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Objective: To compare one-year mortality risk associated with syncope and unexplained fall in older adults with dementia. Methods: 522 patients (aged >65 years) with dementia and history of transient loss of consciousness and/or unexplained falls were evaluated. The diagnosis of syncope was based on European Society of Cardiology guidelines. A “Syncopal Fall” was defined in patients with an initial clinical presentation of unexplained fall, but a final diagnosis of syncope after complete assessment. A “Truly Unexplained Fall” was defined in patients with an initial clinical presentation of unexplained fall, in whom a diagnosis of syncope had been excluded after the diagnostic work-up. One-year follow-up was assessed by phone interview. Results: Follow-up data were available for 501 participants (mean age 83 ± 6 years, 65% female). After a mean follow-up of 324 ± 93 days, death from any cause was reported in 188 participants (24%). Advanced age, male sex, cognitive and functional impairment were associated with a higher mortality rate. Patients with “Truly Unexplained Falls” had a higher mortality risk compared with syncope and “Syncopal Fall”. A diagnosis of “Truly Unexplained Falls” remained an independent predictor of one-year all-cause mortality in multivariate model. Conclusions: We propose the novel diagnostic category of “Truly Unexplained Fall”, resulting from the application of syncope guidelines to subjects with unexplained falls. This condition in older adults with dementia is a predictor of one-year all-cause mortality. For this new high risk profile, we advice a comprehensive geriatric assessment focused on risk factors for fall, aimed at a possible improvement of prognosis.

Carlo Rostagno,1 Alessandro Cartei,2 Gaia Rubbieri,2 Alice Ceccofiglio,2 Roberto Civinini,3 Massimo Curcio,2 Gianluca Polidori,2 Alberto Boccaccini4 1Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; 2Department of Internal and Post-Surgery Unit, AOU Careggi, Florence, Italy; 3Department of Orthopaedics, University of Florence, Florence, Italy; 4Department of Anaesthesia, AOU Careggi, Florence, ItalyCorrespondence: Carlo Rostagno, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, Florence, 50134, Italy, Tel +390557948545, Email carlo.rostagno@unifi.itBackground: In elderly patients with hip fracture, the prevalence of severe aortic stenosis (valve area < 1 cm2) is close to 5%. Few studies have evaluated the prognostic role of aortic stenosis in hip fracture surgery and none has considered the effects of the postoperative setting (intensive care unit vs general ward) on clinical outcome.Purpose: The aim of the present study was to evaluate the factors affecting mortality in patients with severe aortic stenosis undergoing surgery for hip fracture. We also evaluated whether postoperative monitoring in the intensive care unit may affect the prognosis in comparison to return to the general ward after surgery.Patients and Methods: All 2274 patients referred for hip fracture to our tertiary teaching hospital between January 1 2015 and December 31 2019 were screened for the presence of severe aortic stenosis, defined by an aortic valve area < 1.0 cm2.Results: The study included 66 patients (27 males, 39 females) with a mean±SD age of 85± 7 years. The average time between trauma and surgery was 2.6± 3 days. The mean aortic valve area was 0.74± 0.15 cm2. Seven patients died during hospitalization (10.4%). Diabetes, having two or more comorbidities, a low degree of autonomy, heart failure, history of coronary artery disease, atrial fibrillation, postoperative delirium and pulmonary hypertension were associated with poorer outcome. In logistic multivariate analysis, the number of diseases and values of pulmonary artery pressure were the only independent factors related to mortality. In hospital mortality (12 and 9%, respectively) and complication rates were not statistically different between patients referred to the intensive care unit for postoperative monitoring and patients returned to the general ward after surgery.Conclusion: In patients undergoing hip fracture surgery, severe aortic stenosis is associated with high hospital mortality, and two or more comorbidities and pulmonary hypertension are associated with a worse prognosis. The postoperative setting (intensive care unit or general ward) does not affect outcome.Keywords: aortic stenosis, prognosis, hip fracture, elderly

Background The prevalence of Takotsubo syndrome in hip fracture is not known. Methods Hip fracture patients were evaluated in a multidisciplinary unit. Patients with ECG abnormalities and increased troponin I values at the time of hospital admission were included in the study Follow-up was clinical at 30 days and by telephonic interview at one year. Results Between October 1st 2011 to September 30th 2016, 51 of 1506 patients had preoperative evidence of myocardial damage. Eight, all females, fulfilled the Mayo criteria for Takotsubo syndrome, six had no coronary lesions. Hip surgery was uneventful, and all eight were alive at thirty days, and seven of these were still alive after one year. Forty-three patients had myocardial infarction: mortality at thirty days and one year were 11% and 44% (p Conclusion At least 15% of patients with hip fracture and preoperative myocardial damage had Takotsubo syndrome. They were all elderly females. Contrary to myocardial infarction, Takotsubo syndrome has a favourable long term prognosis.

Few information exist about incidence and prognostic significance of postoperative atrial fibrillation (POAF) in patients undergoing hip fracture surgery. In the period comprised between January 2012 and December 2016, we evaluated 3129 patients referred for hip fracture. At hospital admission 277 were in permanent atrial fibrillation and were excluded from the study. POAF was defined as symptomatic or asymptomatic AF of duration > 10 min occurring during hospitalization after hip surgery. In-hospital and 1-year outcomes of POAF patients were compared to that of an age- and sex-matched hip fracture control group. Survival rates were estimated by Kaplan–Meier curves and differences between groups compared by log-rank test. One hundred and four patients (mean age 83.7 years, men 27%) developed POAF (3.6%). Time of onset after surgery was on average 2 days after surgery. Eight POAF patients died during hospitalization. 81.7% were discharged in sinus rhythm. Patients with POAF had a longer time to surgery (3.8 ± 3.3 vs. 2.4 ± 1.6 days, p = 0.0007) and length of hospital stay (19.7 ± 10.4 vs. 14.4 ± 5.1 days p

Objectives: To evaluate the clinical characteristics and the long-term outcome of atrial fibrillation (AF) patients with dementia and history of syncope or falls. Design: Observational: analysis of a prospective registry. Setting and Participants: Between 2012 and 2016, the Syncope and Dementia Registry enrolled patients in 12 geriatric departments. Follow-up evaluation was at 12 months. Measures: Clinical, functional, and cognitive assessment. Results: Of the 522 patients (women, 62.1%; Mini-Mental State Examination 17 ± 6), 26.4% have or presented an AF history. Patients with AF were older (85 ± 6 vs 83 ± 6 years, P = .012), with higher heart rate (78 ± 17 vs. 73 ± 14 bpm, P < .001), prescribed drugs (6.9 ± 2.9 vs 5.9 ± 2.7, P < .001), and an increased number (3.9 ± 2.0 vs 3.0 ± 1.8, P < .001) and severity of comorbidities. Oral anticoagulant therapy was underprescribed (39.9%). Cardiac syncope was more frequently diagnosed (18.8 vs 4.9%, P < .001). At multivariate analysis, AF patients were characterized by advanced age, a higher severity of comorbidities, a greater number of prescribed drugs, an increased heart rate, and a more frequent presence of cardiac symptoms. One-year mortality differed little between patients with and without AF (27.7 vs 22.1%, P = .229). In the arrhythmia group, multivariate predictors of prognosis were disability (number of lost BADLs; P = .020) and a higher heart rate (P = .006). Conclusions and Implications: AF and postural stability-related issues often co-exist in persons with dementia. This complex of conditions is associated with an intricate clinical picture, underprescription of oral anticoagulants, and high long-term mortality. Future studies are needed to evaluate the effects of therapy optimization in this population.

To date, there are no doubts about the evaluation of patients with syncope, while differential diagnoses between presyncope and nonspecific symptoms, generically referred to as dizziness, are complex and not clearly standardized. This paper aims to highlight the most frequent vestibular diseases, which can mimic a pre-syncopal episode in adult and older patients. It should be noted that nonspecific symptoms may be caused by multiple conditions and they can coexist in the same person, making diagnosis even more difficult. Due to nonspecific symptoms and diagnostic complexity, evaluation of patients with presyncope or dizziness should be multidisciplinary, involving the syncope expert and the audiologist, since the first evaluation of the patient in the Emergency Department.

Objectives the association between renal function and delirium has not been investigated in older fracture patients. Creatinine is frequently low in these subjects, which may influence the association between delirium and renal function as estimated with creatinine-based formulas. Cystatin C could be a more reliable filtration marker in these patients. Aim to confirm the association between renal function and delirium in older fracture patients comparing creatinine- and cystatin-based estimated glomerular filtration rate (eGFR) Methods patients aged 65+ requiring surgery for traumatic bone fractures were included. Six equations were used to calculate eGFR, based on serum creatinine and/or cystatin C obtained within 24 h of admission: Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology (CKD-EPIcr, CKD-EPIcys, CKD-EPIcr-cys) and Berlin Initiative Study equations (BIS-1, BIS-2). Delirium was identified with a chart-based method. Results 571 patients (mean age 83) were enrolled. Delirium occurred in the 34% and was associated with a lower eGFR regardless of the equation used. In a multivariable model, the association between moderate renal impairment (eGFR 30–60 ml/min/1.73 m2) and delirium remained significant in patients aged 75–84 and only when estimated with cystatin-based or BIS-1 equations. Only dementia was significantly associated with delirium in subjects 85+. Conclusions in older fracture patients, moderate renal impairment was independently associated with delirium only among subjects aged 75–84, when eGFR was estimated with cystatin-based or BIS 1 equations, and not with the most commonly used equations (MDRD, CKD-EPIcr).

OBJECTIVES To assess the independent effect of delirium on mortality and disability after 1 year of follow-up, in consecutive older patients with hip fracture hospitalized for surgical repair. DESIGN This is a prospective observational study. SETTING AND PARTICIPANTS Patients aged older than 65 years consecutively admitted for hip fracture to the Trauma and Orthopedics Centre of a third-level hospital, between March and October 2014. METHODS Patients were evaluated by a multidisciplinary team. A comprehensive geriatric assessment was performed on admission. Delirium was assessed before and after surgical repair according to the Confusion Assessment Method. Mortality and disability status were collected at 3 months and 1 year after hospital discharge. RESULTS Of 411 patients with hip fracture, 387 (mean age 82 years, female 72%) were enrolled. Delirium was assessed in 50% of the enrolled population. Patients with delirium were older, frequently affected by dementia, severe prefracture disability, history of falls, and polypharmacy. One-year mortality was 19% in all populations, and higher in patients with delirium, although delirium did not show an independent association with mortality, in multivariable analysis. Conversely, delirium was identified as an independent prognostic factor of long-term disability (B-1.606, ES 0.211, P < .001). CONCLUSION AND IMPLICATIONS This study identifies delirium as an independent long-term disability generator, regardless of associated clinical conditions and premorbid cognitive and functional status. This emphasises the importance of delirium prevention through a multidisciplinary approach and the potential role of systematic treatment of risk factors in reducing functional decline, even in subjects with preexistent disability and dementia. Moreover, these data call for research on rehabilitation interventions specifically targeted to these complex patients, with the aim of identifying approaches effective in reducing long-term disability. Conversely, a high level of clinical alertness is required in patients with delirium, as an appropriate treatment of acute diseases should reduce their high mortality risk.

Aim of this study was to explore whether differences in resting hemodynamic parameters may be associated with tilt test results in unexplained syncope. We analyzed age, gender, systolic (SBP), diastolic blood pressure (DBP) and heart rate (HR) by merging three large databases of patients considered likely to be of vasovagal reflex etiology, comparing patients who had tilt-induced reflex response with those who did not. Tilt-induced reflex response was defined as spontaneous symptom reproduction with characteristic hypotension and bradycardia. Relationship of demographics and baseline supine BP to tilt-test were assessed using logistic regression models. Individual records of 5236 patients (45% males; mean age: 60 ± 22 years; 32% prescribed antihypertensive therapy) were analyzed. Tilt-positive (n = 3129, 60%) vs tilt-negative patients had lower SBP (127.2 ± 17.9 vs 129.7 ± 18.0 mmHg, p

Cardiovascular complications in patients undergoing non-cardiac surgery are associated with longer hospital stays and higher in-hospital mortality. The aim of this study was to assess the incidence of in-hospital myocardial infarction and/or myocardial injury in patients undergoing hip fracture surgery and their association with mortality. Moreover, we evaluated the prognostic value of troponin increase stratified on the basis of peak troponin value. The electronic records of 1970 consecutive hip fracture patients were reviewed. Patients &lt, 70 years, those with myocardial infarction &lt, 30 days, and those with sepsis or active cancer were excluded from the study. Troponin and ECG were obtained at admission and then at 12, 24, and 48 h after surgery. Echocardiography was made before and within 48 h after surgery. Myocardial injury was defined by peak troponin I levels &gt, 99th percentile. A total of 1854 patients were included. An elevated troponin concentration was observed in 754 (40.7%) patients in the study population. Evidence of myocardial ischemia, fulfilling diagnosis of myocardial infarction, was found in 433 (57%). ECG and echo abnormalities were more frequent in patients with higher troponin values, however, mortality did not differ between patients with and without evidence of ischemia. Peak troponin was between 0.1 and 1 &micro, g/L in 593 (30.3%). A total of 191 (10 %) had peak troponin I &ge, 1 &micro, g/L, and 98 died in hospital (5%). Mortality was significantly higher in both groups with troponin increase (HR = 1.37, 95% CI 1.1&ndash, 1.7, p &lt, 0.001 for peak troponin I between 0.1 and 1 &micro, g/L, HR = 2.28, 95% CI 1.72&ndash, 3.02, p &lt, 0.0001 for peak troponin &ge, g/L) in comparison to patients without myocardial injury. Male gender, history of coronary heart disease, heart failure, and chronic kidney disease were also associated with in-hospital mortality. Myocardial injury/infarction is associated with increased mortality after hip fracture surgery. Elevated troponin values, but not ischemic changes, are related to early worse outcome.

Introduction Why some individuals with similar demographic characteristics develop syncope during tilt testing (TT) and others do not is unknown and low test sensitivity is claimed. We sought an alternative explanation; resting cardiovascular physiology differs in patients with positive and negative TT. Methods We analyzed age, gender, systolic (SBP), diastolic blood pressure (DBP), and heart rate (HR) using three large syncope patient databases comparing tilt-positive with tilt-negative results after excluding orthostatic hypotension. Positive tilt-response, confirming reflex syncope, was defined as reproduction of spontaneous symptoms with characteristic bradycardia and/or hypotension. Impact of demographic, hemodynamic parameters and prevalent hypertension on TT positivity were assessed using logistic regression models. Results Records of 5236 patients (45% males; mean age, 60±22 years; 32% on antihypertensive therapy) were analyzed. TT was positive in 3129 (60%) and tilt-positive patients had lower SBP (127.2±17.9 vs 129.7±18.0 mmHg, p

Aim of the present study was to investigate the effects of ongoing treatment with DOACs on time from trauma to surgery and on in-hospital clinical outcomes (blood losses, need for transfusion, mortality) in patients with hip fracture. Moreover we evaluated the adherence to current guidelines regarding the time from last drug intake and surgery. In this observational retrospective study clinical records of patients admitted for hip fracture from January 2016 to January 2019 were reviewed. 74 patients were in treatment with DOACs at hospital admission. Demographic data, comorbidities and functional status before trauma were retrieved. As control group we evaluated 206 patients not on anticoagulants matched for age, gender, type of fracture and ASA score. Time to surgery was significantly longer in patients treated with DOACs (3.6 + 2.7 vs. 2.15 ± 1.07 days, p

Background Cardiac pacing is the treatment of choice for cardioinhibitory carotid sinus syndrome (CSS), but syncope recurrence occurs in up to 20% of patients within 3 years. The present study aims at assessing incidence and identifying predictors of syncope recurrence in patients receiving pacing therapy for CSS. Methods The Syncope Clinics of two large regional hospitals in Northern Italy, both following European Syncope Guidelines, combined to perform this study. Retrospective analysis of 3127 consecutive patients undergoing carotid sinus massage (CSM) was performed 2004–2014. Ten-second supine and standing CSM was systematically assessed in patients aged >40 years with suspected reflex syncope as part of the initial evaluation. Syncope recurrence was investigated in those paced for CSS having >6 months' available follow-up. Data were collected from clinical records and patient interviews. Results CSS was diagnosed in 261 patients (8.3%). Pacemakers were implanted in 158, with follow-up data available in 112: 19 (17%) experienced 73 syncope recurrences during a mean follow-up of 89 ± 42 months, yielding an incidence of 0.5 episodes per patient/year. Prodrome, predisposing situations preceding syncope and chronic nitrate therapy were more frequent in patients reporting recurrence. Prodrome and predisposing situations remained independent predictors of post-implantation recurrence on multivariable analysis. Conclusions CSS is a frequent cause of syncope, if CSM is performed during the initial evaluation. Most patients treated by pacing remain asymptomatic during long-term follow-up. In those who have recurrence, its incidence is very low. Prodrome and predisposing situations are predictors of post-implantation recurrence, suggesting presence of hypotensive susceptibility.

OBJECTIVES To determine whether hypotensive drugs may play a pivotal role in inducing orthostatic hypotension (OH)‐related syncope. DESIGN Prospective, observational, multicenter study. SETTING Acute care wards, syncope units, and centers for the diagnosis of dementia. PARTICIPANTS Individuals aged 65 and older with a diagnosis of dementia and 1 or more episodes of transient loss of consciousness of a suspected syncopal nature or unexplained falls during the previous 3 months MEASUREMENTS Blood pressure was measured in the supine position and in the orthostatic position after 1 and 3 minutes. OH was defined as a decrease in systolic blood pressure of 20 mmHg or more and in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing. Univariate and multivariate analyses were used to evaluate associations between hypotensive drugs and their combinations with OH‐related syncope. RESULTS The mean age of the study population (n=522; women, n=324) was 83.5±6.1, and the most frequent comorbidity was arterial hypertension (74.5%); 324 (67.8%) participants had had a syncopal fall and 168 (32.2%) a nonsyncopal fall. The mean number of hypotensive drugs administered (2.9±3.1) did not differ between the two groups. Syncopal falls was OH‐related in 170 participants (48.0%). OH‐related syncopal falls were more frequent in participants receiving nitrates (15.3% vs 9.8%, p=.06), alpha‐blockers (16.5% vs 9.8%, p=.04), or combinations of angiotensin‐converting enzyme inhibitors (ACE‐Is) and diuretics (20.6% vs 13.0%, p=.04), alpha‐blockers and diuretics (8.2% vs 3.3%, p=0.036), and ACE‐Is and nitrates (8.2% vs 3.3%, p=.10). Multivariate analysis confirmed a greater risk of OH‐related syncopal fall for nitrates (relative risk (RR)=1.77), combinations of ACE‐Is and diuretics (RR=1.66), and combinations of ACE‐Is and nitrates (RR=2.32). CONCLUSION In older adults with dementia, OH‐related syncopal falls are significantly related to treatment with nitrates, combinations of ACE‐Is and diuretics, and combinations of ACE‐Is and nitrates.

Background Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study. Methods Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12‑lead ECG was obtained and corrected QT was calculated by the Bazett's formula. One-year followup for death and recurrent syncope was performed. Results Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34–3.26) and diuretics use (OR 1.85; 95% CI 1.18–2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with one-year mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01–3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc. Conclusions We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF.

A structured four-step bedside algorithm, named SponTAneous Nystagmus, Direction, head Impulse test, standiNG (STANDING), has been proposed to differentiate central from peripheral acute vestibulopathy in the Emergency Department (ED). We aimed to evaluate the effective application of STANDING in the management of vertigo in the ED and to define its role in deciding the patient’s pathway after discharge. We retrospectively analysed data from 131 consecutive patients (65% female, mean age 56) undergoing ED visits for a vertigo complaint between April and May 2016. Our study showed that the STANDING algorithm is underused, being performed only in the 18% of patients. The positivity of the STANDING did not influence the choice of the following pathway (e.g. outpatient fast track or discharge). Moreover, a small percentage of patients had a non-audiological diagnosis (mainly presyncope), for which no defined pathways were yet foreseen. Our study emphasized the need for continuous updating with appropriate training courses and the importance of a multidisciplinary assessment of vertigo in the ED.

Background Syncope and dementia have a high prevalence in elderly individuals. Atrial fibrillation (AF) frequently occurs at advanced age. The coexistence of these conditions can be indicative of a clinically relevant frail status. Purpose The aim of this study was to evaluate the characteristics and the long-term outcome of AF patients with dementia and a history of syncope. Methods We evaluated the Syncope and Dementia (SYD) Registry. Data were collected by 11 Geriatric Departments between 2012 and 2016. Follow-up was closed at the 12-month evaluation. Results During the study period, 522 patients (women – 324, 62.1%; MMSE: 17±6) were enrolled. Of these 138 (26.4%) have or presented a history of AF. Patients with AF were older (85±6 vs. 83±6 years, p=0.012), with a higher heart rate (78±17 vs. 73±14 bpm, p At one-year follow-up (8 patients lost), the mortality rate in AF patients was 27.7% (N=36/130). Deceased patients presented a greater degree of disability (number of lost activities of daily living: 3.7±2.3 vs. 2.8±1.9, p=0.020) and a higher heart rate at baseline (85±17 vs. 76±15 bpm, p=0.006). Multivariate analysis (overall predictivity: 74%) confirmed the association of disability (p=0.039) and heart rate (p=0.045) with prognosis. Conclusions AF is frequently present in patients with dementia and a history of syncope. It is usually associated with a more complex clinical picture and high long-term mortality. Heart rate and a higher degree disability seem to be related to prognosis. Acknowledgement/Funding None

OBJECTIVES: To determine whether hypotensive drugs may play a pivotal role in inducing orthostatic hypotension (OH)-related syncope. DESIGN: Prospective, observational, multicenter study. SETTING: Acute care wards, syncope units, and centers for the diagnosis of dementia. PARTICIPANTS: Individuals aged 65 and older with a diagnosis of dementia and 1 or more episodes of transient loss of consciousness of a suspected syncopal nature or unexplained falls during the previous 3 months. MEASUREMENTS: Blood pressure was measured in the supine position and in the orthostatic position after 1 and 3 minutes. OH was defined as a decrease in systolic blood pressure of 20 mmHg or more and in diastolic blood pressure of 10 mmHg or more within 3 minutes of standing. Univariate and multivariate analyses were used to evaluate associations between hypotensive drugs and their combinations with OH-related syncope. RESULTS: The mean age of the study population (n=522; women, n=324) was 83.5±6.1, and the most frequent comorbidity was arterial hypertension (74.5%); 324 (67.8%) participants had had a syncopal fall and 168 (32.2%) a nonsyncopal fall. The mean number of hypotensive drugs administered (2.9±3.1) did not differ between the two groups. Syncopal falls was OH-related in 170 participants (48.0%). OH-related syncopal falls were more frequent in participants receiving nitrates (15.3% vs 9.8%, p=.06), alpha-blockers (16.5% vs 9.8%, p=.04), or combinations of angiotensin-converting enzyme inhibitors (ACE-Is) and diuretics (20.6% vs 13.0%, p=.04), alpha-blockers and diuretics (8.2% vs 3.3%, p=0.036), and ACE-Is and nitrates (8.2% vs 3.3%, p=.10). Multivariate analysis confirmed a greater risk of OH-related syncopal fall for nitrates (relative risk (RR)=1.77), combinations of ACE-Is and diuretics (RR=1.66), and combinations of ACE-Is and nitrates (RR=2.32). CONCLUSION: In older adults with dementia, OH-related syncopal falls are significantly related to treatment with nitrates, combinations of ACE-Is and diuretics, and combinations of ACE-Is and nitrates.

OBJECTIVES: To investigate the etiology of transient loss of consciousness (T-LOC) suspected to be syncope and unexplained falls in elderly adults with dementia. DESIGN: Prospective, observational, multicenter study. SETTING: Acute care wards, syncope units or centers for the diagnosis of dementia. PARTICIPANTS: Individuals aged 65 and older with a diagnosis of dementia and one or more episodes of T-LOC of a suspected syncopal nature or unexplained falls during the previous 3 months were enrolled. MEASUREMENTS: The causes of T-LOC suspected to be syncope and unexplained falls were evaluated using a simplified protocol based on European Society of Cardiology guidelines. RESULTS: Of 357 individuals enrolled, 181 (50.7%) had been referred for T-LOC suspected to be syncope, 166 (46.5%) for unexplained falls, and 10 (2.8%) for both. An initially suspected diagnosis of syncope was confirmed in 158 (87.3%), and syncope was identified as the cause of the event in 75 (45.2%) of those referred for unexplained falls. Orthostatic hypotension was the cause of the event in 117 of 242 (48.3%) participants with a final diagnosis of syncope. CONCLUSION: The simplified syncope diagnostic protocol can be used in elderly people with dementia referred for suspected syncope or unexplained falls. Unexplained falls may mask a diagnosis of syncope or pseudosyncope in almost 50% of cases. Given the high prevalence of orthostatic syncope in participants (~50%), a systematic reappraisal of drugs potentially responsible for orthostatic hypotension is warranted.© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society. Language: en

BACKGROUND: Differential diagnosis between syncope and epilepsy in patients with transient loss of consciousness of uncertain etiology is still unclear. Thus, the aim of the present work is to evaluate the prevalence of syncope in patients with "possible" or "drug-resistant" epilepsy. METHODS: The Overlap between Epilepsy and SYncope Study (OESYS) is a multicenter prospective observational study designed to estimate the prevalence of syncope in patients followed in Epilepsy Centers for "possible" or "drug-resistant" epilepsy and assessed according the European Society of Cardiology (ESC) guidelines of syncope diagnosis. RESULTS: One hundred seven patients were evaluated; 63 (58.9%) had possible and 44 (41.1%) drug-resistant epilepsy. A final diagnosis of isolated syncope was in 45 patients (42.1%), all with possible epilepsy (45/63, 71.4%). Isolated epilepsy was found in 21 patients (19.6%) and it was more frequent in the drug-resistant than in the possible epilepsy group (34.1% vs. 9.5%, p = 0.002). More importantly, syncope and epilepsy coexisted in 37.4% of all patients but the coexistence was more frequent among patients with drug-resistant than possible epilepsy (65.9% vs. 17.5%, p

Background and aim: Syncope and related falls are one of the main causes and the predominant cause of hospitalization in elderly patients with dementia. However, the diagnostic protocol for syncope is difficult to apply to patients with dementia. Thus, we developed a “simplified” protocol to be used in a prospective, observational, and multicenter study in elderly patients with dementia and transient loss of consciousness suspected for syncope or unexplained falls. Here, we describe the protocol, its feasibility and the characteristics of the patients enrolled in the study. Methods: Patients aged ≥65years with a diagnosis of dementia and one or more episodes of transient loss of consciousness during the previous 3months, subsequently referred to a Geriatric Department in different regions of Italy, from February 2012 to May 2014, were enrolled. A simplified protocol was applied in all patients. Selected patients underwent a second-level evaluation. Results: Three hundred and three patients were enrolled; 52.6% presented with episodes suspected to be syncope, 44.5% for unexplained fall and 2.9% both. Vascular dementia had been previously diagnosed in 53.6% of participants, Alzheimer’s disease in 23.5% and mixed forms in 12.6%. Patients presented with high comorbidity (CIRS score=3.6±2), severe functional impairment, (BADL lost=3±2), and polypharmacy (6±3 drugs). Conclusion: Elderly patients with dementia enrolled for suspected syncope and unexplained falls have high comorbidity and disability. The clinical presentation is often atypical and the presence of unexplained falls is particularly frequent.

To evaluate the characteristics of patients referred for dizziness to a Syncope Unit. This is a retrospective study. Of 491 patients referred to the Syncope Unit of Careggi Hospital in 2015, 198 (40.3%) who experienced dizziness alone or associated with a history of transient loss of consciousness were enrolled. All the patients underwent an initial evaluation according to the European Society of Cardiology guidelines on syncope. We compared the clinical characteristics and final diagnosis of patients referred for dizziness alone (n = 64) to those of patients with dizziness and history of transient loss of consciousness (n = 134). The study population had a mean age of 62 ± 20 years (range 16–96 years) and 101 (51%) were female. A final diagnosis of pre-syncope was made in about the 80% of the patients without a previous history of transient loss of consciousness. In this group, other diagnoses were benign paroxysmal positional vertigo (6.3%), transient ischemic attack (4.7%) or psychogenic dizziness (7.8%). Syncope was diagnosed in the 82.7% of the patients with dizziness and history of transient loss of consciousness. Dizziness was the main reason for referral to the Syncope Unit in almost one-third of the patients, in whom pre-syncope was the most frequent final diagnosis. Otological, neurological and psychiatric disorders should be also considered as differential diagnosis, highlighting the importance of a multidisciplinary approach.

Syncope is a common condition. Tilt testing with sublingual nitroglycerin (TT-TNT) provides a test with good specificity and positivity rate in young and old patients. Its use in hypertensive patients with unexplained syncope has not been validated. The aims of this study were to evaluate the positivity rate, specificity and tolerability of TT-TNT in hypertensive patients with unexplained syncope. Five hundred and ten subjects (mean age 55 years) were enrolled, 388 patients with unexplained syncope (73 hypertensive and 315 normotensive) and 122 controls (59 hypertensive and 63 normotensive). All subjects underwent TT-TNT. The responses were classified as positive, negative or exaggerated (aspecific). In hypertensive patients, the usual hypotensive therapy was taken on the day of the test. In hypertensive controls, the positive responses were higher than in normotensives (19% vs 6%, P0.001). The overall specificity was 81% in hypertensives and 94% in normotensives. The positivity rate was significantly lower in hypertensives (55% vs 72%, P0.03). There was no significant difference between young patients and patients65 years. TT was well tolerated, and no serious side effects occurred. TT potentiated with TNT has a lower positivity rate and specificity in hypertensive than in normotensive patients with syncope.

To evaluate the diagnostic relevance of neuroautonomic evaluation in patients with unexplained falls compared to those with a syncope etiologically unexplained after initial evaluation. It is an observational study, comparing 298 patients with unexplained fall with 989 patients with unexplained syncope. Each patient underwent supine and upright blood pressure measurement, tilt testing (TT) and carotid sinus massage (CSM). Patients with unexplained falls were older (75.3 ± 11.1 vs. 63.2 ± 19.2 years, p

Renal aging is a multifactorial process where gender, race, and genetic background and several key mediators such as chronic inflammation, oxidative stress, the renin–angiotensin–aldosterone system, impairment in kidney repair capacities, and background cardiovascular disease play a significant role [1]. Features of the aging kidney include macroscopic and microscopic changes and important functional adaptations, none of which is pathognomonic of aging. The principal anatomical modification is a gradual renal mass reduction that is more pronounced in the renal cortex than in the medulla [2, 3]. From a microscopic point of view, the aging kidney displays glomerular, tubular–interstitial, and vascular changes.

Aims Non-syncopal transient loss of consciousness (T-LOC) encompasses disorders that sometimes resemble syncope, and the differential diagnosis with true syncope may be challenging. The implantable loop recorder (ILR) is potentially useful, but has never been systematically assessed. The aim of the study is to evaluate the diagnostic value of ILR in distinguishing syncope from non-syncopal forms of T-LOC. Methods and results We implanted an ILR in 58 patients (mean age 71 ± 17 years, 25 males) who had had 4.6 ± 2.3 episodes of real or apparent T-LOC, in order to distinguishing epilepsy from syncope (#28), unexplained fall from syncope (#29), or functional pseudo-syncope from syncope (#1). During 20 ± 13 months of follow-up, 33 patients (57%) had a spontaneous event documented by ILR. A diagnosis of syncope was established by ILR documentation of an arrhythmia in 15 (26%) patients: an asystole of 6 s (IQR 4–10 s) duration was documented at the time of the spontaneous event in seven patients with initial suspicion of epilepsy and in five patients with unexplained fall; atrial tachyarrhythmia was documented at the time of the spontaneous event in 1 and 1 patient, respectively, and ventricular tachycardia in 1 patient with unexplained fall. Conversely, in another 18 patients, ILR monitoring documented no significant rhythm abnormalities at the time of T-LOC recurrence, thus excluding an arrhythmic syncope. Finally, ILR was unable to document any syncopal episode in 25 (43%) patients. Among the 15 patients with an established diagnosis of arrhythmic syncope, syncope recurred during follow-up in 2 of 11 patients who were on pacemaker therapy and in 3 of 4 patients who were on other therapies. Conclusion Implantable loop recorder monitoring provides additional diagnostic value in ‘difficult’ patients with an initial diagnosis of non-syncopal real or apparent T-LOC.

OBJECTIVE to evaluate the safety and tolerability of Tilt Testing (TT) and Carotid Sinus Massage (CSM) in octogenarians with unexplained syncope. METHODS patients consecutively referred for transient loss of consciousness to the 'Syncope Units' of three hospitals were enrolled. TT and CSM were performed according to the European Society of Cardiology guidelines on syncope. Complications were evaluated in each group. An early interruption of TT was defined as 'intolerance' and considered as a non-diagnostic response. RESULTS one thousand four hundred and one patients were enrolled (mean age 72 ± 16 years, male 40.8%). Six hundred and ninety-four patients (49.5%) were 80 years old or older (mean age 83 ± 3 years) and 707 (50.5%) were younger (mean age 60 ± 17 years). Complications after TT occurred in 4.5% of older patients and in 2.1% of the younger ones (P = 0.01). All complications were 'minor/moderate', as prolonged hypotension, observed in ∼3% of patients ≥80 years. Major complications such as sustained ventricular tachycardia, ventricular fibrillation, asystole requiring cardiac massage, transient ischaemic attack, stroke and death were not observed in any patient. The presence of orthostatic hypotension and the mean number of syncopal episodes were predictors of TT complications. Intolerance was reported in 2.4% of older patients and 1% of the younger ones (P = 0.08), mainly due to orthostatic intolerance. No complications occurred after CSM. CONCLUSIONS TT and CSM appear to be safe and well tolerated in octogenarians, who should not be excluded by age from the diagnostic work-up of syncope.

There are few studies in literature regarding the differential diagnosis between syncope and epilepsy in patients with transient loss of consciousness (T-LOC) of uncertain etiology. Data obtained on few patients, however, seem to show a common "misdiagnosis" of epilepsy (20-30%) in patients with episodes of T-LOC likely to be syncope. For this reason the Italian Group of Syncope in the elderly (GIS) of the Italian Society of Gerontology and Geriatrics has started multicenter study (Overlapping Between Epilepsy and Syncope Study), with the primary purpose to evaluate the efficiency of cardiovascular tests and neuroautonomic assessments in patients diagnosed with T-LOC of epileptic origin and recurrences despite drug therapy, and as a secondary aim, to evaluate the diagnostic and therapeutic impact of the intervention in terms of recurrence of loss of consciousness.

In cardio-inhibitory Carotid Sinus Syndrome (CI-CSS), syncopal recurrence is expected to occur in up to the 20% of patients after pacing therapy. The present study analyzes post-implantation syncopal recurrence in CI-CSS, to identify predictors of recurrence. We retrieved electronic records

Aims Opinions differ regarding the effectiveness of cardiac pacing in patients affected by reflex syncope. We assessed a standardized guideline-based algorithm in different forms of reflex syncope. Methods and results In this prospective, multi-centre, observational study, patients aged >40 years, affected by severe unpredictable recurrent reflex syncopes, underwent carotid sinus massage (CSM), followed by tilt testing (TT) if CSM was negative, followed by implantation of an implantable loop recorder (ILR) if TT was negative. Those who had an asystolic response to one of these tests received a dual-chamber pacemaker. Population: 253 patients, mean age 70 ± 12 years, median 4 (3–6) syncopes, 89% without or with short prodromes. Of these patients, 120 (47%) received a pacemaker and 106 were followed up for a mean of 13 ± 7 months: syncope recurred in 10 (9%). The recurrence rate was similar in 61 CSM+ (11%), 30 TT+ (7%), and 15 ILR+ (7%) patients. The actuarial total syncope recurrence rate was 9% (95% confidence interval (CI), 6–12) at 1 year and 15% (95% CI, 10–20) at 2 years and was significantly lower than that observed in the group of 124 patients with non-diagnostic tests who had received an ILR: i.e. 22% (95% CI, 18–26) at 1 year and 37% (95% CI, 30–43) at 2 years ( P = 0.004). Conclusion About half of older patients with severe recurrent syncopes without prodromes have an asystolic reflex for which cardiac pacing goes along with a low recurrence rate. The study supports the clinical utility of the algorithm for the selection of candidates to cardiac pacing in everyday clinical practice. Clinical Trial Registration . Unique identifier: [NCT01509534][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01509534&atom=%2Fehj%2Fearly%2F2015%2F03%2F29%2Feurheartj.ehv069.atom

Background and Aims Atrial fibrillation (AF) is the most frequent arrhythmia in elderly patients. Aims of this study were to evaluate the predictors of arterial stiffness after external cardioversion (ECV) of AF and to establish whether a link exists between vascular properties and left atrial diameter (LAD). Methods We studied 33 patients (age 73 ± 12 years). After 5 h from ECV of persistent AF, an echocardiogram was recorded and arterial stiffness was evaluated with cardio-ankle vascular stiffness index (CAVI). Results In multivariate analysis (R = 0.538, p = 0.006), CAVI (mean 9.60 ± 1.63) increased with age (p = 0.018) and with an AF length ≤3 months (p = 0.022). LAD was significantly related to CAVI (p = 0.007) even after adjustment for interventricular septum thickness (p = 0.018) (R = 0.574, p = 0.002). Conclusions In patients with AF, immediately after ECV, arterial stiffness is associated with age and AF length, and could represent an important factor for left atrium remodeling and, therefore, for AF maintenance.

Falls are frequent in the elderly and affect mortality, morbidity, loss of functional capacity and institutionalization. In the older patient the incidence of falls can sometimes be underestimated, even in the absence of a clear cognitive impairment, because it is often difficult to reconstruct the dynamics. It is quite common that forms due to syncope are associated with retrograde amnesia and in 40 to 60% of the cases falls happen in the absence of witnesses. The pathogenesis of falls is often multifactorial, due to physiological age-related changes or more properly pathological factors, or due to the environment. The identification of risk factors is essential in the planning of preventive measures. Syncope is one of major causes of falls. About 20% of cardiovascular syncope in patients older than 70 appears as a fall and more than 20% of older people with Carotid Sinus Syndrome complain of falls as well as syncope. These data clearly state that older patients with history of falls should undergo a cardiovascular and neuroautonomic assessment besides the survey of other risk factors. Multifactorial assessment requires a synergy of various specialists. The geriatrician coordinates the multidisciplinary intervention in order to make the most effective evaluation of the risk of falling, searching for all predisposing factors, aiming towards a program of prevention. In clear pathological conditions it is possible to enact a specific treatment. Particular attention must indeed be paid to the re-evaluation of drug therapy, with dose adjustments or withdrawal especially for antihypertensive, diuretics and benzodiazepines. The Guidelines of the American Geriatrics Society recommend modification of environmental hazards, training paths, hip protectors and appropriate use of support tools (sticks, walkers), which can be effective elements of a multifactorial intervention program. Balance exercises are also recommended. In conclusion, an initial assessment, supported by a comprehensive cardiovascular and neuroautonomic evaluation, allows for reaching a final diagnosis in most cases, demonstrating a key role in the real identification of the etiology of the fall and implementing the treatment measures.

Purpose: Admission to an Intensive Care Unit (ICU) represents a stressful event in patients' life for clinical and psychological reasons. Spouses and relatives can often visit patients during the day for a very limited amount of time. Aim of this study was to evaluate if an Unrestricted Visitation Policy (UVP) could determine an immediate psychological benefit for patients and relatives, when compared to a traditionally restricted (RVP) one. We also wanted to assess wether UVP could increase nurses' emotional stress. Methods: In October 2012, all cognitively integer patients admitted for acute cardiac problems in the three ICUs of the largest hospital of Florence (Italy) were enrolled in the study. UVP (6 h/day) was already a feature in one of the ICUs, the other two both adopt a RVP (2 h/day). The three facilities did not differ in any other way. Patients' levels of anxiety and depression were explored with the Hospital Anxiety and Depression Scale (HADS), health related quality of life with the EuroQol items. Emotional stress in spouses or relatives was evaluated with the Caregiver Stress Test (CST) and the Change in Role Function (CRF) questionnaire. Nurses received the Rapid Stress Assessment questionnaire. Results: We enrolled 59 patients (UVP – N=20, age: 68±11; RVP – N=39, age: 73±11); there were no significant differences between the 2 groups. Myocardial infarction was the most frequent cause of admission (UVP: 55% vs. RVP: 46%). No patients died. At discharge, UVP patients had a lower degree of anxiety (7.0±3.4 vs. 10.3±3.2, p