Search

Background Arrhythmia is one of the most worrisome causes of syncope. Electrocardiographic (ECG) monitoring is crucial for the management of non-low-risk patients in the emergency department (ED). However, its diagnostic accuracy and optimal duration are unknown. We aimed to assess the diagnostic accuracy of ECG monitoring in non-low-risk patients with syncope in the ED. Methods This prospective multicenter observational study included adult patients presenting to the ED after syncope. Patients without an obvious etiology after ED evaluation who were classified by ED physicians as being at non-low risk of adverse events underwent ECG monitoring. We assessed sensitivity, specificity, and diagnostic yield (defined as the proportion of patients with true-positive ECG monitoring findings) of ECG monitoring in the identification of 7- and 30-day adverse and arrhythmic events according to monitoring duration. Results Of 242 patients included in the study, 29 patients had 7-day serious outcomes. Ten additional patients had serious outcomes at 30 days. The overall sensitivity, specificity, and diagnostic yield of ECG monitoring in the identification of 7-day adverse events were 0.55 (95% confidence interval [CI] = 0.36 to 0.74], 0.93 (95% CI = 0.89 to 0.96), and 0.07 (95% CI = 0.04 to 0.10), respectively. The sensitivity, specificity, and diagnostic yield of >12-hour ECG monitoring in the identification of 7-day adverse events were 0.89 (95% CI = 0.65 to 0.99), 0.78 (95% CI = 0.67 to 0.87), and 0.18 (95% CI = 0.12 to 0.28), respectively. Similar results were observed for 30-day adverse events. The median (interquartile range) ECG monitoring time was 6.5 (6 to 15) hours. ECG monitoring findings were positive in 31 patients. Conclusions Although the overall diagnostic accuracy of ECG monitoring is fair, its sensitivity at >12 hours' duration is substantially higher. These results suggest that prolonged (>12 hours) monitoring is a safe alternative to hospital admission in the management of non-low-risk patients with syncope in the ED.

Oxidized low density lipoproteins (oxLDLs) may exert several pro-inflammatory effects that can contribute to the development of coronary artery disease (CAD). Evaluating a possible correlation between oxLDLs and clinical expression of CAD, we measured specific lipid peroxidation indices in healthy subjects and in patients at different clinical stages of CAD. We observed a slight, but not significant, increase in plasma content of cholesterol oxidation products, i.e. oxysterols, in all CAD patients, and a slight, but not significant, increase of 4-hydroxynonenal-protein adducts only in subjects with acute CAD. Moreover, CAD patients showed a plasma rise of specific inflammatory proteins, i.e. C-reactive protein, intercellular adhesion molecule-1, and interleukin-8, but not of monocyte chemotactic protein-1. These preliminary data, without excluding an involvement of oxidative stress and inflammation in CAD, do not show a strict correlation between relevant plasma markers, other than C-reactive protein, and acute phase of the disease.

In a series of 416 women with congenital heart disease seen in the Royal Brompton National Heart and Lung Hospital, London, and the Hospital Giovanni Bosco, Torino, Italy, there were 822 pregnancies. The outcomes of 96 pregnancies in 44 patients with cyanotic congenital heart disease were studied. Patients with the Eisenmenger reaction were excluded. Patients were divided arbitrarily into groups according to the type of maternal congenital cardiac anomaly, and factors influencing maternal and fetal outcome were evaluated. The incidence of maternal cardiovascular complications was high (32%), with one death from endocarditis 2 months after delivery. Forty-one (43%) of 96 pregnancies resulted in a live birth; 15 (37%) were premature. Mean weight of full-term infants was 2575 g. Univariate analysis suggested that maternal disease, Ability Index, hemoglobin, and arterial oxygen saturation before the pregnancy were factors that discriminated between successful and unsuccessful fetal outcome, with hemoglobin and arterial oxygen saturation being the most important predictors. Women with cyanotic congenital heart disease can go through pregnancy with a low risk to themselves, with frequent treatable complications, but there is a high incidence of miscarriage, premature births, and low birth weights. An incidence of congenital heart disease in the fetus of 4.9% (2 of 41 live births) is higher than that found in the normal population.

We conducted a hospital-based case-control study of 153 patients who had been recently diagnosed with myocardial infarction; there were 157 hospital controls. All subjects were 35-70-y-old males who lived in the province of Torino (northern Italy). These individuals were nonsmokers or had quit smoking for at least 6 mo. A protective role of migration from southern Italy was found (age-adjusted odds ratio for northern versus southern origin = 1.82, 95% confidence interval = 1.0, 3.3). Although fat consumption differed greatly between those born in northern Italy and those in southern Italy (i.e., the former used mainly butter and the latter used mainly olive oil during their early lives), it did not explain the migration effect. A family history of myocardial infarction increased the risk of a myocardial infarction (odds ratio = 2.4, 95% confidence interval = 1.1, 4.9). Moderate coffee consumption also increased the risk and was not explained by the known coronary risk factors. Relative risks were up to 4 among both nonsmokers and exsmokers who drank more than 4 cups of coffee each day. We controlled for coffee drinking and found that the association with southern origin appeared strengthened.

OBJECTIVE--To assess the clinical course of adult patients with corrected transposition of the great arteries without associated anomalies. DESIGN--All patients with corrected transposition of the great arteries without associated anomalies were reviewed with complete clinical and echocardiographic assessment. The complications were evaluated in each decade. SETTING--Tertiary centre with a specific unit dealing with "grown-up" adolescent and adult congenital heart disease, designated as a quaternary centre and a general hospital with a referral centre for "grown-up" congenital heart disease. PATIENTS--18 patients (nine male and nine female) aged 16-61 years followed for 1-30 years (mean 10 years). RESULTS--There were no deaths. Six patients had a worsening ability index during follow up. Complications were: (a) complete heart block in seven, three of whom required pacemaker insertion; (b) significant left atrioventricular valve regurgitation in 50%, appearing only in the third decade (12%), with increasing frequency thereafter. Infective endocarditis was responsible for increasing left atrioventricular valve regurgitation in only one patient; (c) supraventricular arrhythmia appeared in the fifth decade, and occurred in all patients over the age of 60 years. One patient aged 61 had recurrent sustained ventricular tachycardia; and (d) congestive heart failure developed only after 50 years in 66%. One patient had severe left atrioventricular valve regurgitation; the function of the systemic ventricle was only moderately reduced in the other three. Three of the nine women had seven uneventful pregnancies. CONCLUSIONS--Patients with corrected transposition of the great arteries without associated defects may remain undiagnosed until adult life. Symptoms occur rarely before the fourth and fifth decades, when rhythm disturbance, left atrioventricular valve regurgitation, and moderately impaired systemic ventricular function cause congestive cardiac failure. The role of pacemaker insertion or surgery for left atrioventricular valve regurgitation needs further assessment.