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Practical Neurology Jun 2024A 56-year-old man reported 2 years of slowly progressive exertional fatigue, presyncope, paraesthesia, generalised weakness and nocturnal bowel frequency. He had an...
A 56-year-old man reported 2 years of slowly progressive exertional fatigue, presyncope, paraesthesia, generalised weakness and nocturnal bowel frequency. He had an abnormal Valsalva ratio and significant postural hypotension. Serum N-terminal pro-B-type natriuretic peptide and troponin T were elevated. Transthoracic echocardiogram identified thickening of the biventricular walls, interatrial septum and atrioventricular valve leaflets. Global longitudinal strain was reduced with relative apical sparing, suspicious for cardiac amyloidosis. Technetium-99m and 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy supported a diagnosis of transthyretin amyloidosis (ATTR). However, urinary Bence Jones protein (kappa) was identified despite a normal kappa/lambda light chain ratio and no serum paraprotein. Bone marrow and buccal biopsy provided histological confirmation of amyloid. The bone marrow had no evidence of plasma cell dyscrasia but positive TTR immunohistochemistry. The patient had a T60A genetic mutation for hereditary ATTR. Overlapping cardiac and autonomic symptoms prompt an amyloid workup, which then must distinguish AL amyloid from ATTR pathology.
PubMed: 38834303
DOI: 10.1136/pn-2023-004048 -
Trauma Surgery & Acute Care Open 2024Troponin T levels are routinely checked in trauma patients after experiencing a ground-level fall to identify potential cardiac causes of syncope. An elevated initial...
PURPOSE
Troponin T levels are routinely checked in trauma patients after experiencing a ground-level fall to identify potential cardiac causes of syncope. An elevated initial troponin prompts serial testing until the level peaks. However, the high sensitivity of the test may lead to repeat testing that is of little clinical value. Here, we examine the role of serial troponins in predicting the need for further cardiac workup in trauma patients after sustaining a fall.
METHODS
Retrospective review of all adult trauma activations for ground-level fall from January 1, 2021 to December 31, 2021 in patients who were hemodynamically and neurologically normal at presentation. Outcomes evaluated included need for cardiology consult, admission to cardiology service, outpatient cardiology follow-up, cardiology intervention and in-hospital mortality.
RESULTS
There were 1555 trauma activations for ground-level fall in the study period. The cohort included 560 patients evaluated for a possible syncopal fall, hemodynamically stable, Glasgow Coma Scale score of 15, and with a troponin drawn at presentation. The initial median troponin was 20 ng/L (13-37). Second troponin values were drawn on 58% (median 33 ng/L (22-52)), with 42% of patients having an increase from first to second test. 29% of patients had a third troponin drawn (median 42 ng/L (26-67)). The initial troponin value was significantly associated with undergoing a subsequent echo (p=0.01), cardiology consult (p<0.01), admission for cardiac evaluation (p<0.01), cardiology follow-up (p<0.01), and in-hospital mortality (p=0.01); the initial troponin was not associated with cardiac intervention (p=0.91). An increase from the first to second troponin was not associated with any of outcomes of interest. Analysis was done with cut-off values of 30 ng/L, 50 ng/L, 70 ng/L, and 90 ng/L; a troponin T threshold of 19 ng/L was significant for cardiology consult (p=0.01) and cardiology follow-up (p=0.04). When the threshold was increased to 50 ng/L, it was also significant for admission for cardiac issue (p<0.01). When the threshold was increased to 90 ng/L, it was significant for the same three outcomes and in-hospital mortality (p=0.04).
CONCLUSION
The initial serum troponin has clinical value in identifying underlying cardiac disease in patients who present after ground-level fall; however, that serial testing is likely of little value. Further, using a cut-off of >50 ng/L as a threshold for further clinical evaluation would improve the utility of the test and likely reduce unnecessary hospital stays and costs for otherwise healthy patients.
LEVEL OF EVIDENCE
Level III.
PubMed: 38831977
DOI: 10.1136/tsaco-2023-001328 -
Integrative Medicine Research Jun 2024Post-viral olfactory dysfunction (PVOD) is the common symptoms of long COVID, lacking of effective treatments. Traditional Chinese medicine (TCM) is claimed to be... (Review)
Review
BACKGROUND
Post-viral olfactory dysfunction (PVOD) is the common symptoms of long COVID, lacking of effective treatments. Traditional Chinese medicine (TCM) is claimed to be effective in treating olfactory dysfunction, but the evidence has not yet been critically appraised. We conducted a systematic review to evaluate the effectiveness and safety of TCM for PVOD.
METHODS
We searched eight databases to identified clinical controlled studies about TCM for PVOD. The Cochrane risk of bias tools and GRADE were used to evaluate the quality of evidence. Risk ratio (RR), mean differences (MD), and 95 % confidence interval (CI), were used for effect estimation and RevMan 5.4.1 was used for data analysis.
RESULTS
Six randomized controlled trials (RCTs) (545 participants), two non-randomized controlled trials (non-RCTs) (112 participants), and one retrospective cohort study (30 participants) were included. The overall quality of included studies was low. Acupuncture ( = 8) and acupoint injection ( = 3) were the mainly used TCM therapies. Five RCTs showed a better effect in TCM group. Four trials used acupuncture, and three trials used acupoint injection. The results of two non-RCTs and one cohort study were not statistically significant. Two trials reported mild to moderate adverse events (pain and brief syncope caused by acupuncture or acupoint injection).
CONCLUSIONS
Limited evidence focus on acupuncture and acupoint injection for PVOD and suggests that acupuncture and acupoint injection may be effective in improving PVOD. More well-designed trials should focus on acupuncture to confirm the benefit.
PROTOCOL REGISTRATION
The protocol of this review was registered at PROSPERO: CRD42022366776.
PubMed: 38831890
DOI: 10.1016/j.imr.2024.101045 -
Journal of Special Operations Medicine... Jun 2024Special Operations Servicemembers presenting with palpitations, pre-syncope, or exertional syncope during rigorous physical training are often experiencing a benign...
Special Operations Servicemembers presenting with palpitations, pre-syncope, or exertional syncope during rigorous physical training are often experiencing a benign condition; however, life-threatening etiologies should be considered. We describe a 43-year-old Special Operator who presented to his medics during selection physical assessment testing with palpitations and lightheadedness, with a subsequent workup revealing arrhythmogenic right ventricular cardiomyopathy (ARVC). His initial electrocardiogram was unremarkable without characteristic ARVC changes. Outpatient evaluation with ambulatory cardiac monitoring recorded numerous episodes of non-sustained ventricular tachycardia. Transthoracic echocardiography demonstrated findings concerning for ARVC, with subsequent cardiac MRI confirming the diagnosis via the 2020 Padua criteria. Management includes activity modification, class III anti-arrhythmic medications, and possible placement of an implantable cardioverter defibrillator to prevent sudden cardiac death. This case demonstrates the importance of maintaining high clinical suspicion for rare diagnoses that present with exertional palpitations, such as arrhythmogenic right ventricular cardiomyopathy, in even our fittest Special Operators.
Topics: Humans; Arrhythmogenic Right Ventricular Dysplasia; Adult; Male; Military Personnel; Electrocardiography; Echocardiography; Anti-Arrhythmia Agents; Magnetic Resonance Imaging; Tachycardia, Ventricular; Defibrillators, Implantable
PubMed: 38830309
DOI: 10.55460/FFIY-8JLW -
Mayo Clinic Proceedings Jul 2024
Topics: Humans; Female; Syncope; Middle Aged; Recurrence; Electrocardiography; Diagnosis, Differential
PubMed: 38829292
DOI: 10.1016/j.mayocp.2023.09.020 -
Clinical Case Reports Jun 2024In contrast to previously thought, arrhythmogenic cardiomyopathy can occur exclusively in the left ventricle in association with autosomal dominant mutation, even...
KEY CLINICAL MESSAGE
In contrast to previously thought, arrhythmogenic cardiomyopathy can occur exclusively in the left ventricle in association with autosomal dominant mutation, even without any skin manifestations.
ABSTRACT
We present a case of a 43-year-old male with left ventricle (LV)-predominant arrhythmogenic cardiomyopathy (ACM) caused by a novel p.Q1830 mutation in the desmoplakin (DSP) gene. The patient had a significant family history of sudden cardiac death (SCD) and presented with presyncope and exertional dyspnea. The patient's electrocardiography (ECG) showed frequent premature ventricular complexes (PVCs) with bigeminy and couplet patterns. Cardiac magnetic resonance imaging (CMR) revealed late gadolinium enhancement of the left ventricle (LV) and ventricular systolic dysfunction, suggesting LV-predominant arrhythmogenic cardiomyopathy. The patient was started on guideline-directed medical therapy (GDMT), and an implantable cardioverter-defibrillator (ICD) was implanted for primary prevention. The patient reported significant improvement in his heart failure symptoms at the 2-year follow-up. The article highlights the importance of timely diagnosis with multimodality imaging and genetic testing and management of the rare DSP-related LV-predominant ACM associated with a high risk of SCD.
PubMed: 38827944
DOI: 10.1002/ccr3.9003 -
ArXiv May 2024Biological systems, particularly the brain, are frequently analyzed as networks, conveying mechanistic insights into their function and pathophysiology. This is the...
Biological systems, particularly the brain, are frequently analyzed as networks, conveying mechanistic insights into their function and pathophysiology. This is the first study of a functional network of cardiac tissue. We use calcium imaging to obtain two functional networks in a subsidiary but essential pacemaker of the heart, the atrioventricular node (AVN). The AVN is a small cellular structure with dual functions: a) to delay the pacemaker signal passing from the sinoatrial node (SAN) to the ventricles, and b) to serve as a back-up pacemaker should the primary SAN pacemaker fail. Failure of the AVN can lead to syncope and death. We found that the shortest path lengths and clustering coefficients of the AVN are remarkably similar to those of the brain. The network is ``small-world," thus optimized for energy use vs transmission efficiency. We further study the network properties of AVN tissue with knock-out of the sodium-calcium exchange transporter. In this case, the average shortest path-lengths remained nearly unchanged showing network resilience, while the clustering coefficient was somewhat reduced, similar to schizophrenia in brain networks. When we removed the global action potential using principal component analysis (PCA) in wild-type model, the network lost its ``small-world" characteristics with less information-passing efficiency due to longer shortest path lengths but more robust signal propagation resulting from higher clustering. These two wild-type networks (with and without global action potential) may correspond to fast and slow conduction pathways. Laslty, a one-parameter non-linear preferential attachment model is a good fit to all three AVN networks.
PubMed: 38827454
DOI: No ID Found -
JACC. Case Reports Jul 2024Cardioneuroablation is a novel approach to treat patients with recurrent vasovagal syncope (VVS), targeting the ganglionated plexi around the atria and thus reducing the...
Cardioneuroablation is a novel approach to treat patients with recurrent vasovagal syncope (VVS), targeting the ganglionated plexi around the atria and thus reducing the vagal input to the heart. This study reports a case of drug-refractory VVS after COVID-19 infection, successfully managed with cardioneuroablation.
PubMed: 38827268
DOI: 10.1016/j.jaccas.2024.102373 -
Cureus May 2024Being an uncommon and challenging disorder, acute aortic dissection (AAD) can have fatal outcomes in the event of missed diagnosis or treatment delay. AAD could easily...
Being an uncommon and challenging disorder, acute aortic dissection (AAD) can have fatal outcomes in the event of missed diagnosis or treatment delay. AAD could easily be misdiagnosed, as symptoms usually mimic other common clinical syndromes showing up in Accident and Emergency (A&E), including acute coronary syndrome (ACS), pericarditis, pulmonary embolism, acute abdomen, musculoskeletal pain, as well as presenting as heart failure, stroke, syncope, and absent peripheral pulses. We present a case of a 77-year-old female who presented to the medical decision unit with acute-onset chest, back, and abdominal pain that occurred on standing for six hours She was thought initially to have acute coronary syndrome based on electrocardiography (ECG) changes, troponin, a normal chest X-ray, and no blood pressure discrepancies in upper extremities. Due to worsening abdominal pain and a previous history of a perforated diverticulum, contrast computed tomography (CT) of the abdomen was arranged and this showed acute type B aortic dissection. By the time the CT was performed, the patient had been in hospital for 16 hours, almost 22 hours from the onset of pain.
PubMed: 38826924
DOI: 10.7759/cureus.59556 -
The Journal of Emergency Medicine Mar 2024In the emergency department (ED), the role of ultrasonography (USG) in risk stratification and predicting adverse events in syncope patients is a current research area....
BACKGROUND
In the emergency department (ED), the role of ultrasonography (USG) in risk stratification and predicting adverse events in syncope patients is a current research area. However, it is still unclear how ultrasound can be combined with existing risk scores.
OBJECTIVES
In this study, it was aimed to examine the contribution of the use of bedside USG to current risk scores in the evaluation of patients presenting to the ED with syncope. The predictive values of the combined use of USG and risk scores for adverse outcomes at 7 and 30 days were examined.
METHODS
The Canadian Syncope Risk Score (CSRS), San Francisco syncope rules (SFSR), USG findings of carotid and deep venous structures, and echocardiography results were recorded for patients presenting with syncope. Parameters showing significance in the 7-day and 30-day adverse outcome groups were utilized to create new scores termed CSRS-USG and SFSR-USG. Predictive values were evaluated using receiver operating characteristic (ROC) analysis. The difference between the predictive values was evaluated with the DeLong test.
RESULTS
The study was carried out with 137 participants. Adverse outcomes were observed in 45 participants (32.8%) within 30 days. 32 (71.7%) of the adverse outcomes were in the first 7 days. For 30-day adverse outcomes, the SFSR-USG (p = 0.001) and CSRS-USG (p = 0.038) scores had better predictive accuracy compared to SFSR and CSRS, respectively. However, there was no significant improvement in sensitivity and specificity values.
CONCLUSION
The use of USG in the evaluation of syncope patients did not result in significant improvement in sensitivity and specificity values for predicting adverse events. However, larger sample-sized studies are needed to understand its potential contributions better.
PubMed: 38824037
DOI: 10.1016/j.jemermed.2024.03.016