Table of contents Preamble Scope of the document 1256 Method 1257 Part 1. Classification, epidemiology and prognosis Definition 1258 Brief overview of pathophysiology of syncope 1258 Classification 1259 Epidemiological considerations 1259 Prognostic stratification: identification of factors predictive of adverse outcome 1260 Part 2. Diagnosis Strategy of evaluation (flow chart) 1262 Initial evaluation (history, physical examination, baseline electrocardiogram) 1264 Echocardiogram 1266 Carotid sinus massage 1266 Tilt testing 1268 Electrocardiographic monitoring (non-invasive and invasive) 1271 Electrophysiological testing 1273 ATP test 1277 Ventricular signal-averaged electrocardiogram 1278 Exercise testing 1278 Cardiac catheterization and angiography 1279 Neurological and psychiatric evaluation 1279 Diagnostic yield and prevalence of causes of syncope 1282

Guidelines on management (diagnosis and treatment) of syncope

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules).

In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed including the assessment of the risk/benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and  2 .

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 Table 1 
Classes of recommendations



View this table:

 Table 2 
Levels of evidence



The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified …

/pdf/guidelines-for-cardiac-pacing-and-cardiac-resynchronization-e8x9bszgsr.pdf

Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association.

Guidelines on management (diagnosis and treatment) of syncope--update 2004.

Clinical profile and long-term follow-up of 37 families with arrhythmogenic right ventricular cardiomyopathy.

Objective: The aim of the present study was to assess the prevalence of subtle morphologic substrates, clinically unrecognizable, underlying sudden cardiac death (SCD) in young people with apparently normal heart. Methods: In the time interval 1979–1998, 273 consecutive cases of SCD in young people (≤35 years) which occurred in the Veneto Region of Italy were prospectively studied. Following exclusion of extracardiac causes of sudden death, the heart was examined according to a detailed morphologic protocol consisting of macroscopic and histologic examination, including study of the specialized conduction system by serial sections. Results: At macroscopic examination, 197 SCD victims (72%) had an overt underlying structural heart disease such as cardiomyopathy in 56, obstructive coronary atherosclerosis in 54, valve disease in 32, non-atherosclerotic coronary artery disease in 28, aortic rupture in 13, postoperative congenital heart disease in five, and other disease in nine. The remaining 76 cases (28%) (50 males and 26 females, aged 4–35 years, mean 23±5 years) had a macroscopically normal heart. A total of 28 of them (37%) had experienced one or more of the following prodroma: syncope, palpitations or both in 20, ECG abnormalities in 18 and arrhythmias in ten. In 79% of them, histologic examination disclosed concealed pathologic substrates consisting of focal myocarditis in 27 cases, regional arrhythmogenic right ventricular cardiomyopathy, mostly localized to RV outflow tract, in nine, and conduction system abnormalities in 24 (leading to ventricular preexcitation in 18 and heart block in six). In 16 hearts (6%) there was no evidence of structural heart disease even after histologic study. Conclusion: Macroscopic heart features were normal in nearly one-third of young SCD victims. In 79% of them, however, histologic study unmasked concealed pathologic substrates such as focal myocarditis or cardiomyopathy and conduction system diseases. A total of 16 victims (6%) had no evidence of structural heart disease and the mechanism of their SCD remained unexplained.

/pdf/sudden-cardiac-death-in-young-people-with-apparently-normal-1x5wpyy6zu.pdf

Sudden cardiac death in young people with apparently normal heart

Arrhythmogenic right ventricular dysplasia is responsible for ventricular tachycardia affecting an apparently healthy heart. It can sometimes lead to sudden death, which may be the presenting symptomatology of the disease. It results from fibro-adipose infiltration of the free wall of the right ventricle, and sometimes of the septum, possibly secondary to myocarditis. The prognosis depends upon the quality of the left ventricle. If it is healthy, the only risk is that of arrhythmia. Treatment using anti-arrhythmic drugs is most often effective and, with proper management, the prognosis is good and the risk of sudden death eliminated. If the left ventricle is abnormal, there is the risk that dysplasia associated with arrhythmia will progress to right then congestive cardiac failure in the context of a dilated idiopathic cardiomyopathy with ventricular tachycardias originating on the right side. Arrhythmogenic right ventricular dysplasia is a notable cause of sudden death in athletes. Routine screening of such individuals is justified, as is that of those with high risk occupations (locomotive and vehicle drivers, etc.).

Right ventricular dysplasia

Arrhythmogenic right ventricular dysplasia (ARVD) may result in sudden death of young and sometimes athletic individuals, while if properly treated it is associated with a good prognosis. It is probably more widespread than currently thought. Comparison of the electrocardiograms of 43 ARVD patients with those of 44 normal individuals provided a new criterion enabling identification of the disease. Measurement of a QRS interval longer than 110 ms in sinus rhythm in lead V1 in an individual with an apparently normal heart enabled identification of the disease with a sensitivity of 55 p. cent and specificity of 100 p. cent if used alone, and a sensitivity of 60 p. cent if used in combination with a prolongation of QRS in lead V3 to greater than 110 ms, but with a specificity of 82 p. cent. After elimination of appearances of right bundle branch block, sensitivity was 50 p. cent for V1. This parameter studied in a hospital population should be validated in minor forms before leading to compulsory ECGs for individuals in high-risk occupations (athletes, public vehicle drivers, etc.).

[Duration of QRS complexes in arrhythmogenic right ventricular dysplasia. A new non-invasive diagnostic marker].

Endocavitary diathermy consists of transmitting the energy of a defibrillator shock to the tip of an intracardiac catheter. The circuit is completed via a neutral plate placed under the patient's back. Energies in the order of 200 to 300 joules produce an electric arc at the catheter tip which causes an abrupt variation in pressure and the creation of a shock wave which modifies the myocardial structures directly in contact with the catheter. This method, which was originally used to treat supraventricular arrhythmias by interrupting the conduction in the His bundle, has recently been extended to the treatment of resistant ventricular tachycardia, and has even been used to interrupt the accessory pathway in certain cases of Wolff-Parkinson-White syndrome. The authors report the basic experimental data and the clinical results obtained with this method in the treatment of 20 cases of arrhythmia, especially in various types of ventricular tachycardia. The very promising results obtained, particularly in cases of ventricular tachycardia, suggest that this is a radical method which can be extended to patients unable to support a surgical operation. Although the follow-up period is only short, these results are encouraging. They confirm the basic principle of diathermy in the treatment of supraventricular tachycardia by interruption of the conduction in the His bundle and for the radical treatment of chronic ventricular tachycardia unresponsive to medical treatment. However, a longer follow-up period is required before we can demonstrate the long term effectiveness of this new therapeutic method.

Endocavitary fulguration. A new method of treating arrhythmia

La sus-denivellation non coronaire du segment ST en precordiales droites a ete decrite chez des sujets ayant presente des episodes de fibrillation ventriculaire au repos. Ce syndrome a ete rapporte a des phenomenes fonctionnels ou a des anomalies structurelles du myocarde. Un cas personnel montre son appartenance aux deux categories : la sus-denivellation du segment ST observee avant, pendant et apres des episodes de trouble du rythme est comparee a Il electrocardiogrammes de la litterature. La dysplasie du ventricule droit est demontree par l'electrocardiographie, l'electrophysiologie et l'echocardiographie. D'autre part, la sus-denivellation du segment ST est classee en trois categories : les formes triangulaire et en dome sont le plus souvent observees au moment des troubles du rythme, la derniere « en selle », jusqu'ici non decrite, apparait comme un equivalent mineur observe en dehors des episodes critiques. Ce dernier aspect est retrouve chez 30 % des cas de dysplasie ventriculaire droite arythmogene cliniquement identifies.

Right precordial leads and sudden death. Relation with arrhythmogenic right ventricular dysplasia

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