Collapse of an early adolescent girl. Syncope? Simple or sinister?

An early adolescent girl presented to the emergency department (ED) of her local hospital following a syncopal episode after a warm bath on a background of increasing breathlessness for 1-year duration. On examination, she was fully alert, no pain or injuries from her syncope, she was warm and well perfused, her respiratory rate at rest was normal and she showed no signs of respiratory distress, there were no signs of seizure activity such as incontinence or tongue biting, she had a raised Jugular Venous Pressure (JVP), a loud pansystolic murmur, there was no cyanosis and no oedema. She was referred for a chest radiograph due to her history of breathlessness and for an ECG based on the examination findings of a murmur. Her ECG showed marked right axis deviation with tall T waves in V1 and P waves in lead II. Therefore, she was referred for an outpatient echocardiogram which demonstrated severely dilated right ventricular (RV) with impaired RV function. She was diagnosed with primary pulmonary hypertension.Her history included red flag symptoms including worsening breathlessness and syncope. Syncopal episodes are common and mostly benign, that is, vasovagal, but attention to a detailed history including constitutional symptoms and examination is crucial to ensure appropriate investigations and management. While causes are commonly benign in paediatrics, it is important to ensure that there are no features of an underlying cause. This includes ruling out commonly seen paediatric presentations that could present as an unwitnessed syncopal episode and this should include seizures, anaemia, arrhythmias, hypotension, hypoglycaemia and pain. If other causes are not ruled out, it can lead to an incorrect diagnosis as found in this patient when she presented a further three times to ED while waiting for her tertiary appointment.

[High risk syncope in a young patient: An uncommon cause]. / Sincope de alto riesgo en paciente joven: Una causa poco frecuente.

Syncope is a frequent consult. It's responsible for 1 to 3% of consults to the emergency room in the United States. The cause is generally benign; however, high-risk cases are potentially deadly and must be identified. We present a case report of a 40-year-old female who presents with syncope, Torsade de Pointes, and ventricular fibrillation. The coronary angiography showed no disease of the coronary arteries. The ventriculography, transthoracic echocardiogram, and cardiac magnetic resonance revealed a mid-ventricular Takotsubo cardiomyopathy. The ECG showed a prolonged QT interval with an inverted T wave. During the first 48 hours, she presented multiple episodes of non-sustained polymorphic ventricular tachycardia. The patient evolved with diminished QTc interval and regression of the wall motion abnormalities. At the 6-month follow-up the patient was asymptomatic, without new episodes.

Dextrocardia with complete atrioventricular block-the right clinical approach to pace a heart on the right hemithorax: a case report.

BACKGROUND: A heart positioned on the right side of the thorax can be more a complex situation than it seems, also the potentially associated congenital cardiopathies are variable. In this regard, patients with dextrocardia presenting with complete atrioventricular block require a thorough anatomical investigation to map the veno-arterial system and potential cardiovascular defects before proceeding with a permanent pacing procedure. CASE PRESENTATION: A 73-year-old Caucasian woman with no significant medical history presented with syncope. Physical examination showed regular heart sounds with an average heart rate of 35-40 beats per minute and no other relevant physical findings. Chest X-rays revealed a heart positioned in the right hemithorax. A standard electrocardiogram revealed complete atrioventricular block with junctional escape rhythm at nearly 35-40 beats per minute. A transthoracic echocardiogram showed a mirror image dextrocardia without any other remarkable abnormalities. Venogram performed using the left peripheral cephalic vein showed normal venous return into the right atrium positioned on the left side. Surgical intervention consisted of permanent dual chamber pacemaker implantation using the left subclavian vein. Discussion is provided based on the relevant medical literature outlining different potential scenarios with associated cardiac and major vessels abnormalities. CONCLUSION: This case highlights an atypical presentation of atrioventricular block in a patient with dextrocardia and situs inversus, for whom a successful dual-pacemaker implantation procedure was performed.

[Syncope : updates in primary care medicine]. / Syncope : nouveautés pour la médecine de premier recours.

Syncope is a common reason for consultations and hospitali-zations. A diagnosis is established in 50 % of cases with the initial assessment. It can also be used to stratify the risk of cardiovascular events or recurrence, and their potentially fatal consequences. This stratification, based on European and American guidelines, is essential for guiding management. Various predictive scores exist, including the Canadian Syncope Risk Score (CSRS), which assesses the risk of serious events within 30 days. The CSRS has limitations in both emergency and outpatient settings. Current guidelines do not include specific scores, highlighting the importance of clinical judgment and the initial assessment for risk stratification.

La syncope est un motif fréquent de consultation et d'hospitalisation. Un diagnostic est établi dans 50 % des cas grâce au bilan initial. Celui-ci permet aussi de stratifier le risque d'événements cardiovasculaires ou de récidive, et leurs conséquences potentiellement fatales. Cette stratification, basée sur les recommandations européennes et américaines, est essentielle pour orienter la prise en charge. Divers scores prédictifs existent, dont le Canadian Syncope Risk Score (CSRS) qui évalue le risque d'événements graves à 30 jours. L'application de ce score comporte des limites tant dans son utilisation au service des urgences que dans la pratique en ambulatoire. Les recommandations actuelles n'incluent pas de scores spécifiques, soulignant l'importance du jugement clinique et du bilan initial pour la stratification du risque.

Return to professional football after ICD implantation in athlete with apical hypertrophic cardiomyopathy.

The risk of sports participation in elite athletes with cardiac disease with an indication for implantable cardioverter-defibrillator (ICD) therapy is largely unknown. Currently, international guidelines provide restrictive sports advice for such athletes. This case report presents a professional football player who after an episode of syncope and diagnosis of apical hypertrophic cardiomyopathy expressed a strong wish to explore the feasibility of returning to elite-level sports. After a shared decision-making and monitored stepwise graduated rehabilitation, the athlete made a full return to professional football. Our case indicates that individualised sports advice in elite athletes with cardiac disease and an ICD may be warranted.

Left anomalous coronary artery originating from the opposite sinus causes acute myocardial infarction with syncope in a young woman: A case report.

RATIONALE: The left anomalous coronary artery originating from the opposite sinus represents a distinct subtype of anomalous coronary arteries originating from the opposite sinus. A comprehensive overview encompassing clinical characteristics, diagnostic approaches, and treatment modalities for this condition is presented herein. PATIENT CONCERNS: The patient, a 17-year-old female, was admitted to the hospital due to chest pain and syncope following multiple exercises. DIAGNOSES: After conducting an electrocardiogram, myocardial injury markers, and echocardiography, she was diagnosed with acute myocardial infarction complicated by syncope. Further examinations including coronary angiography, coronary computed tomography angiography, and cardiac magnetic resonance imaging revealed an anomalous origin of the coronary artery with the left coronary artery (LCA) arising from the right sinus and exhibited intramural course. INTERVENTIONS: The coronary "unroofing" technique was admitted according to her characteristics. The patient achieved successful recovery after surgery with no recurrence of chest pain or syncope during 1 year of follow-up. OUTCOMES: Anomalous origin of the LCA is a rare congenital anatomical anomaly. Surgical intervention represents the primary approach for subsequent management of symptomatic anomalous origin of the coronary artery. Importantly, individuals with anomalous origin of the LCA from the right coronary sinus are at potential risk of sudden cardiac death. LESSONS: Therefore, enhancing diagnostic precision and actively pursuing surgical treatment in confirmed diagnoses can effectively mitigate myocardial ischemia and prevent instances of sudden cardiac death among adolescents and athletes.

Clinical course in older patients diagnosed with syncope treated in Spanish emergency departments: results from the Emergency Department and Elder Needs-17 study. / Evolución clínica de los pacientes mayores diagnosticados de síncope en servicios de urgencias en España: resultados del estudio EDEN-17.

OBJECTIVE: To study factors associated with hospitalization in an unselected population of patients aged 65 years or older treated for syncope in Spanish hospital emergency departments (EDs). To determine the prevalence of adverse events at 30 days in patients discharged home and the factors associated with such events. METHODS: We included all patients aged 65 years or older who were diagnosed with syncope during a single week in 52 Spanish EDs, recording patient clinical and ED case management data. We compared the findings between hospitalized patients and those discharged home, following the latter for 30 days. In discharged patients, we explored predictors of a composite adverse-event outcome (occurrence of any of the following: ED revisits, hospitalization related to the index visit, or any-cause death). RESULTS: A total of 477 patients with syncope were identified; 67 (14%) were admitted, and 5 (7.5%) died. The median (interquartile range) length of hospital stay was 6 days (3-11 days). Comorbidity increased the probability of hospitalization (odds ratio, 2.172; 95% CI, 1.013-4.655). Among the 410 patients (86%) discharged home from the ED, 9.2% experienced an adverse event within 30 days (ED revisits, 8.,1%; hospitalization, 2.2%; death, 1.5%). No factors were associated with the 30-day composite outcome. CONCLUSIONS: The majority of patients aged 65 years or older are discharged home from EDs, and 30-day adverse events, while infrequent, are difficult to predict. Hospitalization was related to comorbidity and an absence of cognitive decline.

OBJETIVO: Investigar en una muestra no seleccionada de población mayor (65 o más años) atendida en servicios de urgencias hospitalarios (SUH) españoles por síncope los factores que se asociaron con la hospitalización, prevalencia de eventos adversos (EA) a 30 días y los factores asociados a estos entre los pacientes dados de alta desde urgencias. METODO: Se incluyeron todos pacientes con 65 o más años diagnosticados de síncope durante una semana en 52 SUH españoles. Se recogieron datos de la situación clínica y el manejo en urgencias, que se compararon entre los pacientes hospitalizados y los dados de alta directamente desde urgencias. Estos últimos fueron seguidos durante 30 días y se identificaron aquellos que presentaron un EA combinado (reconsulta en urgencias u hospitalización relacionada con el evento índice y muerte por cualquier causa), y se investigaron los factores que predecían dicho EA combinado. RESULTADOS: Se identificaron 477 pacientes con síncope. Hospitalizaron 67 (14%), de los que fallecieron 5 (7,5%) y la estancia mediana fue de 6 días (RIC 3-11). La comorbilidad incrementó la probabilidad de ingreso (OR: 2,172, IC 95%: 1,013-4,655). Entre los 410 pacientes dados de alta de urgencias (86%), el 9,2% tuvo un EA durante los 30 días siguientes (reconsulta a urgencias: 8,1%; hospitalización: 2,2%; muerte: 1,5%). Ningún factor se asoció con el riesgo de EA combinado a 30 días. CONCLUSIONES: La mayoría de los pacientes con 65 años o más atendidos en los SUH por síncope son dados de alta directamente desde urgencias, y los EA a los 30 días fueron poco frecuentes, pero difíciles de predecir. La hospitalización se relacionó con presencia de comorbilidad y ausencia de deterioro cognitivo.

Electric storm triggered by short-coupled premature ventricular complexes in a young patient with non-obstructive hypertrophic cardiomyopathy.

Ventricular arrhythmias are commonly associated with hypertrophic cardiomyopathy with and without midventricular obstruction. Although the overall prognosis is relatively good with an annual mortality rate <1%, the propensity to potentially fatal ventricular arrhythmias (ventricular tachycardia) is the most feared complication. Electrical storms are a severe manifestation of ventricular arrhythmias, with poor outcomes. In this report, we present a case of a young patient with non-obstructive hypertrophic cardiomyopathy who presents after a syncopal episode and is found to have an electric storm that is refractory to medical therapy.

Syncope after live attenuated influenza vaccine: Reports to the Vaccine Adverse Event Reporting System (2003-2024).

Vasovagal syncope, or fainting, can be triggered by various stimuli, including medical procedures. Syncope after vaccination has been reported, most commonly among adolescents, and can result in injuries. Using the Vaccine Adverse Event Reporting System (VAERS), we reviewed and summarized reports of syncope after live attenuated influenza vaccine, intranasal (LAIV) administered as the sole vaccine (i.e., no concomitant injections). From June 17, 2003 (date of LAIV licensure in the US) through May 31, 2024, VAERS received 50 reports of syncope after LAIV. Nearly half (23; 46 %) pertained to individuals 10-19 years of age. While the vast majority of reports (35; 70 %) did not describe any injuries, 15 people (30 %) were injured, most commonly by falling and hitting their head or face. Twenty-two people (44 %) required evaluation in the emergency department or doctor's office, including an individual who lost consciousness while he was driving home from the vaccination appointment. He did not report any injuries, but the car was severely damaged. Nearly three-quarters of people (37; 74 %) developed syncope within 15 min after vaccination, but fewer than half of reports (24; 48 %) stated that the patient had waited in the observation area for at 15 min. Based on approximately 111.9 million doses of LAIV distributed in the US during the same time period, the reporting rate is approximately 0.4 per million doses, suggesting that syncope following LAIV is rare. The information summarized here may enable clinicians, patients, and caregivers to make a more informed decision regarding preventing injuries that may occur following LAIV-related syncope.

Single-chamber atrial pacing†+†Micra AV implantation: A case report.

RATIONALE: The use of transvenous pacing leads is associated with the risk of tricuspid valve dysfunction, mainly due to the continuous presence of the leads can have an impact on subsequent tricuspid function and possible operation injury of the tricuspid valve during implantation or operation. PATIENT CONCERNS: A 69-year-old female with a history of syncope for 9 months was admitted to the hospital. The electrocardiogram showed sinus bradycardia, junctional escape rhythm, and a heart rate of 44 bpm. Echocardiography suggested a downward displacement and severe insufficiency of the tricuspid valve and atrial septal defect. DIAGNOSES: The cause of syncope was considered to be sick sinus syndrome. The patient was diagnosed with Ebstein anomaly and is considered a candidate for surgical intervention. INTERVENTIONS: To avoid aggravating tricuspid insufficiency by pacing leads crossing the tricuspid valve and hindering subsequent tricuspid valve surgery, a single-chamber pacing mode with atrial pacing (AAI) lead and Micra AV was chosen for maintaining atrioventricular synchrony after multidisciplinary discussion. OUTCOMES: The patient had stable parameters and was in good general condition at 1- and 3-month outpatient follow-ups after discharge. LESSONS: This is the first case of new implantation of single-chamber atrial pacing + leadless ventricular pacing with Micra AV, an alternative strategy to epicardial or coronary sinus system for tricuspid valve displacement and severe tricuspid regurgitation.

Initial signs in patients with ruptured abdominal aortic aneurysms: time for an expanded triad?

BACKGROUND AND OBJECTIVE: Misdiagnosis of ruptured abdominal aortic aneurysms (rAAA) contributes to delayed treatment and potentially higher mortality. The symptomatology in patients with rAAA is complex and challenging, 25-50% presumably fulfill the criteria of the standard triad of signs (STS). The objective was to determine the initial signs registered for patients with verified rAAAs, and to investigate if an expanded diagnostic triad could increase the diagnostic accuracy. METHODS: A population-based study was conducted among all patients presenting with verified rAAAs in Stockholm County, Sweden, from January 2010 to October 2021. Patients were identified with ICD code 171.3 (rAAA). The STS was defined as (1) abdominal pain, (2) syncope and (3) the finding of a pulsatile abdominal mass, the prevalence of STS was investigated. An expanded triad included similar and related signs commonly registered for patients with rAAA, and was referred to as the modified abdominal aortic aneurysm rupture signs (MARS). The MARS-signs encompassed (1) the registered pain-associated symptoms or signs, (2) all hypovolemic associated signs, and (3) pulsatile abdominal mass and/or ultrasound finding, and the prevalence was similarly investigated. Finally, the STS and MARS were compared to evaluate the usefulness and performance of the MARS-score. RESULTS: A total of 216 patients were identified. The majority were men (77%) with a median age of 78 years. The dominating symptom was abdominal pain (84%), followed by dizziness (50%). Few patients presented with three STS (13%), two STS were found in 37% and one STS in almost half of the patients (41%). By contrast, when applying MARS 35% presented with the complete expanded triad, 47% with two and 17% with one. Comparison of accuracy favored MARS (13 vs. 35% with 3 signs, P < 0.001 for STS vs. MARS) (2 or 3 signs, 48 vs. 82% STS vs. MARS, P < 0.001). CONCLUSIONS: The expanded MARS-signs could aid in easier and faster identification of rAAA patients, thus facilitating the first step with accurate diagnosis into the lifesaving rAAA care chain. Supportive diagnostic mnemonics and tools are especially important when targeting fatal diagnoses such as rAAA. Further studies are needed to investigate the implementation of the MARS-signs in various clinical settings.

Cough-induced severe bradycardia and syncope in a dog.

A 10-year-old spayed female shih tzu dog was brought to the hospital because of recurring syncope that occurred simultaneously with a cough. Physical examination did not reveal an abnormal heart rhythm or abnormal heart sounds. Electrocardiography revealed sinus arrest of 4.7 s with intermittent escape beats during coughing. Additional examinations, including thoracic radiography, clinical pathology, and echocardiography, revealed no abnormalities of concern. Forty-eight-hour Holter monitoring captured 1 syncopal episode following severe coughing, during which the longest sinus arrest lasted 16 s with intermittent escape beats. This observation confirmed our strong suspicion that coughing was the cause of varying degrees of sinus arrest in this dog. Theophylline, codeine, and short-term prednisolone were prescribed to treat the dog's cough. The daily episodes of syncope ceased and coughing decreased. Subsequent 48-hour Holter monitoring revealed no abnormal pauses, and the owner did not report syncope. Theophylline and codeine were continued for 5 mo, during which time no syncope occurred. To our knowledge, this case provides the first clear evidence of a correlation between cough-induced sinus arrest and syncope in a veterinary patient, as confirmed by Holter monitoring and electrocardiography. Key clinical message: Cough-induced severe bradycardia and syncope were identified in a shih tzu dog. After the antitussive medication was adjusted, the signs resolved.

Bradycardie sévère et syncope provoquées par la toux chez un chienUne chienne shih tzu stérilisée âgée de 10 ans a été amenée à l'hôpital en raison d'une syncope récurrente survenue simultanément avec une toux. L'examen physique n'a révélé aucun rythme cardiaque anormal ni bruits cardiaques anormaux. L'électrocardiographie a révélé un arrêt sinusal de 4,7 s avec des battements d'échappements intermittents lors de la toux. Des examens complémentaires, notamment une radiographie thoracique, des analyses en pathologie clinique et une échocardiographie, n'ont révélé aucune anomalie préoccupante. Une surveillance Holter de 48 heures a capturé 1 épisode syncopal à la suite d'une toux sévère, au cours duquel l'arrêt sinusal le plus long a duré 16 s avec des battements d'échappements intermittents. Cette observation a confirmé nos fortes suspicions selon lesquelles la toux était la cause de divers degrés d'arrêt sinusal chez ce chien. De la théophylline, de la codéine et de la prednisolone de courte durée ont été prescrites pour traiter la toux du chien. Les épisodes quotidiens de syncope ont cessé et la toux a diminué. Une surveillance Holter ultérieure de 48 heures n'a révélé aucune pause anormale et le propriétaire n'a pas signalé de syncope. La théophylline et la codéine ont été poursuivies pendant 5 mois, période pendant laquelle aucune syncope ne s'est produite. À notre connaissance, ce cas constitue la première preuve claire d'une corrélation entre l'arrêt sinusal induit par la toux et la syncope chez un patient vétérinaire, comme le confirme la surveillance Holter et l'électrocardiographie.Message clinique clé :Une bradycardie et une syncope sévères induites par la toux ont été identifiées chez un chien shih tzu. Après ajustement du traitement antitussif, les signes ont disparu.(Traduit par Dr Serge Messier).

Syncope in an Otherwise Healthy 74-Year-Old Woman.

CASE PRESENTATION: A 74-year-old woman with a history of hypertension and peripheral artery disease and a reported diagnosis of sarcoidosis presents for an episode of syncope and shortness of breath. She had a history of sarcoidosis diagnosed on chest radiography that showed lymphadenopathy. There were no associated symptoms, and she was not previously treated for sarcoidosis. She previously smoked and had quit smoking 9 years earlier.

Transcutaneous electrical stimulation of the stellate ganglion: A case report on its application in treating carotid sinus syndrome.

RATIONALE: Syncope is a common condition in emergency departments, posing a diagnostic challenge due to its multifactorial nature. Among the potential causes, carotid sinus hypersensitivity leading to carotid sinus syndrome (CSS) is a significant consideration that can severely impact patient quality of life. Despite its importance, establishing effective treatment methods for CSS has been difficult. PATIENT CONCERNS: A 43-year-old male presented with recurrent episodes of syncope, which significantly affected his daily life and well-being. DIAGNOSES: After a thorough evaluation, the patient was diagnosed with CSS, a condition that can be difficult to pinpoint and requires specialized diagnostic procedures to confirm. INTERVENTIONS: The patient was treated with stellate ganglion block therapy, a targeted intervention aimed at addressing the underlying cause of CSS. This treatment was administered over a 12-day period. OUTCOMES: Following the treatment, the patient's symptoms showed gradual improvement, and he was discharged after meeting the clinical cure criteria. During a 7-month follow-up, he remained symptom-free. LESSONS: The case highlights the effectiveness of transcutaneous stellate ganglion block therapy in treating CSS. It suggests that further research and clinical trials are needed to validate this treatment's efficacy, potentially offering a new therapeutic option for patients suffering from CSS.

Case Report and Literature Review: Orthostatic Hypotension Due to Multiple System Atrophy.

Objective: Multiple system atrophy (MSA) is a rare and fatal adult-onset neurodegenerative disease with multiple clinical and pathological variants. The etiology of MSA remains uncertain. Orthostatic hypotension (OH) is the main characteristic of MSA. An upright position can trigger a syncope attack, making it impossible for the patient to stand and walk briefly. Case Study: We report the case of a 67-year-old man with initial symptoms of recurrent syncope and this patient was hospitalized several times, despite multiple therapeutic interventions, his symptoms persisted. Eventually, this patient died at the age of 68 with a diagnosis of MSA. Conclusion: For those patients with neurogenic OH, an underlying neurodegenerative disease should always be considered. Prompt diagnosis, early aggressive treatment, and prediction of complications may have a huge impact on the prognosis of MSA. This article also reviews relevant reported cases to enrich the experience of treating MSA in the clinic.

[Diagnostics and treatment of syncope]. / Diagnostik und Therapie von Synkopen.

The 2018 guidelines of the European Society of Cardiology (ESC) provide improved algorithms for the diagnostics and treatment of syncope. New guidelines on ventricular tachycardia, on the prevention of sudden cardiac death and on cardiomyopathies and pacemakers have refined the recommendations. The detailed medical history and examination are crucial for differentiating between cardiac and noncardiac causes and determining the appropriate treatment. High-risk patients need urgent and comprehensive diagnostics. The basic diagnostics include medical history, physical examination and a 12-lead electrocardiography (ECG). Further tests, such as long-term ECG monitoring, implantable loop recorders and electrophysiological investigations are helpful in unclear cases. The treatment depends on the cause, with pacemaker implantation and implantable cardioverter defibrillators (ICD) being important for cardiac causes, while behavioral measures and medication management have priority for noncardiac syncope.

Continuous Rhythm Monitoring With Implanted Loop Recorders in Children and Adolescents With Brugada Syndrome.

BACKGROUND: Young (<18 years of age) patients with Brugada syndrome (BrS) are often under-represented in BrS studies and their management, especially related to syncopal episodes, remains unclear. OBJECTIVES: This study sought to describe the arrhythmia prevalence among young patients with BrS undergoing continuous rhythm monitoring by implantable loop recorder (ILR) and to assess the etiology behind syncope of undetermined origin. METHODS: A total of 147 patients with BrS with ILR were enrolled in 12 international centers and divided into pediatric (age <12 years; n = 77, 52%) and adolescents (age 13-18 years; n = 70, 48%). RESULTS: Mean age was 11.3 years, 53 patients (36.1%) were female, and 31 (21.1%) had spontaneous type 1 electrocardiograms. Over a median follow-up of 3.6 years (Q1-Q3: 1.6-4.8 years), an arrhythmic event was recorded in 33 patients (22.4%), mainly of nonventricular origin: 15 atrial (10.2%) and 16 bradyarrhythmic events (10.9%). Ventricular arrhythmias occurred in 4 patients, all with spontaneous BrS, and were fever-related in one-half. Among all patients with recurrence of syncope during follow-up, true arrhythmic syncope was documented in 5 (17.8%), and it was due to bradyarrhythmias or atrial arrhythmias in 3 cases (60%). CONCLUSIONS: Continuous rhythm monitoring with ILRs in young patients with BrS detects a broad range of arrhythmias. Ventricular arrhythmias occur predominantly in patients with spontaneous type 1 electrocardiograms and during fever. Despite the young age, bradyarrhythmias and atrial arrhythmias are frequent and represent the cause of arrhythmic syncope in 60% of patients. Young patients with BrS with syncope of undetermined origin may benefit from ILR implant.