Aim
To assess the clinical efficacy of orthostatic training (OT) and its effect on the autonomic activity.
Methods
OT was performed in 38 patients (13 males, age 36.4 ± 15.2 years). Baroreflex ...sensitivity (BRS), heart rate variability, and quality of life (SF 36) were assessed before and after 6 months of OT. Patients with no recurrence of syncope and reduction of the presyncope number to one‐third or less were classified as responders.
Results
Compliance to OT was low. Only 55% (38 from 69 patients) completed the training programme; 28 patients were responders (74%) and 10 patients were nonresponders. Before OT, BRS in upright position was lower in responders than in nonresponders (sitting: 8.05 ± 3.94 ms/mm Hg vs 12.51 ± 5.3 ms/mm Hg, P = 0.04, standing: 5.08 ± 2.34 ms/mm Hg vs 7.54 ± 2.16 ms/mm Hg, P = 0.02). After OT, BRS increased in responders (sitting: 8.05 ± 3.94 ms/mm Hg to 9.31 ± 4.49 ms/mm Hg, P = 0.05; standing: 5.08 ± 2.34 ms/mm Hg to 5.96 ± 2.38 ms/mm Hg, P = 0.03). No differences in supine BRS were observed. In responders, low frequency (LF) and high frequency (HF) power in sitting and standing positions significantly increased after OT (P < 0.05). In nonresponders, there was no significant rise in BRS, LF, and HF after OT. A significant increase in quality of life was noted in responders, but not in nonresponders.
Conclusions
OT reduced symptoms in 74% patients who trained regularly. However, the compliance to training was low. Possible mechanism of OT is reconditioning effect on baroreceptor reactivity in upright position.
Orthostatic hypotension (OH) is an abnormal blood pressure response to standing, which is associated with an increased risk of adverse outcomes such as syncope, falls, cognitive impairment, and ...mortality. Medical therapy is one the most common causes of OH, since numerous cardiovascular and psychoactive medications may interfere with the blood pressure response to standing, leading to drug-related OH. Additionally, hypotensive medications frequently overlap with other OH risk factors (e.g., advanced age, neurogenic autonomic dysfunction, and comorbidities), thus increasing the risk of symptoms and complications. Consequently, a medication review is recommended as a first-line approach in the diagnostic and therapeutic work-up of OH, with a view to minimizing the risk of drug-related orthostatic blood pressure impairment. If symptoms persist after the review of hypotensive medications, despite adherence to non-pharmacological interventions, specific drug treatment for OH can be considered. In this narrative review we present an overview of drugs acting on the cardiovascular and central nervous system that may potentially impair the orthostatic blood pressure response and we provide practical suggestions that may be helpful to guide medical therapy optimization in patients with OH. In addition, we summarize the available strategies for drug treatment of OH in patients with persistent symptoms despite non-pharmacological interventions.
Holter electrocardiography (ECG) assists in the diagnosis of arrhythmias. Its use in the inpatient setting has been described solely for the evaluation of stroke and syncope. Our aim was to assess ...its diagnostic value for other conditions in the internal medicine department. We included all hospitalized patients between 2018 and 2021 in a tertiary referral center. The primary outcome was a diagnostic Holter recording a new arrhythmia that led to a change in treatment. Overall, 289 patients completed a 24-h inpatient Holter ECG for conditions other than syncope or stroke, with 39 (13%) diagnostic findings. The highest diagnostic value was found in patients admitted for pre-syncope (19%), palpitations (18%), and unexplained heart failure exacerbation/dyspnea (17%). A low diagnostic yield was found for the evaluation of chest pain (5%). Heart failure with preserved ejection fraction (adjusted OR 2.3, 95% CI 1.1-5.4, p = 0.04), and baseline ECG with either a bundle branch block (AOR 4.2, 95% CI 1.9-9.2, p < 0.01) or atrioventricular block (first or second degree, AOR 5, 95% CI 2.04-12.3, p < 0.01) were among the independent predictors for a diagnostic test. Inpatient Holter ECG monitoring may have value as a diagnostic tool for selected patients with conditions other than syncope or stroke.
Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of ...falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio 95% CI: 2.24 1.06-4.74;
=0.03) or lisinopril (hazard ratio 95% CI: 2.61 1.03-6.72;
=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
This article informs the general pediatrician about the diagnosis, evaluation, and treatment of teenage patients with presyncope and loss of consciousness. The focus is on distinguishing noncardiac ...fainting from life-threatening syncope. Current treatment strategies of vasovagal syncope and postural orthostatic tachycardia syndrome are also outlined.
Sentinel Symptoms in Unexplained Cardiac Arrest. Background: Warning symptoms may provide an opportunity to diagnose genetic disorders leading to preventative therapy. We explored the symptom history ...of patients with apparently unexplained cardiac arrest to determine the frequency of sentinel symptoms.
Methods: Patients with apparently unexplained cardiac arrest and no evident cardiac disease underwent systematic clinical evaluation. Patients and first‐degree relatives were interviewed to determine the presence of cardiac symptoms, and those with syncope underwent 2 structured Calgary Syncope Score questionnaires to determine the probable mechanism of syncope.
Results: One hundred consecutive cardiac arrest patients (age 43.0 ± 13.4 years, 60% male) and 63 first‐degree relatives (age 37.6 ± 16.3 years, 54% female) were enrolled. Previous cardiac symptoms were present in 69% of cardiac arrest patients compared to 43% of family members (P = 0.001). Prior syncope was present in 26% of cardiac arrest patients, compared to 22% of family members (P = 0.59). Twenty‐four of 25 cardiac arrest patients who completed the syncope questionnaires had a syncope versus seizure score <1 favoring syncope. The area under the receiver operator curve (ROC) for the syncope mechanism score was 0.79 for identifying patients with subsequent cardiac arrest (95% CI, 0.6328–0.9395, P = 0.004). A score of ≤–2 had a sensitivity of 68% and specificity of 85%. Thirty percent of patients with a proven genetic cause had preceding syncope versus 19% in patients with noninherited or idiopathic causes (P = 0.032).
Conclusions: Syncope that may represent a sentinel event is present in a modest proportion of patients and family members, and is often suggestive of an arrhythmia. (J Cardiovasc Electrophysiol, Vol. 23, pp. 60‐66, January 2012)
Drowning is likely to result from impairment of consciousness when scuba diving. Causes include toxic effects of breathing gas, including nitrogen narcosis and oxygen toxicity, and arterial gas ...embolism.
Review of the medical records of scuba divers who had impaired consciousness underwater that could not be attributed to toxic effects of breathing gas or arterial gas embolism.
Four scuba divers had episodes of impaired consciousness when at shallow depths (8-18 m) underwater. The descriptions of the episodes were very similar. Three had histories of recurrent episodes of vasovagal syncope on land.
Absence of other causes for their impaired consciousness underwater leads to the conclusion that the probable cause was vasovagal syncope.
There are conflicting data regarding the prognostic value of syncope in patients with acute pulmonary embolism (APE).
We retrospectively reviewed data of 552 consecutive adults with computed ...tomography pulmonary angiogram-confirmed APE to determine the correlates and outcome of the occurrence of syncope at the time of presentation.
Among 552 subjects with APE (mean age 54years, 47% men), syncope occurred in 12.3% (68/552). Compared with subjects without syncope, those with syncope were more likely to have admission systolic blood pressure<90mmHg (odds ratio (OR) 5.788, P<0.001), and an oxygen saturation<88% on room air (OR 5.560, P<0.001), right ventricular dilation (OR 2.480, P=0.006), right ventricular hypokinesis (OR 2.288, P=0.018), require mechanical ventilation for respiratory failure (OR 3.152, P=0.014), and more likely to receive systemic thrombolysis (OR 4.722, P=0.008). On multivariate analysis, syncope on presentation was an independent predictor of a massive APE (OR 2.454, 95% CI 1.109–5.525, P=0.03) after adjusting for patients' age, sex, requirement of antibiotics throughout hospitalization, peak serum creatinine, admission oxygen saturation<88% and admission heart rate>100bpm. There was no difference in mortality in cases with APE with or without syncope (P=0.412).
Syncope at the onset of pulmonary embolization is a surrogate for submassive and massive APE but is not associated with higher in-hospital mortality.
Syncope is a common cause for hospitalization and may be related to comorbidity and concurrent medication. The objective of this study was to determine the incidence, comorbidity, and pharmacotherapy ...in a nationwide cohort of patients hospitalized with syncope.
An observational study including patients with the diagnosis of syncope identified from the Danish National Patient Register in the period 1997-2009. All patients were matched on sex and age with five controls from the Danish population. We estimated the incidence of syncope and the association with comorbidities and pharmacotherapy by conditional logistic regression analyses. We identified 127 508 patients with a first-time diagnosis of syncope median age 65 years (interquartile range 49-81), 52.6% female. The age distribution of the patients showed three peaks around 20, 60, and 80 years of age with the third peak occurring 5-7 years earlier in males. Cardiovascular disease and cardiovascular drug therapy was present in 28 and 48% of the patients, respectively. We found significant association between cardiovascular disease and the risk of admission for syncope increasing with younger age; age 0-29 years odds ratio (OR) = 5.8, confidence interval (CI): 5.2-6.4), age 30-49 (OR = 4.4, CI: 4.2-4.6), age 50-79 (OR = 2.9, CI: 2.8-3.0), and age above 80 (OR = 2.0, CI: 1.9-2.0). Cardiovascular pharmacotherapy associated with age and risk of syncope was similar.
In a nationwide cohort of patients hospitalized for first syncope we found significant association between cardiovascular comorbidity and pharmacotherapy and the risk of syncope. The occurrence of syncope displayed an age distribution with important gender-specific differences and higher incidence rates than previously reported.
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