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  • Patients with syncope often suffer secondary trauma

    2019-04-15

    Patients with syncope often suffer secondary trauma. Major morbidities such as fractures and injuries from motor vehicle accidents have been reported in 6% of patients, whereas minor injuries such as lacerations and bruises have been reported in 29% [1]. Recurrent syncope was associated with fractures and soft tissue injury in 12% of patients [8]. In a recent report on emergency department (ED) patients, minor and major trauma was reported in 29.1% and 4.7% of cases, respectively [9]. Moreover, clinical studies have shown that secondary trauma due to syncope is associated with poor short-term prognosis [10,11]. Although head injuries suffered by patients with syncope would seem to be a serious side effect, very few studies have addressed secondary head injuries in patients with syncope, so the correlation between clinical diagnosis and secondary head injury is unclear. The aim of our study was to identify the characteristics of patients hospitalized for syncope due to arrhythmia, and the role of secondary head injuries.
    Methods
    Results We reviewed the records of all 5590 inpatients during our target orexin receptor antagonist and identified 273 patients (4.8%) with syncope or syncope-like conditions. These patients comprised 179 men and 94 women with an average age of 61±17 years. The patients\' baseline characteristics are shown in Table 1. There were more men (66%) than women (34%) (p<0.001). The mode was 70–79 years of age when sex was ignored (Fig. 1). The histogram of female patient age was bimodal with peaks in the 20–29 and 70–79-year age groups, whereas the mode for men was in the 60–69-year age group. We performed 102 tilt table tests (37%) and 68 EPS (25%) to diagnose syncope. The final diagnoses are shown in Table 2. The most common cause of syncope in our patient population was cardiac syncope (53%), and arrhythmic syncope comprised 43% of all cases. Non-syncopal T-LOC was rare (2%) in this study. The cause of syncope could not be determined in 33 patients (11%) despite in-hospital testing and management . The patients with arrhythmic syncope were older than those with non-arrhythmic syncope were (p<0.001). Patients with arrhythmic syncope were significantly more likely to be >65 years (p<0.001), have an abnormal ECG (p<0.001), or have an abnormal TTE (p<0.05) than patients with non-arrhythmic syncope. Furthermore, head trauma was more common in patients with arrhythmic syncope than in patients with non-arrhythmic syncope (30% vs. 16%, p<0.01; Table 3). There were no significant differences between the patients with arrhythmic syncope and the patients with non-arrhythmic syncope in terms of sex ratio, rate of syncope during exercise, or the number of patients requiring emergency hospitalizations. Multivariate logistic regression analysis yielded similar results except for an abnormal TTE (Table 4). The predictors of arrhythmic syncope were age >65 years (estimated odds ratio [eOR] 2.3; 95% confidence interval [95% CI] 1.3–3.9, p<0.005), head injury (eOR 2.3; 95% CI 1.2–4.3; p<0.01), and abnormal ECG (eOR 2.2; 95% CI, 1.2–3.9; p<0.01). Specific arrhythmia-related treatments in the 273 syncopal patients included 59 (22%) cardiac pacemaker implantations, 19 (7%) implantable cardioverter-defibrillator implantations, and 35 (13%) radiofrequency catheter ablation procedures.
    Discussion In this study, we sought to determine the characteristics that distinguished arrhythmic syncope from non-arrhythmic syncope among hospital inpatients in a cardiology department. Patients with arrhythmic syncope more frequently had an abnormal ECG and were >65 years of age than patients with non-arrhythmic syncope. In addition, the occurrence of a secondary head injury was significantly more common in patients with arrhythmic syncope. Several studies have described the effects of injury in patients with syncope in the ED. Unger et al. reported that the predictors of mortality were age, presence of heart disease or an abnormal ECG, decreasing number of previous syncopal attacks, and the presence of trauma [10]. In the short-term prognosis of syncope study, concomitant trauma was an independent risk factor for the development of severe adverse outcomes in the first 10 days after a syncopal episode (OR 2.9; 95% CI, 1.4–5.9) [11]. However, Bartoletti et al. reported that in all of the traumas, there was no significant difference in the rate of head trauma between patients with and without a syncopal condition [9]. They also reported that the prevalence of trauma did not differ from that of non-trauma in patients with arrhythmic syncope. The correlation between syncopal causes and secondary trauma due to syncope in the results of these studies was not clear despite the fact that trauma would be expected to be strongly related to mortality in patients with T-LOC. In our study, we speculated that the onset of arrhythmic syncope is more rapid than that of non-arrhythmic syncope, and we only evaluated head traumas and compared arrhythmic syncope with all other types of syncope. Thus, we could determine the correlation between head trauma and syncope cause. In our study, multivariate analysis did not find abnormal echocardiogram findings to be a predictive factor of arrhythmic syncope. Sarasin et al. reported that arrhythmic syncope occurred in 17% of all patients with syncope, and abnormal ECG, age >65 years, and history of congestive heart failure were predictors of arrhythmia in patients with unexplained syncope after an ED assessment [7]. Although the study conditions differed in the present study, the first 2 predictors in the study of Sarasin et al. were identical to our findings. They also separately reported that arrhythmias were diagnosed in 12 of 24 patients (50%) with echocardiogram findings of systolic dysfunction only in patients with unexplained syncope and a positive cardiac history or abnormal ECG [12]. They concluded that echocardiography is useful for risk stratification by measuring the left ventricular function, a predictor of arrhythmias, in selected patients only. Thus, abnormal echocardiogram findings could be a predictor of arrhythmia-related syncope, which was not observed in the present study likely because of the small number of patients and the patients\' clinical characteristics.