Implantable loop recorders for assessment of syncope: increased diagnostic yield and less adverse outcomes with the latest generation devices.

AIM: Aim of the study was to compare the diagnostic yield of implantable loop recorders (ILR) of two successive generations for the assessment of syncope. METHODS: Data on patients who had undergone ILR implantation for unexplained syncope in four Italian public hospitals were retrospectively acquired from the Medtronic Clinical Service database. After implantation, routine follow-up examinations were performed every 90 days, while urgent examinations were carried out in the event of syncope recurrence. RESULTS: The following findings were regarded as diagnostic: ECG documentation of a syncope recurrence; documentation of any of the arrhythmias listed by the current guidelines as diagnostic findings even if asymptomatic. Between November 2002 and March 2010, 107 patients received an ILR (40 Medtronic Reveal® Plus; 67 Medtronic Reveal® DX/XT) and underwent at least one follow-up examination. Diagnoses were made in 7 (17.5%) and 24 (35.8%) (P=0.043) patients, with a median time of 228 and 65 days, respectively. Three (42.9%) and 21 (87.5%) (P=0.029) diagnoses were based on automatically detected events, while adverse outcomes occurred in 6 and in 1 (P=0.01) patients, respectively. CONCLUSION: Our results show that the new-generation device offer a higher diagnostic yield, mainly as a result of its improved automatic detection function, and is associated with fewer adverse outcomes.

Developmental profile of plasma androgens in cockerels genetically selected for mating frequency.

Plasma levels of androstenedione (AE), testosterone (T), and dihydrotestosterone (DHT) were measured at 1, 56, 112, and 168 days of age by radioimmunoassay in lines of cockerels divergently selected for male mating frequency. Values for total androgen (total A = AE + DHT + T) were also computed. No significant differences in mean hormone values were found between lines at any age. Hormone patterns throughout development were also similar for both lines. Plasma AE and T increased between Days 1 and 56, stabilized through Day 112, and rose again prior to 168 days of age. In contrast, DHT levels were low throughout Day 112 and rose significantly by Day 168. Total A in the high mating line was low throughout Day 112 with significant increases occurring by Day 168. In the low mating line, total A was low on Day 1, increased significantly by Day 56, and it remained unchanged through Day 112. Peak values occurred by Day 168. Within line correlation analyses between AE, T, DHT, and total A revealed a more uniform hormonal state throughout development in the high mating line than in the low mating line. Because no differences were found between the mating lines in baseline levels of individual androgens or in concentration patterns of androgens up through the attainment of sexual maturity, it appears that neither posthatch baseline levels nor posthatch temporal androgen concentrations control male sexual behavior in the mating lines of birds.

Diurnal, premating, and postmating testosterone levels in roosters genetically selected for mating frequency.

Circulating testosterone (T) levels were measured in roosters from lines genetically selected for high (HM) and low (LM) mating frequency and the randombred control (AC) base population. Lights were provided from 0600 through 2000 hr. A dirunal profile was determined by sampling at 0600, 1200, 1800, and 2400 hr. Plasma T levels prior to mating, immediately after mating, and 1 and 3 hr after mating were measured. By 1800 hr, AC males had higher T levels than both HM and LM males, which had levels that were similar to each other. Testosterone was at a minimum at 0600 hr and peaked at 2400 hr. Lines differed significantly both before and after mating with AC males highest, HM males intermediate, and LM males lowest. Control males had higher than baseline values prior to and after mating. Testosterone levels of AC males were correlated with their mating frequencies.

Predictors of clinical efficacy of 'Ablate and Pace' therapy in patients with permanent atrial fibrillation.

OBJECTIVE: To evaluate the 2-year clinical improvement after 'Ablate and Pace' therapy and to identify the variables able to influence the efficacy of this therapy in patients with permanent atrial fibrillation (AF). Design Prospective multicentre observational study. Setting Cardiology departments of 19 general hospitals in Italy, Spain and Greece. PATIENTS: 171 patients with drug-refractory severely symptomatic permanent AF considered for AV junction ablation. Interventions Patients underwent AV junction ablation, received a right ventricular (RV) pacing or echo-guided cardiac resynchronisation (CRT) pacing and were followed-up to 24 months. Main outcome measures Non-responders to Ablate and Pace therapy were defined those patients who, during the follow-up period had clinical failure (defined as death or hospitalisation due to heart failure, or worsening heart failure) or showed no improvement in their clinical condition. RESULTS: Responders were 63% of RV-paced patients and 83% of CRT-paced patients. Another 27% showed no clinical improvement (7%) or worsened (20%) (non-responders group). On multivariable Cox regression analysis, CRT mode and echo-optimised CRT were the only independent protective factors against non-response (HR=0.24, 95% CI 0.10-0.58, p=0.001 and HR=0.22, 95% CI 0.07-0.77, p=0.018 respectively). On comparing freedom from non-response, a trend in favour of echo-optimised CRT versus simultaneous biventricular pacing (p=0.077) was seen. CONCLUSIONS: In patients affected by severely symptomatic permanent AF, Ablate and Pace therapy yielded a clinical benefit in 63% of RV-paced patients and 83% of CRT-paced patients. CRT pacing and echo-optimised CRT were the only independent predictor of clinical benefit.

Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: the EGSYS score.

OBJECTIVE: To develop, in patients referred for syncope to an emergency department (ED), a diagnostic score to identify those patients likely to have a cardiac cause. DESIGN: Prospective cohort study. SETTING: ED of 14 general hospitals. PATIENTS: 516 consecutive patients with unexplained syncope. INTERVENTIONS: Subjects underwent a diagnostic evaluation on adherence to Guidelines of the European Society of Cardiology. The clinical features of syncope were analysed using a standard 52-item form. In a validation cohort of 260 patients the predictive value of symptoms/signs was evaluated, a point score was developed and then validated in a cohort of 256 other patients. MAIN OUTCOME MEASUREMENTS: Diagnosis of cardiac syncope, mortality. RESULTS: Abnormal ECG and/or heart disease, palpitations before syncope, syncope during effort or in supine position, absence of autonomic prodromes and absence of predisposing and/or precipitating factors were found to be predictors of cardiac syncope. To each variable a score from +4 to -1 was assigned to the magnitude of regression coefficient. A score >or=3 identified cardiac syncope with a sensitivity of 95%/92% and a specificity of 61%/69% in the derivation and validation cohorts, respectively. During follow-up (mean (SD) 614 (73) days) patients with score >or=3 had a higher total mortality than patients with a score <3 both in the derivation (17% vs 3%; p<0.001) and in the validation cohort (21% vs 2%; p<0.001). CONCLUSIONS: A simple score derived from clinical history can be usefully employed for the triage and management of patients with syncope in an ED.

Management of patients with syncope referred urgently to general hospitals.

OBJECTIVE: To evaluate the incidence and the strategy of management of syncope admitted urgently to a general hospital. BACKGROUND: The management of patients with syncope is not standardized. METHODS: The study was a prospective observational registry from a sample of 28 general hospitals in Italy and enroled all consecutive patients referred to their emergency rooms from November 5th 2001 to December 7th 2001 who were affected by transient loss of consciousness as the principal symptom. RESULTS: The incidence of syncope was 0.95% (996 of 105,173 patients attending). Forty-six percent were hospitalized, mostly in the Department of Internal Medicine. The mean in-hospital stay was 8.1+/-5.9 days. A mean of 3.48 tests was performed per patient. A definite diagnosis was made in 80% of cases, neurally-mediated syncope being the most frequent. The findings of each of the 28 hospitals participating in the survey were separately evaluated. We observed great inter-hospital and inter-department heterogeneity regarding the incidence of emergency admission, in-hospital pathways, most of the examinations performed and the final assigned diagnosis. For example, the execution of carotid sinus massage ranged from 0% in one hospital to 58% in another (median 12.5%); tilt testing ranged from 0 to 50% (median 5.8%); the final diagnosis of neurally-mediated syncope ranged from 10 to 78.6% (median 43.3%). CONCLUSION: Great inter-hospital and inter-department heterogeneity in the incidence and management of syncope was observed in general hospitals. As a consequence, we were unable to describe a uniform strategy for the management of syncope in everyday practice.