Syncope Unit Research Articles

Investigating Skeletal Muscle Pump Function Using Thigh EMG, Thigh NIRS, And Stroke Volume Data In The FRAILMatics Physiological Cohort

Abstract Background The pioneering female physiologist Frances Hellebrandt first highlighted the significance of the skeletal muscle pump in circulation in the 1930s. However, the mechanisms underlying the muscle pump's function remain elusive, particularly in older individuals. It is thought that during muscle contraction, increased intramuscular pressure facilitates the expulsion of blood from the muscle's veins, aiding venous return. This contraction-induced pressure gradient assists in pushing blood towards the heart, increasing preload, and subsequently stroke volume (SV). In this study we investigated muscle pump activity using continuous measurements of thigh muscle activity, thigh total haemoglobin concentration (Hb), and cardiac SV. Methods 22 individuals (aged 70.8±5.3 years, 77.3% female) recruited from a Falls and Syncope Unit (St James’s Hospital, Dublin) underwent non-invasive measurements of Hb (NIRS PortaLite, Artinis Medical Systems, The Netherlands), electromyography (EMG) (Shimmer3, Research Ltd, Ireland), and SV (Finapres Nova, Finapres Medical Systems, The Netherlands) during a 10-second thigh squeeze test. Pre-processing involved data quality checks, alignment, and resampling. 60-second regions of interest were extracted, normalised, and processed using MATLAB (R2023a, TheMathWorks, Inc., Natick, MA, USA). Cross-correlation and Granger causality analyses were conducted to explore relationships between signals. Results Thigh Hb and EMG signals lagged 8.4 and 8.5 seconds behind SV, respectively. Granger Causality analysis revealed a significant causal relationship from both Hb and EMG to SV in 68% of participants at measured lags. Conclusion The observed ~8.5-second lag between thigh measurements and SV implies a plausible temporal relationship between muscle activation and venous return, further supported by significant causal relationships found in a substantial portion of participants using Granger causality analysis. These findings underscore the importance of continued research in this area, not only for advancing our understanding of physiological mechanisms but also for informing potential clinical applications aimed at optimising cardiovascular health and function.

The Effect of Fludrocortisone on Ambulatory Blood Pressure Markers of Falls Risk Amongst Older People with Falls

Abstract Background Fludrocortisone is frequently used to raise blood pressure in older patients with falls due to hypotension, yet evidence to support its use is limited. The aim of this study was to assess changes in Ambulatory Blood Pressure Monitors (ABPM) markers of future falls risk seen after commencing/increasing Fludrocortisone in older people with falls due to orthostatic hypotension (OH) or vasovagal syncope. Methods A cohort of older patients (≥65 years) attending a tertiary-referral falls & syncope unit and prescribed Fludrocortisone were included. ABPM at index visit and follow-up (after commencing/increasing Fludrocortisone) were analysed, with specific focus on markers of future falls risk: overall Systolic Blood Pressure (sBP), minimum sBP, sBP variability & ‘dips’ in systolic sBP <100 mm Hg. These variables were compared pre and post Fludrocortisone using paired t-tests. Results Twenty-three patients (median age 74 years (SD 6.05), 3/4 with OH) were followed for median 4.5 (SD 6.53) months. Two-thirds were commenced on Fludrocortisone, with the dose increased in the rest. Patients commencing Fludrocortisone had a significant increase in overall sBP from 110.13mmHg (95% CI 104.26 – 116.00) to 127.93mmHg (95% CI 120.00 – 135.87) (p<0.001) at follow-up, and a significant increase in minimum sBP from 82.2mmHg (95% CI 76.25 – 88.15) to 99.87mmHg (95% CI 91.47 – 108.26) (p=0.001). There was also a significant reduction in the number of SBP ‘dips’ after commencing Fludrocortisone (9.6 pre to 2.67 post, (95% CI 0.08 – 5.25), p=0.004)), and after commencing/increasing Fludrocortisone dose (8.09 pre to 2.74 post (95% CI 0.62 – 4.85) (p=0.012)). Conclusion This study provides clinical data on the effectiveness of Fludrocortisone in older patients with falls due to hypotension, demonstrating significantly improved markers of future falls risk. Overall sBP increased significantly by 16% and minimum sBP increased by over 20% after starting Fludrocortisone. The number of SBP ‘dips’ also significantly reduced, by over 70% in those who commenced Fludrocortisone.

Implementing a Pilot Geriatric Oncology Service at a National Cancer Centre in Dublin

Abstract Background The American Society of Clinical Oncology and International Society of Geriatric Oncology recommend comprehensive geriatric assessment (CGA) for older adults commencing systemic anti-cancer treatments (SACTs) (1, 2). Routine CGA is lacking in cancer centres nationally. Methods A pilot, interdisciplinary geriatric-oncology (GO) clinic comprising a geriatric medicine consultant and specialist registrar, medical oncology fellow, physiotherapist and occupational therapist was established Dec 2023. New oncology patient referrals were screened applying the G8 tool; a score of ≤14 triggering referral. Polypharmacy was defined as ≥5 regular medications. Frailty was assessed using Clinical Frailty Scale (CFS) and cognition using Montreal Cognitive Assessment (MoCA). Results To date, 30 patients have attended the clinic; mean age 77.2 (SD5) years (range 68-85); 73% female, 50% with a CFS score of ≥4. Sixty-percent (n=18) were due to commence chemotherapy, the remainder hormonal or targeted treatment. Polypharmacy was identified in 66.6% (n=20), with 13.3% (n=4) having an anti-cholinergic burden score of ≥3, MoCAs were completed in 60% (n=18), of whom 77.8% (n=14) had an abnormal result (<26/30 MoCA or <18/22 MoCA blind). Twenty-six percent (n=8) reported ≥1 fall in the preceding six-months. Deprescribing interventions were completed in 40% (n=12); 58.3% (n=7) had ≥2 medications stopped. Medications most commonly deprescribed included opioids (n=2), antihypertensives (n=2), statins (n=2). Ambulatory blood pressure monitors were arranged for 33.3% (n=10) and DEXAs for 40% (n=12) and appropriately actioned. Follow up was arranged in the Falls and Syncope Unit for 7%, day hospital 10%, geriatric outpatients 10%, group psycho-oncology sessions 20%, specialist cancer rehabilitation physiotherapy service 17%. Parkinsons disease and dementia were diagnosed in 1 and 1 patients, respectively. Each patient had a detailed assessment and plan forwarded to their treating oncologist. Conclusion The development of a dedicated GO service is in line with international standards. By undergoing CGA, geriatric syndromes amenable to intervention were identified in patients.

The triggers of situational syncope do not influence the head-up tilt test response and prognosis.

The study evaluated the positivity rate, haemodynamic responses, and prognosis in terms of syncopal recurrence among patients with situational syncope (SS) stratified according to the underlying situational triggers. We retrospectively evaluated all consecutive patients with SS who underwent nitroglycerine (NTG)-potentiated head-up tilt test (HUTT) at Syncope Unit of the University of Campania 'Luigi Vanvitelli'-Monaldi Hospital from 1 March 2017 to 1 May 2023. All patients were followed for at least one year. The study population was divided according to the underlying triggers (micturition, swallow, defaecation, cough/sneeze, post-exercise). Two hundred thirty-six 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; defaecation 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). Situational syncope appears to be a homogenous syndrome, and different triggers do not impact the HUTT response or syncope recurrence at 1 year.

A More Targeted and Selective Use of Implantable Loop Recorders Improves the Effectiveness of Syncope Units: A Single-Center Experience.

Syncope remains a common medical problem. Recently, the role of dedicated syncope units and implantable loop recorders has emerged in the investigation of unexplained syncope. This study aims to investigate the possibilities for a more rational and targeted use of various diagnostic tools. In this retrospective single-center study, 196 patients with unexplained syncope were included between March 2019 and February 2023. Various diagnostic tools were utilized during the investigation, according to clinical judgement. Patients were retrospectively allocated into Group A (including those who, among other tests, underwent loop recorder insertion) and Group B (including patients investigated without loop recorder implantation). Data were compared with Group C, including patients assessed prior to syncope unit establishment. There was no difference between Group A (n = 133) and Group B (n = 63) in the diagnostic yield (74% vs. 76%, p = 0.22). There were significant differences between Groups A and B regarding age (67.3 ± 16.9 years vs. 48.3 ± 19.1 years, p < 0.001) and cause of syncope (cardiogenic in 69% of Group A, reflex syncope in 77% of Group B, p < 0.001). Electrocardiography-based diagnosis occurred in 55% and 19% of Groups A and B, respectively (p < 0.001). The time to diagnosis was 4.2 ± 2.7 months in Group A and 7.5 ± 5.6 months in Group B (p < 0.001). In Group C, the diagnostic yield was 57.9% and the electrocardiography-based diagnostic yield was 18.3%. A selective use of loop recorders according to clinical and electrocardiographic characteristics increases the effectiveness of the structured syncope unit approach and further preserves financial resources.

Long-term impact of the implementation of a syncope unit: 14 years of care optimization

Abstract Syncope, a prevalent cause of emergency department (ED) visits, often triggers unnecessary hospitalizations due to its intricate management. In recent years, dedicated syncope units (SUs) have emerged, initially showing a reduction in admission rates compared to traditional approaches. These abstract aims to convey the extended impact of implementing a specialized Syncope Unit (SU) within a hospital setting over 14 years. This prospective study examines SU outcomes over the first 14 years of operation, with a specific focus on admission rates. Between 2005 and 2019, our hospital's ED handled 1,835,219 visits, with 16,516 (8.9%) related to syncope. On average, 1,101±60 syncope patients received attention annually, with a slight decrease over the study period. The SU evaluated a total of 3,225 patients, averaging 215±31 patients per year. Notably, the number of SU patients remained consistent, while the number of hospitalized patients steadily declined from 40% in 2005 to 15% in 2019. In conclusion, the implementation of the SU led to a substantial and sustained reduction in the admission rate for syncope patients, showcasing a lasting positive impact on syncope management within the ED. This positive impact could also be due to indirect benefits resulting from the creation of the SU.

The Tilt Test in the Assessment of Syncope and Pre-syncope. Effective and safe? Analysis of a Series of 2364 Patients over 6 Years

The tilt table test (TT) provides relevant information about individual susceptibility to neuro-mediated hypotension and bradycardia. Its importance has been questioned. In this work, we analyze the results and safety of TT in the investigation of syncope, presyncope or postural dizziness. Cross-sectional study, with TT exams performed by specialists in cardiac arrhythmias, in the period 2016-2021, in a syncope unit. Analyzes were performed using the Mann-Whitney test, multiple logistic regression, with a significant p value &lt;0.05. The protocols used were Westminster or Italian protocol. There were 2364 TT performed, 61.7% female, aged 51.1 (31-71) years. The positivity rate was 32.6%, 37.2% with pharmacological sensitization (p&lt; 0.01). For the investigation of syncope, positivity was 34.2% (477) x 30.65% (285) for other symptoms (p&lt;0.001), while evaluating syncope and presyncope together the difference was 37.55% (623) x 20.9% (139) for other symptoms (p&lt;0.001). Positivity was higher in males (p&lt;0.01; OR=1.40(1.16-1.69)), in sensitized tests (p&lt;0.01;2.01(1.64-2, 38)), in patients with early orthostatic hypotension (OH) with symptoms (p &lt;0.01; 9.68(4.13-27.44)). The complication rate was 3.29%, but without severity. The TT remains an important and safe methodology in clinical practice for the investigation of patients with suspected neurally mediated syndromes.

Brain MRI and EEG overemployment in patients with vasovagal syncope: results from a tertiary syncope unit

BackgroundThe diagnosis of vasovagal syncope (VVS) is mainly based on history-taking and physical examination. However, brain Magnetic Resonance Imaging (MRI) and Electroencephalogram (EEG) are commonly used in the diagnostic course of VVS, despite not being indicated in the guidelines. This study aims to find the possible associated factors with the administration of brain MRI and EEG in patients with VVS.MethodsPatients with a diagnosis of VVS from 2017 to 2022 were included. Several demographic and syncope features were recorded. The association of these was assessed with undergoing MRI, EEG, and either MRI or EEG. Univariate and multivariable logistic regression models were also used to calculate odds ratios (OR) and 95% confidence intervals (CI).ResultsA total of 1882 patients with VVS were analyzed, among which 810 underwent MRI (43.04%), 985 underwent EEG (52.34%), and 1166 underwent MRI or EEG (61.96%). Head trauma (OR 1.38, 95% CI 1.06 to 1.80), previous neurologist visit (OR 6.28, 95% CI 4.24 to 9.64), and gaze disturbance during syncope (OR 1.75, 95% CI 1.13 to 2.78) were all positively associated to the performance of brain MRI/EEG. Similar results were found for urinary incontinence (OR 2.415, 95% CI 1.494 to 4.055), amnesia (OR 1.421, 95% CI 1.053 to 1.930), headache after syncope (OR 1.321, 95% CI 1.046 to 1.672), and tonic-clonic movements in head-up tilt table test (OR 1.501, 95% CI 1.087 to 2.093). However, male sex (OR 0.655, 95% CI 0.535 to 0.800) and chest pain before syncope (OR 0.628, 95% CI 0.459 to 0.860) had significant negative associations with performing brain MRI/EEG.ConclusionBased on our findings, performing MRI or EEG was common among VVS patients while it is not indicated in the majority of cases. This should be taken into consideration to prevent inappropriate MRI/EEG when there is a typical history compatible with VVS.

Current ED syncope management in Italian hospitals and prospects for optimization: a national survey.

To investigate current ED management of patients with syncope in Italy and opportunities for optimization, we carried out a questionnaire survey involving 102 directors of ED facilities in our country, of any complexity level, with 55.9% located in the North, 97% equipped with an ED Observation Unit (EDOU), and 21.8% with an outpatient Syncope Unit (SU). 43.6% of EDs management is not standardized. Clinical judgment and monitoring are the main factors leading management while old age and neuropsychic comorbidities the most hindering it. More than one third of ED facilities treats fewer than half of patients in EDOU. Most of respondents (73.7%) reported an admission rate within 20%, primarily in cardiology, in the case of an established or suspected cardiac etiology of syncope. In most centers, the referral to the general practitioner is the priority path at discharge from ED. Nearly 50% of participants rated syncope management in their own center as sub-optimal. To optimize it, 98% of them believe that is appropriate to implement a standardized approach, with and a large majority focusing on increasing diagnostic yield and safety; other priorities include application of guidelines, implementation of care pathways, enhancement of the role of EDOU, and direct path to the SU. This study highlights that the management of syncope patients in our country requires a further improvement, especially through standardization of pathways and adoption of innovative organizational solutions. Admissions appear to be lower than reported in the literature but this finding must be confirmed by a multicentric study based on direct collection of data.

Diagnostic approach at specialized syncope units in the netherlands: a cross-sectional, nationwide survey

Abstract Introduction The European Society of Cardiology Guidelines recommend a structural approach for the initial evaluation of syncope patients, yet implementation of such approach appears cumbersome. There are several specialized Syncope Units in the Netherlands. Here we investigated the diagnostic strategy of specialized Syncope Units and adherence areas for syncope patients. Purpose We aimed to identify the current network of Syncope Units in the Netherlands and to assess to which extent the units fulfil requirements as indicated by the European Heart Rhythm Association consensus and the current guidelines. Methods All units Neurology, Internal Medicine, and Cardiology in hospitals in the Netherlands were contacted. Units with specialized Syncope care were included and requested to fill out a questionnaire of 25 questions regarding which medical specialties are involved during evaluation, which diagnostic tests are available and being performed and which adherence regions were associated. We specifically investigated whether the Syncope Units adhered to the consensus statements 1 and 3 as described by the European Heart Rhythm Association position paper as gold standard for best practices. Results Specialized care for syncope was reported in 20/72 hospitals. Most (17/20) reported that multiple specialties are involved during the initial evaluation. 19/20 had either Neurology, Cardiology, or both responsible for the Syncope Unit. 18/20 perform guideline-based orthostatic blood pressure measurement. A non-invasive-beat-to-beat blood pressure monitor was present in 11/20 units. 16/20 perform tilt table testing and do &amp;gt; 48 per year, 3/16 this was during the initial evaluation and 15/20 perform carotid sinus massage. The adherence areas cover 64.2% of the Netherlands. Both European Heart Rhythm Association consensus statements 1 and 3 for best practice were met in 4/20 of the Syncope Units, 4/20 only met consensus statement 1 and 14/20 only met consensus statement 3. Conclusion We identified 20 Syncope Units in the Netherlands. The diagnostic approach varies in the medical specialties involved, protocols for cardiovascular testing, and timing of diagnostic tests. Most units did not completely perform the Guideline suggested initial evaluation. Four out of 20 Syncope Units met the European Heart Rhythm Association consensus statements for best clinical practice.Overview Syncope Units NetherlandsAdherence of the Syncope Unit

Sex and age differences in clinical presentation and head-up tilt test results in patients with vasovagal syncope

Abstract Background Previous evidence indicates important sex- and age-specific characteristics of vasovagal syncope (VVS), which may be relevant to diagnostic and therapeutic approaches. Purpose To investigate differences in presentation, symptoms, and head-up tilt test (HUTT) response in patients with VVS based on biological sex and age groups. Methods This study analyzed data from the HUTT registry at a tertiary syncope unit between 2017 and 2022, including adults aged 18 years or older who were diagnosed with VVS. The diagnosis was based on clinical criteria, and conformed with the latest syncope guidelines. Clinical features and head-up tilt test results were recorded and analyzed to understand the sex and age-specific characteristics of VVS. HUTT was performed using an electrically-controlled tilt table, with continuous hemodynamic monitoring, according to the Italian protocol. The type of response to HUTT was decided according to the Vasovagal Syncope International Study (VASIS) criteria, and HUTT was only considered positive if syncope occurred during the test. Results Among 1,914 eligible patients, 49% were female, and the mean age was 46.43 ± 17.77. Male participants were significantly older (44 vs 49 years of age, P&amp;lt;0.001), and had higher rates of diabetes mellitus (10% vs 7%) and hypertension (25% vs 19%), while female patients had a higher prevalence of anemia (24% vs 11%). There was a non-significant trend for more emergency department visits among males (7% vs 5%). Females were more likely to experience prodromal symptoms such as nausea and abdominal discomfort, typical cutaneous symptoms, and less typical prodromes like aura. Compared to males, female patients were also more likely to report specific triggers, which helps establish the diagnosis of VVS and makes avoidance of triggers possible. On the other hand, females were more likely to experience seizure-like movements, and experienced more post-syncopal symptoms. The head-up tilt test results were not significantly different based on sex (Figure 1). Younger patients were more likely to experience specific triggers and manifest prodromal symptoms, compared to older individuals, which highlights the challenges for diagnosis of VVS in older age. In contrast, younger patients with VVS were more likely to present with seizure-like movements and abnormal gaze during the VVS episode. There was a non-significant trend for higher rates of urinary incontinence during VVS among older patients. Older patients were less likely to have a cardioinhibitory response during HUTT, which confirms findings from previous studies (Figure 2). Conclusion The present study highlights the differences in the clinical presentation of VVS based on sex and age, providing valuable information for diagnosis and management of this condition. Further studies are needed to understand the mechanisms behind these differences and to develop tailored treatment plans for VVS.

Increased levels of circulating endostatin are linked to orthostatic hypotension

Abstract Background Orthostatic hypotension (OH) occurs when blood pressure regulation fails. The underlying molecular mechanism of OH remain largely unexplored. Endostatin is a biologically active molecule cleaved by matrix metalloproteinases, elastases and cathepsins from collagen XVIII in the extracellular matrix and inhibits angiogenesis. Circulating levels of endostatin have been proposed to be involved in blood pressure (BP) regulation, by inducing nitric oxide release. To date, the relationship between endostatin and OH have not been examined. Purpose We aimed to investigate circulating levels of endostatin in patients with verified OH by tilt test at a tertiary syncope unit compared with healthy age- and sex-matched controls from the same geographical region. Methods We performed an age- and sex-matched case-control study in 150 patients with OH verified by positive head-up tilt-testing and other cardiovascular autonomic tests at a tertiary syncope unit, and 150 healthy controls with negative active standing tests and no history of syncope, orthostatic intolerance, and endocrine disease. High-sensitivity chemiluminescence sandwich immunoassay was used to measure circulating levels of endostatin in a blinded fashion. Receiver operating characteristic curves were constructed to analyze the discriminative ability of endostatin in OH compared with healthy controls. Multivariate logistic regression was used to assess the association between endostatin, OH and hemodynamic variables adjusting for age and sex. Results Study characteristics are displayed in the Table. Patients with OH had significantly higher absolute levels of circulating endostatin compared with healthy controls (59,024 ± 2513 vs. 44,090 ± 1978 pg/mL, p&amp;lt;0.001). Multivariate-adjusted logistic regression analysis controlling for age, sex, minimum systolic and minimum diastolic BP during tilt, identified endostatin as an independent determinant for OH (beta-coefficient 0.80, p=0.025). The obtained area under the curve was 0.70, P&amp;lt;0.001, Figure). Conclusions Our findings indicate that patients with orthostatic hypotension have increased circulating levels of endostatin, independent of age, sex, and hemodynamic variables. Our results highlight the relevance of investigating the molecular pathways related to orthostatic hypotension. Further studies are warranted to assess the prognostic and therapeutic role of endostatin assessment in individuals with orthostatic hypotension.Tablestudy characteristicsFigureROC Curve

Remote monitoring of implantable cardiac monitors in patients with unexplained syncope: Predictors of false-positive alert episodes.

Remote monitoring is recommended for patients with implantable cardiac monitors (ICMs), but compared to other cardiac implantable devices, ICMs are less accurate and transmit a higher number of alerts. The aim of this study was to investigate the predictors of false-positive (FP) arrhythmic alerts in patients with unexplained syncope who were implanted with ICM and followed by an automatic remote monitoring system. We retrospectively evaluated all consecutive patients who received a long-sensing vector ICM for unexplained syncope between January 2019 to September 2021 at our Syncope Unit. The primary endpoint was the incidence of the first FP episode. The secondary endpoints included assessing the incidence of FP episodes for all types of algorhythms and indentifying the reasons for the misdetection of these episodes. Among 105 patients (44.8% males, median age 51 years), 51 (48.6%) transmitted at least one FP alert during a median follow-up of 301 days. The presence of pre-ventricular complexes (PVCs) on the resting electrocardiogram was the only clinical characteristic associated with an increased risk of FP alerts (adjusted Hazard ratio [HR] 5.76 [2.66-12.4], p=0.010). The other significant device-related variables were a low-frequency filter at 0.05Hz versus the default 0.5Hz (adjusted HR 3.82 [1.38-10.5], p=0.010) and the R-wave amplitude (adjusted HR 0.35 [0.13-0.99], p=0.049). Patients who have PVCs are at higher risk of inappropriate ICM activations. To reduce the occurrence of FP alerts, it may be beneficial to target a large R-wave amplitude during device insertion and avoid programming a low-frequency filter at 0.05Hz.

Syncope and Cannabis: hypervagotonia from chronic abuse? A case report and literature review

BackgroundCannabis is the most consumed drug worldwide and number of users is increasing, particularly among youth. Moreover, cannabis potential therapeutic properties have renewed interest to make it available as a treatment for a variety of conditions. Albeit rarely, cannabis consumption has been associated with cardiovascular diseases such as arrhythmias, myocardial infarction (MI) and potentially sudden death.Case presentationA 24-year-old woman presented to the emergency department sent by her cardiologist because of a recent finding of a 16 seconds asystole on the implantable loop recorder (ILR) she implanted 7 months before for recurrent syncopes. She declared that she is a heavy cannabis user (at least 5 cannabis-cigarette per day, not mixed up with tobacco, for no less than 12 years) and all syncopes occurred shortly after cannabis consumption. After a collective discussion with the heart team, syncope unit, electrophysiologists and toxicologist, we decided to implant a dual chamber pacemaker with a rate response algorithm due to the high risk of trauma of the syncopal episodes. 24 months follow-up period was uneventful.ConclusionsCannabis cardiovascular effects are not well known and, although rare, among these we find ischemic episodes, tachyarrhythmias, symptomatic sinus bradycardia, sinus arrest, ventricular asystole and possibly death. Because of cannabis growing consumption both for medical and recreational purpose, cardiovascular diseases associated with cannabis use may become more and more frequent. In the light of the poor literature, we believe that cannabis may produce opposite adverse effects depending on the duration of the habit. Acute administration increases sympathetic tone and reduces parasympathetic tone; conversely, with chronic intake an opposite effect is observed: repetitive dosing decreases sympathetic activity and increases parasympathetic activity. Clinicians should be aware of the increased risk of cardiovascular complications associated with cannabis use and should investigate its consumption especially in young patients presenting with cardiac dysrhythmias.

Diagnostic and societal impact of implementing the syncope guidelines of the European Society of Cardiology (SYNERGY study)

BackgroundSyncope management is fraught with unnecessary tests and frequent failure to establish a diagnosis. We evaluated the potential of implementing the 2018 European Society of Cardiology (ESC) Syncope Guidelines regarding diagnostic yield, accuracy and costs.MethodsA multicentre pre-post study in five Dutch hospitals comparing two groups of syncope patients visiting the emergency department: one before intervention (usual care; from March 2017 to February 2019) and one afterwards (from October 2017 to September 2019). The intervention consisted of the simultaneous implementation of the ESC Syncope Guidelines with quick referral routes to a syncope unit when indicated. The primary objective was to compare diagnostic accuracy using logistic regression analysis accounting for the study site. Secondary outcome measures included diagnostic yield, syncope-related healthcare and societal costs. One-year follow-up data were used to define a gold standard reference diagnosis by applying ESC criteria or, if not possible, evaluation by an expert committee. We determined the accuracy by comparing the treating physician’s diagnosis with the reference diagnosis.ResultsWe included 521 patients (usual care, n = 275; syncope guidelines intervention, n = 246). The syncope guidelines intervention resulted in a higher diagnostic accuracy in the syncope guidelines group than in the usual care group (86% vs.69%; risk ratio 1.15; 95% CI 1.07 to 1.23) and a higher diagnostic yield (89% vs. 76%, 95% CI of the difference 6 to 19%). Syncope-related healthcare costs did not differ between the groups, yet the syncope guideline implementation resulted in lower total syncope-related societal costs compared to usual care (saving €908 per patient; 95% CI €34 to €1782).ConclusionsESC Syncope Guidelines implementation in the emergency department with quick referral routes to a syncope unit improved diagnostic yield and accuracy and lowered societal costs.Trial registrationNetherlands Trial Register, NTR6268

331 Patient experience in a Falls and Syncope service in a large Irish teaching hospital

Abstract Background The measurement of patient satisfaction provides valuable information about patients’ perceptions of their received healthcare. It is an excellent measure of the quality of care delivered by a healthcare facility. This allows service providers to continue to move towards patient-centred care. A positive patient experience is an important aim that leads to better clinical outcomes. Methods A 20-question patient satisfaction survey was developed for an outpatient Falls and Syncope Unit in order to assess the patient’s perception of service delivery. All patients attending the service were invited to complete the survey over a 2-month period in 2022. Results 71 responses were received. 76% of respondents found their appointment beneficial, and 94% felt their appointment was necessary. Satisfaction with staff ranged between 97–99%. 98% of patients felt they were treated with respect and 88% felt free to express complaints, with 97% satisfactory telephone interaction with the service. 60% of patients received a patient information leaflet, with 97% of patients finding the information leaflets provided useful. Twenty-five respondents (31%) indicated further information on their care would have been beneficial. Conclusion This patient satisfaction survey provided positive feedback for all staff on care delivered in the Falls and Syncope service. Recommendations for changes in practice included increased use of patient information leaflets, in order to improve patients’ experience, since 97% of patients found information leaflets useful and 40% of patients did not receive a leaflet.

256 How prevalent are markers of blood pressure instability on Ambulatory Blood Pressure Monitoring of older people with falls, faints &amp; dizziness?

Abstract Background In older people with BP-related falls, the mechanisms that usually tightly control Blood Pressure (BP) may be less efficient, leading to BP instability. This may manifest as specific markers on Ambulatory Blood Pressure Monitoring (ABPM), including BP variability, BP dipping and absence of nocturnal dipping/reverse dipping. The aim of this study therefore is to ascertain the prevalence of APBM markers of BP Instability among older people with falls/faints/dizziness and examine if there is an age-gradient seen for these markers. Methods ABPM data (minimum 25 BP values measured across 24 hours) was collected for 83 consecutive patients aged ≥70 years attending a tertiary-referral Falls &amp; Syncope Unit with falls, fainting or dizziness. Data analysed included BP Variability (standard deviation (SD) of BP values, i.e. measurement of the oscillation of BP measurements); Nocturnal dipping (decrease in average night BP compared to average day BP) and BP dips (number of systolic BP values &amp;lt;100 mm Hg). Results: Of the analysed ABPMs(n = 83, mean age 78 years, 48% female), mean number of readings per device was 34.6 (33.7–35.5). The average SD for overall systolic BP was 15.9. Over 15% of patients had an average SD ≥20 for systolic BP based on the full ABPM, reflecting high levels of BP variability. There was a significant age gradient seen for nocturnal dipping with mean change −0.30 (−9.3–8.8) in those aged ≥85 years compared to +10.9(7.3–14.6) in the 70–74 years age group. The mean number of systolic BP values&amp;lt;100 mm Hg was 2.9 (1.7–4.0). Conclusion Older patients attending with falls/faints/dizziness demonstrate significant BP variability, aberrant nocturnal dipping profiles and frequent systolic BP values dipping below 100 mm Hg. Further work is required to establish if these ABPM aberrancies are reliable predictors of future falls and potentially modifiable targets to reduce falls burden among older people.

Definitive aetiology of unexplained syncope after cardiovascular autonomic tests in a tertiary syncope unit.

Syncope is a common condition with many possible causes, ranging from benign to life-threatening aetiologies. Establishing a diagnosis can be difficult, and specialized syncope units, using cardiovascular autonomic tests (CATs), including a head-up tilt test, can increase the diagnostic yield. However, up to one-fifth of examined patients have inconclusive CAT results. The aim of the present study was to investigate the predictive value of history, and clinical findings for unexplained syncope after CAT and characterize the group with negative results. Consecutive syncope patients [n = 2663, 61% women, median age 52 (32-69) years] were evaluated and CAT explained aetiology of syncope in 79% of cases, whereas 21% remained unexplained. Predictors of negative CAT were older age at first syncope (+8% higher odds per 10-year increment, P = 0.042), higher supine heart rate (HR; +12% per 10 b.p.m.; P = 0.003), absence of prodromes (+48%; P < 0.001), hypertension (+45%; P = 0.003), diabetes (+82%; P < 0.001), heart failure (+98%; P = 0.014), and coronary artery disease (+51%; P = 0.027). Compared with vasovagal syncope, patients with negative CAT were older, reported more often the absence of prodromes, and had a higher burden of cardiovascular comorbidities. A cardiovascular autonomic test established the cause of syncope in 79% of patients evaluated in a syncope unit. Syncope without prodromes and cardiovascular comorbidities were significant predictors of failure to reveal an aetiology from assessment by CAT. These are known risk factors for cardiac syncope and patients with inconclusive CAT warrant further investigation.

Cerebral Oxygenation Responses to Standing in Young Patients with Vasovagal Syncope.

Vasovagal syncope (VVS) is common in young adults and is attributed to cerebral hypoperfusion. However, during active stand (AS) testing, only peripheral and not cerebral hemodynamic responses are measured. We sought to determine whether cerebral oxygenation responses to an AS test were altered in young VVS patients when compared to the young healthy controls. A sample of young healthy adults and consecutive VVS patients attending a Falls and Syncope unit was recruited. Continuous beat-to-beat blood pressure (BP), heart rate, near-infrared spectroscopy (NIRS)-derived tissue saturation index (TSI), and changes in concentration of oxygenated/deoxygenated Δ[O2Hb]/Δ[HHb] hemoglobin were measured. BP and NIRS-derived features included nadir, peak, overshoot, trough, recovery rate, normalized recovery rate, and steady-state. Multivariate linear regression was used to adjust for confounders and BP. In total, 13 controls and 27 VVS patients were recruited. While no significant differences were observed in the TSI and Δ[O2Hb], there was a significantly smaller Δ[HHb] peak-to-trough and faster Δ[HHb] recovery rate in VVS patients, independent of BP. A higher BP steady-state was observed in patients but did not remain significant after multiple comparison correction. Young VVS patients demonstrated a similar cerebral circulatory response with signs of altered peripheral circulation with respect to the controls, potentially due to a hyper-reactive autonomic nervous system. This study sets the grounds for future investigations to understand the role of cerebral regulation during standing in VVS.

P452 VASOVAGAL SYNCOPE AND COVID–19

Abstract Scope. The aim of the study was to evaluate how the Covid–19 state of emergency affected the activity of the Syncope Unit (SU). During the lockdown, the outpatient activities of the SU were suspended(1). Materials. From March 2020 to March 2021, approximately 95 patients booked for the Tilt–up test were medically evaluated by teleconsultation and televiewer. Vasovagal syncope (VVS) (61%), orthostatic hypotension (OH) (5%) was diagnosed. The patients were trained, through television and video tutorials, in the use of counter pressure maneuvers (PCM) and tilt training, while dietary indications were provided and the importance of adequate oral hydration and the need to take, as recommended by the guidelines, 2–3l of water per day. We retrospectively observed the result at the end of the lockdown period: patients with VVS and OH called by the SU no longer needed to perform tilt up tests because they had obtained a significant reduction in syncope in 90% of cases. Discussion Reflex syncope is the most frequent, representing 21% of all types of syncope (2). Accurate history and physical examination are necessary for the diagnosis, sometimes a guided path in the SU in the unexplained forms. The indicated therapy is non–pharmacological (increase the salt and water content in the diet, avoid triggers, tilt training)(2) and, especially in young people, has been shown to prevent recurrences(2). Back pressure maneuvers (PCM) are effective in preventing syncope(3); oral hydration increases blood volume and improves symptoms(4). Conclusions The Covid–19 state of emergency, through the use of telemedicine tools, has made it possible to reach the diagnosis of reflex syncope through an accurate anamnestic evaluation, has allowed patients to be reassured about the benignity of the events and has motivated patients to implement the recommended non–pharmacological therapies. This has made it possible to reduce the number of tilt tests to be performed when the SU reopens.