Complementary effectiveness of carotid sinus massage and tilt testing for the diagnosis of reflex syncope in patients older than 40 years: a cohort study.

AIMS: Indications, methodology, and diagnostic criteria for carotid sinus massage (CSM) and tilt testing (TT) have been standardized by the 2018 Guidelines on Syncope of the European Society of Cardiology. Aim of this study was to assess their effectiveness in a large cohort which reflects the performance under 'real-world' conditions. METHODS AND RESULTS: We analysed all patients who had undergone CSM and TT in the years 2003-2019 for suspected reflex syncope. Carotid sinus massage was performed according to the 'Method of Symptoms'. Tilt testing was performed according to the 'Italian protocol' which consists of a passive phase followed by a sublingual nitroglycerine phase. For both tests, positive test was defined as reproduction of spontaneous symptoms in the presence of bradycardia and/or hypotension. Among 3293 patients (mean age 73 ± 12 years, 48% males), 2019 (61%) had at least one test positive. A bradycardic phenotype was found in 420 patients (13%); of these, 60% were identified by CSM, 37% by TT, and 3% had both test positive. A hypotensive phenotype was found in 1733 patients (53%); of these, 98% were identified by TT and 2% had both TT and CSM positive. CONCLUSION: The overall diagnostic yield of the tests in patients >40-year-old with suspected reflex syncope was 61%. Both CSM and TT are useful for identifying those patients with a bradycardic phenotype, whereas CSM has a limited value for identifying the hypotensive phenotype. Since the overlap of responses between tests is minimal, both CSM and TT should be performed in every patient over 40 years receiving investigation for unexplained but possible reflex syncope.

Reproducibility of carotid sinus massage.

AIMS: The reproducibility of carotid sinus massage (CSM) is debated. The aim of this study was to assess the reproducibility according to the methodology and diagnostic criteria defined by the guidelines on syncope of the European Society of Cardiology. METHOD: Among 2800 patients with syncope who underwent CSM in the years 2005-2019, 109 patients (62 males; mean age 76 ± 10 years) had performed a second CSM after a median of 28 months. Carotid sinus hypersensitivity (CSH) was diagnosed when CSM elicited a pause of >3 s and/or a fall in systolic blood pressure >50 mm Hg without reproduction of spontaneous symptoms. Carotid sinus syndrome (CSS) was established when spontaneous symptoms were reproduced in the presence of bradycardia and/or hypotension. RESULTS: The reproducibility of CSM was 78% for 18 CSS patients, 41% for 29 CSH patients, and 77% for 62 negative patients. The corresponding interrater agreement was good for CSS (kappa = 0.66), moderate for negative CSM (kappa = 0.42), and poor for CSH (kappa = 0.30). Combining CSH and negative tests, their reproducibility rose to 90% with kappa = 0.66. CONCLUSION: CSS but not CSH has a good reproducibility. About half of patients with CSH had a negative response at the second test, thus suggesting a great overlap between them.

Syncope in patients paced for atrioventricular block.

AIMS: Although syncope is the main reason for cardiac pacing in ∼40% of patients affected by atrioventricular block (AVB), very few data are available on the benefit of cardiac pacing in preventing syncopal recurrences. METHODS AND RESULTS: We retrospectively evaluated 229 consecutive patients (124 males, age 80 ± 10 years) who had received a permanent pacemaker from January 2009 to December 2013 for AVB and syncope (94 patients, 41%) or AVB without syncope (135 patients, 59%). In patients with AVB and syncope, a third-degree or Mobitz II second-degree AVB had been documented in 73 and was only suspected in another 21, all of whom had bundle branch block. Follow-up was available in 223 patients. At 5 years, the actuarial syncope recurrence rate was 1% (95% CI, 0-3) in patients with documented AVB plus syncope and 3% (95% CI, 1-5) in those without syncope, whereas it was 14% (95% CI, 0-28) in patients with undocumented AVB plus syncope (P = 0.001). The actuarial combined recurrence rate of syncope and/or pre-syncope was 2% (95% CI, 0-4) in patients without syncope, 8% (95% CI, 0-17) in patients with documented AVB plus syncope, and 19% (95% CI, 1-37) in patients with undocumented AVB plus syncope, P = 0.002. All syncopes occurred in patients without overt structural heart disease (SHD), the corresponding actuarial estimate being 4% (95% CI, 0-6) at 1 year and 6% (95% CI, 4-8) at 5 years (P = 0.002 vs. patients with SHD). CONCLUSIONS: Cardiac pacing is highly effective in preventing syncopal recurrences when AVB is documented. Syncope may recur in a non-negligible minority of paced patients when AVB is suspected but not documented and in patients without SHD.

Long-Term Outcome of Patients with Bifascicular Block and Unexplained Syncope Following Cardiac Pacing.

BACKGROUND: According to the ACC/AHA/HRS guidelines, cardiac pacing is reasonable in patients with bifascicular block (BF-B) and syncope when other causes have been excluded. The purpose of this study was to assess the long-term outcome of patients with BF-B and unexplained syncope following cardiac pacing. METHODS AND RESULTS: Between 2009 and 2015, we identified 43 consecutive patients (mean age of 78 ± 12 years, 64% males) who presented with syncope and BF-B and had received a pacemaker (PM). During a mean follow-up period of 31 ± 21 months, syncope recurred in seven patients (16%): 7% (95% standard error [SE] ± 3%) at 1 year and 18% (95% SE ± 7%) at 5 years. At univariable analysis, the only predictor of syncope recurrence was empiric pacing (P = 0.03). There were no syncope recurrences in the 12 patients who received a PM following a positive electrophysiological study (EPS) and the five patients with documentation of paroxysmal atrioventricular block (AVB) during cardiac monitoring (insertable loop recorder [ILR]), (EPS/ILR Group, n = 17) compared to seven of 26 (27%) patients who received empiric pacing (Empiric Group, n = 26; P = 0.02). Progression to high-degree AVB was documented during follow-up in 16 (37%) patients: nine of 17 (53%) patients in the EPS/ILR Group and seven of 26 (27%) patients in the Empiric Group (P = 0.11). There were no injuries reported during ILR monitoring. CONCLUSIONS: We have shown that syncope recurs not infrequently in patients with BF-B who received pacing for syncope. Nearly one in four patients who had empiric pacing suffered syncope recurrence compared to no recurrences in patients who received a PM following a positive EPS or documentation of transient AVB.

Clinical context and outcome of carotid sinus syndrome diagnosed by means of the 'method of symptoms'.

AIMS: The prevalence and outcome of carotid sinus syndrome (CSS) reported in the literature vary owing to differences in indications and methods of carotid sinus massage (CSM). METHODS AND RESULTS: We performed CSM on all patients aged 40 years and above with unexplained syncope after the initial evaluation. Carotid sinus massage was performed in the supine and standing positions on both sides for 10 s during continuous electrocardiogram and blood pressure monitoring; CSS was diagnosed in the event of an abnormal response to CSM in association with reproduction of spontaneous symptoms ('method of symptoms'). From July 2005 to July 2012, CSS was found in 164 (8.8%) of 1855 patients (mean age 77 ± 9 years, 73% males): 81% had an asystolic reflex (mean pause 7.6 ± 2.2 s) and 19% a vasodepressor reflex (mean lowest systolic blood pressure 65 ± 15 mmHg). Potential multifactorial causes of syncope (orthostatic hypotension, bundle branch block, bradycardia, tachyarrhythmias) were found in 74% of patients. One hundred forty-one patients received the proper care [advice on lifestyle measures in all, discontinuation (#40) or reduction (#17) of antihypertensive drugs, pacemaker implantation (#57)] and were followed up for 39 ± 25 months. Syncope recurred in 23 patients; the actuarial syncopal recurrence rate was 7% at 1 year and 26% at 5 years. Total syncopal episodes decreased from 91 per year during the 2 years before evaluation to 21 episodes per year during follow-up (P = 0.001). On Cox proportional-hazards regression, a mixed or vasodepressor response to tilt testing was the only independent predictor of syncopal recurrence (hazard ratio = 1.8; P = 0.01). CONCLUSION: Carotid sinus massage by means of the 'method of symptoms' indentifies a clinical syndrome with definite features and outcome. A treatment strategy involving lifestyle measures, reduction of antihypertensive drugs and cardiac pacing when appropriate is effective in reducing the syncopal recurrence rate.

A cost-effectiveness analysis of empagliflozin for heart failure patients across the full spectrum of ejection fraction in Spain: combined results of the EMPEROR-Preserved and EMPEROR-Reduced trials.

BACKGROUND: Heart failure (HF) is a chronic condition with considerable clinical burden for patients and economic burden for healthcare systems. Treatment for HF is typically based on ejection fraction (EF) phenotype. The cost-effectiveness of empagliflozin + standard of care (SoC) compared to SoC has been examined for HF phenotypes below or above 40% EF separately, but not across the full spectrum of EF in Spain. METHODS: The results of two preexisting, validated, and published phenotype-specific Markov cohort models were combined using a population-weighted approach, reflecting the incidence of each phenotype in the total HF population in Spain. A probabilistic sensitivity analysis was performed by sampling each model's probabilistic results. RESULTS: Empagliflozin + SoC compared to SoC resulted in increased life-years (LYs) (6.48 vs. 6.35), quality-adjusted LYs (QALYs) (4.80 vs. 4.63), and healthcare costs (€19,090 vs. €18,246), over a lifetime time horizon for the combined HF population in Spain. The incremental cost-effectiveness ratio (ICER) was €5,089/QALY. All subgroup, scenario, and probabilistic ICERs were consistently below €10,000/QALY. CONCLUSIONS: Empagliflozin is the first treatment with established efficacy and cost-effectiveness for HF patients across EF from the perspective of healthcare payers in Spain. Empagliflozin also proved to be cost-effective for all subgroups of patients included in the analysis.

Cone and seed pests of Pinus pinea: assessment and characterization of damage.

Cone and seed insects have played a key role in the decline of stone pine nut production in Italy. To evaluate the impact caused by native Palearctic and exotic insects, a greater knowledge of pest symptoms is required. During 2008-2009, first and second-year stone pine cones, as well as the seeds produced, were examined in Tuscany (Italy) to assess viability. Insect damage was characterized based on external signs on the cones and seed endosperms, and the impact of recorded insect species on nut production was evaluated. In the current study, cones attacked by anobiid beetles and Dioryctria spp. were observed, as well as asymptomatic dead cones and cones with resin drops and patches, that could not easily be related to a damaging agent. As regards the anobiid beetles, adults of Ernobius parens (Mulsant and Rey) and E. impressithorax Pic emerged from cones in laboratory rearing. A low number of cones damaged by Dioryctria spp. was recorded whereas high percentages of cones showed resin exudates. The presence of resin cannot be definitely related to a damaging agent, although the feeding activity of Leptoglossus occidentalis Heidemann could be one of the reasons. Damage by L. occidentalis was assessed by seed observation. Most of the seeds displayed tissues that had been damaged by this pest.

Restoring sinus rhythm results in blood pressure reduction in patients with persistent atrial fibrillation and a history of hypertension.

INTRODUCTION: The long-term effects of atrial fibrillation (AF) on blood pressure (BP) in patients with hypertension (HTN) remain unclear. We hypothesized that restoration of normal sinus rhythm (NSR) results in a decrease in BP despite the expected increase in cardiac output. METHODS AND RESULTS: Twenty-four-hour BP measurements were obtained during AF, and on Day 1 and Day 30 post-successful cardioversion in 18 patients with AF and HTN (cardioversion group), and another 22 patients with AF and HTN with no immediate plans for cardioversion (control group). Except for the duration of AF, the clinical characteristics and use of medications were similar between the groups. In the cardioversion group, a significant decrease in diastolic blood pressure (DBP) and mean blood pressure (MBP) were noted on Day 1 post-cardioversion with no significant change in systolic blood pressure (SBP): 117/74/88 ± 13/9/9 mmHg during AF and 116/70/85 ± 13/9/10 mmHg during Day 1 post-cardioversion (P = 0.68; <0.01 and 0.04 for SBP, DBP, and MBP, respectively). In the 13 subjects who remained in NSR at Day 30, DBP and MBP decreased further on Day 30 when compared to Day 1 with no significant change in SBP: 118/76/90 ± 13/7/8 mmHg during AF; 119/72/88 ± 12/8/9 mmHg during Day 1; and 118/69/86 ± 10/8/7 mmHg during Day 30 post-cardioversion (P = 0.97; <0.001 and 0.03 for SBP, DBP, and MBP, respectively). In the control group, no significant changes in BP were noted. CONCLUSION: Restoring NSR in patients with AF and HTN resulted in a sustained decrease in DBP and MBP. To our knowledge, this is the first study to show that maintenance of NSR improves BP control in patients with AF and HTN.

Diagnosis, management, and outcomes of patients with syncope and bundle branch block.

AIMS: Although patients with syncope and bundle branch block (BBB) are at high risk of developing atrio-ventricular block, syncope may be due to other aetiologies. We performed a prospective, observational study of the clinical outcomes of patients with syncope and BBB following a systematic diagnostic approach. METHODS AND RESULTS: Patients with ≥1 syncope in the last 6 months, with QRS duration ≥120 ms, were prospectively studied following a three-phase diagnostic strategy: Phase I, initial evaluation; Phase II, electrophysiological study (EPS); and Phase III, insertion of an implantable loop recorder (ILR). Overall, 323 patients (left ventricular ejection fraction 56 ± 12%) were studied. The aetiological diagnosis was established in 267 (82.7%) patients (102 at initial evaluation, 113 upon EPS, and 52 upon ILR) with the following aetiologies: bradyarrhythmia (202), carotid sinus syndrome (20), ventricular tachycardia (18), neurally mediated (9), orthostatic hypotension (4), drug-induced (3), secondary to cardiopulmonary disease (2), supraventricular tachycardia (1), bradycardia-tachycardia (1), and non-arrhythmic (7). A pacemaker was implanted in 220 (68.1%), an implantable cardioverter defibrillator in 19 (5.8%), and radiofrequency catheter ablation was performed in 3 patients. Twenty patients (6%) had died at an average follow-up of 19.2 ± 8.2 months. CONCLUSION: In patients with syncope, BBB, and mean left ventricular ejection fraction of 56 ± 12%, a systematic diagnostic approach achieves a high rate of aetiological diagnosis and allows to select specific treatment.

Resynchronization of the left ventricular contraction by tailored programming of right and left ventricular pacing.

AIMS: The prerequisite and the rationale for the benefit of cardiac resynchronization therapy (CRT) is that it is able to resynchronize left ventricular (LV) walls that have a delayed activation. METHODS AND RESULTS: In 69 consecutive patients who underwent biventricular (BIV) pacemaker implantation, we assessed the magnitude of intraventricular resynchronization achieved by means of simultaneous (BIV 0) and sequential BIV pacing (with an individually optimized VV interval value among +80 ms and -80 ms) using pulsed-wave tissue Doppler imaging techniques and in particular the measurement of the intra-LV electromechanical delay. The intra-LV delay was defined as the difference between the longest and the shortest activation time in the six basal segments of the LV. An abnormal intra-LV delay was defined as a value >41 ms. The intra-LV delay was 63 +/- 28 ms baseline, decreased to 44 +/- 26 ms with BIV 0 and to 26 +/- 15 ms with optimized BIV (P = 0.001). BIV 0 determined the shortest delay in 28 (41%) patients (23 +/- 12 ms). In 41 (59%) patients, a better resynchronization was achieved with optimized VV intervals (LV first in 32 and RV first in 5) or single-chamber pacing (LV in 3 and RV in 1). With BIV 0, the intra-LV delay remained abnormal in 41% and was longer than baseline in 30% of patients compared with 9 and 12% with optimized BIV, respectively (P = 0.001). CONCLUSION: A sub-optimal resynchronization is achieved with simultaneous BIV pacing in most patients. A tailored programming of the relative contribution of RV and LV pacing forms the prerequisite for improving CRT results.

Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope.

OBJECTIVES: We hypothesized that isometric arm exercises were able to increase blood pressure (BP) during the phase of impending vasovagal syncope and allow the patient to avoid losing consciousness. BACKGROUND: Hypotension is always present during the prodromal phase of vasovagal syncope. METHODS: We evaluated the effect of handgrip (HG) and arm-tensing in 19 patients affected by tilt-induced vasovagal syncope. The study consisted of an acute single-blind, placebo-controlled, randomized, cross-over tilt-table efficacy study and a clinical follow-up feasibility study. RESULTS: In the acute tilt study, HG was administered for 2 min, starting at the time of onset of symptoms of impending syncope. In the active arm, HG caused an increase in systolic blood pressure (SBP) from 92 +/- 10 mm Hg to 105 +/- 38 mm Hg, whereas in the placebo arm SBP decreased from 91 +/- 11 mm Hg to 73 +/- 21 mm Hg (p = 0.008). Heart rate behavior was similar in the two arms. In the active arm, 63% of patients became asymptomatic, versus 11% in the control arm (p = 0.02); conversely, only 5% of patients developed syncope, versus 47% in the control arm (p = 0.01). The patients were trained to self-administer arm-tensing treatment as soon as symptoms of impending syncope occurred. During 9 +/- 3 months of follow-up, the treatment was actually performed in 95/97 episodes of impending syncope (98%) and was successful in 94/95 (99%). No patients suffered injury or other adverse morbidity related to the relapses. CONCLUSIONS: Isometric arm contraction is able to abort impending vasovagal syncope by increasing systemic BP. Arm counter-pressure maneuvers can be proposed as a new, feasible, safe, and well accepted first-line treatment for vasovagal syncope.

Mechanism of syncope in patients with positive adenosine triphosphate tests.

OBJECTIVES: We prospectively evaluated the mechanism of syncope in patients with positive adenosine triphosphate (ATP) tests (defined as the induction of atrioventricular [AV] block with a ventricular pause >/=6 s after an intravenous bolus of 20 mg ATP). BACKGROUND: Patients with unexplained syncope tend to have more positive ATP tests results than those without syncope. METHODS: An implantable loop recorder (ILR) was inserted in 36 ATP-positive patients (69 +/- 10 years; 22 women; median of 6 syncopal episodes); 15 of them also had a positive response to tilt testing. RESULTS: During the follow-up of 18 +/- 9 months, 18 patients (50%) had syncopal recurrence and 16 (44%) had an electrocardiographically documented episode: AV block (n = 3: paroxysmal in 2 and permanent in 1), AV block followed by sinus arrest (n = 1), sinus arrest (n = 5), sinus bradycardia <40 beats/min (n = 2), normal sinus rhythm (n = 2), sinus tachycardia (n = 1), rapid atrial fibrillation (n = 1), and ectopic atrial tachycardia (n = 1). Bradycardia was documented in a total of 11 cases (69%), and a long ventricular pause (4 to 29 s) was present in eight cases (50%). All three patients with ILR-documented AV block had previously had a negative tilt test, whereas seven of eight with ILR-documented sinus bradycardia or sinus arrest had previously had a positive tilt test. CONCLUSIONS: In patients with adenosine-sensitive syncope, the mechanism of syncope is heterogeneous, although bradycardia is the most frequent finding. Adenosine triphosphate-induced AV block predicts AV block as the mechanism of spontaneous syncope in only a few tilt-negative patients.

Effects of climate on pine processionary moth fecundity and on its egg parasitoids.

Climate change may be affecting the fecundity of phytophagous insects as well as impacting their natural enemies. However, temperature impacts these two insect groups differently, disrupting population regulation mechanisms, and ultimately, possibly culminating in an outbreak of the host. The pine processionary moth (PPM) is one of the most harmful insects of the Mediterranean basin. Not only are PPM larvae harmful to plants, but they are also dangerous to humans because of their urticating hairs. Although some information is available on climate change effects on the PPM, little is known about its potential effects on PPM egg parasitoids, especially on their distribution range or on their role in controlling PPM populations. The aim of this article was to verify the effects of climate on PPM fecundity and on its egg parasitoids. Our results show that climate warming may affect the PPM positively, but not its egg parasitoids. Specifically, during our study mild winters directly favored the PPM, while increasing summer temperatures (over 30°C) also favored the PPM indirectly, by decreasing parasitism rates. We predict that ever-milder winters will not only favor PPM development, but also encourage it to spread in otherwise previously inhospitable environments.

Assessment of the vasodepressor reflex in carotid sinus syndrome.

BACKGROUND: Assessment of the vasodepressor reflex in carotid sinus syndrome is influenced by the method of execution of the carotid sinus massage and the coexistence of the cardioinhibitory reflex. METHODS AND RESULTS: Carotid sinus massage reproduced spontaneous symptoms in 164 patients in the presence of hypotension or bradycardia (method of symptoms). When an asystolic pause was induced, the vasodepressor reflex was reassessed after suppression of the asystolic reflex by means of 0.02 mg/kg IV atropine. An isolated vasodepressor form was found in 32 (20%) patients, who had lowest systolic blood pressure (SBP) of 65±15 mm Hg. Of these, only 21 (66%) patients had an SBP fall ≥50 mm Hg, which is the universally accepted cut-off value for the diagnosis of the vasodepressor form. Conversely, a lowest SBP value of ≤85 mm Hg (corresponding to the fifth percentile) detected 97% of vasodepressor patients, but was also present in 84% of the 132 patients with an asystolic reflex. These latter patients had both asystole ≥3 s (mean 7.6±2.2 s) and SBP fall to 63±22 mm Hg: in 46 (28%) patients, symptoms persisted after atropine (mixed form), in the remaining 86 (52%) patients, symptoms did not (cardioinhibitory form) persist. CONCLUSIONS: The current definition of ≥50 mm Hg SBP fall failed to identify one third of patients with isolated vasodepressor form. A cut-off value of symptomatic SBP of ≤85 mm Hg seems more appropriate, but it is unable to identify cardioinhibitory forms. In asystolic forms, atropine testing is able to distinguish a cardioinhibitory form from a mixed form.

Effect of clinical triggers on positive responses to tilt-table testing potentiated with nitroglycerin or clomipramine.

The effect of clinical triggers on tilt-table testing (TTT) responses has not been systematically evaluated. In the present study, we evaluated the effect of clinical triggers on positive responses to TTT potentiated with nitroglycerin (which acts mainly through peripheral dilation) or clomipramine (which acts mainly through a central serotoninergic mechanism). We enrolled 380 consecutive adult patients. In 66 patients, syncope was triggered by emotional distress (central trigger), in 161 by specific situations or prolonged standing (peripheral trigger), and in 153 syncope occurred in the absence of any detectable trigger. Nitroglycerin TTT, performed in 252 patients, consisted of a passive phase of 20 minutes followed, if negative, by sublingual administration of 400 µg nitroglycerin spray and continuation of tilting for 15 minutes. Clomipramine TTT, performed in 128 patients, consisted of 20 minutes of tilting with intravenous administration of 5 mg clomipramine during the first 5 minutes. The positivity of nitroglycerin TTT was greater in patients with clinical triggers (71% central and 75% peripheral) than in those without (36%). With clomipramine TTT, the positivity rate was greater in patients with central triggers (92%) than in those with peripheral triggers (45%) or no triggers (30%). The cardioinhibitory form was more frequent in patients with a central trigger than in the other 2 groups (34% vs 12% and 7%) and with clomipramine TTT than with nitroglycerin TTT (19% vs 11%, respectively). In contrast, mixed or vasodepressor forms were more frequently induced by nitroglycerin TTT (41% vs 24%). In conclusion, the presence of clinical triggers increased the positivity of TTT and influenced the type of response. We found some specificity of nitroglycerin and clomipramine for peripheral and central mechanisms.

The hemodynamic pattern of the syndrome of delayed orthostatic hypotension.

PURPOSE: We investigated the hemodynamic mechanisms underlying the syndrome of delayed orthostatic hypotension (OH) and the hemodynamic effect of the treatment with leg compression bandages. METHODS: Non-invasive monitoring of systolic blood pressure (SBP), heart rate (HR), cardiac output (CO), stroke volume (SV), and total peripheral resistance (TPR) was performed during tilt testing in patients affected by delayed OH compared to age- and sex-matched controls. Thirteen patients (68 +/- 14 years) and nine controls (68 +/- 8 years) were studied. RESULTS: Immediately after tilt-up, SBP progressively decreased in patients but not in controls. Symptoms developed at 100 +/- 7 mmHg. At the end of the test, SBP was significantly lower in patients than in controls. TPR progressively decreased in patients but not in controls. SV and CO did not change significantly. HR increased progressively in the patients until the end of the test and remained unchanged in controls. Active treatment with compression bandages avoided the decrease in SBP and TPR, while CO showed minimal variation. CONCLUSION: In patients affected by delayed OH, the progressive decrease of SBP is associated with progressive decrease of TPR, while CO and SV show little variation; the compensatory increase in HR is insufficient to compensate for the decline in blood pressure.

Recurrent unexplained palpitations (RUP) study comparison of implantable loop recorder versus conventional diagnostic strategy.

OBJECTIVES: The aim of the study was to compare the diagnostic yield and the costs of implantable loop recorder (ILR) with those of the conventional strategy in patients with unexplained palpitations. BACKGROUND: In patients with unexplained palpitations, especially in those with infrequent symptoms, the conventional strategy, including short-term ambulatory electrocardiogram (ECG) monitoring and electrophysiological study, sometimes fails to establish a diagnosis. METHODS: We studied 50 patients with infrequent (< or =1 episode/month), sustained (>1 min) palpitations. Before enrollment, patients had a negative initial evaluation, including history, physical examination, and ECG. Patients were randomized either to conventional strategy (24-h Holter recording, a 4-week period of ambulatory ECG monitoring with an external recorder, and electrophysiological study) (n = 24) or to ILR implantation with 1-year monitoring (n = 26). Hospital costs of the 2 strategies were calculated. RESULTS: A diagnosis was obtained in 5 patients in the conventional strategy group, and in 19 subjects in the ILR group (21% vs. 73%, p < 0.001). Despite the higher initial cost, the cost per diagnosis in the ILR group was lower than in the conventional strategy group (euro 3,056 +/- euro 363 vs. euro 6,768 +/- euro 6,672, p = 0.012). CONCLUSIONS: In subjects without severe heart disease and with infrequent palpitations, ILR is a safe and more cost-effective diagnostic approach than conventional strategy.

Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: a randomized single-blind controlled study.

OBJECTIVES: This study sought to assess the efficacy of compression bandage of legs and abdomen in preventing hypotension and symptoms. BACKGROUND: Progressive orthostatic hypotension can occur in elderly people during standing. METHODS: Twenty-one patients (70 +/- 11 years) affected by symptomatic progressive orthostatic hypotension underwent 2 tilt-test procedures, with and without elastic bandage of the legs (compression pressure 40 to 60 mm Hg) and of the abdomen (compression pressure 20 to 30 mm Hg) in a randomized crossover fashion. Leg bandage was administered for 10 min and was followed by an additional abdominal bandage for a further 10 min. Symptoms were evaluated by a 7-item Specific Symptom Score (SSS) questionnaire before and after 1 month of therapy with elastic compression stockings of the legs (prescribed in all patients irrespective of the results of the tilt study). RESULTS: In the control arm, systolic blood pressure decreased from 125 +/- 18 mm Hg immediately after tilting to 112 +/- 25 mm Hg after 10 min of sham leg bandage and to 106 +/- 25 mm Hg after 20 min despite the addition of sham abdominal bandage. The corresponding values with active therapy were 129 +/- 19 mm Hg, 127 +/- 17 mm Hg (p = 0.003 vs. control), and 127 +/- 21 mm Hg (p = 0.002 vs. control). In the active arm, 90% of patients remained asymptomatic, versus 53% in the control arm (p = 0.02). During the month before evaluation, the mean SSS score was 35.2 +/- 12.1 with dizziness, weakness, and palpitations accounting for 64% of the total score. The SSS score decreased to 22.5 +/- 11.3 after 1 month of therapy (p = 0.01). CONCLUSIONS: Lower limb compression bandage is effective in avoiding orthostatic systolic blood pressure decrease and in reducing symptoms in elderly patients affected by progressive orthostatic hypotension.