Aims Syncope can lead to injuries. We determined the frequency, severity, and predictors of injuries due to syncope in cohorts of syncope patients. Methods and results Participants were enrolled in the POST2 (fludrocortisone) and POST4 (midodrine) vasovagal syncope (VVS) randomized trials, and POST3 enrolled patients with bifascicular block and syncope. Injury was defined as minor (bruising, abrasions), moderate (lacerations), and severe (fractures, burns, joint pain), and recorded up to 1 year after enrolment. A total of 459 patients (median 39 years) were analysed. There were 710 faints occurred in 186 patients during a 1-year follow-up. Fully 56/186 (30%) of patients were injured with syncope (12% of overall group). There were 102 injuries associated with the 710 faints (14%), of which 19% were moderate or severe injuries. Neither patient age, sex, nor the presence of prodromal symptoms associated with injury-free survival. Patients with bifascicular block were more prone to injury (relative risk 1.98, P = 0.018). Patients with ≥4 faints in the prior year had more injuries than those with fewer faints (relative risk 2.97, P < 0.0001), but this was due to more frequent syncope, and not more injuries per faint. In VVS patients, pharmacological therapy significantly reduced the likelihood of an injury due to a syncopal spell (relative risk 0.64, P = 0.015). Injury severity did not associate with age, sex, or prior-year syncope frequency. Conclusion Injuries are frequent in syncope patients, but only 4% of injuries were severe. None of age, sex, and prodromal symptoms associate with injury.
Aims Vasovagal syncope (VVS) is the most common type of syncope and is usually considered a benign disorder. The potential for injury is worrisome but the likelihood is unknown. We aimed to determine the proportion of patients injured due to VVS. Methods and results A systematic search of studies published until August 2020 was performed in multiple medical and nursing databases. Included studies had data on the proportion of patients with injury due to VVS prior to study enrolment. Random effects methods were used. Twenty-three studies having 3593 patients met inclusion criteria. Patients were diagnosed clinically with VVS, and 82% had >2 syncopal episodes before enrolment. Tilt test was positive in 60% and 14 studies reported comorbidities (32.6% hypertensive). The weighted mean injury rate was 33.5% [95% confidence interval (CI): 27.3–40.5%]. The likelihood of injury correlated with population age (r = 0.4, P = 0.05), but not with sex, positive tilt test, or hypertension. The injury rates were 25.7% (95% CI: 19.1–32.8%) in studies with younger patients (mean age ≤50 years, n = 1803) and 43.4% (95% CI: 34.9–52.3%) in studies with older patients (P = 0.002). Nine studies reported major injuries; with a weighted mean rate of major injuries of 13.9% (95% CI: 9.5–19.8%). Conclusion Injuries due to syncope are frequent, occurring in 33% of patients with VVS. The risk of major injuries is substantial. Older patients are at higher risk. Clinicians should be aware of the risk of injuries when providing care and advice to patients with VVS.
Background: Initial orthostatic hypotension (IOH) is defined by a large drop in blood pressure (BP) within 15 s of standing. IOH often presents during an active stand, but not with a passive tilt, suggesting that a muscle activation reflex involving lower body muscles plays an important role. To our knowledge, there is no literature exploring how sympathetic activation affects IOH. We hypothesized involuntary muscle contractions before standing would significantly reduce the drop in BP seen in IOH while increasing sympathetic activity would not. Methods: Study participants performed 4 sit-to-stand maneuvers including a mental stress test (serial 7 mental arithmetic stress test), cold pressor test, electrical stimulation, and no intervention. Continuous heart rate and beat-to-beat BP were measured. Cardiac output and systemic vascular resistance were estimated from these waveforms. Data are presented as mean±SD. Results: A total of 23 female IOH participants (31±8 years) completed the study. The drops in systolic BP following the serial 7 mental arithmetic stress test (−26±12 mm Hg; P =0.004), cold pressor test (−20±15 mm Hg; P <0.001), and electrical stimulation (−28±12 mm Hg; P =0.01) were significantly reduced compared with no intervention (−34±11 mm Hg). The drops in systemic vascular resistance following the serial 7 mental arithmetic stress test (−391±206 dyne×s/cm 5 ; P =0.006) and cold pressor test (−386±179 dyne×s/cm 5 ; P =0.011) were significantly reduced compared with no intervention (−488±173 dyne×s/cm 5 ). Cardiac output was significantly increased upon standing (7±2 L/min) compared with during the sit (6±1 L/min; P <0.001) for electrical stimulation. Conclusion: Sympathetic activation mitigates the BP response in IOH, while involuntary muscle contraction mitigates the BP response and reduces symptoms. Active muscle contractions may induce both of these mechanisms of action in their pretreatment of IOH. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03970551.
RESUMOIntrodução: O teste de esforço cardiopulmonar (TECP) fornece dados que orientam tratamento, prognóstico e tomadas de decisões. Entretanto, seu uso na insuficiência cardíaca de fração de ejeção normal (ICFEN) ainda não está bem esclarecido, em especial considerando novas variáveis que vêm despontando. Objetivos: Comparar o comportamento das principais variáveis diagnósticas e prognósticas do TECP entre dois grupos: pacientes com insuficiência cardíaca de fração de ejeção reduzida (ICFER) e pacientes com ICFEN. Métodos: Foram avaliados 36 pacientes com insuficiência cardíaca em classe funcional II-III da NYAH: 20 com ICFEN e 16 com ICFER do ambulatório de insuficiência cardíaca do Hospital Universitário Antônio Pedro (UFF). Os pacientes do Grupo ICFER selecionados foram os com FE < 35% e os do grupo ICFEN seguiram os critérios diagnósticos da Sociedade Europeia de Cardiologia de 2007. Realizou-se TECP, em esteira com protocolo de rampa, com analisador de gases VO2000. Foram aplicados teste t de Student, Mann-Whitney, teste de Fisher, modelo linear generalizado e de Cochran-Mantel-Haenszel para as análises estatísticas. Resultados: O grupo ICFEN apresentou níveis mais elevados da pressão arterial em repouso, na resposta ao esforço, na potência circulatória e ventilatória, além de um maior tempo de recuperação da cinética do consumo de oxigênio. Não houve diferença em relação a outras variáveis prognósticas do TECP para o grupo ICFER. Conclusões: A pressão arterial de repouso e em esforço, a potência circulatória e ventilatória e a cinética de recuperação do VO 2 (T1/2) foram as variáveis que apresentaram maior valor discriminativo entre os grupos pelo TECP.Palavras-chave: teste de esforço; insuficiência cardíaca, exercício. ABSTRACTIntroduction: The cardiopulmonary exercise testing (CPX) provides data that guide treatment, prognosis and decision making. However its use in heart failure with normal ejection fraction (HFnEF) is still not all clear, especially considering new variables that are emerging. Objective: To compare the behavior of key diagnostic and prognostic variables of CPX testing between two groups; patients with heart with reduced ejection fraction of (HfrEF) and those with HFnEF). Methods: 36 patients with heart failure were evaluated in Nyah functional class II-III: 20 with HFnEF and 16 patients with HFrEF at the Hospital Universitário Antônio Pedro (UFF). The patients from HFrEF group were those with EF<35%, and those from the HFnEF group follow the diagnostic criteria of the European Society of Cardiology 2007. CPX was performed on a treadmill with a ramp protocol, with gas analyzer VO2000. The Student t test, Mann-Whitney test and Fisher, generalized linear model and the Cochran-Mantel-Haenszel test for statistical analysis were applied. Results: The HFnEF group presented higher levels of blood pressure at rest, higher response to exertion, higher circulatory and ventilatory power, and longer recovery kinetics of oxygen uptake. There was no difference in relation to other prognostic variable...
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