cardiovascular-agents and Syncope

Hypertrophic cardiomyopathy is the most common inherited cardiovascular disease. It is characterized by increased ventricular wall thickness and is highly complex due to its heterogeneous clinical presentation, several phenotypes, large number of associated causal mutations and broad spectrum of complications. It is caused by mutations in sarcomeric proteins, which are identified in up to 60% of cases of the disease. Clinical manifestations of Hypertrophic Cardiomyopathy include shortness of breath, chest pain, palpitations and syncope, which are related to the onset of diastolic dysfunction, left ventricular outflow tract obstruction, ischemia, atrial fibrillation and abnormal vascular responses. It is associated with an increased risk of sudden cardiac death, heart failure and thromboembolic events. In this article, we discuss the diagnostic and therapeutic aspects of this disease.

Topics: Animals; Atrial Fibrillation; Cardiac Surgical Procedures; Cardiomyopathy, Hypertrophic; Cardiovascular Agents; Clinical Trials as Topic; Death, Sudden, Cardiac; Diagnostic Techniques, Cardiovascular; Drug Evaluation, Preclinical; Dyspnea; Genetic Association Studies; Heart; Heart Failure; Heart Septum; Heart Ventricles; Humans; Muscle Proteins; Pacemaker, Artificial; Penetrance; Risk Assessment; Sarcomeres; Syncope

Topics: Adult; Androstenes; Anxiety; Blood Volume; Cardiovascular Agents; Catheter Ablation; Combined Modality Therapy; Confusion; Contraindications; Diagnosis, Differential; Fatigue; Female; Hemodynamics; Humans; Leg; Mast Cells; Norepinephrine; Norepinephrine Plasma Membrane Transport Proteins; Posture; Renin-Angiotensin System; Sodium Chloride; Sympathetic Nervous System; Syncope; Syndrome; Tachycardia

Quality improvement in cardiology over the past decade focused on management of acute coronary syndrome with invasive and innovative medical therapies, optimizing treatment of congestive heart failure and the development of repair procedures in valvular heart disease. On the other hand cardiologist and the attendant physicians are confronted with changes in the characteristics of patients in the light of demographic facts. Comorbidity and polypharmacy raise the need for clear concepts. Therapeutic and diagnostic tools of geriatric medicine may help in that context.

Topics: Aged; Aged, 80 and over; Bradycardia; Cardiovascular Agents; Drug Interactions; Drug Therapy, Combination; Frail Elderly; Heart Diseases; Humans; Long QT Syndrome; Prescription Drugs; Syncope; Tachycardia

The disorders of autonomic control associated with orthostatic intolerance are a diverse group of infirmities that can result in syncope and near syncope (as well as a host of other complaints). A basic understanding of these disorders is essential to both diagnosis and proper treatment. These infirmities are not new, what has changed is our ability to recognize them. It has been said that "the world undergoes change in the human consciousness. As this consciousness changes, so does the world." On going studies will continue to help better define the broad spectrum of these disorders, and to elaborate better diagnostic and treatment modalities.

Topics: Autonomic Agents; Autonomic Nervous System Diseases; Cardiovascular Agents; Humans; Hypotension, Orthostatic; Patient Education as Topic; Posture; Syncope

Topics: Antihypertensive Agents; Cardiovascular Agents; Humans; Hypotension, Orthostatic; Syncope

To test the hypothesis that female prevalence is greater than expected among reported cases of torsades de pointes associated with cardiovascular drugs that prolong cardiac repolarization.. A MEDLINE search of the English-language literature for the period of 1980 through 1992, using the terms torsade de pointes, polymorphic ventricular tachycardia, atypical ventricular tachycardia, proarrhythmia, and drug-induced ventricular tachycardia, supplemented by pertinent references (dating back to 1964) from the reviewed articles and by personal communications with researchers involved in this field.. Ninety-three articles were identified describing at least one case of polymorphic ventricular tachycardia (with gender specified) associated with quinidine, procainamide hydrochloride, disopyramide, amiodarone, sotalol hydrochloride, bepridil hydrochloride, or prenylamine. A total of 332 patients were included in the analysis following application of prospectively defined criteria (eg, corrected QT [QTc] interval of 0.45 second or greater while receiving drug).. Clinical and electrocardiographic descriptors were extracted for analysis. Expected female prevalence for torsades de pointes associated with quinidine, procainamide, disopyramide, and aminodarone was conservatively estimated from gender-specific data reported for antiarrhythmic drug prescriptions in 1986, as derived from the National Disease and Therapeutic Index, a large pharmaceutical database; expected female prevalence for torsades de pointes associated with sotalol, bepridil, and prenylamine was assumed to be 50% or less since these agents are prescribed for male-predominant cardiovascular conditions.. Women made up 70% (95% confidence interval, 64% to 75%) of the 332 reported cases of cardiovascular-drug-related torsades de pointes, and a female prevalence exceeding 50% was observed in 20 (83%) of 24 studies having at least four included cases. When analyzed according to various descriptors, women still constituted the majority (range, 51% to 94% of torsades de pointes cases), irrespective of the presence or absence of underlying coronary artery or rheumatic heart disease, left ventricular dysfunction, type of underlying arrhythmia, hypokalemia, hypomagnesemia, bradycardia, concomitant digoxin treatment, or level of QTc at baseline or while receiving drug. When cases of torsades de pointes were analyzed by individual drug, observed female prevalence was always greater than expected, representing a statistically significant difference (P < .05) for all agents except procainamide.. These findings strongly suggest that women are more prone than men to develop torsades de pointes during administration of cardiovascular drugs that prolong cardiac repolarization. The pathophysiological basis for, and therapeutic implications of, this gender disparity should be further investigated.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Amiodarone; Bepridil; Cardiovascular Agents; Disopyramide; Female; Humans; Male; Middle Aged; Prenylamine; Procainamide; Quinidine; Risk Factors; Sex; Sotalol; Syncope; Tachycardia, Ventricular; Torsades de Pointes

Syncope usually has a cardiovascular source, so neurologic evaluation has a low diagnostic yield in these patients. Cardiac arrhythmias in persons with or without structural heart disease can produce syncope. Neurocardiogenic dysfunction that results in diminished venous return and hypercontractility is another frequent cause. Postural hypotension or left ventricular outflow obstruction may also be to blame. Careful history taking and physical examination, head-up tilt testing, echocardiography or radionuclide isotope imaging, and electrophysiologic study are often diagnostic. However, syncope remains undiagnosed in some patients, and they may require periodic reassessment. Treatment options are available for most cardiovascular disorders, among them use of pharmacologic agents; catheter, surgical, or radio-frequency modification of certain tachycardias; and permanent pacing.

Topics: Cardiac Pacing, Artificial; Cardiovascular Agents; Cardiovascular Diseases; Echocardiography; Education, Medical, Continuing; Electrocoagulation; Electrophysiology; Humans; Radionuclide Imaging; Syncope

The aim of this study was to examine the effect on symptoms in patients with induced cardioinhibitory carotid sinus syndrome (ICSS) when treated or not treated with a pacemaker.. Sixty patients with a history of syncope or pre-syncope and ICSS were randomized to receive a permanent pacemaker (P group, n = 30) or no pacing (NP group, n = 30). ICSS was defined as a ventricular pause (i.e. asystole) lasting 3 s or more in response to carotid sinus stimulation. The patients were seen at 3 and 12 months and at symptoms. At 12 months, the rate of syncope in the NP group was 40% (n = 12) compared with 10% (n = 3) in the P group (P = 0.008). The majority (11 of 12) of the syncope recurrences in the NP group occurred during the first 3 months. Pre-syncope occurred in two patients (7%) in the NP group and in eight (27%) in the P group. Ten patients (33%) with recurrent syncope in the NP group later crossed-over to receive pacemaker implant.. A history of syncope or pre-syncope, plus ICSS, was a strong predictor of subsequent syncope or pre-syncope. Most of the new symptoms occurred within 3 months. Pacemaker treatment effectively reduced syncope and/or resulted in milder symptoms.

Topics: Aged; Cardiac Pacing, Artificial; Cardiovascular Agents; Carotid Sinus; Female; Humans; Male; Middle Aged; Pacemaker, Artificial; Recurrence; Regression Analysis; Syncope; Syndrome; Tilt-Table Test; Treatment Outcome

To investigate the value of head-up tilt table testing (HUTT) with low-dose isosorbide dinitrate (ISDN) in the evaluation of patients with unexplained syncope and to compare the results of HUTT with ISDN and HUTT with isoproterenol.. Forty-three patients with unexplained syncope (21 women, with a mean age of 45.4 18 years) and 18 control subjects without syncope (eight women, with a mean age of 45.8 12 years) were tilted (80 ) for 30 min (passive period). When this period was negative, 2.5 mg sublingual ISDN was administered and patients were observed for an additional 15 min (ISDN period). The first 25 patients studied (10 women, with a mean age of 46.2 18 years) were tested again after a mean period of three weeks using the isoproterenol protocol. After the passive period, intravenous isoproterenol was administered (1 to 3 g/min) to patients lying in the supine position, and they were tilted again (80 ) for 10 min (isoproterenol period).. During the passive period, 10 of 43 patients (23%) had a positive response compared with none in the control group. Syncope was observed in another 14 patients and in two control subjects during the ISDN period. The positivity rate (sensitivity) and specificity of HUTT with low dose ISDN were 56% and 89%, respectively. Among the patients (n=25) tested with the isoproterenol protocol, 14 (56%) patients had syncope. The agreement rate between the protocols was 78.9%.. The total positivity rate of HUTT significantly increased with the use of the low dose ISDN, while specificity remained high. Due to its simplicity and tolerability, the ISDN protocol can be chosen when the results of the passive period tilt testing are negative.

Topics: Administration, Sublingual; Adult; Cardiovascular Agents; Female; Humans; Infusions, Intravenous; Isoproterenol; Isosorbide Dinitrate; Male; Middle Aged; Sensitivity and Specificity; Syncope; Syncope, Vasovagal; Tilt-Table Test

Study of cardiovascular drugs usage, among elderly subjects admitted to the emergency department for syncopal falls in Rhône-Alpes region. Polypharmacy and cardiovascular medication usage are risk factors for falls in the elderly. This study included subjects aged 75 and over, admitted in the emergency department for falls, based on evaluation data of professional practices carried out in the Nord Alpine region by the French Network of North-Alps Emergency Departments (Réseau Nord Alpin des Urgences, RENAU). The patients included were divided into 4 groups: "syncope", "accidental falls", "repeated falls" and "other types of fall". From the emergency room admission prescriptions, we studied the consumption of cardiovascular drugs in number and quality in the "syncope" group compared to other types of falls. The main objective in this study was to highlight higher cardiovascular drug usage among the elderly patients admitted to the emergency department for syncopal falls, in comparison with other types of falls. We included 1,476 patients among whom 262 patients came for "syncopal falls". We found superior usage of cardiovascular medication among syncopal falls compared to other type of falls (p < 0,01). However, there is no statistically significant association between inappropriate cardiovascular drug prescriptions, and the type of falls. The "standardized" fall assessment whose orthostatic hypotension investigation, is not always exhaustive in the emergency room. Orthostatic hypotension diagnostic is insufficiently sought in the emergency room. This study highlights a significantly higher usage of diuretic medication within the syncope group, in comparison to the other groups, and especially loop diuretic. Antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, calcium inhibitor) are also recurrent within the syncope group compared to the others. A careful supervising of these prescriptions among elderly patients seems required. These data prompt to revise prescriptions during fall related hospitalizations, and then with the primary-care physician, or with the cardiologist.

Topics: Accidental Falls; Aged; Cardiovascular Agents; Emergency Service, Hospital; Hospitalization; Humans; Hypotension, Orthostatic; Syncope

Syncope accounts for 1% of emergency department (ED) visits, yet few experience a serious adverse event (SAE). Two-thirds of syncope patients are transported to the ED by ambulance, placing considerable burden on emergency medical services (EMS), and many of these transports may be unnecessary. We estimated the proportion of syncope patients who fell into a low-risk category based on an ED diagnosis of vasovagal syncope and the absence of EMS intervention, hospitalization, or SAE.. We conducted a multicentre prospective cohort study enrolling adult syncope patients transported to the ED by ambulance over 13 months. We collected demographics and EMS interventions, and followed patients for 30 days to identify all SAE, including death, dysrhythmia, myocardial infarction, aortic dissection, pulmonary embolism, subarachnoid hemorrhage, significant hemorrhage, and related procedural interventions.. Of 990 (67.2%) patients transported to the ED by ambulance, 121 had EMS interventions, 137 suffered 30-day SAE, 393 (39.7%; 95%CI 36.6, 42.8) were deemed low risk, 41 patients with vasovagal syncope were lost to follow-up, and 298 patients were diagnosed with non-vasovagal syncope. During transport, 121 (12.2%; 95%CI 10.2, 14.3) patients underwent some EMS intervention, and 137 (14.6%; 95%CI 12.4, 16.9) suffered SAEs within 30 days.. About 40% of patients transported to the ED by ambulance are at low risk and may not benefit from paramedic care or transport to a hospital. A robust clinical decision tool would help identify patients safe for treat-and-release, diversion to alternative care, or rapid offload into low-acuity ED areas, potentially reducing EMS workload and cost.. Les syncopes motivent 1 % des consultations au service des urgences (SU), mais le malaise entraîne peu d’événements indésirables graves (EIG). Ainsi, deux tiers des patients ayant subi une syncope sont transportés en ambulance au SU, ce qui impose un lourd fardeau sur les services médicaux d’urgence (SMU), et pourtant bon nombre de transports effectués seraient non nécessaires. Aussi l’étude visait-elle à estimer la proportion de patients ayant subi une syncope dont l’état serait jugé à faible risque d’après le diagnostic de syncope vasovagale posé au SU ainsi que d’après l’absence d’intervention faite par les SMU, d’hospitalisation ou d’EIG.. Il s’agit d’une étude prospective de cohortes, multicentrique, menée chez des adultes qui ont subi une syncope et qui ont été transportés en ambulance au SU, sur une période de 13 mois. Ont été recueillies des données démographiques ainsi que les notes sur les interventions effectuées par les SMU; à cela s’ajoute un suivi de 30 jours aux fins de collecte de renseignements sur tout EIG : mort, arythmie, infarctus du myocarde, dissection de l’aorte, embolie pulmonaire, hémorragie sous-arachnoïdienne, hémorragie importante et gestes interventionnels liés aux troubles en question.. Au total, 990 patients (67,2 %) ont été transportés en ambulance au SU; sur ce nombre, 121 ont subi des interventions pratiquées par les SMU; 137 ont connu un EIG au cours des 30 jours suivant le malaise; 393 (39,7 %; IC à 95 % : 36,6-42,8) ont été jugés à faible risque; 41 ayant fait une syncope vasovagale ont été perdus de vue durant le suivi; et 298, ont fait une syncope non vasovagale. Durant le transport, 121 patients (12,2 %; IC à 95 % : 10,2-14,3) ont subi une forme quelconque d’intervention par les SMU et, au cours des 30 jours de suivi, 137 (14,6 %; IC à 95 % : 12,4-16,9) ont connu un EIG.. Environ 40 % des patients transportés en ambulance au SU connaissent un faible risque et, dans leur cas, la prestation de soins paramédicaux ou le transport à l’hôpital pourraient ne pas être nécessaires. Un outil d’aide à la décision clinique qui soit digne de confiance pourrait faciliter le repérage des patients dont l’état se prêterait au traitement suivi du congé, à une orientation vers d’autres types de soins ou à un passage rapide dans des zones de petites urgences, ce qui permettrait à la fois de réduire la charge de travail des SMU ainsi que les coûts.

Topics: Ambulances; Antiemetics; Arrhythmias, Cardiac; Canada; Cardiac Pacing, Artificial; Cardiovascular Agents; Cohort Studies; Drug Utilization; Emergency Service, Hospital; Female; Glucose; Humans; Hypnotics and Sedatives; Male; Middle Aged; Sweetening Agents; Syncope

Syncope is a sudden loss and gain of consciousness. Traditionally, it is caused by the abnormalities of neurological, cardiac or vasovagal systems. We present a case of a 19-year-old woman presenting with recurrent syncopal episodes with no apparent cause. Examination and investigations were unremarkable for any aetiology except positive tilt tests for postural orthostatic tachycardia syndrome. The purpose of this report is to make physicians aware of the unique presentation of this rare aetiology with recurrent syncopal episodes and the novel management approach.

Topics: Cardiovascular Agents; Electrocardiography; Female; Humans; Ivabradine; Postural Orthostatic Tachycardia Syndrome; Syncope; Tilt-Table Test; Young Adult

A 26-year-old man presented to our syncope service with debilitating daily palpitations, shortness of breath, presyncope and syncope following a severe viral respiratory illness 4 years previously. Mobitz type II block had previously been identified, leading to a permanent pacemaker and no further episodes of frank syncope. Transthoracic echocardiography, electophysiological study and repeated urine metanepherines were normal. His palpitations and presyncope were reproducible on deep inspiration, coughing, isometric hand exercise and passive leg raises. We demonstrated rapid increases in heart rate with no change in morphology on his 12 lead ECG. His symptoms were resistant to fludrocortisone, flecainide, β blockers and ivabradine. Initiation of clonidine in combination with ivabradine led to rapid resolution of his symptoms. We suggest that an excessive respiratory sinus arrhythmia was responsible for his symptoms and achieved an excellent response with the centrally acting sympatholytic clonidine, where previous peripherally acting treatments had failed.

Topics: Adrenergic alpha-2 Receptor Agonists; Adult; Benzazepines; Cardiovascular Agents; Clonidine; Cough; Drug Therapy, Combination; Dyspnea; Echocardiography; Electrocardiography; Humans; Inhalation; Ivabradine; Male; Syncope; Tachycardia; Tachycardia, Sinus; Treatment Outcome

Sinoatrial node dysfunction (SND) is an important cause of syncope in the elderly. Though the diagnosis can be relatively straightforward in the persistent form of SND, it can be elusive when the dysfunction is intermittent. For intermittent SND, the diagnosis may require prolonged electrocardiographic recordings with an external or internal loop recorder, or an invasive electrophysiologic study. Ivabradine, an If inhibitor that slows sinoatrial discharge rate, is widely used for the treatment of chronic angina or heart failure. Though the drug is contraindicated in patients with known SND as it may exacerbate symptoms, we propose that a simple ivabradine suppression test, followed by a 24-h monitorization of heart rhythm, could be valuable to aid diagnosis of intermittent SND. The test we propose could be used prior to prolonged electrocardiographic monitoring in patients with suspected SND, but both the diagnostic accuracy and the safety should be evaluated with studies prior to implementation.

Topics: Benzazepines; Cardiology; Cardiovascular Agents; Clinical Trials as Topic; Electrocardiography; Electrophysiology; Heart Rate; Humans; Ivabradine; Monitoring, Physiologic; Pacemaker, Artificial; Reproducibility of Results; Sick Sinus Syndrome; Sinoatrial Node; Syncope

We explored the risks/benefits of revascularization versus medical management in syncope patients with obstructive coronary artery disease (CAD).. We retrospectively examined Medicare patients ≥65 years undergoing percutaneous coronary intervention (PCI) for syncope at 539 CathPCI Registry hospitals with ≥70% stenosis in at least 1 coronary artery, excluding those with ST-segment elevation myocardial infarction (MI), cardiogenic shock, left main disease, and coronary artery bypass grafting. In a propensity-matched population, we compared short-term (90-day) all-cause readmission risk and long-term (3-year) risks of readmission for syncope and MI, as well as mortality in those receiving PCI versus medical management.. Among 14,674 syncope patients, 9,549 (65%) had at least 1-vessel obstructive CAD. After exclusions, 3,196 of 7,338 patients (44%) underwent PCI. In the propensity-matched cohort, there was no significant difference in 90-day all-cause readmission risk (28.2% vs 30.3%, adjusted hazard ratio [HR] 0.92, 95% CI 0.83-1.02) or long-term risks of readmission for syncope (7.0% vs 6.1%, adjusted HR 1.06, 95% CI 0.83-1.35). PCI-treated patients had significantly higher risk of readmission for MI (5.6% vs 4.0%, adjusted HR 1.56, 95% CI 1.18-2.06) but lower risk of long-term mortality (27.0% vs 30.3%, adjusted HR 0.86, 95% CI 0.77-0.97) than medically managed patients.. In patients presenting with syncope and obstructive CAD, PCI was not associated with significant improvements in the risk of readmission but was associated with lower long-term mortality compared with medical therapy, suggesting the need to more definitively assess the benefit of PCI among elderly syncope patients.

Topics: Aged; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Vessels; Female; Humans; Male; Outcome and Process Assessment, Health Care; Patient Readmission; Percutaneous Coronary Intervention; Propensity Score; Retrospective Studies; Risk Assessment; Syncope; United States

Topics: Adrenal Cortex Hormones; Biopsy; Cardiomyopathies; Cardiovascular Agents; Catheter Ablation; Combined Modality Therapy; Cyclophosphamide; Defibrillators, Implantable; Electrocardiography; Heart Septum; Humans; Hypertrophy, Right Ventricular; Lymph Nodes; Magnetic Resonance Imaging; Male; Middle Aged; Sarcoidosis; Sarcoidosis, Pulmonary; Syncope; Tachycardia, Ventricular; Ultrasonography

We report a case of a patient with recurrent syncope and paroxysmal atrial fibrillation whose clinical status greatly improved after a period of orthostatic training. The potential efficacy of this non-pharmacological measure in modulating the autonomic tone is discussed below.

Topics: Adult; Aspirin; Atrial Fibrillation; Cardiovascular Agents; Follow-Up Studies; Heart Rate; Humans; Male; Physical Stimulation; Syncope; Treatment Outcome

Pericardial defects are rare in both people and dogs. They may be congenital or acquired in origin, and partial or total in extent. Commonly, pericardial defects are incidental findings at autopsy; however, diagnostic methods such as thoracic radiography and echocardiography can be useful in the ante mortem diagnosis of pericardial defects. This report describes the first case of a dog with syncope, supraventricular tachycardia, and a partial left pericardial defect with herniation of the left auricle for which extensive ante mortem diagnostic information was available. Partial absence of the pericardium should be considered in dogs with disproportionate enlargement of cardiac chambers for which other congenital and acquired heart diseases are ruled out.

Topics: Animals; Cardiovascular Agents; Dog Diseases; Dogs; Electrocardiography; Female; Heart Atria; Heart Diseases; Hernia; Pericardium; Syncope

Inherited heart conditions are the most common cause of sudden cardiac death in those under the age of 35 and the leading cause of non-traumatic death in young athletes. Hypertrophic cardiomyopathy (HCM) is the most common inherited heart disease affecting 1 in 500 of the population. Some patients may exhibit severe left ventricular hypertrophy, others may show nothing more than an abnormal ECG. Left ventricular hypertrophy most commonly manifests in the second decade of life. Sudden death is rare and usually affects patients in the first three decades whereas older patients present with heart failure, atrial fibrillation and stroke. Arrhythmogenic right ventricular cardiomyopathy is a rare, autosomal dominant heart muscle disorder which affects between 1 in 1,000 and 1 in 5,000 of the population. Dilated cardiomyopathy (DCM) is characterised by a dilated left ventricle with impaired function that cannot be explained by ischaemic heart disease, hypertension or valvular heart disease. At least 25% of cases of DCM are familial. DCM may be associated with multisystem conditions such as muscular dystrophy. Chemotherapy and certain other drugs, alcohol abuse and myocarditis may also lead to a dilated and poorly contracting left ventricle. In many cases the first manifestation of an inherited cardiomyopathy can be a sudden cardiac arrest. Other presentations include chest pain or breathlessness during exertion, palpitations and syncope. In many of the cardiomyopathies, the diagnosis can be made with a standard ECG and echocardiogram. However if the diagnosis is not certain or the cardiologist wishes to look at the heart structure in greater detail, a cardiac MRI may be performed.

Topics: Adult; Arrhythmias, Cardiac; Cardiomyopathies; Cardiovascular Agents; Death, Sudden, Cardiac; Desmoplakins; Disease Management; Echocardiography; Electric Countershock; Electrocardiography; Female; Heart Rate; Humans; Magnetic Resonance Imaging; Male; Mutation; Myocardium; Syncope

Recurrent syncope is a major cause of hospitalizations and may be associated with cardiovascular co-morbidities. Despite this, prognostic factors and the clinical characteristics among patients are not well described. Therefore, we identified and analyzed data on all patients >50 years of age discharged after a first-time episode of syncope in the period 2001 to 2009 through nationwide administrative registries. We identified the clinical characteristics of 5,141 patients ≥85 years of age and 23,454 patients <85 years of age. Multivariate Cox models were used to assess prognostic factors associated with the end point of recurrent syncope according to age. We found that those with syncope and ≥85 years were more often women (65% vs 47%) and generally had a greater prevalence of noncardiovascular co-morbidities, whereas the prevalence of cardiovascular co-morbidities was more heterogeneously distributed across age groups. Overall, significant baseline predictors of recurrent syncope were aortic valve stenosis (hazard ratio [HR] 1.48, 95% confidence interval [CI] 1.31 to 1.68), impaired renal function (HR 1.34, 95% CI 1.15 to 1.58), atrioventricular or left bundle branch block (HR 1.32, 95% CI 1.16 to 1.51), male gender (HR 1.18, 95% CI 1.12 to 1.24), chronic obstructive pulmonary disorder (HR 1.10, 95% CI 1.02 to 1.19), heart failure (HR 1.10, 95% CI 1.02 to 1.21), atrial fibrillation (HR = 1.09, 95% CI 1.01 to 1.19), age per 5-year increment (HR 1.09, 95% CI 1.07 to 1.10), and orthostatic medications per increase (HR 1.06, 95% CI 1.03 to 1.09). Atrial fibrillation and impaired renal function both exhibited less prognostic importance for recurrent syncope in the elderly compared with younger population (p for interactions <0.01). In conclusion, predictive factors of recurrent syncope were closely associated with increased cardiovascular risk profile age and gender. The use of multiple orthostatic medications additively increased the risk of recurrences representing a need for strategies to reduce unnecessary polypharmacy.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Comorbidity; Denmark; Female; Humans; Male; Middle Aged; Polypharmacy; Prevalence; Proportional Hazards Models; Registries; Risk Assessment; Risk Factors; Survival Rate; Syncope

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.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Cohort Studies; Comorbidity; Denmark; Female; Hospitalization; Humans; Incidence; Male; Middle Aged; Registries; Risk; Sex Factors; Syncope; Treatment Outcome; Young Adult

To evaluate the long-term prognostic impact of baseline symptoms in a cohort of hypertrophic cardiomyopathy (HCM) patients.. We considered 84 HCM patients symptomatic at diagnosis: 26 (31%) with heart failure (group 1), 34 (40%) with syncope/palpitations (group 2) and 24 (29%) with chest pain (group 3). During a median follow-up of 102 (53-187) months, 25 (30%) patients died/underwent heart transplant (HTx), 14 of 26 (54%) in group 1, 10 of 34 (29%) in group 2 and one of 24 (4%) in group 3. At 12, 60 and 120 months, HTx-free survival rates were 100, 79 and 52% in group 1, vs. 100, 97 and 69% in group 2, vs. 96, 96 and 96% in group 3, respectively (P = 0.008). At multivariate analysis, heart failure [hazard ratio (HR) 2.59, confidence interval (CI) 95% 1.09-6.17, P = 0.032] and left atrium diameter (HR 1.83, CI 95% 1.16-2.89, P = 0.009) emerged as independent predictors of death/HTx, with incremental prognostic power with respect to echo Doppler variables of left ventricular systolic and diastolic dysfunction [area under the curve (AUC) of receiver operating characteristics (ROC) curves at 5 years: 0.90 vs. 0.78, respectively, P = 0.03].. Clinical presentation emerged as a relevant prognostic tool in HCM patients symptomatic at onset, as heart failure was associated with a particularly poor outcome. Heart failure and left atrium diameter at diagnosis showed incremental prognostic power compared with echo Doppler assessment of left ventricular systolic and diastolic dysfunction.

Topics: Adolescent; Adult; Aged; Arrhythmias, Cardiac; Cardiomyopathy, Hypertrophic; Cardiovascular Agents; Chest Pain; Chi-Square Distribution; Child; Child, Preschool; Disease-Free Survival; Echocardiography, Doppler; Female; Heart Atria; Heart Failure; Heart Transplantation; Humans; Infant; Italy; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Predictive Value of Tests; Prognosis; Proportional Hazards Models; Registries; Risk Factors; Syncope; Time Factors; Ventricular Function, Left; Young Adult

Topics: Adenosine; Atrioventricular Block; Atrioventricular Node; Bundle of His; Cardiovascular Agents; Child; Electrocardiography; Female; Humans; Pacemaker, Artificial; Syncope

The aim of this study was to investigate the long-term prognosis of non-interventionally followed patients with myocardial bridge and angiographic milking of the left anterior descending (LAD) coronary artery.. All of the coronary angiography records from May 2000 to November 2007 were reevaluated and patients who had more than 70% narrowing during systole on LAD were eligible for the present study. Follow-up was carried out by physical examination, echocardiography, and treadmill exercise testing. The clinical situations of the patients, medical treatment at the time of follow-up, and experienced events (death, myocardial infarction, or revascularization) were recorded.. There were 59 eligible patients (44 male, 74.6%). The mean age of the patients was 54 +/- 11 years. The bridges were located in the proximal, mid, and distal portion of the LAD in 17 (28.8%), 20 (33.9%), and 22 (37.3%) patients, respectively. Distributions of the narrowing degree were as follows: between 70% to 89% in 33 (56%) patients and 90% to 100% in 26 (44%) patients. Mean follow-up duration of the group was 37 +/- 13 months (range 15-65 mo). The clinical presentation during follow-up was stable angina in 9 (15.3%) cases, atypical angina in 12 (20.3%), atypical chest pain in 13 (22%), dyspnea in 3 (5.1%), and syncope in 3 (5.1%) cases. There were no experienced events and/or hospitalizations related to cardiac disease. Echocardiographic examination revealed normal systolic ventricular function. Only 17 (28.8%) patients continued to use medication. Most of them were on beta-blocker therapy.. Patients with myocardial bridges and angiographic milking of the LAD coronary artery have a good long-term prognosis.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Cineangiography; Coronary Angiography; Coronary Stenosis; Dyspnea; Echocardiography; Exercise Test; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Bridging; Myocardial Ischemia; Registries; Severity of Illness Index; Syncope; Time Factors; Treatment Outcome

Slow coronary flow is an angiographic phenomenon characterized by delayed opacification of vessels in the absence of any evidence of obstructive epicardial coronary disease. In this article, we present serious clinical manifestations of extremely slow coronary flow in two hypertensive patients with preserved ejection fraction in echocardiographical examination: a 57 year-old woman with acute coronary syndrome and temporary ST elevation; and a 65 year-old man with atrial tachycardia which was leading to sudden arrest of circulation. The woman was admitted to hospital due to recurrent syncope and chest pain. Because of severe bradycardia, an AAI pacemaker was implanted. Coronary angiography without evident obstructive lesion revealed extremely slow flow of dye through arteries. The man was admitted to hospital because of heart palpitations (paroxysmal atrial tachycardia, PAT) followed by chest pain. During hospitalization, a sudden arrest of circulation in the course of supraventricular tachycardia of 220/min with atrioventricular conduction of 1:1 occurred. Coronary arteriography did not show any occlusions in the coronary arteries, although extremely slow dye flow was seen. Electrophysiological examination revealed arrhythmia of the left atrial (PAT) (tricuspid valve anulus mapping) without induced ventricular arrhythmia. Because of symptomatic bradyarrhythmia, a VVI heart pacemaker was implanted. Over a 12-month observation, his heart rate remained under control, and the patient did not complain of chest pains or heart palpitations.

Topics: Acute Coronary Syndrome; Aged; Angina Pectoris; Blood Flow Velocity; Bradycardia; Cardiac Pacing, Artificial; Cardiovascular Agents; Combined Modality Therapy; Coronary Angiography; Coronary Circulation; Coronary Disease; Drug Therapy, Combination; Electrocardiography; Female; Heart Rate; Humans; Male; Middle Aged; Syncope; Tachycardia, Paroxysmal; Tachycardia, Supraventricular; Treatment Outcome

To determine whether outcomes of tilt-table tests improved after withdrawal of fall-risk-increasing drugs (FRIDs).. Prospective cohort study.. Geriatric outpatient clinic.. Two hundred eleven new, consecutive outpatients, recruited from April 2003 until December 2004.. Tilt-table testing was performed on all participants at baseline. Subsequently, FRIDs were withdrawn in all fallers in whom it was safely possible. At a mean follow-up of 6.7 months, tilt-table testing was repeated in 137 participants. Tilt-table testing addressed carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), and vasovagal collapse (VVC). Odds ratios (ORs) of tilt-table-test normalization according to withdrawal (discontinuation or dose reduction) of FRIDs were calculated using multivariate logistic regression analysis.. After adjustment for confounders, the reduction of abnormal test outcomes (ORs) according to overall FRID withdrawal was 0.34 (95% confidence interval (CI)=0.06-1.86) for CSH, 0.35 (95% CI=0.13-0.99) for OH, and 0.27 (95% CI=0.02-3.31) for VVC. For the subgroup of cardiovascular FRIDs, the adjusted OR was 0.13 (95% CI=0.03-0.59) for CSH, 0.44 (95% CI=0.18-1.0) for OH, and 0.21 (95% CI=0.03-1.51) for VVC.. OH improved significantly after withdrawal of FRIDs. Subgroup analysis of cardiovascular FRID withdrawal showed a significant reduction in OH and CSH. These results imply that FRID withdrawal can cause substantial improvement in cardiovascular homeostasis. Derangement of cardiovascular homeostasis may be an important mechanism by which FRID use results in falls.

Topics: Accidental Falls; Aged; Cardiovascular Agents; Carotid Sinus; Female; Humans; Hypotension; Hypotension, Orthostatic; Male; Mobility Limitation; Psychotropic Drugs; Risk Factors; Syncope; Syncope, Vasovagal; Tilt-Table Test

Topics: Acetylcholine; Angina Pectoris; Bundle-Branch Block; Calcium Channel Blockers; Cardiovascular Agents; Coronary Vasospasm; Death, Sudden, Cardiac; Defibrillators, Implantable; Electrocardiography; Humans; Myocardial Ischemia; Syncope; Ventricular Fibrillation

Two patients with life-threatening episodes of ventricular fibrillation (VF) showed typical ST elevation in V1-V3 leads. Both had spontaneous clinical episodes of resting angina. Intracoronary injection of acetylcholine provoked coronary vasospasm and ST elevation was the same as Brugada-type ST elevation in 1 case but not in the other. Calcium channel antagonist was prescribed to prevent coronary vasospasm but Brugada-type ST elevation and the occurrence of VF could not be prevented. The symptoms accompanied both cases. Considering these cases, the pathogenesis of Brugada syndrome should differ from that of coronary vasospasm because it could not be prevented by calcium channel antagonist.

Topics: Acetylcholine; Amlodipine; Calcium Channel Blockers; Cardiovascular Agents; Coronary Vasospasm; Defibrillators, Implantable; Diltiazem; Electric Countershock; Electrocardiography; Fatal Outcome; Heart Function Tests; Humans; Male; Middle Aged; Myocardial Ischemia; Syncope; Ventricular Fibrillation

The authors used 2 national Veterans Health Administration databases to identify outpatient medications and all 30 Elixhauser comorbidities for 2579 unique patients, age 65+ years, hospitalized for syncope in fiscal year 2004. For comparison, we identified other elderly patients hospitalized with acute myocardial infarction (N = 4491), fracture (N = 2797), or pneumonia (N = 9473). The categories of medications included drugs that affect the cardiovascular, central nervous, or the muscular skeletal system. The most notable differences between syncope compared to acute myocardial infarction patients occurred in central nervous system drugs in anticonvulsants/barbiturates, antidepressants, antihistamine/antinauseants, antipsychotics, and cholinesterase inhibitors (P < .0018). Comparing syncope patients with fracture patients, the central nervous medication profile was similar, but the cardiovascular medication profile differed (P < .0018); their hypertension comorbidities also differed (60.45% vs 46.34%); (P < .0016). These findings indicate significant potential associations that warrant further study. Studies linking national outpatient medications to hospitalizations for specific conditions can foster the development of more proactive pharmacovigilance systems.

Topics: Aged; Cardiovascular Agents; Central Nervous System Agents; Comorbidity; Fractures, Bone; Hospitalization; Humans; Myocardial Infarction; Outpatients; Pneumonia; Residence Characteristics; Syncope; United States; United States Department of Veterans Affairs

To determine the prevalence, predictors, and prognosis of patients with multiple potential causes of syncope.. This is a retrospective cohort study with prospective follow-up of consecutive patients with syncope of uncertain cause who were referred to the electrophysiology service for syncope evaluation from January 1, 1996, through December 31, 1998. The main outcome measures were prevalence of multiple potential causes of syncope, survival of patients with multiple potential causes of syncope compared with survival of patients with a single cause, and clinical predictors of multiple potential causes of syncope.. A total of 987 patients were studied (mean +/- SD age, 58.0 +/- 21.4 years; male, 550 [55.7%]). Multiple potential causes were present in 182 patients (18.4%). Patients with multiple potential causes of syncope had a lower survival rate at 4 years, 73.1% (95% confidence interval, 64.6%-82.8%), vs those with a single cause, 89.3% (95% confidence interval, 86.4%-92.2%) (P < .001). Multivariate predictors of multiple potential causes were older age, atrial fibrillation, use of cardiac medications, and New York Heart Association classification II, III, and IV.. Of the patients evaluated for syncope, 18.4% had multiple potential causes. The presence of multiple potential causes was an independent predictor of increased mortality among patients with syncope.

Topics: Age Factors; Atrial Fibrillation; Cardiovascular Agents; Cardiovascular Diseases; Carotid Sinus; Databases, Factual; Female; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Outcome Assessment, Health Care; Predictive Value of Tests; Prevalence; Prognosis; Proportional Hazards Models; Prospective Studies; Recurrence; Retrospective Studies; Survival Analysis; Syncope; United States

It is widely assumed in clinical practice that drug treatment associated with hypotension can result in falls and syncope, but there is actually very little evidence to support this. Therefore the data in all patients whose cardiovascular medications were stopped at a falls/syncope clinic were analysed to see if their symptoms were altered and if renewal of these medications was necessary at subsequent visits. Of 338 consecutive referrals, cardiovascular medications had been stopped in 65 (19%). At follow up 78% reported improvement in their original presenting symptoms and renewal of medication was not necessary in 77% off antianginals, 69% off antihypertensives, and 36% off antiarrhythmics. It was concluded that adjusting cardiovascular medications could help in the management of falls and syncope and may obviate the need for other treatment. These medications can be stopped in select patients if there is regular monitoring and this should reduce unwanted side effects and costs of these drugs.

Topics: Accidental Falls; Aged; Aged, 80 and over; Cardiovascular Agents; Female; Follow-Up Studies; Humans; Male; Middle Aged; Outpatient Clinics, Hospital; Recurrence; Retrospective Studies; Syncope; Unnecessary Procedures

Cardiovascular drugs are the most often prescribed drug class in Germany. The objective of this study is to analyze the adverse drug reaction (ADR) profiles of these drugs and to identify some targets for prevention of ADR.. Since 1997 specially trained medical staff members of five Pharmacovigilance Centers in Germany prospectively screened all hospital admissions at the departments of internal medicine of five large teaching hospitals. ADR leading to hospital admission were registered and reported. Especially ADR caused by cardiovascular drugs and all factors, which could have been important for their occurrence were analyzed.. 559 of 2270 (24.6%) registered ADR cases were related to cardiovascular drugs. The drugs most frequently related to ADR were angiotensin inhibitors (17.9%), digitalis (17.3%), calcium channel blockers (13.9%), beta blockers (12.8%), and diuretics (12.2%). The most often observed ADR were arrhythmias (27.1%), syncopes and blood pressure dysregulations (25.1%), gastrointestinal symptoms (12.4%), and metabolic disorders (10.2%). 72% of patients were older than 65 years. Older patients were on a significantly higher number of drugs (6.2 +/- 2.4 vs 5.5 +/- 3.2; p < 0.001) than the younger ones. Furthermore, they were hospitalized significantly longer (13.2 +/- 9.9 vs 15.3 +/- 9.3 days; p < 0.01). Eleven patients (2%) died because of ADR due to cardiovascular drugs.. Cardiovascular drugs are frequently used. They are prescribed mainly to older patients. Often observed ADR can be prevented effectively by considering their indication, by a clear definition of the therapeutic target, by a dose adjustment to the individual clinical parameters of the patient and by regular control investigations. The large number of drug-induced rhythm disorders--in particular bradycardia--show that extraordinary attention should be paid to rhythm-affecting drugs. The detailed instruction of the patient about therapeutic aims, risks and a concrete guideline for the therapy/drug handling is generally necessary.

Topics: Adrenergic beta-Antagonists; Adverse Drug Reaction Reporting Systems; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Arrhythmias, Cardiac; Calcium Channel Blockers; Cardiac Glycosides; Cardiovascular Agents; Diuretics; Drug Interactions; Female; Germany; Humans; Incidence; Male; Retrospective Studies; Syncope

An electrophysiological study and a provocative test of coronary artery spasm was attempted in a 68-year-old man who was having syncopal attacks and chest pain. His electrocardiogram had the characteristics of Brugada syndrome and ventricular fibrillation (VF) was induced by programmed electrical stimulation. ST-segment elevation became exaggerated by procainamide, which could not prevent the induction of VF. Coronary angiography revealed no stenotic lesions, and spasm in the left coronary artery was induced by intracoronary administration of acetylcholine with similar chest pain to that experienced before. Under treatment with diltiazem and flecainide, which suppressed the induction of VF, the patient experienced no recurrence of symptoms despite persistent ST-segment elevation. No previous reports have described coronary spasm associated with Brugada-type ECG abnormalities, and patients with syncope should be evaluated carefully.

Topics: Acetylcholine; Aged; Anti-Arrhythmia Agents; Calcium Channel Blockers; Cardiovascular Agents; Chest Pain; Coronary Angiography; Coronary Vasospasm; Diagnosis, Differential; Diltiazem; Electric Stimulation; Electrocardiography; Electrophysiology; Flecainide; Humans; Male; Syncope; Syndrome; Vasodilator Agents; Ventricular Fibrillation

ATP and its related nucleoside, adenosine, are ubiquitous biological compounds with potent depressant activity on the atrioventricular node. We hypothesized that an increased susceptibility of the atrioventricular node to adenosine may, in some cases, play a role in the genesis of syncope.. The study was performed in two parts. In part 1, we evaluated the effects of a bolus injection of 20 mg ATP in a group of 60 patients (57+/-19 years, 31 men) with syncope of unexplained origin and in 90 control subjects without syncope (55+/-17 years, 46 men). In control subjects, the upper 95th percentile of the maximum RR interval distribution, during ATP-induced atrioventricular block (AVB), was 6000 ms. In the syncope group, 28% of patients had a maximum RR interval above this limit (P=.000). The distribution of the maximum RR interval below the 95th percentile was similar in the two groups. In part 2, we validated the ATP test in 24 patients who had the fortuitous ECG recording of a spontaneous syncope caused by a transient asystolic pause (AVB in 15 and sinus arrest in 9). The ATP test caused AVB with an asystolic pause of > or = 6000 ms in 53% of the patients with documented AVB but in none (0%) of the patients with documented sinus arrest (P=.01). Among the patients with spontaneous AVB, the ATP test was abnormal in 6 of the 7 patients (86%) in whom all conventional investigations for syncope had been negative and in 2 of the 8 patients (25%) who had shown positivity (P=.03).. An increased susceptibility to ATP testing is present in patients with SUO and patients with syncope due to paroxysmal AVB. Thus, a logical inference is that ATP testing can be used to identify patients with syncope due to paroxysmal AVB. The results of this study form the necessary background for future prospective studies with an aim to validate this assumption.

Topics: Adenosine; Adenosine Triphosphate; Adult; Aged; Atrioventricular Node; Cardiovascular Agents; Case-Control Studies; Diagnosis, Differential; Electrocardiography; Female; Heart Block; Humans; Male; Middle Aged; Predictive Value of Tests; Syncope

To present baseline data from a prospective study of postprandial hypotension in 499 elderly persons in a long-term health care facility.. Analyses of baseline data for a prospective study.. A large long-term health care facility where 499 ambulatory or wheelchair-bound residents were studied.. The 499 residents were > or = 62 years of age, mean age 80 +/- 9 years (range 62-100), 71% female, 29% male, 66% white, 27% black, 7% Hispanic, 68% ambulatory, and 32% wheelchair-bound.. The mean maximal decrease in postprandial systolic and diastolic blood pressures was 15 +/- 6 mm Hg/6 +/- 2 mm Hg. The mean maximal decrease in postprandial systolic blood pressure occurred 15 minutes after eating in 13% of residents, 30 minutes after eating in 20% of residents, 45 minutes after eating in 26% of residents, 60 minutes after eating in 30% of residents, and 75 minutes after eating in 11% of residents. Of 499 residents, 118 (24%) had a maximal decrease in postprandial systolic blood pressure of > or = 20 mm Hg. The mean maximal decrease in postprandial systolic blood pressure was 24 +/- 5 mm Hg in residents with syncope in the prior 6 months and 14 +/- 5 mm Hg in residents without syncope (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was 21 +/- 5 mm Hg in residents with falls in the preceding 6 months and 13 +/- 4 mm Hg in residents without falls (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was significantly greater in residents treated with angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics, nitrates, digoxin, and psychotropic drugs than in residents not treated with these drugs. The mean maximal decrease in postprandial systolic and diastolic blood pressures was not significantly different in elderly blacks, Hispanics, and whites.. A more severe reduction in postprandial systolic blood pressure correlates with a history of syncope or falls in the previous 6 months. Long-term follow-up is being planned to determine whether a marked reduction in postprandial systolic blood pressure in elderly persons correlates with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality.

Topics: Accidental Falls; Aged; Aged, 80 and over; Blood Pressure; Cardiovascular Agents; Eating; Female; Humans; Hypotension; Long-Term Care; Male; Middle Aged; Nursing Homes; Prospective Studies; Psychotropic Drugs; Syncope

Topics: Aged; Aged, 80 and over; Aging; Cardiovascular Agents; Cardiovascular Diseases; Cardiovascular Physiological Phenomena; Cardiovascular System; Coronary Disease; Female; Humans; Syncope

Topics: Cardiovascular Agents; Electrophysiology; Humans; Syncope

The records of 483 patients admitted to the emergency room because of syncope were reviewed. Forty-one patients were found to have drug-related syncope. Thirty-nine experienced syncope related to drugs administered for cardiovascular disease. The most frequently associated diseases were anginal syndrome (22 patients), hypertension (13 patients), and a history of myocardial infarction (6 patients). Thirty-eight patients experienced symptomatic orthostatic hypotension following drug taking (nitrates in 19 patients, beta blockers in 10 patients, nifedipine in 3 patients, prazosin and quinidine in 2 patients each, methyldopa and verapamil in 1 patient each). One patient developed complete heart block as a result of digoxin intoxication. Two patients developed the characteristic picture of anaphylactic reaction (1 with ampicillin, 1 with dipyrone). During one-year follow-up, without the offending medications, no further syncopal episodes were reported by these patients. We conclude that drug-related syncope was more common among our patients with syncope than had been reported previously. It is suggested that drug-related syncope should be taken into consideration in any patient with syncope who is treated by any of the above-mentioned drugs.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Diagnosis, Differential; Female; Humans; Male; Medical History Taking; Middle Aged; Retrospective Studies; Syncope

Indications for permanent pacing in the bradyarrhythmias are summarized. In the absence of symptoms, pacing is justified only when Mobitz type II block or complete atrioventricular (AV) block is localized in the bundle-branch system. All other abnormalities of impulse generation or conduction (incomplete AV block of any type, atrial fibrillation with slow ventricular response, or sinus node dysfunction) must be shown to be stable and intrinsic and to cause CNS symptoms or hemodynamic compromise to justify pacing. Isolated intra-Hisian abnormality without failure of AV conduction is benign. Measurement of HV interval does not contribute significant information. Correlation of carotid sinus sensitivity with carotid sinus syncope is poor (5%). Bradyarrhythmia produced by minimal effective doses of an essential drug is a rare indication for pacing and requires special documentation. Inadequate indications, sources of error, and misconceptions are discussed. Generally, it is important to exclude drug effect, transient clinical states, and correctable systemic disease as causes of the abnormality before making a conclusion about pacing.

Topics: Atrial Fibrillation; Atrioventricular Node; Bradycardia; Bundle of His; Bundle-Branch Block; Cardiac Pacing, Artificial; Cardiovascular Agents; Carotid Sinus; Electrophysiology; Heart Block; Heart Conduction System; Heart Rate; Humans; Myocardial Infarction; Pacemaker, Artificial; Sick Sinus Syndrome; Syncope

Topics: Cardiovascular Agents; Digitalis; Drug-Related Side Effects and Adverse Reactions; Humans; Syncope