Diagnosis of Brugada Syndrome With a Sodium-Channel-Blocker Test: Who Should Be Tested? Who Should Not?

Intravenous infusion of sodium-channel blockers (SCB) with either ajmaline, flecainide, procainamide, or pilsicainide to unmask the ECG of Brugada syndrome is the drug challenge most commonly used for diagnostic purposes when investigating cases possibly related to inherited arrhythmia syndromes. For a patient undergoing an SCB challenge, the impact of a positive result goes well beyond its diagnostic implications. It is, therefore, appropriate to question who should undergo a SCB test to diagnose or exclude Brugada syndrome and, perhaps more importantly, who should not. We present a critical review of the benefits and drawbacks of the SCB challenge when performed in cardiac arrest survivors, patients presenting with syncope, family members of probands with confirmed Brugada syndrome, and asymptomatic patients with suspicious ECG.

[Diagnostic and intervention value of implantable cardiac monitor in patients over 60 years of age with unexplained syncope].

Objective: To investigate the value of implantable cardiac monitor (ICM) in the diagnosis and treatment of patients over 60 years old with unexplained syncope. Methods: This was a multi-center, prospective cohort study. Between June 2018 and April 2021, patients over the age of 60 with unexplained syncope at Beijing Hospital, Fuwai Hospital, Beijing Anzhen Hospital and Puren Hospital were enrolled. Patients were divided into 2 groups based on their decision to receive ICM implantation (implantation group and conventional follow-up group). The endpoint was the recurrence of syncope and cardiogenic syncope as determined by positive cardiac arrhythmia events recorded at the ICM or diagnosed during routine follow-up. Kaplan-Meier survival analysis was used to compare the differences of cumulative diagnostic rate between the 2 groups. A multivariate Cox regression analysis was performed to determine independent predictors of diagnosis of cardiogenic syncope in patients with unexplained syncope. Results: A total of 198 patients with unexplained syncope, aged (72.9±8.25) years, were followed for 558.0 (296.0,877.0) d, including 98 males (49.5%). There were 100 (50.5%) patients in the implantation group and 98 (49.5%) in the conventional follow-up group. Compared with conventional follow-up group, patients in the implantation group were older, more likely to have comorbidities, had a higher proportion of first degree atrioventricular block indicated by baseline electrocardiogram, and had a lower body mass index (all P<0.05). During the follow-up period, positive cardiac arrhythmia events were recorded in 58 (58.0%) patients in the ICM group. The diagnosis rate (42.0% (42/100) vs. 4.1% (4/98), P<0.001) and the intervention rate (37.0% (37/100) vs. 2.0% (2/98), P<0.001) of cardiogenic syncope in the implantation group were higher than those in the conventional follow-up group (all P<0.001). Kaplan-Meier survival analysis showed that the cumulative diagnostic rate of cardiogenic syncope was significantly higher in the implantation group than in the traditional follow-up group (HR=11.66, 95%CI 6.49-20.98, log-rank P<0.001). Multivariate analysis indicated that ICM implantation, previous atrial fibrillation, diabetes mellitus or first degree atrioventricular block in baseline electrocardiogram were independent predictors for cardiogenic syncope (all P<0.05). Conclusions: ICM implantation improves the diagnosis and intervention rates in patients with unexplained syncope, and increases diagnostic efficiency in patients with unexplained syncope.

Implantable cardiac monitor and leadless pacemaker in the management of syncope due to intermittent high-degree atrioventricular block: a case report.

BACKGROUND: Lead dislodgements, tricuspid valve failure, and wound infections are prominent issues addressed by leadless pacemakers (LPM). These devises have emerged as viable alternatives to conventional transvenous pacemakers. LPMs offer minimized complications and effective pacing, particularly beneficial for elderly patients with a low body mass index (BMI) who are at heightened infection of risk. The Micra AV leadless pacemaker was released in the US in 2020, featuring a VDD pacing mode akin to conventional pacemakers. It senses atrial activity to pace ventricular beats while maintaining the natural atrioventricular activation sequence. Micra AV achieves atrioventricular synchronization through mechanical sensing principles. Ongoing research aims to assess its efficacy, implantation feasibility, and clinical safety. CASE PRESENTATION: An 83-year-old man with a history of syncope was the focus of this case study. An implantable cardiac monitor (ICM) recorded occasional high-degree atrioventricular block in the patient. Subsequently, the Micra AV was implanted via the left femoral vein, and its settings were adjusted in accordance with data obtained from the ICM. No significant issues regarding pacing threshold or impedance were found during the follow-up examinations post-surgery. Importantly, the patient experienced a noticeable reduction in symptoms compared to before the implantation. DISCUSSION: This case underscores the significance of ICM monitoring in elucidating cardiac events leading to syncope and guiding appropriate treatment. It also highlights the successful outcomes and reliable implantation of the Micra AV for managing high-degree atrioventricular block. This study contributes to the growing body of evidence supporting the adoption of leadless pacemakers as a viable option for patients requiring cardiac pacing, particularly those vulnerable to complications associated with traditional pacemakers. It provides real-world evidence of Micra AV's efficacy and safety, further validating its role in clinical practice.

Symptom progression in neuromyelitis optica spectrum disorder from ataxia through syncope to neuropathic pain: A case report.

RATIONALE: Neuromyelitis optica spectrum disorder (NMOSD) involves autoimmune and inflammatory responses in the central nervous system, primarily affecting the optic nerves and spinal cord. Atypical presentations such as ataxia and syncope complicate the diagnosis, and lesions in the medulla are easily mistaken for cerebral infarction. This case report emphasizes the need to recognize such manifestations to avoid misdiagnosis and ensure timely treatment. PATIENT CONCERNS: This case report presents an NMOSD female patient who experienced ataxia, syncope, and neuropathic pain during her illness. DIAGNOSIS: NMOSD. INTERVENTIONS: The patient managed her blood sugar with insulin, controlled neuropathic pain with pregabalin, and underwent 5 plasma exchanges. OUTCOMES: Significant improvement was noted 1 week post-plasma exchange, with complete resolution of neuropathic pain and no symptom recurrence reported at 6-month follow-up. LESSONS: Atypical manifestations of NMOSD, such as ataxia, syncope, and trigeminal neuralgia, increase diagnostic difficulty. Recognizing these symptoms is crucial to avoid misdiagnosis and ensure timely and appropriate treatment for patients.

Procedural and Intermediate-term Results of the Electroanatomical-guided Cardioneuroablation for the Treatment of Supra-Hisian Second- or Advanced-degree Atrioventricular Block: the PIRECNA multicentre registry.

AIMS: Prior case series showed promising results for cardioneuroablation in patients with vagally induced atrioventricular blocks (VAVBs). We aimed to examine the acute procedural characteristics and intermediate-term outcomes of electroanatomical-guided cardioneuroablation (EACNA) in patients with VAVB. METHODS AND RESULTS: This international multicentre retrospective registry included data collected from 20 centres. Patients presenting with symptomatic paroxysmal or persistent VAVB were included in the study. All patients underwent EACNA. Procedural success was defined by the acute reversal of atrioventricular blocks (AVBs) and complete abolition of atropine response. The primary outcome was occurrence of syncope and daytime second- or advanced-degree AVB on serial prolonged electrocardiogram monitoring during follow-up. A total of 130 patients underwent EACNA. Acute procedural success was achieved in 96.2% of the cases. During a median follow-up of 300 days (150, 496), the primary outcome occurred in 17/125 (14%) cases with acute procedural success (recurrence of AVB in 9 and new syncope in 8 cases). Operator experience and use of extracardiac vagal stimulation were similar for patients with and without primary outcomes. A history of atrial fibrillation, hypertension, and coronary artery disease was associated with a higher primary outcome occurrence. Only four patients with primary outcome required pacemaker placement during follow-up. CONCLUSION: This is the largest multicentre study demonstrating the feasibility of EACNA with encouraging intermediate-term outcomes in selected patients with VAVB. Studies investigating the effect on burden of daytime symptoms caused by the AVB are required to confirm these findings.

Patient Perception of Cough in Interstitial Lung Disease; Impact of Cough Hypersensitivity.

INTRODUCTION: Cough is common in interstitial lung disease (ILD) and is associated with disease progression, yet its mechanisms are understudied. We investigated cough hypersensitivity features and impact in ILD. METHODS: Participants with ILD and cough (n = 195) completed a multiple choice and free text questionnaire on cough sensations/triggers and impacts. RESULTS: The majority of participants were male (54%), aged > 65 (64%), with idiopathic pulmonary fibrosis (IPF, 75%). Common cough triggers were body position (74%), physical activity (72%), and talking (62%). Common laryngeal sensations were globus (43%), and itch/tickle (42%). Cough impacted everyday life in 55%, and all activities in 31%, causing exhaustion (59%), social embarrassment (70%), urinary incontinence (46% females), and syncope/pre-syncope (12%). The total number of cough-provoking sensations/triggers correlated with impacts; ρ = 0.73, p < 0.001. CONCLUSION: Cough hypersensitivity symptoms are prevalent in ILD and detrimentally affect quality of life. Further studies investigating mechanisms of cough hypersensitivity and targeted pharmacotherapy are warranted.

A 30-Year-Old Woman With Arthralgia, Progressive Dyspnea, and a Syncope Episode.

CASE PRESENTATION: A 30-year-old White woman with presumed rheumatoid arthritis accompanied by CT scan evidence of eosinophilic pneumonitis was referred to the ED by her rheumatologist for an investigation of the progression of dyspnea. Approximately 6 months before, the patient reported experiencing diffuse interphalangeal arthralgias (both proximal and distal) that affected the wrists, knees, and feet. These symptoms were accompanied by Modified Medical Research Council scale grade 2 dyspnea. During the initial assessment, the patient exhibited slight pallor and had no indications of inflammatory activity in the joints. Furthermore, the cardiovascular physical examination and the auto-antibody laboratory profile yielded normal results. However, a wrist ultrasound scan revealed evidence of active synovitis; a chest CT scan displayed multifocal bilateral ground-glass opacities and mild thickening of the interlobular septa. These findings suggested the presence of eosinophilic disease or an acute interstitial process related to collagen vascular disease. Consequently, the patient's treatment commenced with a weekly dose of methotrexate (10 mg). Despite the intervention, 2 months later, the patient returned, reporting persistent arthralgia and a worsening of dyspnea, now classified as Modified Medical Research Council scale grade 3. Subsequently, the rheumatologist referred her to the ED for further assessment. During the initial emergency evaluation, the patient experienced a syncope episode accompanied by orthostatic prodromal symptoms that included dizziness, nausea, and malaise.

An Unusual ST-Segment Elevation in Unexplained Syncope.

This case report describes a patient in their 70s with a lambda wave pattern on electrocardiography.

Fasciculoventricular accessory pathway masked extensive atrioventricular conduction system disease in a patient with PRKAG2 syndrome.

A 23-year-old male with a history of ventricular pre-excitation and atrial flutter presented for evaluation after recurrent syncope. The possible mechanism of syncope erroneously attributed to pre-excited atrial flutter with fast heart rates in the first hospitalization. The patient was found to have advanced heart block and PRKAG2 genetic mutation in the second hospitalization. The genetic findings and clinical features are consistent with PRKAG2 syndrome (PS). PS is a rare, autosomal dominant inherited disease, characterized by ventricular pre-excitation, supraventricular tachycardia, and cardiac hypertrophy. It is frequently followed by atrial-fibrillation-induced ventricular fibrillation and advanced heart blocks. An accurate differential diagnosis of syncope is important because of the different arrhythmic features and clinical course of PS.

Assessing the Predictive Value of Combining Risk Scoring Systems and Ultrasonography for Short-Term Adverse Outcomes in Syncope: A Prospective Observational Study.

BACKGROUND: In the emergency department (ED), the role of ultrasonography (USG) in risk stratification and predicting adverse events in syncope patients is a current research area. However, it is still unclear how ultrasound can be combined with existing risk scores. OBJECTIVES: In this study, it was aimed to examine the contribution of the use of bedside USG to current risk scores in the evaluation of patients presenting to the ED with syncope. The predictive values of the combined use of USG and risk scores for adverse outcomes at 7 and 30 days were examined. METHODS: The Canadian Syncope Risk Score (CSRS), San Francisco syncope rules (SFSR), USG findings of carotid and deep venous structures, and echocardiography results were recorded for patients presenting with syncope. Parameters showing significance in the 7-day and 30-day adverse outcome groups were utilized to create new scores termed CSRS-USG and SFSR-USG. Predictive values were evaluated using receiver operating characteristic (ROC) analysis. The difference between the predictive values was evaluated with the DeLong test. RESULTS: The study was carried out with 137 participants. Adverse outcomes were observed in 45 participants (32.8%) within 30 days. 32 (71.7%) of the adverse outcomes were in the first 7 days. For 30-day adverse outcomes, the SFSR-USG (p = 0.001) and CSRS-USG (p = 0.038) scores had better predictive accuracy compared to SFSR and CSRS, respectively. However, there was no significant improvement in sensitivity and specificity values. CONCLUSION: The use of USG in the evaluation of syncope patients did not result in significant improvement in sensitivity and specificity values for predicting adverse events. However, larger sample-sized studies are needed to understand its potential contributions better.

Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report.

BACKGROUND: Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. CASE REPORT: A 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum ß-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.

Diagnostic Yield of head Computed Tomography in Patients with Syncope: Sex Differences.

BACKGROUND: Syncope is responsible for approximately 1-3% of all emergency department (ED) visits and up to 6% of all hospital admissions in the United States. Although often of no long-term consequence, syncope can be the first presentation of a range of serious conditions such as strokes, tumors, or subarachnoid hemorrhages. Head computed tomography (CT) scanning is therefore commonly ordered in the ED for patients presenting with syncope to rule out any of these conditions, which may present without other associated physical or neurological findings on initial examination. However, the diagnostic yield of head CTs in patients presenting with syncope is unclear. OBJECTIVES: To determine the diagnostic yield of head CT in the ED in patients with syncope. METHODS: We conducted an observational analytical retrospective cross-sectional study on 360 patients diagnosed with syncope who underwent a head CT to determine the diagnostic yield of syncope to determine whether head CT is necessary for every patient presenting with syncope to the ED. RESULTS: The total of new CT findings was 11.4%. Percentages varied between men (12.8%) and women (9.7%), P = 0.353. There were no significant differences between sexes regarding the findings in head CT, yet the incidence increased, especially among elderly males. CONCLUSIONS: Age had a more significant impact on diagnostic yield of syncope than head CT. The use of a head CT scan as a routine diagnosis tool in patients with syncope is unjustifiable unless there is an indication based on medical history or physical examination.

[Syncopes - differential diagnoses and treatment]. / Synkopen ­ Differenzialdiagnosen und Behandlungsmöglichkeiten.

Syncope is a sudden loss of consciousness (transient loss of consciousness, TLOC) caused by a lack of cerebral perfusion that resolves spontaneously and completely after a short period of time 1. With a lifetime prevalence of 40% and constituting about 1% of all emergency department admissions, syncope is a common and medically relevant problem 2 3. The underlying causes of syncope are diverse and associated with significantly different prognoses. A structured approach is essential to identify high-risk patients and ensure appropriate treatment. This article aims at providing an overview of the current recommendations for the diagnosis and treatment of syncope.

Fatal arrhythmia associated with novel coronavirus 2019 infection: Case report and literature review.

RATIONALE: The novel coronavirus of 2019 (COVID-19) has inflicted significant harm on the cardiovascular system. Patients presenting with fatal chronic arrhythmias after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are rare, arrhythmia caused by SARS-CoV-2 infection need to be taken seriously. PATIENT CONCERNS: Three female patients were admitted to the hospital with syncopal symptoms. Previously, they had been identified to have COVID-19 infection and none of the patients had a preexisting history of arrhythmia, and upon hospital admission, no electrolyte imbalances associated with arrhythmias were observed. However, following SARS-CoV-2 infection, patients exhibit varying degrees of syncope symptoms. DIAGNOSES: A high-degree atrioventricular block was diagnosed after a comprehensive evaluation of the patient's clinical manifestations and electrocardiogram (ECG) performance. INTERVENTIONS: We performed ECG monitoring of the patient and excluded other causes of arrhythmia. The patient was discharged from the hospital after permanent pacemaker implantation and symptomatic treatment. OUTCOMES: The outpatient follow-ups did not reveal a recurrence of syncope or complications related to the pacemaker in any of the three patients. LESSONS: Some patients did not exhibit any obvious respiratory symptoms or signs following SARS-CoV-2 infection. This suggests that the cardiac conduction system may be the preferred target for some SARS-CoV-2 variants. Therefore, in addition to investigating the causes of malignant arrhythmias, special attention should be paid to SARS-CoV-2 infection in patients with developing arrhythmias. Additionally, permanent pacemaker implantation may be the most suitable option for patients who already have malignant arrhythmias.

Incidental and anticipated arrhythmic diagnoses in patients with an implantable cardiac monitor.

AIMS: In this study, we investigated a cohort of unselected patients with various indications for an implantable cardiac monitor (ICM). Our main objectives were to determine the incidence of arrhythmic diagnoses, both anticipated and incidental in relation to the ICM indication, and to assess their clinical relevance. METHODS: We examined remote monitoring transmissions from patients with an ICM at four Italian sites to identify occurrences of cardiac arrhythmias. Concurrently, we collected data on medical actions taken in response to arrhythmic findings. RESULTS: The study included 119 patients, with a median follow-up period of 371 days. ICM indications were syncope/presyncope (46.2%), atrial fibrillation management (31.1%), and cryptogenic stroke (22.7%). In the atrial fibrillation management group, atrial fibrillation was the most common finding, with an incidence of 36% [95% confidence interval (CI) 22-55%] at 18 months. Rates of atrial fibrillation were not significantly different between patients with cryptogenic stroke and syncope/presyncope [17% (95% CI 7-40%) vs. 8% (95% CI 3-19%), P  = 0.229].For patients with cryptogenic stroke, the incidence of asystole and bradyarrhythmias at 18 months was 23% (95% CI 11-45%) and 42% (95% CI 24-65%), respectively, similar to estimates obtained for patients implanted for syncope/presyncope ( P  = 0.277 vs. P  = 0.836).Overall, 30 patients (25.2%) required medical intervention following ICM-detected arrhythmias, predominantly involving atrial fibrillation ablation (10.9%) and medication therapy changes (10.1%). CONCLUSION: In a real-life population with heterogeneous insertion indications, approximately 25% of patients received ICM-guided medical interventions within a short timeframe, including treatments for incidental findings. Common incidental arrhythmic diagnoses were bradyarrhythmias in patients with cryptogenic stroke and atrial fibrillation in patients with unexplained syncope.