Multiple causes of syncope in the elderly: diagnostic outcomes of a Dutch multidisciplinary syncope pathway.

Aims: To assess the diagnostic outcomes of a multidisciplinary pathway for elderly syncope patients. Methods and results: Observational cohort study at a Fall and Syncope Clinic, including consecutive syncope patients aged ≥65 years between 2011 and 2014. Measurements: The sort, number, and accuracy of diagnoses resulting in syncope. Secondary outcomes: reliability of the medical history and the number of electrocardiogram (ECG) abnormalities. The 117 included patients (72% females) had a mean age of 80 ± 6.5 years and a mean of 11 ± 5 (mainly cardiovascular) comorbidities. We found 212 contributing diagnoses. Symptomatic orthostatic/postprandial hypotension was present in 45%, cardiac causes in 44% (rhythm or conduction disorders 24%, aortic stenosis 4%, cardiomyopathies 2%, suspected cardiac causes 15%), and reflex syncope in 21%; 6% remained without any explanation. The diagnosis of the cause of syncope was uncertain in 34.2%, probable in 15.4%, and definite/most likely in 50.4%. Cognitive impaired patients were less likely to give a reliable medical history regarding their syncope (72% vs. 98% in cognitive intact patients, P = 0.001). In only 25% of patients a useful eyewitness account was available. 64% of ECGs showed relevant abnormalities; 26% was suggestive of cardiac syncope, of which 20% showed an indication for device implantation. Conclusion: The majority of our elderly syncope patients had multiple contributing factors, often in addition to their primary diagnosis. Orthostatic/postprandial hypotension and cardiac disorders were the most frequent. Using a multidisciplinary approach, one or more possible explanations for the syncope were found in 94% of patients, with a definite diagnosis in 50%.

Incidence and predictors of pacemaker reprogramming: potential consequences for remote follow-up.

AIMS: Remote follow-up (FU) enables to cope with the expanding number of pacemaker (PM) FU. Although remote FU offers comparable monitoring options to in-office FU, reprogramming of device settings is not available, thereby imposing a potentially important restriction to the applicability of remote FU.  The aim of this study was to assess in a large cohort of bradycardia PM recipients, the incidence of PM reprogramming during long-term FU and its predictors, to judge the possibilities for remote FU. METHODS AND RESULTS: Between 2003 and 2010 all in-office FU of 1517 bradycardia PM recipients included in the FOLLOWPACE study were recorded. Only 24.5% of all 13 258 recorded FU visits >3 months after implantation were visits-with-reprogramming (VWRs), occurring in 1158 patients (79%). Fifty percent of patients were free of reprogramming at 9 months, and 29% at 24 months. Using multivariable binary logistic regression analysis, the following patient characteristics were predictive for frequent PM reprogramming, defined as >3 VWRs during 3 year FU: age, a history of atrial arrhythmias, PM complication <3 months after implantation, congestive heart failure, PM indication, and lead fixation method. This model had a receiver operating characteristic area of 0.66 (95% confidence interval 0.61-0.71). CONCLUSION: This study observed a low proportion of VWR (∼25%) during a mean FU of 5.3 years; however, those patients at high risk for PM reprogramming cannot easily be predicted. The vast majority of patients (>80%) do not need frequent reprogramming, suggesting a potential benefit of using remote FU to reduce the number of unnecessary in-office visits.

Prospective evaluation of non-pharmacological treatment in vasovagal syncope.

AIMS: Initial treatment of vasovagal syncope (VVS) consists of assuring an adequate fluid and salt intake, regular exercise and application of physical counterpressure manoeuvres. We examined the effects of this non-pharmacological treatment in patients with frequent recurrences. METHODS AND RESULTS: One hundred patients with > or =3 episodes of VVS in the 2 years prior to the start of the study openly received non-pharmacological treatment. We evaluated this treatment both with respect to syncopal recurrences, factors associated with recurrence, and quality of life (QoL). The median number of syncopal recurrences was lower in the first year of non-pharmacological treatment compared with the last year before treatment (median 0 vs. 3; P < 0.001), but 49% of patients experienced at least one recurrence. In multivariable analysis, a higher syncope burden prior to inclusion was significantly associated with syncopal recurrence. Disease-specific QoL improved over time, with larger improvements for patients with more reduction in syncope burden. CONCLUSION: In patients with frequent recurrences of VVS, non-pharmacological treatment has a beneficial effect on both syncopal recurrence and QoL, but nearly half of these patients still experience episodes of syncope.

Right atrial preventive and antitachycardia pacing for prevention of paroxysmal atrial fibrillation in patients without bradycardia: a randomized study.

AIMS: To investigate the efficacy of preventive and antitachycardia pacing (ATP) in patients with symptomatic paroxysmal atrial fibrillation (AF) without bradyarrhythmias. METHODS AND RESULTS: In this randomized cross-over pilot study, we randomized 38 symptomatic paroxysmal AF patients 'without' bradyarrhythmias to atrial pacing lower rate 70 ppm and prevention and ATP therapies ON or to atrial pacing lower rate 34 ppm and prevention and ATP therapies OFF during 12 weeks with a 4 week washout period in between. The atrial lead was preferably placed in the inter-atrial septum. Antiarrhythmic drugs were continued during the study. Primary endpoint was AF burden. Mean age was 62 +/- 9 years and 27 (71%) patients had lone AF. Septal lead placement was accomplished in 26 (68%) patients. During the treatment ON, there was a trend for AF burden reduction [from median 3.3% (1.0-15.2) to 2.4% (0.2-12.2), P = 0.06, reduction 27%]. If septal lead placement was accomplished, AF burden reduction was statistically significant [44% reduction, from median 2.5% (1.0-8.0) to 1.4% (0.2-8.4), P = 0.03]. Quality of life and symptoms did not change, also not in the septal group. CONCLUSION: A hybrid therapy of preventive and ATP pacing and antiarrhythmic drugs may significantly reduce but not abolish AF burden if septal pacing is realized.

Different patterns of orthostatic hypotension in older patients with unexplained falls or syncope: orthostatic hypotension patterns in older people.

PURPOSE: To evaluate different patterns of orthostatic hypotension (OH) and its relation to mortality in older patients with unexplained falls or syncope. METHODS: This is an observational cohort study in consecutive patients aged ≥ 65 years with unexplained falls or syncope at a Fall Syncope day clinic November 2011 until May 2016. OH is defined as a decrease in systolic blood pressure (BP) ≥ 20 mmHg and/or in diastolic BP ≥ 10 mmHg during standing test. Main outcomes are the baseline characteristics and prevalence of patients with classical OH (decrease BP until 3 min), delayed OH (decrease of BP from 5 to 10 min) and continuous OH (decrease of BP for 10 min). Secondary outcome is the relation between different OH patterns and mortality. RESULTS: Of 374 patients with a mean age of 80 year (SD 6.6), 56% of the patients had OH: 16% had classical OH, 8% delayed OH, 32% had continuous OH and 44% had no OH. Patients with continuous OH and patients with delayed OH tended to have a higher mortality compared to patients with classical OH, 14 vs. 5% (P = 0.07) and 17 vs. 5% (P = 0.06). This possible relation between OH patterns and mortality could not be confirmed in multivariate analysis. CONCLUSIONS: In these very old patients, there are various patterns of decline in standing BP. Delayed and continuous OH will be missed if BP is measured only for 3 min during standing. This is important because patients with continuous OH and delayed OH might have a relation with mortality. Our results encourage additional studies investigating the relation between different OH patterns and mortality.

Cognitive Impairment Is Very Common in Elderly Patients With Syncope and Unexplained Falls.

OBJECTIVES: To evaluate the prevalence of cognitive impairment (CI), including mild CI and dementia, in elderly patients with syncope and unexplained falls. In this population, we compared the use of the Mini-Mental State Examination (MMSE) with a cognitive screening test that assesses executive dysfunction typical of subcortical (vascular) CI, that is, the Montreal Cognitive Assessment (MoCA). DESIGN: Observational cohort study. SETTING: Outpatient fall and syncope clinic. PARTICIPANTS: Consecutive patients aged ≥65 years with syncope and unexplained falls without loss of consciousness. MEASUREMENTS: Baseline characteristics, functional status, MMSE, MoCA, and magnetic resonance imaging scans of the brain. MAIN OUTCOME: prevalence of CI, comparing the MMSE with the MoCA. CI was defined as an MMSE/MoCA score <26. SECONDARY OUTCOMES: MMSE/MoCA overall and subdomain scores, Fazekas and medial temporal lobe atrophy scores. RESULTS: We included 200 patients, mean age 79.5 (standard deviation 6.6) years (Syncope Group: n = 101; Fall Group: n = 99). Prevalence of CI was 16.8% (MMSE) versus 60.4% (MoCA) in the Syncope Group (P < .001) and 16.8% (MMSE) versus 56.6% (MoCA) in the Fall Group (P < .001). Prevalence of CI did not differ between the Syncope Group and Fall Group with either method. Executive dysfunction was present in both groups. CONCLUSION: CI is as common in elderly patients with syncope as it is in patients with unexplained falls, with an overall prevalence of 58%. The MMSE fails as a screening instrument for CI in these patients, because it does not assess executive function. Therefore, we recommend the MoCA for cognitive screening in older patients with syncope and unexplained falls.

Reduction of atrial tachyarrhythmia episodes during the overdrive pacing period using the post-mode switch overdrive pacing (PMOP) algorithm.

BACKGROUND: Early recurrences within 10 minutes after termination of an atrial tachyarrhythmia, such as atrial tachycardia (AT), atrial flutter, or atrial fibrillation (AF) episodes, account for a large part of paroxysmal AT/AF episodes. It is unclear whether these arrhythmias can be suppressed by overdrive pacing. OBJECTIVE: We set out to prove that overdrive pacing is effective in preventing early recurrences of AT/AF. METHODS: This AT500 (DDDRP device, Bakken Research Center Medtronic, Maastricht, The Netherlands) post-mode switch overdrive pacing (PMOP) study is a randomized controlled trial designed to test the efficacy of overdrive pacing on the suppression of early recurring AT/AF episodes. With the PMOP feature, overdrive pacing is activated 12 ventricular beats after device-confirmed termination of an AT/AF episode with a programmed duration and rate. If at least four episodes of 1 minute in duration occurred within the run-in period of 1 month, patients were randomized to one of the three settings (PMOP off and PMOP 10 minutes at 90 bpm or 120 bpm) for 2 months. At 2 and 4 months, patients were crossed over to another arm. At 6 months, all patients were programmed with PMOP on at 90 bpm for 30 minutes. RESULTS: We enrolled 122 and randomized 50 patients. Sixty percent of all stored AT/AF episodes occurred within 10 minutes after a previous episode; 31% occurred after device-determined termination and before the device reached the overdrive rate (17-27 ventricular beats after termination), and 29% of the episodes occurred while the device was pacing at the programmed overdrive rate. Thirty-seven percent of the average percentage of episodes during the overdrive period was prevented by the randomized settings of PMOP 90 bpm/10 min (P = .01, paired t-test, n = 39) and 120 bpm/10 min (P = .03, n = 35). In addition, for the nonrandomized setting of PMOP 90 bpm/30 min, the average number of episodes during the overdrive period was significantly smaller than the percentage of episodes occurring during the corresponding off period of 30 minutes (P = .05, n = 33). No significant differences in burden and episodes were found between the PMOP settings and the corresponding off periods. CONCLUSIONS: This is the first randomized controlled clinical trial to prove that overdrive pacing is effective in preventing early recurrences of AT/AF. However, shortcomings of the PMOP algorithm, such as late activation, need further improvement.

Occlusion of the coronary sinus: a complication of resynchronisation therapy for severe heart failure.

The finding of complete obstruction of the proximal coronary sinus after left ventricular (LV) lead extraction during LV lead replacement is uncommon. In our case, we used a large collateral branch of the middle cardiac vein as an alternative route to the postero-lateral region. We have termed this the 'collateral approach'.