geoffrey modest medical blogs

Finally a guideline on syncope management (s ee  syncope guidelines JACC2017  in  dropbox , or  10.1016/j.jacc.2017.03.003) , these  from the Am Heart Assn/Am College of Cardiology .  Many of us, I think, have been relying on suggestions from such sources as UpToDate, which are not rigorously evaluated and  validated by at least a semi-independent association (the American Heart Association, though does have intrinsic potential biases  for more cardiologic workup and investigation than a truly independent organization such as the National Institutes of Health in the US or National  Institute for Health and  Care  Excellence NICE  in the  UK, does take the issue of upfront conflicts of interest more seriously than most other specialty groups, in this case with neither the chair nor vice-chair with any stated conflicts of interest, as well as 8  of the 15 committee  members without stated confl...

vasovagal syncope is pretty common, but there are no documented effective treatments. Fludrocortisone has potential by improving venous return: its efficacy was evaluated in the Prevention of Syncope Trial 2 -- POST 2 trial (see  syncope fludrocortisone jacc2016​  in  dropbox , or Sheldon R. JACC 2016; 68: 1). details: --210 patients (71% female, median age 30, BMI 24, HR 70 bpm, BP 112/70) with a mean of 15 syncopal episodes over 9 years --randomized to fludrocortisone at the highest tolerated doses (from 0.05-0.2 mg/d, titrated over 2 weeks, with most achieving the 0.2  mg dose) vs placebo and followed for 1 year --inclusion criteria: >13  yo , >2 lifetime syncopal episodes; exclusions: diabetes, hepatic disease BP>135/85, "significant comorbidities", or if when standing 5 minutes they had postural tachycardia of >30 bpm, or orthostatic hypotension of >20/10 mmHg. --results     --9...

in recent study looked at factors which might distinguish cardiac syncope from vasovagal syncope in children up to 18 years old (see  syncope in kids j peds 2013  in dropbox, or http://dx.doi.org/10.1016/j.jpeds.2013.07.023  ).  the study was set in a pediatric cardiology clinic including 89 patients who had vasovagal syncope over a one year period, compared with children with known cardiac syncope (given the relative rarity of cardiac syncope, they searched their files and found 17 patients who had significant cardiac disease and syncope).  8 with cardiac syncope had long QT syndrome, 3 had cardiomyopathy (2 HOCM), and one of each had  left coronary artery originating from the right aortic cusp, primary pulmonary hypertension, myocarditis with ventricular tachycardia, catecholaminergic polymorphic ventricular tachycardia, cardiac fibroma, and idiopathic ventricular tachycardia (notably, no Brugada or arrhythmogenic right ventricular dysplasia). resul...