Symptoms and signs associated with syncope in young people with primary cardiac arrhythmias.

BACKGROUND: It is often reported that clinical symptoms are useful in differentiating cardiac from non-cardiac syncope. Studies in the young are rare. This study was designed to capture the symptoms and signs reported by patients with cardiac syncope before the patients or their attending clinicians knew the final diagnosis. METHODS: Retrospective case-note review of 35 consecutive unrelated gene-positive probands with a proven cardiac channelopathy. RESULTS: The presentation leading to diagnosis of cardiac channelopathy was resuscitated sudden cardiac death in 7 patients; syncope in 20; collapse with retained consciousness in 2; palpitations in 1 and an incidental finding in 5. For the 20 patients with syncope (LQTS 18, Brugada syndrome 2), median age at presentation was 13.9 years (1.8 day to 40.8 years). Of the 17 patients able to describe the onset of syncope, 11 (65%) had at least one symptom prior to collapse, though none reported nausea. Dizziness or lightheadedness was the most frequent symptom, being experienced by 8 (47%). Nine (of 20) patients (45%) had witnessed seizure-like activity and 8 (40%) had urinary incontinence. Nineteen patients were capable of describing the post-syncopal period, of whom 15 (79%) reported symptoms, the most common (12; 65%) being drowsiness or exhaustion. CONCLUSIONS: Cardiac syncope in the young frequently presents with symptoms and signs that are typically associated with other causes of transient loss of consciousness, including vasovagal syncope and seizure disorders. The presence of symptoms may not be as helpful in differentiating arrhythmic from non-arrhythmic events as is often supposed. A thorough history, appropriate investigations and a high index of suspicion remain essential in the assessment of syncope.

Misdiagnosis of long QT syndrome as epilepsy at first presentation.

STUDY OBJECTIVE: Long QT syndrome has significant mortality, which is reduced with appropriate management. It is known that long QT syndrome masquerades as other conditions, including seizure disorders. We aim to evaluate a series of patients with genetically confirmed long QT syndrome to establish the frequency of delayed recognition. We also examine causes and potential consequences of diagnostic delay. METHODS: A consecutive case series of patients with long QT syndrome was identified through the Cardiac Inherited Disease Registry in New Zealand between 2000 and 2005. Detailed retrospective review of 31 cases was undertaken. The primary outcome was the time from first presentation with sudden loss of consciousness to a diagnosis of long QT syndrome. If the diagnosis was not made at the initial presentation, it was considered delayed. For the patients with a delayed diagnosis, the median duration of delay was compared between the subgroup of patients initially misdiagnosed with epilepsy and the others. RESULTS: Genetic mutations in 31 probands were consistent with long QT type 1 in 18 (58%) patients, long QT type 2 in 10 (32%) and long QT type 3 in 3 (10%). Median age at diagnosis was 21 years (1 day to 54 years). Thirteen patients (39%) experienced diagnostic delay after presentation with syncope or seizure: median delay 2.4 years (2 months to 23 years). Electroencephalograms were obtained in 10 patients; 5 were diagnosed with epilepsy. For those labeled epileptic, diagnostic delay was significantly longer than with other misdiagnoses: estimated median difference 9.75 years (95% confidence interval 7.6 to 20.7 years). During the delay period, 4 sudden unexplained deaths reportedly occurred in young relatives. Ten of the 13 had an ECG before diagnosis, with unrecognized pulse rate-corrected QT interval prolongation in 8 cases (range 0.47 to 0.65 seconds). CONCLUSION: Delayed diagnosis of long QT syndrome is frequent. Symptoms are often attributed to alternative diagnoses, most commonly seizure disorder. Patients labeled as epileptic experience a particularly long diagnostic delay. ECGs were frequently requested, but interpretation errors were common. Given the potentially preventable mortality of long QT syndrome, emergency physicians investigating syncope and seizure should maintain a high index of suspicion.

Acute coronary syndrome induced by capecitabine therapy.

Capecitabine, a new member of the fluoropyrimidine family, is an orally administered drug that delivers fluorouracil (5-FU) selectively to the tumour. Although the cardiotoxicity of 5-FU is well documented, there is little published data about cardiovascular adverse effects of Capecitabine. This case highlights the possible development of acute coronary syndrome as a side effect of Capecitabine therapy.

Pacing and Implantable Cardioverter Defibrillator Options for the Elderly in Australia and New Zealand.

This review seeks to determine the extent to which age impacts the access to pacemaker and implantable cardioverter defibrillator (ICD) technology in Australia and New Zealand. The limited available data suggest a number of consistent trends: 1) implant rates for both pacemakers and ICDs are increasing in both Australia and New Zealand; 2) the elderly are increasingly well catered for in terms of pacemaker implantation, especially in Australia (54% of pacemaker recipients aged at or above 80 in 1997); 3) there is a progressive trend to more dual chamber pacing in the elderly in both countries; 4) age appears to be a barrier to the access to ICDs, especially in New Zealand, which is likely related to the high cost of these devices; and 5) limited data suggest that Australia physicians consider age less of a barrier to the access to high technology implantable devices, compared with their New Zealand counterparts, likely reflecting their greater prosperity and financial commitment to health care. Finally, this review clearly documents the need for improved prospective data collection in both countries. (c)1999 by CVRR, Inc.