Publications by authors named "Martina Rafanelli"

40 Publications

Hypotensive episodes revealed by ambulatory blood pressure monitoring in nursing home residents.

J Am Geriatr Soc 2021 Nov 20. Epub 2021 Nov 20.

Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.17570DOI Listing
November 2021

Unexplained falls in the elderly.

Minerva Med 2021 Sep 13. Epub 2021 Sep 13.

Syncope Unit, Department of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy -

Falls are a geriatric syndrome affecting mortality, morbidity, and institutionalization. Falls are also the leading cause of unintentional injury and a common emergency department presentation. Physical and psychological issues may develop after falling, leading to increase in dependency and disability and their relative costs. The pathogenesis of falls is multi-factorial, being indeed the result of the interaction between increased individual susceptibility, high risk activities and environmental hazards. The patient should be evaluated for gait, standing balance, mobility, muscle weakness, cognitive status, osteoporosis risk, sensorial impairment, urinary incontinence, functional status, and for possible residential environmental hazards. It is also mandatory to obtain a full report of the circumstances and a careful therapeutic recognition. However not all falls are explainable. Indeed, retrograde amnesia and the frequent absence of a witness complicate history collection of falls in older adults. In this case, "the management of unexplained falls should be the same as that for unexplained syncope" as stated by the latest version of the European Society of Cardiology guidelines on syncope. In this context, the investigation of the cardiovascular autonomic nervous system and the use of implantable loop recorder have an increasing role. The present paper addresses the diagnostic approach to falls in older adults through a comprehensive multifactorial risk assessment and examines evidence and gaps on fall prevention strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S0026-4806.21.07749-1DOI Listing
September 2021

Underlying hemodynamic differences are associated with responses to tilt testing.

Sci Rep 2021 09 9;11(1):17894. Epub 2021 Sep 9.

Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.

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 < 0.001), DBP (76.2 ± 11.5 vs 77.7 ± 11.7 mmHg, p < 0.001) and HR (68.0 ± 11.5 vs 70.5 ± 12.5 bpm, p < 0.001). In multivariable analyses, tilt-test positivity was independently associated with younger age (Odds ratio (OR) per 10 years:1.04; 95% confidence interval (CI), 1.01-1.07, p = 0.014), SBP ≤ 128 mmHg (OR:1.27; 95%CI, 1.11-1.44, p < 0.001), HR ≤ 69 bpm (OR:1.32; 95%CI, 1.17-1.50, p < 0.001), and absence of hypertension (OR:1.58; 95%CI, 1.38-1.81, p < 0.001). In conclusion, among patients with suspected reflex syncope, younger age, lower blood pressure and lower heart rate are associated with positive tilt-test result.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41598-021-97503-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8429732PMC
September 2021

The Impact of COVID-19 Outbreak on Syncope Units Activities in Italy: A Report from the Italian Multidisciplinary Working Group on Syncope (GIMSI).

Int J Environ Res Public Health 2021 08 31;18(17). Epub 2021 Aug 31.

Geriatrics and Intensive Care Unit, Hypertension Centre-Syncope Unit University of Florence and Careggi Hospital, 50134 Florence, Italy.

The aim of our study was to evaluate the impact of the COVID-19 outbreak on Syncope Units (SUs) Activities in Italy. Data about types of SU activities and admissions were obtained from 10 SUs throughout Italy, certified by the Italian Multidisciplinary Working Group on Syncope (GIMSI), from 10 March 2020 to 31 December 2020 and compared with the same time frame in 2019. A remarkable reduction in overall non-invasive diagnostic tests (-67%; < 0.001) and cardiac invasive procedure. Elective cardiac pacing procedures disclosed a significant decrease (-62.7%; < 0.001); conversely, the decrease of urgent procedures was not significant (-50%; 0.08). There was a significantly increased rate of patients who underwent both telemedicine follow-up visits (+225%, < 0.001) and cardiac implantable electronic devices (CIEDs) remote monitoring follow-up visits (+100%; < 0.001). The COVID-19 outbreak was associated with a remarkable decrease in all clinical activities of Syncope Units in Italy, including both non-invasive tests and cardiac invasive procedures; conversely, a significant increase in telehealth activities was shown.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/ijerph18179194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8431220PMC
August 2021

Detection of subclinical atrial fibrillation after cryptogenic stroke using implantable cardiac monitors.

Eur J Intern Med 2021 10 8;92:86-93. Epub 2021 Jul 8.

"Luigi Sacco" Department of Biomedical and Clinical Sciences, University of Milan, Milano, Italy. Electronic address:

Background: Implantable cardiac monitor (ICM) revealed subclinical atrial fibrillation (SCAF) in up to 30% of cryptogenic stroke (CS) patients in randomized trials. However, real world data are limited.

Objectives: We investigated SCAF occurrence, treatments, clinical outcomes and predictors of SCAF in a multicenter real-world population subjected to ICM after CS.

Methods: From September 2016 to November 2019, 20 Italian centers collected data of consecutive patients receiving ICM after CS and followed with remote and outpatient follow-up according to clinical practice. All device-detected AF events were confirmed by the cardiologist to diagnose SCAF.

Results: ICM was implanted in 334 CS patients (mean age±SD 67.4±11.5 years, 129 (38.6%) females, 242 (76.1%) with CHADS-VASC score≥4). During a follow-up of 23.6 (IQR 14.6-31.5) months, SCAF was diagnosed in 92 (27.5%) patients. First episode was asymptomatic in 81 (88.1%). SCAF daily burden ≥5 minutes was 22.0%, 24.1% and 31.5% at 6, 12, and 24 months after ICM implantation. Median time to first day with AF was 60 (IQR 18-140) days. Female gender, age>69 years, PR interval>160 ms and cortical-subcortical infarct type at enrolment were independently associated with an increased risk of SCAF.

Conclusions: In a real-world population, ICM detected SCAF in more than a quarter of CS patients. This experience confirms the relevance of implanting CS patients, for maximizing the possibilities to detect AF, following failure of Holter monitoring, according to guidelines. However, there is need to demonstrate that shift to oral anticoagulation following SCAF detection is associated with reduced risk of recurrent stroke.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejim.2021.06.022DOI Listing
October 2021

Evaluation of Patients with Syncope in the Emergency Department: How to Adjust Pharmacological Therapy.

Medicina (Kaunas) 2021 Jun 11;57(6). Epub 2021 Jun 11.

Syncope Unit, Geriatric and Intensive Care Unit, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.

The rate of syncope in the Emergency Department ranges between 0.9 and 1.7%. Syncope is mostly related to a underlying reflex or orthostatic mechanism. A bradycardic or a hypotensive phenotype, may be identified. The latter is the most common and could be constitutional or drug induced. Consequently, obtaining an accurate drug history is an important step of the initial assessment of syncope. As anti-hypertensive medication might be responsible for orthostatic hypotension, managing hypertension in patients with syncope requires finding an ideal balance between hypotensive and cardiovascular risks. The choice of anti-hypertensive molecule as well as the therapeutic regimen and dosage, influences the risk of syncope. Not only could anti-hypertensive drugs have a hypotensive effect but opioids and psychoactive medications may also be involved in the mechanism of syncope. Proper drug management could reduce syncope recurrences and their consequences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/medicina57060603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8231040PMC
June 2021

Hypertension management in frail older adults: a gap in evidence.

J Hypertens 2021 03;39(3):400-407

Geriatric Intensive Care Unit, Department of Geriatrics, Referral Centre for Hypertension Management in Older Adults, Careggi Hospital and University of Florence, Florence, Italy.

Hypertension management is challenging in frail older adults. The balance between treatment risks and benefits may be difficult to achieve due to an increased vulnerability to treatment-related adverse events, and limited evidence is available to support clinical decisions. The effects of frailty on blood pressure are unclear, as well as its impact on antihypertensive treatment benefits. Appropriate blood pressure targets in frail patients are debated and the frailty measure which best inform clinical decisions in hypertensive patients has yet to be identified. Therefore, hypertension management in frail older adults still represents a 'gap in evidence'. Knowledge of currently available literature is a fundamental prerequisite to develop future research and may help to implement frailty assessment and improve hypertension management in this vulnerable population. Given these premises, we present a narrative review illustrating the most relevant issues that are a matter of debate and that should be addressed in future studies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/HJH.0000000000002685DOI Listing
March 2021

Complementary effectiveness of carotid sinus massage and tilt testing for the diagnosis of reflex syncope in patients older than 40 years: a cohort study.

Europace 2020 11;22(11):1737-1741

Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy.

Aims: Indications, methodology, and diagnostic criteria for carotid sinus massage (CSM) and tilt testing (TT) have been standardized by the 2018 Guidelines on Syncope of the European Society of Cardiology. Aim of this study was to assess their effectiveness in a large cohort which reflects the performance under 'real-world' conditions.

Methods And Results: We analysed all patients who had undergone CSM and TT in the years 2003-2019 for suspected reflex syncope. Carotid sinus massage was performed according to the 'Method of Symptoms'. Tilt testing was performed according to the 'Italian protocol' which consists of a passive phase followed by a sublingual nitroglycerine phase. For both tests, positive test was defined as reproduction of spontaneous symptoms in the presence of bradycardia and/or hypotension. Among 3293 patients (mean age 73 ± 12 years, 48% males), 2019 (61%) had at least one test positive. A bradycardic phenotype was found in 420 patients (13%); of these, 60% were identified by CSM, 37% by TT, and 3% had both test positive. A hypotensive phenotype was found in 1733 patients (53%); of these, 98% were identified by TT and 2% had both TT and CSM positive.

Conclusion: The overall diagnostic yield of the tests in patients >40-year-old with suspected reflex syncope was 61%. Both CSM and TT are useful for identifying those patients with a bradycardic phenotype, whereas CSM has a limited value for identifying the hypotensive phenotype. Since the overlap of responses between tests is minimal, both CSM and TT should be performed in every patient over 40 years receiving investigation for unexplained but possible reflex syncope.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/europace/euaa204DOI Listing
November 2020

Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications.

Drugs Aging 2020 10;37(10):725-738

Syncope Unit and Referral Centre for Hypertension Management in Older Adults, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy.

Orthostatic hypotension (OH) is an abnormal blood pressure response to standing, which is associated with an increased risk of adverse outcomes such as syncope, falls, cognitive impairment, and mortality. Medical therapy is one the most common causes of OH, since numerous cardiovascular and psychoactive medications may interfere with the blood pressure response to standing, leading to drug-related OH. Additionally, hypotensive medications frequently overlap with other OH risk factors (e.g., advanced age, neurogenic autonomic dysfunction, and comorbidities), thus increasing the risk of symptoms and complications. Consequently, a medication review is recommended as a first-line approach in the diagnostic and therapeutic work-up of OH, with a view to minimizing the risk of drug-related orthostatic blood pressure impairment. If symptoms persist after the review of hypotensive medications, despite adherence to non-pharmacological interventions, specific drug treatment for OH can be considered. In this narrative review we present an overview of drugs acting on the cardiovascular and central nervous system that may potentially impair the orthostatic blood pressure response and we provide practical suggestions that may be helpful to guide medical therapy optimization in patients with OH. In addition, we summarize the available strategies for drug treatment of OH in patients with persistent symptoms despite non-pharmacological interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s40266-020-00796-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524811PMC
October 2020

Low Creatinine Potentially Overestimates Glomerular Filtration Rate in Older Fracture Patients: A Plea for an Extensive Use of Cystatin C?

Eur J Intern Med 2021 Feb 25;84:74-79. Epub 2020 Jul 25.

Geriatric Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy. Electronic address:

Aim: Muscle mass is frequently reduced in older patients experiencing injurious falls and may further reduce during hospitalization for bone fracture. In these patients, renal function may be overestimated, because it is usually calculated using serum creatinine, which is strictly related to muscle mass. We evaluated if creatinine levels change during hospitalization in older patients with fracture. We also assessed the role of cystatin C as a more appropriate marker of renal function, comparing estimated glomerular filtration rate (eGFR) according to different formulas based on creatinine and/or cystatin C levels.

Methods: Patients aged 65+ years, consecutively hospitalized for fracture, were enrolled in a prospective cohort study. Creatinine and cystatin C levels were measured at baseline and in the post-operative period; eGFR was calculated using six equations based on creatinine and/or cystatin C.

Results: 425 patients were enrolled (mean age 84 years, mean creatinine 0.97 mg/dL, mean cystatin C 1.53 mg/L). Creatinine levels significantly decreased after surgery (p<0.001), while cystatin C remained stable. According to creatinine-based formulas, eGFR was < 60 mL/min/1.73 m in 29-30% at baseline and only in 17% participants in the post-operative period. Conversely, according to equations including cystatin C, eGFR was < 60 mL/min/1.73 m in half to three-quarters of the sample at all assessments.

Conclusions: In older fractured patients, creatinine levels decline during hospital stay and may possibly overestimate renal function, whereas cystatin C remains stable. Whether cystatin C is a more reliable marker of renal function in this specific population should be further investigated.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejim.2020.06.016DOI Listing
February 2021

Blood pressure management in hypertensive patients with syncope: how to balance hypotensive and cardiovascular risk.

J Hypertens 2020 12;38(12):2356-2362

IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital.

: Managing hypertension in syncope patients requires the accurate balancing of hypotensive and cardiovascular risks. On the basis of the available literature, this study analyses the complex inter-relationship between these clinical problems and presents an algorithm strategy to guide hypertension management in patients affected by syncope episodes. A SBP target of 120 mmHg is recommended in patients with a low syncope risk and a high cardiovascular risk. In patients with a high syncope risk and a low cardiovascular risk, and in older (70+) frail individuals, a less intensive treatment is advisable, targeting SBP of 140 mmHg. SBP values up to 160 mmHg can be tolerated in severe frailty or disability.Patients with hypertension and syncope may benefit from team-based care by a 'Blood Pressure Team' including experts on hypertension and syncope and a geriatrician. The team should carry out a multidimensional assessment to balance syncope and cardiovascular risk and develop therapeutic strategies customized to individuals' frailty and functional status.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/HJH.0000000000002555DOI Listing
December 2020

Plasma adenosine and neurally mediated syncope: ready for clinical use.

Europace 2020 06;22(6):847-853

Laboratory of Biochemistry, Timone Hospital, Marseille, France.

Either central or peripheral baroreceptor reflex abnormalities and/or alterations in neurohumoral mechanisms play a pivotal role in the genesis of neurally mediated syncope. Thus, improving our knowledge of the biochemical mechanisms underlying specific forms of neurally mediated syncope (more properly termed 'neurohumoral syncope') might allow the development of new therapies that are effective in this specific subgroup. A low-adenosine phenotype of neurohumoral syncope has recently been identified. Patients who suffer syncope without prodromes and have a normal heart display a purinergic profile which is the opposite of that observed in vasovagal syncope patients and is characterized by very low-adenosine plasma level values, low expression of A2A receptors and the predominance of the TC variant in the single nucleotide c.1364 C>T polymorphism of the A2A receptor gene. The typical mechanism of syncope is an idiopathic paroxysmal atrioventricular block or sinus bradycardia, most often followed by sinus arrest. Since patients with low plasma adenosine levels are highly susceptible to endogenous adenosine, chronic treatment of these patients with theophylline, a non-selective adenosine receptor antagonist, is expected to prevent syncopal recurrences. This hypothesis is supported by results from series of cases and from observational controlled studies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/europace/euaa070DOI Listing
June 2020

Blood pressure and long-term mortality in older patients: results of the Fiesole Misurata Follow-up Study.

Aging Clin Exp Res 2020 Oct 30;32(10):2057-2064. Epub 2020 Mar 30.

University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy.

Background: Optimal blood pressure (BP) control can prevent major adverse health events, but target values are still controversial, especially in older patients with comorbidities, frailty and disability.

Aims: To evaluate mortality according to BP values in a cohort of older adults enrolled in the Fiesole Misurata Study, after a 6-year follow-up.

Methods: Living status as of December 31, 2016 was obtained in 385 subjects participating in the Fiesole Misurata Study. Patients' characteristics were analysed to detect predictors of mortality. At baseline, all participants had undergone office BP measurement and a comprehensive geriatric assessment.

Results: After a 6-year follow-up, 97 participants had died (25.2%). After adjustment for comorbidities and comprehensive geriatric assessment, mortality was significantly lower for SBP 140-159 mmHg as compared with 120-139 mmHg (HR 0.54, 95% CI 0.33-0.89). This result was also confirmed in patients aged 75 + (HR 0.49, 95% CI 0.29-0.85), and in those with disability (HR 0.36, 95% CI 0.15-0.86) or taking antihypertensive medications (HR 0.49, 95% CI 0.28-0.86).

Discussion: An intensive BP control may lead to greater harm than benefit in older adults. Indeed, the European guidelines recommend caution in BP lowering in older patients, especially if functionally compromised, to minimize the risk of hypotension-related adverse events.

Conclusions: After a 6-year follow-up, mortality risk was lower in participants with SBP 140-159 mmHg as compared with SBP 120-139 mmHg, in the overall population and in the subgroups of subjects aged 75 + , with a disability or taking anti-hypertensive medications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s40520-020-01534-yDOI Listing
October 2020

Orthostatic hypotension and health outcomes: an umbrella review of observational studies.

Eur Geriatr Med 2019 Dec 7;10(6):863-870. Epub 2019 Nov 7.

Primary Care Department Azienda USL Toscana Sud Est, 58100, Grosseto, Italy.

Purpose: Orthostatic hypotension (OH) is associated with older age and many negative clinical outcomes in geriatric practice. We aimed to capture the breadth of outcomes that have been associated with the presence of OH and systematically assess the quality, strength and credibility of these associations using an umbrella review with integrated meta-analyses.

Methods: We systematically searched several major databases from their commencements through to 16th May 2019 for meta-analyses of observational studies of OH and any health-related outcome. We used these metrics to categorize the strength of evidence of significant outcomes (p < 0.05) from class I (convincing) to class IV (weak), according to the pre-established criteria.

Results: From 975 abstracts, seven meta-analyses of 12 outcomes were included. For each outcome, the median number of studies was four, and the median number of participants was 46,493, with a median of 3630 incident cases. There was suggestive (class III) evidence that OH was associated with significantly higher risk of coronary heart disease (HR = 1.32, 95% CI 1.12-1.56), stroke (HR = 1.22, 95% CI 1.08-1.38), congestive heart failure (HR = 1.30, 95% CI 1.09-1.55), all-cause mortality (RR = 1.50, 95% CI 1.24-1.81), falls (OR = 1.84, 95% CI 1.39-2.44), and dementia (HR = 1.22, 95% CI 1.11-1.35).

Conclusion: The current evidence base indicates that OH is significantly associated with a range of adverse cardiovascular, cognitive, and mortality outcomes in older people, although the strength of this evidence remains only suggestive. Further research in larger samples and with lower risk of bias is required to build a fuller picture of the impact of OH on health.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s41999-019-00239-4DOI Listing
December 2019

Autonomic dysfunction: Diagnosis and management.

Handb Clin Neurol 2019 ;167:123-137

Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States. Electronic address:

The autonomic nervous system is designed to maintain physiologic homeostasis. Its widespread connections make it vulnerable to disruption by many disease processes including primary etiologies such as Parkinson's disease, multiple system atrophy, dementia with Lewy bodies, and pure autonomic failure and secondary etiologies such as diabetes mellitus, amyloidosis, and immune-mediated illnesses. The result is numerous symptoms involving the cardiovascular, gastrointestinal, and urogenital systems. Patients with autonomic dysfunction (AUD) often have peripheral and/or cardiac denervation leading to impairment of the baroreflex, which is known to play a major role in determining hemodynamic outcome during orthostatic stress and low cardiac output states. Heart rate and plasma norepinephrine responses to orthostatic stress are helpful in diagnosing impairment of the baroreflex in patients with orthostatic hypotension (OH) and suspected AUD. Similarly, cardiac sympathetic denervation diagnosed with MIBG scintigraphy or F-DA PET scanning has also been shown to be helpful in distinguishing preganglionic from postganglionic involvement and in diagnosing early stages of neurodegenerative diseases. In this chapter, we review the causes of AUD, the pathophysiology and resulting cardiovascular manifestations with emphasis on the diagnosis and treatment of OH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/B978-0-12-804766-8.00008-XDOI Listing
April 2020

Renal function and delirium in older fracture patients: different information from different formulas?

Eur J Intern Med 2020 01 8;71:70-75. Epub 2019 Nov 8.

Geriatric Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Viale Pieraccini 6, 50139 Florence, Italy. Electronic address:

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-EPI, CKD-EPI, CKD-EPI) 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 m) 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-EPI).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejim.2019.10.022DOI Listing
January 2020

Increasing Prevalence of Orthostatic Hypotension as a Cause of Syncope With Advancing Age and Multimorbidity.

J Am Med Dir Assoc 2019 05 26;20(5):586-588. Epub 2019 Mar 26.

Department of Geriatrics, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamda.2019.01.149DOI Listing
May 2019

Usefulness of Tilt Testing and Carotid Sinus Massage for Evaluating Reflex Syncope.

Am J Cardiol 2018 08 1;122(3):517-520. Epub 2018 May 1.

Syncope Unit, Geriatric Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy. Electronic address:

Thirty years ago Tilt Testing (TT) was described as a tool in the diagnostic work-up of vasovagal syncope; after its initial success, some flaws have become evident. The concept of hypotensive susceptibility has provided the test a new relevance, shifting from diagnosis only, to therapeutic management. Carotid Sinus Massage (CSM) was introduced at the beginning of the XX century; the technique has evolved over years, whereas the concept of carotid sinus syndrome (CSS) has remained unchanged and uncontested for more than half a century. Nowadays, CSS is a matter of debate, with new classifications and criteria coming on the scene. Recently, a common central etiological mechanism has been hypothesized for reflex syncope, manifesting as CSS, vasovagal syncope or both. In this context, TT and CSM acquire an important role in clinical practice, being essential for a complete diagnosis and treatment. Recalling their historical background, the present paper illustrates an actual interpretation of TT and CSM.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjcard.2018.04.033DOI Listing
August 2018

Incidence and predictors of syncope recurrence after cardiac pacing in patients with carotid sinus syndrome.

Int J Cardiol 2018 Sep;266:119-123

Syncope Unit, Geriatric Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy. Electronic address:

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2018.03.144DOI Listing
September 2018

Retrospective analysis of patients with dizziness evaluated in Syncope Unit: a real life experience.

Eur Geriatr Med 2018 Jun 9;9(3):383-387. Epub 2018 May 9.

Syncope Unit, Department of Geriatrics, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.

Purpose: To evaluate the characteristics of patients referred for dizziness to a Syncope Unit.

Methods: 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).

Results: 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.

Conclusion: 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s41999-018-0058-yDOI Listing
June 2018

Syncope: Electrocardiographic and Clinical Correlation.

Card Electrophysiol Clin 2018 06;10(2):371-386

Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Azienda Ospedaliero Universitaria Careggi, Viale Pieraccini 6, Florence 50139, Italy.

Syncope is a frequent condition, owing to a transient global cerebral hypoperfusion, that may depend on a reduction of vascular total peripheral resistance and/or cardiac output. Cardiac syncope doubled the risk of death from any cause and increased the risk of nonfatal and fatal cardiovascular events. Arrhythmias are the most common cardiac causes of syncope. Both bradyarrhythmias and tachyarrhythmias may predispose to syncope. The first line evaluation relies on clinical history, physical examination, active standing test, 12-lead echocardiogram. The diagnostic yield of electrophysiological study in detecting the cause of syncope depends highly on the pretest probability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ccep.2018.02.007DOI Listing
June 2018

Differential diagnosis of unexplained falls in dementia: Results of "Syncope & Dementia" registry.

Eur J Intern Med 2018 04 3;50:41-46. Epub 2018 Feb 3.

Syncope Unit, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejim.2017.11.006DOI Listing
April 2018

Clinical differences among the elderly admitted to the emergency department for accidental or unexplained falls and syncope.

Clin Interv Aging 2017 13;12:687-695. Epub 2017 Apr 13.

Geriatrics Unit.

It is difficult to distinguish unexplained falls (UFs) from accidental falls (AFs) or syncope in older people. This study was designed to compare patients referred to the emergency department (ED) for AFs, UFs or syncope. Data from a longitudinal study on adverse drug events diagnosed at the ED (ANCESTRAL-ED) in older people were analyzed in order to select cases of AF, syncope, or UF. A total of 724 patients (median age: 81.0 [65-105] years, 66.3% female) were consecutively admitted to the ED (403 AF, 210 syncope, and 111 UF). The number of psychotropic drugs was the only significant difference in patients with AF versus those with UF (odds ratio [OR] 1.44; 95% confidence interval 1.17-1.77). When comparing AF with syncope, female gender, musculoskeletal diseases, dementia, and systolic blood pressure >110 mmHg emerged as significantly associated with AF (OR 0.40 [0.27-0.58], 0.40 [0.24-0.68], 0.35 [0.14-0.82], and 0.31 [0.20-0.49], respectively), while valvulopathy and the number of antihypertensive drugs were significantly related to syncope (OR 2.51 [1.07-5.90] and 1.24 [1.07-1.44], respectively). Upon comparison of UF and syncope, the number of central nervous system drugs, female gender, musculoskeletal diseases, and SBP >110 mmHg were associated with UF (OR 0.65 [0.50-0.84], 0.52 [0.30-0.89], 0.40 [0.20-0.77], and 0.26 [0.13-0.55]), respectively. These results indicate specific differences, in terms of demographics, medical/pharmacological history, and vital signs, among older patients admitted to the ED for AF and syncope. UF was associated with higher use of psychotropic drugs than AF. Our findings could be helpful in supporting a proper diagnostic process when evaluating older patients after a fall.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2147/CIA.S127824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5399985PMC
October 2017

Syncope and Epilepsy coexist in 'possible' and 'drug-resistant' epilepsy (Overlap between Epilepsy and Syncope Study - OESYS).

BMC Neurol 2017 Feb 28;17(1):45. Epub 2017 Feb 28.

Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini, 80131, Naples, Italy.

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 < 0.001).

Conclusions: Isolated syncope was diagnosed in ≈ 70% of patients with possible epilepsy. Syncope and epilepsy coexisted in ≈ 20% of patients with possible and in ≈ 60% of patients with drug-resistant epilepsy. These findings highlight the need of ESC guidelines of syncope approach in patients with possible and drug-resistant epilepsy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12883-017-0822-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5330016PMC
February 2017

In Hospital and 3-Month Mortality and Functional Recovery Rate in Patients Treated for Hip Fracture by a Multidisciplinary Team.

PLoS One 2016 7;11(7):e0158607. Epub 2016 Jul 7.

SOD Geriatria, AOU Careggi, Firenze, Italy.

Objectives: Medical comorbidities affect outcome in elderly patients with hip fracture. This study was designed to preliminarily evaluate the usefulness of a hip-fracture unit led by an internal medicine specialist.

Methods: In-hospital and 3-month outcomes in patients with hip fracture were prospectively evaluated in 121 consecutive patients assessed before and followed after surgery by a multidisciplinary team led by internal medicine specialist; 337 consecutive patients were recalled from ICD-9 discharge records and considered for comparison regarding in-hospital mortality.

Results: In the intervention period, patients treated within 48 hours were 54% vs. 26% in the historical cohort (P<0.0001). In-hospital mortality remained stable at about 2.3 per 1000 person-days. At 3 months, 10.3% of discharged patients had died, though less than 8% of patients developed postoperative complications (mainly pneumonia and respiratory failure). The presence of more than 2 major comorbidities and the loss of 3 or more BADL were independent predictors of death. 50/105 patients recovered previous functional capacity, but no independent predictor of functional recovery could be identified. Mean length of hospital stay significantly decreased in comparison to the historical cohort (13.6± 4.7 vs 17 ± 5 days, p = 0.0001). Combined end-point of mortality and length of hospitalization < 12 days was significantly lower in study period (27 vs 34%, p <0.0132).

Conclusions: Identification and stabilization of concomitant clinical problems by internal medicine specialists may safely decrease time to surgery in frail subjects with hip fracture. Moreover, integrated perioperative clinical management may shorten hospital stay with no apparent increase in in-hospital mortality and ultimately improve the outcome. These results are to be confirmed by a larger study presently ongoing at our institution.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0158607PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936690PMC
July 2017

High blood pressure and syncope: orthostatic hypotension as a link.

Monaldi Arch Chest Dis 2016 06 22;84(1-2):729. Epub 2016 Jun 22.

University of Florence.

The prevalence of hypertension increases with the age. Diagnostic criteria are the same as for the young, but in older adults isolated systolic hypertension is more frequent, due to loss of vascular compliance. Blood pressure should be measured on both sides in the seated position, moreover in the supine and upright position to detect orthostatic hypotension. Ambulatory blood pressure monitoring is useful to detect white coat hypertension and masked hypertension, to tailor the treatment and search for diurnal and nocturnal blood pressure pattern abnormalities. Given that frailty can affect the relationship between blood pressure and mortality, the clinician should properly evaluate and monitor physical performance and cognitive status, throughout specific tools, as the Fried Frailty Phenotype, aiming at a systolic blood pressure target between 130 and 150 mmHg. Before starting hypotensive drugs, a careful risk and benefits' evaluation should be performed given the high risk of hypertension and hypotension consequences and the frequent coexistence of orthostatic hypotension, which predisposes to syncope and falls.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4081/monaldi.2015.729DOI Listing
June 2016

Etiology of Syncope and Unexplained Falls in Elderly Adults with Dementia: Syncope and Dementia (SYD) Study.

J Am Geriatr Soc 2016 08 28;64(8):1567-73. Epub 2016 Jun 28.

Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.14225DOI Listing
August 2016

The pathophysiologic mechanisms associated with hypotensive susceptibility.

Clin Auton Res 2016 08 20;26(4):261-8. Epub 2016 Jun 20.

Division of Cardiovascular Medicine, School of Medicine and Public Health, University of Wisconsin, H4/534 Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792-3248, USA.

Introduction: Patients with vasovagal syncope (VVS) and positive tilt table test (TTT) were not found to benefit from pacing in the ISSUE-3 trial despite the presence of spontaneous asystole during monitoring. "Hypotensive susceptibility" unmasked by TTT was reported as a possible explanation. The purpose of this study was to assess the pathophysiologic mechanisms associated with hypotensive susceptibility.

Methods: 366 consecutive patients with the diagnosis of VVS who also had TTT were identified. Baroreflex gain (BRG) in addition to blood pressure (BP) and heart rate (HR) responses during the first 20 min of TTT were analyzed and compared between patients with positive TTT (n = 275, 75 %) and negative TTT (n = 91, 25 %).

Results: The mean BRG was similar between the groups (12.5 ± 6.3 versus 12.4 ± 6.3 ms/mmHg, p = 0.72); however, an age-dependent decrease was noted (17.6 ± 4.8, 15.0 ± 6.0, 10.6 ± 4.2, 10.3 ± 6.4 and 9.9 ± 8.5 ms/mmHg for patients <21, 21-40, 41-60, 61-80 and >80 years old, respectively; p < 0.001). In addition, we saw a main effect of age on the type of response with a greater prevalence of a vasodepressor response in older subjects (p < 0.001). During the first 20 min of TTT, BP was similar in patients with tilt-positive VVS when compared with patients with tilt-negative VVS; however, HR was significantly lower.

Conclusion: BRG is similar in tilt-positive VVS patients when compared with tilt-negative VVS patients. An age-dependent decrease in BRG was noted with a higher prevalence of a vasodepressor response seen in older patients. The clinical significance of the blunted HR response in tilt-positive VVS remains to be determined.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10286-016-0362-xDOI Listing
August 2016

Safety and tolerability of Tilt Testing and Carotid Sinus Massage in the octogenarians.

Age Ageing 2016 Mar 31;45(2):242-8. Epub 2016 Jan 31.

School of Medicine and Institute of Neuroscience, Trinity College, St James's Hospital, Dublin, Ireland.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ageing/afw004DOI Listing
March 2016

Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study.

Europace 2016 Sep 26;18(9):1427-33. Epub 2015 Nov 26.

Ospedale Villa Scassi, Genova, Italy.

Aims: The aim of this study was to determine the long-term effects and determinants of success of cardiac pacing in patients affected by reflex syncope enrolled in the Syncope Unit Project 2 (SUP 2) study. Initial results have validated the effectiveness of a standardized guideline-based algorithm which can be used in clinical practice in order to select suitable candidates for cardiac pacing.

Methods And Results: In this prospective, multicentre, observational study, patients aged >40 years, affected by severe unpredictable recurrent reflex syncope, 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. Of 281 patients who met the inclusion criteria, 137 (49%) received a pacemaker and were followed up for a mean of 26 ± 11 months: syncope recurred in 25 (18%) of them. At 3 years, the actuarial syncope recurrence rate was 20% [95% confidence interval (CI) 12-30] and was significantly lower than in 142 patients who did not receive a pacemaker and were observed by means of an ILR [43% (95% CI 29-57), P = 0.01]. The 3-year recurrence rate was not different among 78 CSM+, 38 TT+, and 21 ILR+ patients, whereas it was lower in 20 patients with negative TT [5% (95% CI 0-15)] than in 61 patients with positive TT [24% (95% CI 10-38)].

Conclusion: The benefit of cardiac pacing is maintained at 3 years, irrespective of the index diagnostic test, and is maximum in patients with negative TT.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01509534.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/europace/euv343DOI Listing
September 2016
-->