duration, and spontaneous complete recovery. This definition of syncope has been developed by the Task Force for the Diagnosis and Management of Syncope of the ESC and endorsed by the EHRA, European Heart Failure Association and European Heart Rhythm Society. Transient loss of consciousness is a term that encompasses all disorders characterized by self-limited LOC, irrespective of mechanism.1–3 By including the mechanism of unconsciousness, i.e. transient global cerebral hypoperfusion, the current syncope definition excludes other causes of T-LOC such as epileptic seizures and concussion, as well as certain common syncope mimics, such as psychogenic pseudosyncope. ### Definition of a Syncope Unit An SU is a facility featuring a standardized approach to the diagnosis and management …

An approach to the evaluation and management of syncope in adults

#### Summary points Cohort and population based studies suggest that around 40% of the adult population has experienced a syncopal episode (usually described as a “faint” or “blackout”),1 2 w1 w2 with women more likely than men to report such an episode.w1-3 The incidence is higher with advancing age,2 w3 and this trend coincides with the increase in prescription of vasoactive drugs and increasing incidence of cardiac arrhythmia in the elderly population. Although comprehensive reviews and guidelines are available for specialists who care for patients referred with syncope,3 4 w4 w5 guidance for the non-specialist is sparse. This review provides guidance for generalists who encounter patients who have had transient loss of consciousness that may be syncopal in nature. It is based on cohort studies, randomised controlled trial evidence, and expert consensus guidelines. #### Sources and selection criteria We searched Medline, PubMed, and Cochrane databases for English articles whose titles included the keywords “syncope”, “vasovagal syncope”, “orthostatic hypotension”, tilt table test”, “cardiac arrhythmia”, or “sudden cardiac death”, with and without the limits “meta-analysis”, “review”, and “randomised controlled trial”. We also consulted recent international guidelines on syncope (including the specialist societies the European Society of Cardiology and the American Heart Association/American College of Cardiology Foundation), and reviewed our personal archives and relevant current textbooks. Patients with transient loss of consciousness often present non-specifically with an episode of …