Holter monitoring represents a valuable diagnostic tool to document intermittent arrhythmias in the work-up of, for example, syncope, presyncope, collapse, falls, dizziness, stroke, palpitations, and a rapid heartbeat. In addition, it may help in the diagnosis of intermittent ischemia and channelopathies, particularly in the form of 12-lead Holter monitoring. Continuous ECG registration typically lasts from 24-48 h. The use of Holter monitoring is limited in patients with rare symptoms (< 1 × per month) and in recordings full of artifacts. The interpretation of a Holter recording combines an automatic analysis with a manual reassessment. The clinical relevance of many arrhythmias can only be considered together with symptoms and activity of the patient at the time of the event. Therefore, a patient diary accompanying the ECG recording is crucial. Systematic assessment of the ECG recording and knowledge about a number of pitfalls in Holter monitoring can optimize the interpretation of the recording.
UNASSIGNED: Das Langzeit-EKG stellt ein wertvolles Diagnostikum zur Dokumentation intermittierender Arrhythmien in der Abklärung von z. B. Synkopen, Präsynkopen, Kollaps, unklaren Stürzen, Schwindel, Schlaganfallursachen, Palpitationen und Herzrasen dar. Auch in der Diagnostik von Ischämie und Kanalerkrankungen kann es hilfreich sein, v. a. als 12-Kanal-Langzeit-EKG. Die Dauer des kontinuierlich aufzeichnenden Langzeit-EKGs liegt meist zwischen 24 und 48 h. Limitiert ist die Aussagekraft des Langzeit-EKGs bei seltenen Symptomen (< 1-mal pro Monat) und bei artefaktreicher Aufzeichnung. Die Auswertung erfolgt optimalerweise mittels manueller Kontrolle einer automatischen Voranalyse. Die Bedeutung vieler Arrhythmien kann erst im Zusammenhang mit der Symptomatik und vor dem Hintergrund der Aktivität des Patienten eingeschätzt werden, weshalb ein parallel zur EKG-Aufzeichnung geführtes Patiententagebuch essenziell ist. Eine systematische Befundung und die Berücksichtigung zahlreicher Fallstricke optimieren die Interpretation eines Langzeit-EKGs.

暂无摘要。

Consumption of fava beans in a patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency, also called favism, can lead to a haemolytic crisis. We report the case of a 69-year-old patient of Iranian origin admitted to the emergency department following syncope. The patient\'s comprehensive interview and blood analysis revealed that the patient presented a haemolytic crisis triggered by fava beans consumption, due to previously undiagnosed G6PD deficiency. The pathophysiology of favism is complex and clinical presentations of G6PD deficiency are numerous due to multiple genetic variants. Indirect signs, such as the presence of methemoglobinaemia and hemighosts on the blood smear, can aid in the diagnosis. This case highlights the importance of considering G6PD deficiency as a potential diagnosis in case of haemolytic crisis, even in elderly patients.

The objective was to assess if post-exercise ingestion of carbonated water in a hot environment ameliorates hypotension, enhances cerebral blood flow and heat loss responses, and positively modulates perceptions and mood states. Twelve healthy, habitually active young adults (five women) performed 60 min of cycling at 45% peak oxygen uptake in a hot climate (35°C). Subsequently, participants consumed 4°C carbonated or non-carbonated (control) water (150 and 100 mL for males and females regardless of drink type) at 20 and 40 min into post-exercise periods. Mean arterial pressure decreased post-exercise at 20 min only (P = 0.032) compared to the pre-exercise baseline. Both beverages transiently (∼1 min) increased mean arterial pressure and middle cerebral artery mean blood velocity (cerebral blood flow index) regardless of post-exercise periods (all P ≤ 0.015). Notably, carbonated water ingestion led to greater increases in mean arterial pressure (2.3 ± 2.8 mmHg vs. 6.6 ± 4.4 mmHg, P < 0.001) and middle cerebral artery mean blood velocity (1.6 ± 2.5 cm/s vs. 3.8 ± 4.1 cm/s, P = 0.046) at 20 min post-exercise period compared to non-carbonated water ingestion. Both beverages increased mouth exhilaration and reduced sleepiness regardless of post-exercise periods, but these responses were more pronounced with carbonated water ingestion at 40 min post-exercise (mouth exhilaration: 3.1 ± 1.4 vs. 4.7 ± 1.7, P = 0.001; sleepiness: -0.7 ± 0.91 vs. -1.9 ± 1.6, P = 0.014). Heat loss responses and other perceptions were similar between the two conditions throughout (all P ≥ 0.054). We show that carbonated water ingestion temporarily ameliorates hypotension and increases the cerebral blood flow index during the early post-exercise phase in a hot environment, whereas it enhances mouth exhilaration and reduces sleepiness during the late post-exercise phase.

暂无摘要。

Cor triatriatum (CT) or a triatrial heart is a rare congenital anomaly in which one of the atrial chambers is divided by a fibromuscular membrane. Of the two variants, CT dexter (right-sided CT) is still further rare than CT sinister (left-sided CT). Although CT sinister presents with features of left heart obstructive disease mimicking mitral stenosis, CT dexter is usually asymptomatic and is found incidentally on imaging. Here, we present a patient with an unusual case of complete heart block who was found to have CT dexter along with right ventricular noncompaction on imaging.

UNASSIGNED: Guidelines and risk scores have sought to standardize the management of syncope in the emergency department (ED), but variation in practice remains.
UNASSIGNED: The purpose of this study was to explore factors associated with admission for patients presenting to the ED with low-risk syncope.
UNASSIGNED: Our study population included adult patients in the Nationwide Emergency Department Sample between 2006 and 2019 who presented to an ED with a primary diagnosis of syncope. Multivariable hierarchical logistic regression analyses determined the association of patient or hospital factors with admission. Reference effect measures methodology assessed the relative contributions of patient, hospital, and unmeasured hospital factors.
UNASSIGNED: Of the 3,206,739 qualifying encounters during the study period, 804,398 (25.1%) met low-risk criteria. Of these patients, 20,260 were admitted to the hospital (2.5%). Factors associated with increased odds of admission included increasing age and weekend presentation to the hospital, while female sex, lack of medical insurance, hospital region, teaching status, and higher ED volume decile were associated with lower odds of admission. Reference effect measures methodology demonstrated that unmeasured site variability contributed the widest range of odds for admission (odds ratio [OR] 5th percentile vs 95th percentile 0.23-4.38) compared with the composite patient (OR 0.33-3.68) or hospital (OR 0.65-1.30) factors.
UNASSIGNED: Admission patterns for low-risk syncope varies widely across institutions. Unmeasured site variation contributes significantly to the variability in admission rates, suggesting which hospital a patient presents to plays a disproportionate role in admission decisions. Further guidance to reduce practice variation in syncope care in the ED is needed.

BACKGROUND: The aim of our study was to evaluate the prevalence and clinical predictors of vasodepressor (VD) response during head-up tilt test (HUTT) in patients with history of syncope admitted to a tertiary referral syncope unit.
METHODS: We retrospectively evaluated all consecutive patients who underwent HUTT for suspected or established reflex syncope at our institution from March 1st, 2017, to June 1st, 2023. VD response was defined when syncope occurred during hypotension along with no or slight (< 10% bpm) decrease of heart rate. Univariate and multivariate analyses were performed to test the association of VD response to HUTT with a set of clinical covariates.
RESULTS: 1780 patients (40 ± 19.9 years; 49.3% male) were included; among them, 1132 (63 %) showed a positive response to HUTT and 124 (7.0%) had a VD response. The prevalence of VD response showed a peak after 69 years (11.52% vs 6.18%; P = 0.0016), mainly driven by male patients (13.7% vs 4.9%; P < 0.0001). At multivariate analysis, age (OR: 1.15; P = 0.0026) was independently associated to HUTT-induced VD syncope; in contrast, smoking (OR: 0.33: P = 0.0009) and non-classical presentation of syncope (OR: 0.55; P = 0.0029) inversely correlated with VD syncope.
CONCLUSIONS: VD response represents the less frequent responses among those induced by HUTT, accounting up to 7% of overall responses. A gender and age-related distribution has been shown. Advanced age was the only independent predictor of VD syncope; conversely, smoking and non-classical presentation of syncope reduced the probability of VD response to HUTT.

BACKGROUND: Following standard syncope care, after exclusion of cardiac syncope, further workup is generally only recommended in cases of severe syncope due to consequential risk such that syncope is associated with injury or negative impacts on quality of life. This study is aimed to identify incidence and risk factors of severe syncope due to consequential risk, in a cohort of ED patients with non-cardiac syncope.
METHODS: In a sample of 356 cases, we we conducted a case-control study comparing personal data, drug regimen, comorbidities, characteristics of syncope and previous episodes in patients with vs. without a severe syncope.
RESULTS: Patients with severe syncope (120, 31.7% of total) resulted more frequently treated with a polypharmacy and CNS agents and affected by comorbidities entailing risk of falling; they more frequently had syncope occurred in a risky context, unwitnessed (55.8%), not preceded by prodromes (56.6%) and with clinical characteristics different from reflex syncope (82.3%); in these patients, previous episodes more frequently were clustered in the last years and complicated by major injuries. Absence of witnesses and prodromes and ED diagnosis different from reflex syncope resulted to be independently associated with severe syncope due to consequential risk.
CONCLUSIONS: Syncope has a negative impact on a patient\'s life, through injuries or other personal consequences, in roughly one third of cases; to identity these patients, needing further investigation, emergency physicians should focus on episodes not preceded by prodromes, unwitnessed and with characteristic other than reflex syncope. Nonetheless, specific tools are needed to evaluate the impact of syncope on quality of life, to avoid clogging the path after ED discharge.

OBJECTIVE: The study evaluated the positivity rate, hemodynamic responses, and prognosis in terms of syncopal recurrence among patients with situational syncope (SS) stratified according to the underlying situational triggers.
METHODS: We retrospectively evaluated all consecutive patients with SS who underwent nitroglycerin (NTG)-potentiated HUTT at Syncope Unit of the University of Campania \"Luigi Vanvitelli\" - Monaldi Hospital from March 1st, 2017, to May 1st, 2023. All patients were followed for at least one year. The study population was divided according to the underlying triggers (micturition, swallow, defecation, cough/sneeze, post-exercise).
RESULTS: 236 SS patients (mean age 50± 19.3 years; male 63.1%) were enrolled; among them, the situational trigger was micturition in 109 patients (46.2%); swallow in 32 (13.6%) patients; defecation in 35 (14.8%) patients; post-exercise in 41 (17.4%) patients and cough/sneeze in 17 (7.2%) patients. There were no significant differences in baseline clinical characteristics and HUTT responses between different situational triggers. The Kaplan-Meier analysis did not show a statistically different rate of syncope recurrence across patients stratified by baseline situational triggers (log-rank p=0.21).
CONCLUSIONS: SS appears to be a homogenous syndrome and different triggers do not impact the HUTT response or syncope recurrence at 1 year.