Arrhythmic Syncope Research Articles

A Clinical Approach to a Family History of Sudden Death

Sir William Osler reportedly once said, “Varicose veins are the result of an improper selection of grandparents.” Indeed, our family history strongly influences many aspects of our cardiovascular system, with the magnitude of effect ranging from very strong for autosomal dominant genetic disorders to more subtle in the setting of complex multigenic diseases like coronary atherosclerosis and hypertension. Accordingly, the standard evaluation of any new patient who presents to a physician includes assessment of their family history. Unfortunately, the family history may sometimes be discounted as noncontributory without detailed review. This can be exacerbated by busy office schedules with declining amounts of time available for comprehensive evaluations. A few minutes saved might seem to justify the lack of focus on an aspect of history that is sometimes deemed not to be particularly useful. However, a thorough assessment of family history also may provide the key diagnostic information to determine the cause of an illness, to determine who else is at risk of disease within the family, to add useful prognostic information, and to help for family planning and reproductive decisions. A family history of sudden death should prompt consideration of a wide range of heritable cardiovascular conditions, including many monogenic disorders (Table). However, the terms used by the lay public to describe sudden death may not adequately explain the cause of death on initial consideration. For instance, the phrase “heart attack” may be used to describe sudden death of any etiology. Further questioning may help one to discern whether there was a history of heart failure, cardiomyopathy, coronary artery disease (or its risk factors), aortic aneurysm, or features of syndromic disorders that are associated with sudden death. View this table: Table. Monogenic Disorders Associated With Sudden Death A 40-year-old man presents to a physician for evaluation of palpitations. These occur briefly about once per …

Outcome of patients with syncope beyond the implantable loop recorder

The implantation of an implantable loop recorder (ILR) leads to the diagnosis in about 35% of patients with syncope of unknown origin. Information on outcome of patients in whom a diagnosis is not reached during the lifetime of the device is scarce. The aim of our study is to determine the outcome of these patients in terms of syncope recurrence and survival. An ILR was implanted to 97 patients with syncope of unknown origin. Patients were classified in groups A and B depending on their high or low risk, respectively, of having arrhythmic syncope. Diagnosis had not been reached in 60 patients (62%) when the ILR battery reached end operational life. Five patients were lost to follow up. During a median follow-up of 48 months after ILR explantation (interquartile range 36-56), 22 patients (40%) had recurrence of syncope (32% in group A vs. 48% in group B, P = 0.3). Syncopes with no neurally mediated profile were more frequent in group A (18 vs. 0%, P = 0.05) and neurally mediated profile syncopes were more frequent in group B (44 vs. 11%, P = 0.007). Five patients died, four of them in group A and 1 in group B (P = 0.4). No sudden or cardiac deaths were detected during follow-up. All deaths were due to non-cardiac causes. Recurrent syncope is common in patients in whom a diagnosis is not established after the full battery life of an ILR. The prognosis of these patients seems to be good, without observed sudden or cardiac death.

Long-term efficacy of low doses of quinidine on malignant arrhythmias in Brugada syndrome with an implantable cardioverter-defibrillator: A case series and literature review

To prevent the recurrence of ventricular arrhythmias (VA) in Brugada syndrome (BrS), only quinidine has been consistently reported to have a beneficial effect. Recommended doses are ≥ 1 g/d. The efficacy of lower doses of quinidine has been suggested on the basis of a few isolated experiences. To describe the efficacy and safety of doses ≤ 600 mg/d of quinidine after cardioverter-defibrillator implantation in BrS at 2 referral centers and to compare those results with a comprehensive review of the literature. In a retrospective analysis of medical records from the 2 centers, 6 men with BrS who received ≤ 600 mg/d of quinidine sulfate or hydroquinidine after cardioverter-defibrillator implantation were identified. Quinidine was initiated after arrhythmic syncope or appropriate shocks, including arrhythmic storm in 4. A literature search was performed to find previous cases with symptomatic BrS reported as having received ≤ 600 mg/d of quinidine. Quinidine prevented recurrence of VA in all patients from our series without side effects during a median follow-up of 4 years (from 2 to 8 years). In the literature review, 14 additional adults were found. With the exception of 3, quinidine effectively suppressed arrhythmic events in all of them. Four subjects who discontinued the medication experienced VA recurrence, successfully treated by restarting quinidine. Low doses of quinidine were well tolerated and effective to prevent the recurrence of VA, including arrhythmic storm, in subjects with BrS with an implantable cardioverter-defibrillator. Effectiveness of quinidine or hydroquinidine in doses ≤ 600 mg/d is 85%.

Surgical resection of primary cardiac lymphoma presenting as a huge mass: report of two cases

Primary cardiac lymphoma (PCL) is a rare malignancy that is sometimes diagnosed at later stages because it is not associated with specific symptoms. Although chemotherapy is the standard for treating PCL, the value of surgical resection is controversial. We describe two patients who were treated by surgical resection and chemotherapy. Case 1 is a 37-year-old man with a history of acute lymphocytic leukemia and shortness of breath, and Case 2 is a 70-year-old woman with general fatigue. Both of them were presented at hospital. In Case 2, arrhythmic syncope occurred and direct current cardioversion was performed. Echocardiography showed a massive tumor in the right atrium and disturbed hemodynamics in both cases. The restricted venous return was alleviated by emergency surgery. The pathology report indicated primary cardiac lymphoma that was regressed by post-operative chemotherapy. A massive PCL should be surgically resected to prevent sudden death.

Syncope in Brugada syndrome patients: Prevalence, characteristics, and outcome

The report from the 2nd Consensus Committee on BrS suggests that all patients with syncope without a "clear extracardiac cause" should have an implantable cardioverter-defibrillator (ICD). However, a clear extracardiac cause for syncope may be difficult to prove. The purpose of this study was to characterize syncope in patients with Brugada syndrome (BrS). All patients diagnosed with BrS at our institution between 1999 and 2010 were enrolled in a prospective registry. Patients with suspected arrhythmic syncope (group 1) were compared to patients with nonarrhythmic syncope (group 2) and to patients with syncope of doubtful origin (group 3). Of 203 patients with BrS, 57 (28%; 44 male, age 46 ± 12 years) experienced at least 1 syncope. Group 1 consisted of 23 patients, all of whom received an ICD. In group 2 (17 patients), 3 received an ICD because of a positive electrophysiologic study. In group 3 (17 patients), 6 received an implantable loop recorder and 6 received an ICD. After mean follow-up of 65 ± 42 months, 14 patients in group 1 remained asymptomatic, 4 had recurrent syncope, and 6 had appropriate ICD therapy. In group 2, 9 patients remained asymptomatic and 7 had recurrent neurocardiogenic syncope. In group 3, 7 remained asymptomatic and 9 had recurrent syncope. One patient from each group died from a noncardiac cause. In the present study, syncope occurred in 28% of patients with BrS. The ventricular arrhythmia rate was 5.5% per year in group 1. In 30%, the etiology of the syncope was questionable. No sudden cardiac death occurred in groups 2 and 3.

Syncope: a rare manifestation of a common condition

A previously active, fi t, well 71-year-old man, presented to our cardiology department in January, 2011, with a recent history of syncope. This occurred suddenly on two separate occasions, with rapid recovery after a few seconds, but resulting in injury. There were no associated symptoms. Both events occurred after non-strenuous exertion, with one or two further episodes of pre-syncope while at rest. A working diagnosis of arrhythmic cardiogenic syncope was made. He had no exertional symptoms or additional risk factors for coronary disease. He took no medications. ECG corrected QT interval, echocardiography, and tilt table test were normal. A 24 h ambulatory ECG showed normal rhythm. Exercise treadmill testing was stopped at 7 min because of fatigue. There were no ECG changes and the target heart rate (220 minus age beats per min) was achieved. Nuclear myocardial perfusion scanning did not show any evidence of myocardial ischaemia. Since the most likely diagnosis was syncope caused by cardiac arrhythmia, arrangements were made for an implantable cardiac loop recording device (ILR) (Reveal, Medtronic, Minneapolis, USA). 1 month later our patient was urgently admitted to the cardiology department after experiencing an episode of pre-syncope. Interrogation of the loop recorder data (fi gure A) showed non sustained ventricular fi brillation preceded by ST segment depression. This fi nding raised the possibility of silent ischaemia triggering arrhythmia. Urgent coronary angiography showed clinically signifi cant stenosis in the left anterior descending (LAD) artery (fi gure B; see also appendix), and inpatient surgical revascularisation with a single vein graft to the LAD was undertaken without complication. 8 months after surgery the patient was well, taking aspirin, a β-blocker, and a

Implantable loop recorders are cost-effective when used to investigate transient loss of consciousness which is either suspected to be arrhythmic or remains unexplained

To assess the cost-effectiveness of implantable loop recorders (ILRs) in people with transient loss of consciousness (TLoC), which, after initial assessment and specialist cardiovascular assessment, is either suspected to be arrhythmic in origin or remains unexplained. This analysis was conducted to inform clinical guideline recommendations made by the National Institute for Health and Clinical Excellence (NICE) on the management of TLoC. Decision analytic modelling was used to estimate the costs and benefits of using ILRs compared with a strategy of no further diagnostic testing. Diagnostic outcomes were estimated from a systematic review and used to populate a decision tree model. To capture the main consequences of diagnosis, the costs and benefits of treatment for several clinically significant arrhythmias were estimated within the model. We used a cost-utility approach, in which benefits are measured using quality adjusted life years (QALYs), and took a UK National Health Service (NHS) and personal social services perspective. The cost per QALY was £17,400 in patients with unexplained syncope and £16,400 in patients with suspected arrhythmic syncope. Sensitivity analysis found that the cost-effectiveness estimates are fairly robust despite the areas of uncertainty identified in the evidence and assumptions used to inform the model. Implantable loop recorder monitoring is likely to be a cost-effective strategy in people presenting to the UK NHS who are experiencing infrequent episodes of TLoC which either remain unexplained or are suspected to be arrhythmic after initial assessment and specialist cardiovascular assessment. Implantable loop recorder monitoring has been recommended by NICE for these populations.

Time course of B-type natriuretic peptides changes after ventricular fibrillation in humans: Relationship with cardiac syncope

Increased levels of plasma brain natriuretic peptides (BNP and NT-proBNP) have been observed in humans during arrhythmias but the time course and causality of such relationship have never been documented. Ventricular fibrillation induced in the cardiac electrophysiology laboratory to test implantable cardioverter defibrillator (ICD) functioning, furnish a unique clinical model mimicking the hemodynamic changes occurring in daily life during an arrhythmic syncope.

Rationale and design for programming implantable cardioverter-defibrillators in patients with primary prevention indication to prolong time to first shock (PROVIDE) study

Shock therapy delivery by implantable cardioverter-defibrillators (ICD) can be painful and may have negative psychological consequences. Reducing shock burden for patients with ICDs and cardiac resynchronization therapy defibrillators (CRT-Ds) may have beneficial consequences. This may be achieved by avoiding inappropriate shocks for supraventricular tachycardia (SVT) and by limiting appropriate shocks to only those that are necessary to convert ventricular arrhythmias. The programming implantable cardioverter-defibrillators in patients with primary prevention indication to prolong time to first shock study (PROVIDE) is a prospective, randomized, multicentre study that will test the hypothesis that a combination of pre-selected ventricular tachyarrhythmia detection, anti-tachycardia pacing, and SVT discriminator parameters will prolong the time to first shock without increasing arrhythmic syncope in patients receiving ICDs for primary prevention. Patients receiving St Jude Medical ICDs and CRT-Ds for primary prevention will be randomized 1:1 to one of two arrhythmia detection and therapy approaches. The study will enroll and follow 1600 patients for at least 1 year or until 226 first shocks have been documented in the total study population. The primary endpoint of the study is the mean time to first shock and the safety endpoint is the rate of arrhythmic syncope. The PROVIDE trial is a randomized controlled study, designed to assess if a pre-selected combination of programming parameters can reduce shock burden among patients receiving ICDs/CRT-Ds for primary prevention.

A 26-Year-Old Woman with Recurrent Loss of Consciousness

The case of a 26-year-old woman with congenital long QT syndrome and recurrent arrhythmic syncope which had been misdiagnosed as a seizure disorder is presented. Useful criteria for discriminating between loss of consciousness due to congenital long QT syndrome and loss of consciousness caused by seizure activity are discussed. The multiple potential causes and clinical implications of a prolonged QT interval, as well as the clinical features and management of congenital long QT syndrome are reviewed.

Stellenwert diagnostischer Methoden in der Synkopenabklärung

After the initial evaluation including detailed history, physical examination, electrocardiogram, and orthostatic blood pressure measurements, risk stratification should follow, if the cause of syncope is still unclear in order to define the acuteness and extensiveness of the further diagnostic evaluation. The documentation of arrhythmia during syncope is the gold standard for diagnosis of arrhythmic syncope. The implantable loop recorder should be integrated early in the diagnostic work-up. In patients >40 years with otherwise unexplained syncope, carotid sinus massage is recommended. In suspected reflex-mediated syncope, the tilt test is able to confirm the diagnosis and gives information about the underlying pathomechanisms, while electrophysiological studies have still a proven indication in patients with previous myocardial infarction and preserved left ventricular function. The adenosine triphophate test has no clinical relevance in the diagnostics of syncope. Echocardiography plays an important role in the risk stratification by diagnosing structural cardiac disease. In patients experiencing syncope associated with exertion, exercise stress testing is indicated. Finally, a coronary angiogram should be performed, if ischemia triggered syncope is suspected. A routinely performed neurological evaluation is not recommended.

Vom Bewusstseinsverlust zur Synkope

Syncope is the most frequent cause for transient loss of consciousness. Recent ESC guidelines pinpoint the position of syncope within the context of loss of consciousness. The individual risk of syncope is determined by various factors. Odds are that almost one in two women and one in four men suffers from syncope at least once in their lives. Age-dependent risk is highest at both the age of 15 and after the 60(th) birthday. Only a fraction of cases are witnessed by a doctor, which makes it difficult to analyze. Prognosis after syncope is strictly related to the existence of structural heart disease. Therefore, its diagnosis and therapy should be given priority. In case of high risk of recurrence, syncope should be adequately treated to prevent further relapse, regardless of the primary disease. Syncopes are classified on the basis of their pathophysiological cause: reflex syncope, orthostatic syncope, arrhythmic cardiac syncope, mechanically caused syncope due to structural cardiovascular disease, and syncope due to cerebrovascular disease. The cause of up to one third of syncopes remains unknown; however, the majority of which are probably reflex syncopes.

Heart rate variability in patients with syncopes

Syncope may be the result of primary bradycardia or tachycardia, vasovagal syncope, or noncardiac syncope. Risk factors and outcome scores to predict prognosis in patients with syncope have been developed. Although these correlate with morbidity and mortality in patients with syncope, their relationship with the mechanism of syncope has not been investigated.The purpose of this study was to identify clinical predictors of primary bradycardia in a cohort of patients undergoing prolonged monitoring for unexplained syncope.One hundred nineteen patients underwent prolonged monitoring with an implantable or external loop recorder after assessment at a single-center, tertiary care arrhythmia service. Fifty-two patients with recurrent syncope during monitoring were classified according to the mechanism of syncope (International Study on Syncope of Uncertain Etiology [ISSUE] classification). Clinical predictors of primary arrhythmic syncope were identified.Twenty patients were classified with primary arrhythmia and 32 patients were classified with nonarrhythmic syncope. Five clinical variables were associated with primary arrhythmia: left bundle branch block, structural heart disease, and syncope without prodrome increased the likelihood of primary arrhythmia; a normal baseline ECG and history of syncope in childhood decreased the likelihood of primary arrhythmia. After multiple logistic regression, risk factors for the diagnosis of primary arrhythmia included syncope without warning symptoms and structural heart disease. The presence of left bundle branch block correlated perfectly with primary arrhythmia, whereas a normal ECG reduced the likelihood of primary arrhythmia.Clinical predictors of primary arrhythmia in patients with recurrent syncope include normal ECG and structural heart disease. Left bundle branch block is an important finding in patients with unexplained syncope.

Prospective evaluation of diagnostic work-up in syncope patients: results of the PL-US registry

Syncope is a common problem. Demographic and clinical characteristics of patients admitted to different types of centres may vary, physician's adherence to the guidelines has been examined only in a few studies, and the requirements for implantable loop recorders (ILR) have not been well defined. The aim of this study was to (i) compare demographic and clinical characteristics of patients with syncope diagnosed and treated in tertiary electrophysiology cardiac centres and those attending syncope units or general hospitals, (ii) assess how physicians adhere to the published guidelines, and (iii) calculate the requirement for ILR insertion. In total, 669 consecutive patients with syncope, admitted to 18 electrophysiological cardiac tertiary centres over a mean of 3 months (range 1-10 months), entered a special Internet database called the PL-US (Polish patients with Unexplained Syncope) registry. Detailed demographic and clinical characteristics of the patients, including the results of all diagnostic tests performed, were analysed. Adherence to the guidelines was assessed, based on the published recommendations. The ILR implantation was indicated when (i) all other tests were inconclusive (unexplained syncope) and (ii) syncope associated with injury or presence of organic heart disease or past medical history and ECG suggesting arrhythmic syncope. Syncope of cardiac/arrhythmic origin was the most frequent diagnosis (53%), followed by reflex syncope (33%). Adherence to the guidelines was less than satisfactory-measurement of blood pressure in an upright position, carotid sinus massage, exercise testing, and electrophysiological study were underused, whereas prolonged ECG monitoring and neurological consultations were overused. Unexplained syncope had 58 (9%) patients, and 42 (72%) of them had indication for ILR which accounts for 6% of the whole study population. The calculated need for ILR was 222 implants/million inhabitants/year. Patients with syncope admitted to the tertiary electrophysiology cardiac centres are a highly selected group of patients with syncope and differ in their characteristics as well as underlying diseases to those managed at general hospitals, outpatient clinics, or special syncope units. In Poland, the adherence to the published guidelines is far from satisfactory. At least 6% of all consecutive patients with syncope are candidates for ILR insertion.

Citalopram-induced long QT syndrome and torsade de pointes: Role for concomitant therapy and disease

Although citalopram is considered to be a safe antidepressant drug, some cases of arrhythmic disorders, syncope, or intoxication leading to lethal outcomes have been described over the last few years. We report the case of citalopram-induced long QT syndrome complicated by torsade de pointes in a young woman, in whom the role for antihypertensive treatment with diuretics and intercurrent flu-like syndrome is discussed.

Predicting the cause of syncope from clinical history in patients undergoing prolonged monitoring

Syncope may be the result of primary bradycardia or tachycardia, vasovagal syncope, or noncardiac syncope. Risk factors and outcome scores to predict prognosis in patients with syncope have been developed. Although these correlate with morbidity and mortality in patients with syncope, their relationship with the mechanism of syncope has not been investigated. The purpose of this study was to identify clinical predictors of primary bradycardia in a cohort of patients undergoing prolonged monitoring for unexplained syncope. One hundred nineteen patients underwent prolonged monitoring with an implantable or external loop recorder after assessment at a single-center, tertiary care arrhythmia service. Fifty-two patients with recurrent syncope during monitoring were classified according to the mechanism of syncope (International Study on Syncope of Uncertain Etiology [ISSUE] classification). Clinical predictors of primary arrhythmic syncope were identified. Twenty patients were classified with primary arrhythmia and 32 patients were classified with nonarrhythmic syncope. Five clinical variables were associated with primary arrhythmia: left bundle branch block, structural heart disease, and syncope without prodrome increased the likelihood of primary arrhythmia; a normal baseline ECG and history of syncope in childhood decreased the likelihood of primary arrhythmia. After multiple logistic regression, risk factors for the diagnosis of primary arrhythmia included syncope without warning symptoms and structural heart disease. The presence of left bundle branch block correlated perfectly with primary arrhythmia, whereas a normal ECG reduced the likelihood of primary arrhythmia. Clinical predictors of primary arrhythmia in patients with recurrent syncope include normal ECG and structural heart disease. Left bundle branch block is an important finding in patients with unexplained syncope.

Strategic Programming of Detection and Therapy Parameters in Implantable Cardioverter-Defibrillators Reduces Shocks in Primary Prevention Patients: Results From the PREPARE (Primary Prevention Parameters Evaluation) Study

Our purpose was to demonstrate that strategically chosen implantable cardioverter-defibrillator (ICD) ventricular tachycardia (VT) or ventricular fibrillation (VF) detection and therapy parameters can reduce the combined incidence of device-delivered shocks, arrhythmic syncope, and untreated sustained symptomatic VT/VF (morbidity index). Strategically chosen ICD VT/VF detection and therapy parameters have been shown in previous studies to reduce the number of shocked episodes. In the PREPARE (Primary Prevention Parameters Evaluation) study, these prior strategies were combined with additional strategies specific to primary prevention patients. The PREPARE study was a prospective, cohort-controlled study that analyzed 700 patients (biventricular [Bi-V] ICD and non-Bi-V ICD) with primary prevention indications for an ICD from 38 centers followed for 1 year. VT/VF was detected for rates > or =182 beats/min that were maintained for at least 30 of 40 beats. Antitachycardia pacing was programmed as the first therapy for regular rhythms with rates of 182 to 250 beats/min, and supraventricular tachycardia discriminators were used for rhythms < or =200 beats/min. The control cohort consisted of 689 primary prevention patients from the EMPIRIC (Comparison of Empiric to Physician-Tailored Programming of Implantable Cardioverter Defibrillators Trial) (non-Bi-V ICD, physician arm only) and MIRACLE ICD (Multicenter InSync Implantable Cardioversion Defibrillation Randomized Clinical Evaluation) (Bi-V ICD) trials for whom VT/VF detection and therapy programming were not controlled. The PREPARE programming significantly reduced the morbidity index incidence density (0.26 events/patient-year for PREPARE study patients vs. 0.69 control cohort, p = 0.003). The PREPARE study patients were less likely to receive a shock in the first year compared with control patients (9% vs. 17%, p < 0.01). The incidence of untreated VT and arrhythmic syncope was similar between the PREPARE study patients and the control cohort. Strategically chosen VT/VF detection and therapy parameters can safely reduce shocks and other morbidities associated with ICD therapy in patients receiving an ICD for primary prevention indications. (PREPARE-Primary Prevention Parameters Evaluation; NCT00279279).

Implantable loop recorder for recurrent syncope: influence of cardiac conduction abnormalities showing up on resting electrocardiogram and of underlying cardiac disease on follow-up developments

The implantable loop recorder is a useful diagnostic tool in dealing with recurrent syncope in patients. We tested to determine the influence of cardiac conduction abnormalities that turn up on resting electrocardiogram (ECG) and the impact of underlying cardiac disease on developments during follow-up. Ninety-five consecutive patients received an implantable loop recorder to monitor recurrent syncope (n = 4.9+/-3.8) of unknown aetiology after cardiac investigations, including an electrophysiological study. Resting ECG was abnormal, suggesting an arrhythmic syncope, in 29 (30.5%) patients, while 21 (22.1%) patients had an underlying cardiac disease. During an average follow-up period of 10.2+/-5.2 months, 43 (45.2%) patients developed a new syncope associated in 27 of them (62.8%) with an arrhythmic event. Syncope was no more frequent in the subgroup of patients with cardiac conduction abnormalities on resting ECG, while the frequency of arrhythmic events was similar whether or not the ECG was normal. In the subgroup of patients with cardiac disease with normal left ventricular ejection fraction, the occurrence of syncope was less frequent, and the number of arrhythmic events was no greater in these patients. Implantable loop recorder is a useful diagnostic tool for recurrent syncope of unknown aetiology.

Clinical trials update from Heart Rhythm 2007 and Heart Failure 2007: CARISMA, PREPARE, DAVID II, SAVE‐PACE, PROTECT and AREA‐IN‐CHF

This article provides information and a commentary on trials relevant to the pathophysiology, prevention and treatment of heart failure, presented at Heart Rhythm 2007 organised by the Heart Rhythm Society which was held in Denver, USA and Heart Failure 2007 organised by the Heart Failure Association of the European Society of Cardiology which was held in Hamburg, Germany. Unpublished reports should be considered as preliminary data, as analyses may change in the final publication. The CARISMA study suggests that non-invasive screening tests may help to identify post-MI patients who may benefit from ICD therapy. Data from the PREPARE study show that more conservative ICD programming can reduce morbidity at the cost of an increased risk of arrhythmic syncope. DAVID II indicates that atrial pacing may be a safe alternative to ventricular back-up pacing in patients with left ventricular dysfunction and standard indications for an ICD. The incidence of persistent atrial fibrillation in patients with sinus node disease in SAVE-PACE was reduced by dual chamber minimal ventricular pacing compared to conventional dual chamber pacing. The pilot phase of the PROTECT studies confirmed 30 mg as the dose of the selective A1 adenosine receptor antagonist KW-3902 to be used in pivotal studies. AREA-IN-CHF failed to show a beneficial effect of canrenone on LV volumes compared to placebo however some beneficial effects on secondary clinical endpoints were observed.

Synkope

Syncope is a transient, self-limiting loss of consciousness usually leading to a fall. The onset of syncope is relatively rapid and the subsequent recovery is spontaneous, complete and usually prompt. As syncope is a symptom, the aim of the diagnostic work-up is to assess whether there is a syncope or another "nonsyncopal" condition, whether there are clinical features suggesting the diagnosis, whether the patient has an increased risk for mortality or recurrent episodes, and whether the patient must be admitted to hospital. The diagnostic work-up is given for two cases: a 68-year-old male with insulin-dependent diabetes experienced his first syncope after lunch. The clinical judgment suggested a neurocardiogenic syncope. The initial evaluation consisting of history, physical examination and twelve-lead ECG evidenced that the patient received several drugs for arterial hypertension so that an orthostatic hypotension had to be ruled out. The twelve-lead ECG showed a left bundle branch block suggesting an arrhythmic syncope and the need for additional diagnostics: an echocardiography mainly to assess the left ventricular function which was normal, and a 24-h long-term ECG to rule out arrhythmias which were not observed. The patient gets an explanation of his risk and the reassurance about his excellent prognosis and some preventive lifestyle modifications such as sufficient volume intake. The second case is a sick 58-year-old male with tracheal cough und aggravating breathing who had a syncope on his way to the toilette. The cause of the syncope was related to a bronchitis with high fever. The patient received a causative treatment and recovered completely.