Effect of early cryoballoon ablation on atrial fibrillation recurrence-A Danish nationwide register study.

INTRODUCTION: Cryoballoon ablation is a safe and efficient rhythm control strategy in atrial fibrillation (AF) patients. The impact of time from diagnosis to ablation is unclear. The aim of this study was to examine the impact of timing of first-time cryoballoon ablation on AF recurrence in a nationwide cohort of AF patients. METHODS AND RESULTS: From nationwide registers, all AF patients ≥18 years of age who underwent first-time AF cryoballoon ablation in Denmark from 2012 to 2018 were included. The AF patients were stratified by ablation timing: Early group (≤1 year after AF diagnosis), intermediate group (1-3 years after AF diagnosis), and late group (≥3 years after AF diagnosis). By adjusted Cox regression models, the effect of timing on AF recurrence was examined. This study included 1064 AF patients with a median age of 63 years. Most patients were male (66%) and had paroxysmal AF (67%). The 1-year risk of AF recurrence increased from 31% in the early group to 41% and 44% in the intermediate and late group. The hazard ratios (95% confidence intervals) were 1.28 (0.95, 1.74) in the intermediate group and 1.42 (1.09, 1.86) in the late group when compared to the early group. Continuous diagnosis-to-ablation time seemed to have the greatest impact on AF recurrence within the first 2 years. CONCLUSION: In AF patients undergoing cryoballoon ablation, late timing of ablation was associated with a significantly higher AF recurrence rate when compared to early timing of ablation. These findings support early cryoballoon ablation to improve the outcomes after ablation.

Thromboembolic risk in 16 274 atrial fibrillation patients undergoing direct current cardioversion with and without oral anticoagulant therapy.

AIMS: To study the risk of thromboembolism in a nationwide cohort of atrial fibrillation patients undergoing direct current (DC) cardioversion with or without oral anticoagulant coverage. METHODS AND RESULTS: A retrospective study of 16 274 patients in Denmark discharged from hospital after a first-time DC cardioversion for atrial fibrillation between 2000 and 2008. Use of oral anticoagulant therapy within 90 days prior and 360 days after DC cardioversion was obtained from the Danish Register of Medicinal Product Statistics. The risk of thromboembolism was estimated by calculating incidence rates and by multivariable adjusted Cox proportional-hazard models. During the initial 30 days following discharge, the thromboembolic incidence rate was 10.33 per 100 patient-years for the no prior oral anticoagulant therapy group [n = 5084 (31.2%)], as compared with 4.00 per 100 patient-years for the prior oral anticoagulant therapy group [n = 11 190 (68.8%)], [hazard ratio associated with no prior oral anticoagulant therapy was 2.25; 95% confidence interval (CI), 1.43-3.53]. Thromboembolic risk stratification by the CHADS2 and CHA2DS2-VASc scores did not change the results. Hazard ratio with no oral anticoagulant therapy was 2.21; 95% CI, 0.79-6.77 and 2.40; 95% CI, 1.46-3.95 with CHA2DS2-VASc score 0-1 and CHA2DS2-VASc score 2 or more, respectively. CONCLUSION: Direct current cardioversion for atrial fibrillation without oral anticoagulation is associated with a high risk of thromboembolism. Notably, the risk is high in the initial period after cardioversion, indicating a hazardous association between DC cardioversion without anticoagulation and thromboembolism.

Automated external defibrillators inaccessible to more than half of nearby cardiac arrests in public locations during evening, nighttime, and weekends.

BACKGROUND: Despite wide dissemination, use of automated external defibrillators (AEDs) in community settings is limited. We assessed how AED accessibility affected coverage of cardiac arrests in public locations. METHODS AND RESULTS: We identified cardiac arrests in public locations (1994-2011) in terms of location and time and viewed them in relation to the location and accessibility of all AEDs linked to the emergency dispatch center as of December 31, 2011, in Copenhagen, Denmark. AED coverage of cardiac arrests was defined as cardiac arrests within 100 m (109.4 yd) of an AED and further categorized according to AED accessibility at the time of cardiac arrest. Daytime, evening, and nighttime were defined as 8 am to 3:59 pm, 4 to 11:59 pm, and midnight to 7:59 am, respectively. Of 1864 cardiac arrests in public locations, 61.8% (n=1152) occurred during the evening, nighttime, or weekends. Of 552 registered AEDs, 9.1% (n=50) were accessible at all hours, and 96.4% (n=532) were accessible during the daytime on all weekdays. Regardless of AED accessibility, 28.8% (537 of 1864) of all cardiac arrests were covered by an AED. Limited AED accessibility decreased coverage of cardiac arrests by 4.1% (9 of 217) during the daytime on weekdays and by 53.4% (171 of 320) during the evening, nighttime, and weekends. CONCLUSIONS: Limited AED accessibility at the time of cardiac arrest decreased AED coverage by 53.4% during the evening, nighttime, and weekends, which is when 61.8% of all cardiac arrests in public locations occurred. Thus, not only strategic placement but also uninterrupted AED accessibility warrant attention if public-access defibrillation is to improve survival after out-of-hospital cardiac arrest.

Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study.

BACKGROUND: Uncertainty remains over optimal antithrombotic treatment of patients with atrial fibrillation presenting with myocardial infarction and/or undergoing percutaneous coronary intervention. We investigated the risk and time frame for bleeding following myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation according to antithrombotic treatment. METHODS AND RESULTS: Patients with atrial fibrillation and admitted with myocardial infarction or for percutaneous coronary intervention between 2000 and 2009 (11 480 subjects, mean age 75.6 years [SD ±10.3], males 60.9%) were identified by individual level linkage of nationwide registries in Denmark. Fatal or nonfatal (requiring hospitalization) bleeding was determined according to antithrombotic treatment regimen: triple therapy (TT) with vitamin K antagonist (VKA)+aspirin+clopidogrel, VKA+antiplatelet, and dual antiplatelet therapy with aspirin+clopidogrel. We calculated crude incidence rates and adjusted hazard ratios by Cox regression models. Within 1 year, 728 bleeding events were recorded (6.3%); 79 were fatal (0.7%). Within 30 days, rates were 22.6, 20.3, and 14.3 bleeding events per 100 person-years for TT, VKA+antiplatelet, and dual antiplatelet therapy, respectively. Both early (within 90 days) and delayed (90-360 days) bleeding risk with TT exposure in relation to VKA+antiplatelet was increased; hazard ratio 1.47 (1.04;2.08) and 1.36 (0.95;1.95), respectively. No significant difference in thromboembolic risk was observed for TT versus VKA+antiplatelet; hazard ratio, 1.15 (0.95;1.40). CONCLUSIONS: High risk of bleeding is immediately evident with TT after myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation. A continually elevated risk associated with TT indicates no safe therapeutic window, and TT should only be prescribed after thorough bleeding risk assessment of patients.

Serial measurements of high-sensitivity cardiac troponin T after exercise stress test in stable coronary artery disease.

OBJECTIVE: The aim was to assess serial measurements of high-sensitivity cardiac troponin T (hs-cTNT) post-exercise in patients with stable coronary artery disease (CAD). METHODS: Twelve patients with positive coronary angiograms (CAD positives) and 12 controls performed an exercise stress test. RESULTS: CAD positive had higher baseline and peak concentrations of hs-cTNT than controls. Significant increases in hs-cTNT were seen in both groups after exercise. In two-third of patients the peak in hs-cTNT was above the 99th percentile. CONCLUSION: hs-cTNT is higher in patients with stable coronary disease than in controls and exceeds the diagnostic cut-off value for myocardial infarction in a majority of patients with CAD after exercise.

Accuracy of the ICD-10 discharge diagnosis for syncope.

AIMS: Administrative discharge codes are widely used in epidemiology, but the specificity and sensitivity of this coding is unknown and must be validated. We assessed the validity of the discharge diagnosis of syncope in administrative registers and reviewed the etiology of syncope after workup. METHODS AND RESULTS: Two samples were investigated. One sample consisted of 5262 randomly selected medical patients. The other sample consisted of 750 patients admitted or seen in the emergency department (ED) for syncope (ICD-10: R55.9) in three hospitals in Denmark. All charts were reviewed for baseline characteristics and to confirm the presence/absence of syncope and to compare with the administrative coding. In a sample of 600 admitted patients 570 (95%) and of 150 patients from ED 140 (93%) had syncope representing the positive predictive values. Median age of the population was 69 years (IQR: ± 14). In the second sample of 5262 randomly selected medical patients, 75 (1.4%) had syncope, of which 47 were coded as R55.9 yielding a sensitivity of 62.7%, a negative predictive value of 99.5%, and a specificity of 99.9%. CONCLUSION: ED and hospital discharge diagnostic coding for syncope has a positive predictive value of 95% and a sensitivity of 63%.

Association Between Pulmonary Vascular Volume and Cardiac Structure and Function in Patients With Atrial Fibrillation.

Pulmonary vascular abnormalities, quantified from computed tomography scans, have frequently been observed in patients with pulmonary diseases. However, little is known about pulmonary vascular changes in patients with cardiac disease. Thus, we aimed to examine the cardiopulmonary relation in patients with atrial fibrillation (AF) by comparing pulmonary vascular volume (PVV) to echocardiographic measures and AF severity. A total of 742 patients (median age 63 years, 70% men) who underwent ablation for AF were included. Preprocedural cardiac computed tomography was used to measure the total and small-vessel PVV, along with the pulmonary artery to aorta ratio and the degree of emphysema. The association between PVV and echocardiographic parameters was evaluated using a multivariable linear regression analysis. Lower total and small-vessel PVV were associated with more impaired measures of cardiac structure and function, including but not limited to left ventricular ejection fraction and peak atrial longitudinal strain. Patients with reduced total and small-vessel PVV had higher odds of having persistent AF than paroxysmal AF in the unadjusted logistic regression analyses. However, after clinical and echocardiographic adjustments, only reduced small-vessel PVV remained independently associated with persistent AF (odds ratio 1.90, 95% confidence interval 1.26 to 2.87, p = 0.002). In conclusion, pulmonary vascular remodeling is associated with persistent AF and with more impaired measures of cardiac structure and function, providing further insights into heart-lung interactions in this patient group.

The relation between age, sex, comorbidity, and pharmacotherapy and the risk of syncope: a Danish nationwide study.

AIMS: Syncope is a common cause for hospitalization and may be related to comorbidity and concurrent medication. The objective of this study was to determine the incidence, comorbidity, and pharmacotherapy in a nationwide cohort of patients hospitalized with syncope. METHODS AND RESULTS: An observational study including patients with the diagnosis of syncope identified from the Danish National Patient Register in the period 1997-2009. All patients were matched on sex and age with five controls from the Danish population. We estimated the incidence of syncope and the association with comorbidities and pharmacotherapy by conditional logistic regression analyses. We identified 127 508 patients with a first-time diagnosis of syncope [median age 65 years (interquartile range 49-81), 52.6% female]. The age distribution of the patients showed three peaks around 20, 60, and 80 years of age with the third peak occurring 5-7 years earlier in males. Cardiovascular disease and cardiovascular drug therapy was present in 28 and 48% of the patients, respectively. We found significant association between cardiovascular disease and the risk of admission for syncope increasing with younger age; age 0-29 years [odds ratio (OR) = 5.8, confidence interval (CI): 5.2-6.4), age 30-49 (OR = 4.4, CI: 4.2-4.6), age 50-79 (OR = 2.9, CI: 2.8-3.0), and age above 80 (OR = 2.0, CI: 1.9-2.0). Cardiovascular pharmacotherapy associated with age and risk of syncope was similar. CONCLUSION: In a nationwide cohort of patients hospitalized for first syncope we found significant association between cardiovascular comorbidity and pharmacotherapy and the risk of syncope. The occurrence of syncope displayed an age distribution with important gender-specific differences and higher incidence rates than previously reported.

Left atrial contractile strain predicts recurrence of atrial tachyarrhythmia after catheter ablation.

BACKGROUND: Despite improvement in treatment strategies of atrial fibrillation (AF), a considerable number of patients still experience recurrence of atrial tachyarrhythmia (ATA) following catheter ablation (CA). This study aimed to investigate the prognostic value of left atrial (LA) deformation analysis in a large group of patients undergoing CA for AF. METHODS: This study included 678 patients with AF. Echocardiography including two-dimensional speckle tracking echocardiography (2DSTE) was performed in all patients prior to CA. Logistic regression analysis was used to assess the association between ATA recurrence and LA strain during reservoir phase (LASr), LA strain during contraction phase (LASct), and LA strain during conduit phase (LAScd). RESULTS: During one-year follow-up, 274 (40%) experienced ATA recurrence. Median age of the included study population was 63.2 years (IQR: 55.5, 69.5) and 485 (72%) were male. Patients with recurrence had lower LASr (22.6% vs. 25.1%, p = 0.001) and LASct (10.7% vs. 12.4%, p < 0.001). No difference in LAScd was observed. After adjusting for potential clinical and echocardiographic confounders LASr (OR = 1.04, CI95% [1.01; 1.07], p = 0.015, per 1% decrease) and LASct (OR = 1.06, CI95% [1.02; 1.11], p = 0.007, per 1% decrease) remained independent predictors of recurrence. However, in patients with a normal-sized LA (LA volume index<34 mL/m2), only LASct remained an independent predictor of recurrence (OR = 1.07, CI95% [1.01; 1.12], p = 0.012, per 1% decrease). CONCLUSION: In patients undergoing CA for AF, LA deformation analysis by 2DSTE could be of use in risk stratification in clinical practice regarding ATA recurrence, even in patients with a normal-sized LA.

NT-ProBNP independently predicts long-term mortality in patients admitted for coronary angiography.

Recently, research interests are focussed on biomarkers to predict the outcome in patients with coronary artery disease (CAD). We examined whether the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) could predict outcome in patients who underwent elective or acute coronary angiography (CAG). A total of 337 patients with suspected CAD who underwent elective or acute CAG were followed up for a mean period of 6.7 years. Primary end points were all-cause mortality (ACM) and the combined end point of ACM, nonfatal myocardial infarction, and revascularization. In all, 53 (16%) patients died and 88 (26%) patients reached the combined end point. Preprocedural NT-proBNP above 32 pmol/L independently predicted ACM (hazard ratio [HR] 3.11; confidence interval [CI]: 1.60-6.07; P = .001) and the combined end point (HR 2.44 [CI: 1.50-3.97]; P < .001). This study indicates that high NT-proBNP is an independent predictor of ACM on long-term follow-up. N-terminal-proBNP is a reliable predictive marker of mortality in the setting of stable or unstable angina.

Epidemiological studies on syncope.

The epidemiology and prognosis of ''fainting'' or syncope has puzzled physicians over the years. Is fainting dangerous? This is a question often asked by the patient--and the answer is ''it depends on a lot of things''. The diverse pathophysiology of syncope and the underlying comorbidites of the patients play an essential role. In epidemiology these factors have major impact on the outcome of the patients. Until recently, even the definition of syncope differed from one study to another which has made literature reviews difficult. Traditionally the data on epidemiology of syncope has been taken from smaller studies from different clinical settings with wide differences in patient morbidity. Through the extensive Danish registries we examined the characteristics and prognosis of the patients hospitalized due to syncope in a nationwide study. The aims of the present thesis were to investigate: 1) the use, validity and accuracy of the ICD-10 diagnosis of syncope R55.9 in the National Patient Registry for the use of this diagnosis in the epidemiology of syncope, 2) diagnostics used and etiology of a random selection of patients who had a discharge diagnosis of R55.9, 3) the incidence, prevalence and cardiovascular factors associated with the risk of syncope, 4) the prognosis in healthy individuals discharged after syncope, and 5) the prognosis of patients after syncope and evaluation of the CHADS2 score as a tool for short- and long-term risk prediction. The first studies of the present thesis demonstrated that the ICD-10 discharge diagnosis could reliably identify a cohort of patients admitted for syncope and that the discharge code carried a high number of unexplained cases despite use of numerous tests. The last studies showed that syncope is a common cause for hospital contact in Denmark and that the risk of syncope is tightly associated with cardiovascular co-morbidities and use of pharmacotherapy. Furthermore in patients with no co-morbidities (or healthy individuals), syncope is a significant and independent prognostic factor of adverse cardiovascular outcome and death compared to the background population. Lastly, evaluation of the CHADS2 score, as a tool for risk stratification, showed that it provided additional prognostic information on short- and long-term cardiovascular mortality in syncope patients compared to controls.

Epidemiological studies on syncope--a register based approach.

The epidemiology and prognosis of 'fainting' or syncope has puzzled physicians over the years. Is fainting dangerous? This is a question often asked by the patient--and the answer is 'it depends on a lot of things'. The diverse pathophysiology of syncope and the underlying comorbidites of the patients play an essential role. In epidemiology these factors have major impact on the outcome of the patients. Until recently, even the definition of syncope, differed from one study to another which has made literature reviews difficult. Traditionally the data on epidemiology of syncope has been taken from smaller studies from different clinical settings with wide differences in patient morbidity. Through the extensive Danish registries we examined the characteristics and prognosis of the patients hospitalized due to syncope in a nationwide study. The aims of the present thesis were to investigate: 1) the use, validity and accuracy of the ICD-10 diagnosis of syncope R55.9 in the National Patient Registry for the use of this diagnosis in the epidemiology of syncope, 2) diagnostics used and etiology of a random selection of patients who had a discharge diagnosis of R55.9, 3) the incidence, prevalence and cardiovascular factors associated with the risk of syncope, 4) the prognosis in healthy individuals discharged after syncope, and 5) the prognosis of patients after syncope and evaluation of the CHADS2 score as a tool for short and long-term risk prediction. The first studies of the present thesis demonstrated that the ICD-10 discharge diagnosis could reliably identify a cohort of patients admitted for syncope and that the discharge code carried a high number of unexplained cases despite use of numerous tests. The last studies showed that syncope is a common cause for hospital contact in Denmark and that the risk of syncope is tightly associated with cardiovascular comorbidities and use of pharmacotherapy. Furthermore in patients with no comorbidities (or healthy individuals), syncope is a significant and independent prognostic factor of adverse cardiovascular outcome and death compared to the background population. Lastly evaluation of the CHADS2 score, as a tool for risk stratification, showed that it provided additional prognostic information on short and long-term cardiovascular mortality in syncope patients compared to controls.

Prognosis among healthy individuals discharged with a primary diagnosis of syncope.

OBJECTIVES: This study sought to examine the risk of major cardiac adverse events and death in a nationwide cohort of patients without previous comorbidity admitted for syncope. BACKGROUND: Syncope is a common clinical event, but knowledge of prognosis is not fully elucidated in healthy individuals. METHODS: Patients without previous comorbidity admitted for syncope in Denmark from 2001 to 2009 were identified in nationwide administrative registries and matched by sex and age with 5 control subjects from the Danish population. The risk of death or recurrent syncope, implantation of pacemaker or implantable cardioverter-defibrillator, and cardiovascular hospitalization were analyzed with multivariable Cox proportional hazard models. RESULTS: We identified 37,017 patients with a first-time diagnosis of syncope and 185,085 control subjects; their median age was 47 years (interquartile range, 32 to 63 years) and 47% were male. A total of 3,023 (8.2%) and 14,251 (7.1%) deaths occurred in the syncope and the control population, respectively, yielding an event rate of 14.3 per 1,000 person-years (PY) in the syncope population. Multivariable Cox regression analysis demonstrated a significantly increased risk of all-cause mortality (hazard ratio [HR]: 1.06; 95% confidence interval [CI]: 1.02 to 1.10), cardiovascular hospitalization event rate of 26.5 per 1,000 PY (HR: 1.74; 95% CI: 1.68 to 1.80), recurrent syncope event rate of 45.1 per 1,000, stroke event rate of 6.8 per 1,000 PY (HR: 1.35; 95% CI: 1.27 to 1.44), and pacemaker or implantable cardioverter-defibrillator event rate of 4.2 per 1,000 PY (HR: 5.52; 95% CI: 4.67 to 5.73; p < 0.0001). CONCLUSIONS: The first admission for syncope among healthy individuals significantly predicts the risk of all-cause mortality, stroke, cardiovascular hospitalization, device implantation, and recurrent syncope.

Unexplained Syncope and Diagnostic Yield of Tests in Syncope According to the ICD-10 Discharge Diagnosis.

BACKGROUND: The etiology of syncope according to the discharge diagnosis from hospital admissions has not been examined before. Therefore the aims of this study were to examine the diagnostic yield of tests and frequency of unexplained cases during admission and after workup after an ICD-10 diagnosis of syncope. METHODS: A retrospective chart review of 600 patients discharged with the primary ICD-10 discharge diagnosis of syncope R55.9 was performed. Causes and clinical characteristics of syncope according to the physician were noted both after initial discharge and after workup. RESULTS: During a mean follow-up period of 2.5 years (SD: ± 1.30) several diagnostic tests were used (mean number of tests per patient was 4.7 (SD: ± -2.0)) and the mean length of admission was 2.1 days (± 1.5).The final diagnosis after workup was reflex syncope in 21%, cardiac 18%, orthostatic hypotension 10%, other causes 4% and unknown/unexplained syncope in 48% with wide age differences. The diagnostic yield of tests was generally low and differed widely depending on usage during admission or usage during subsequent workup. CONCLUSIONS: The underlying etiology of syncope remains difficult to establish despite the high use of diagnostic tests and the diagnostic yield of many tests implemented in the care path is generally low.

Evaluation of the CHADS2 risk score on short- and long-term all-cause and cardiovascular mortality after syncope.

BACKGROUND: Syncope risk stratification is difficult and has not been implemented clinically. HYPOTHESIS: The CHADS2 score can be applied as a risk stratification tool for predicting mortality after an episode of syncope. METHODS: All patients discharged from emergency departments with a first-time diagnosis of syncope from 2001 to 2009 where identified from nationwide registers in Denmark and matched on sex and age with a control population. Risk of all-cause or cardiovascular death was analyzed by multivariable Cox models. RESULTS: A total of 37,705 patients were included. There were a total of 7761 deaths (21%), of which 52% were cardiovascular vs 27 862 (15%) deaths in the control population. The risk of cardiovascular death was significantly increased with increasing CHADS2 score (CHADS2 score: 1-2, hazard ratio [HR]: 9.11, 95% confidence interval [CI]: 8.25-10.07; CHADS2 score: 3-4, HR: 17.32, 95% CI: 15.42-19.47; CHADS2 score: 5-6, HR: 26.66, 95% CI: 21.40-33.21) relative to CHADS2 score of 0. A CHADS2 score of 0 was associated overall with very low event rates (15.1 deaths per 1000 person-years) but was associated with increased relative risk in the syncope population compared to controls. Syncope predicted 1-week, 1-year, and long-term mortality across CHADS2 scores compared to controls but did not reach significance in CHADS2 scores of 5 to 6. CONCLUSIONS: Increasing CHADS2 score significantly predicts mortality in patients discharged with a diagnosis of syncope, and a CHADS2 score of 0 was associated with a very low absolute mortality. Compared to controls, syncope was associated with increased short- and long-term mortality, particularly in the lower CHADS2 scores.

Comparison of incidence, predictors, and the impact of co-morbidity and polypharmacy on the risk of recurrent syncope in patients <85 versus ≥85 years of age.

Recurrent syncope is a major cause of hospitalizations and may be associated with cardiovascular co-morbidities. Despite this, prognostic factors and the clinical characteristics among patients are not well described. Therefore, we identified and analyzed data on all patients >50 years of age discharged after a first-time episode of syncope in the period 2001 to 2009 through nationwide administrative registries. We identified the clinical characteristics of 5,141 patients ≥85 years of age and 23,454 patients <85 years of age. Multivariate Cox models were used to assess prognostic factors associated with the end point of recurrent syncope according to age. We found that those with syncope and ≥85 years were more often women (65% vs 47%) and generally had a greater prevalence of noncardiovascular co-morbidities, whereas the prevalence of cardiovascular co-morbidities was more heterogeneously distributed across age groups. Overall, significant baseline predictors of recurrent syncope were aortic valve stenosis (hazard ratio [HR] 1.48, 95% confidence interval [CI] 1.31 to 1.68), impaired renal function (HR 1.34, 95% CI 1.15 to 1.58), atrioventricular or left bundle branch block (HR 1.32, 95% CI 1.16 to 1.51), male gender (HR 1.18, 95% CI 1.12 to 1.24), chronic obstructive pulmonary disorder (HR 1.10, 95% CI 1.02 to 1.19), heart failure (HR 1.10, 95% CI 1.02 to 1.21), atrial fibrillation (HR = 1.09, 95% CI 1.01 to 1.19), age per 5-year increment (HR 1.09, 95% CI 1.07 to 1.10), and orthostatic medications per increase (HR 1.06, 95% CI 1.03 to 1.09). Atrial fibrillation and impaired renal function both exhibited less prognostic importance for recurrent syncope in the elderly compared with younger population (p for interactions <0.01). In conclusion, predictive factors of recurrent syncope were closely associated with increased cardiovascular risk profile age and gender. The use of multiple orthostatic medications additively increased the risk of recurrences representing a need for strategies to reduce unnecessary polypharmacy.

[Cardiac tamponade and purulent pericarditis caused by Streptococcus pneumoniae]. / Hjertetamponade og purulent perikarditis forårsaget af Streptococcus pneumoniae.

Purulent pericarditis is a rare entity in the modern antibiotic era. Despite advances in treatment and diagnostics, purulent pericarditis remains a life-threatening disease. We present a case with cardiac tamponade due to purulent pericarditis caused by Streptococcus pneumoniae. A 67 year-old woman was admitted with massive pericardial fluid. The patient was treated successfully with drainage and intravenous penicillin. Due to the high mortality of this disease, early diagnosis, aggressive pericardial drainage and appropriate antibiotic therapy are essential.

[Methylphenidate induced ST elevation acute myocardial infarction]. / Methylphenidatinduceret ST-elevations-myokardieinfarkt.

Adult attention deficit and hyperkinetic disorder (ADHD) is increasingly diagnosed and treated with methylphenidate. We present the case of an 20 year-old man, who was diagnosed with ADHD and suffered a ST elevation acute myocardial infarction due to coronary vasospasm related to an overdose, and subsequent episodes of myocardial injury due to the use and misuse of methylphenidate over a period of two years. We recommend an increased attention to the subscription of methylphenidate to patients, who are at risk of misuse and patients, who have a cardiovascular history.