- Email: [email protected]
Long-term outcome of patients with syncope associated with coronary artery disease and a nondiagnostic electrophysiologic evaluation
ABSTRACTS
pain or rapid deterioration of previously stable angina within 24 hours met inclusion criteria if they had EC6 changes compatible with myocardial ischemia, a history of previous myocardial infarction, positive findings on coronary angiography or myocardial scintigraphy, ora positive stress test. Of the 1,209 patients enrolled in the Thrombin Inhibition in Myocardial Ischemia (TRIM) trial (a prospective, double-blind randomized trial), 232 patients qualified for this study. Approximately two thirds of these patients were classified as having unstable angina pectoris, although almost one third had non-Q-wave myocardial infarctions. The study found that patients with a cTnT level greater than or equal to 0.20 [~m/L or at least 1 episode of ST-segment elevation were at a 3.1% risk of death or acute myocardial infarction within 30 days. Patients with both cTnT elevations and STsegment elevation events had a 25,8% event rate by 30 days. Patients with neither risk factor had a 1.7% event rate for the same interval. Identifying the low-risk patients in this latter category could allow for shortened ICU stays in this group. The authors concluded that ST-segment monitoring enhances the prognostic value of troponin levels in the risk stratification of UCAD patients.
[Editor's note: The authors do not emphasize that, of the 65patients with elevated troponin levels, there were no subsequent events in the 27patients who had less than 1episode of ST-segmentelevation during the 24-hour monitoring period. A larger study, perhaps using several levels of c TnT, is needed to define this potentially important subgroup of patients.] Bruce Evans, MO
Suicide within 12 months of contact with mental health services: National clinical survey Appleby L, Shaw J, Amos T, et al BMJ 318:1235-1239 May 1999 This retrospective survey sought to characterize the clinical circumstances under
OCTOBER 1999, PART 1
34:4
which psychiatric patients commit suicide. The study compared 2,177 suicides reported to Britain's National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, based atthe University of Manchester. All cases involved patients who had contact with mental health services in the year before death, which accounted for approximately one quarter of all suicides reported to the inquiry. Psych.iatric inpatient and outpatient cases were included. Men were most likelyto die by hanging. Women most frequently used psychotropic drugs to commit suicide by overdose. The most common primary diagnoses were depression, schizophrenia, personality disorder, and alcohol dependence. Thirty-eight percent had a history of alcohol abuse, whereas 28% bad abused other drugs. Twenty-two percent of suicides occurred within the first year of onset of the primary disorder, 67% had a history of previous admission to a mental health service, and 63% had a history of self-harm. One hundred eighty-six of the 2,177 cases considered occurred in outpatient settings before the first scheduled follow-up appointment, with the highest incidence being in the week after discharge from an inpatient facility. During the final contact before suicide, 84% of patients were felt by providers to be at low or no risk of suicide. Although this questionnaire-based study lacked case controls and probably incorporated bias on the part of reporting clinicians, the authors noted several interventions that could lower the incidence of suicide. Inpatient cases suggested that structural considerations to reduce hangings and minimize barriers to direct observation would result in fewer deaths. Closer supervision, including immediate follow-up and improved medication compliance, was identified as being most likelyto reduce the frequency of outpatient suicides.
Long-term outcome of patients with syncope associated with coronary artery disease and a nondiagnostic electrophysiologic evaluation Link MS, Kyong-Mee SK, Homoud MK, et al Am J Cardiol 83:1334-1337 May 1999 This article represents a longitudinal survey of outcomes in patients with coronary artery disease (CAD)and negative electrophysiologic (EPS)testing. Sixty-eight patients with syncope, CAD, and a nondiagnostic EPStest were enrolled and followed for an average of 30 months (range 1 to 65 months). During that time 17 patients (25%) had recurrent symptoms. Eight of these patients were subsequently found to have symptomatic bradycardia or heart block. Eighty-eight percent of these had a bundle branch block on initial presentation. Medication reactions (2), seizures (1), and supraventriculartachycardia (1)accounted for 4 of the remaining syncopal events. The remaining recurrent syncope remained undiagnosed. Three patients had implanted cardioverter/defibrillators (ICDs) placed on presentation despite a negative workup and 2 of these patients demonstrated ventricular arrhythmias during the follow-up period. There were 7 (10%) deaths during the follow-up period; 2 from sudden cardiac death and 3 from heart failure.
[Editor's note: Only 13% of individuals who committed suicide were thought to be at moderate risk at the time of final contact, whereas only2% were categorized as high risk. A Io wer threshold for inclusion in these categories appears to be needed in order to identify at-risk patients.]
[Editor's note: The authors conclude that patients with CAD and syncope have a high risk for recurrent events even in the face of negative EPS studies. Although many of these events (12%) were relatively benign bradycardias or heart blocks, a significant percentage (6%) were sudden cardiac death or ventricular arrhythmias. The authors do not conclude that pacemaker/ /CO devices should be implanted prophylactically in all of these pa tients, but they do make the point that further studies should attempt to delineate a subgroup of patients who might benefit from this therapy.]
Bruce Evans, MD
Kevin Merrell, MD, PhD
ANNALS OF EMERGENCY MEDICINE
57 1
pain or rapid deterioration of previously stable angina within 24 hours met inclusion criteria if they had EC6 changes compatible with myocardial ischemia, a history of previous myocardial infarction, positive findings on coronary angiography or myocardial scintigraphy, ora positive stress test. Of the 1,209 patients enrolled in the Thrombin Inhibition in Myocardial Ischemia (TRIM) trial (a prospective, double-blind randomized trial), 232 patients qualified for this study. Approximately two thirds of these patients were classified as having unstable angina pectoris, although almost one third had non-Q-wave myocardial infarctions. The study found that patients with a cTnT level greater than or equal to 0.20 [~m/L or at least 1 episode of ST-segment elevation were at a 3.1% risk of death or acute myocardial infarction within 30 days. Patients with both cTnT elevations and STsegment elevation events had a 25,8% event rate by 30 days. Patients with neither risk factor had a 1.7% event rate for the same interval. Identifying the low-risk patients in this latter category could allow for shortened ICU stays in this group. The authors concluded that ST-segment monitoring enhances the prognostic value of troponin levels in the risk stratification of UCAD patients.
[Editor's note: The authors do not emphasize that, of the 65patients with elevated troponin levels, there were no subsequent events in the 27patients who had less than 1episode of ST-segmentelevation during the 24-hour monitoring period. A larger study, perhaps using several levels of c TnT, is needed to define this potentially important subgroup of patients.] Bruce Evans, MO
Suicide within 12 months of contact with mental health services: National clinical survey Appleby L, Shaw J, Amos T, et al BMJ 318:1235-1239 May 1999 This retrospective survey sought to characterize the clinical circumstances under
OCTOBER 1999, PART 1
34:4
which psychiatric patients commit suicide. The study compared 2,177 suicides reported to Britain's National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, based atthe University of Manchester. All cases involved patients who had contact with mental health services in the year before death, which accounted for approximately one quarter of all suicides reported to the inquiry. Psych.iatric inpatient and outpatient cases were included. Men were most likelyto die by hanging. Women most frequently used psychotropic drugs to commit suicide by overdose. The most common primary diagnoses were depression, schizophrenia, personality disorder, and alcohol dependence. Thirty-eight percent had a history of alcohol abuse, whereas 28% bad abused other drugs. Twenty-two percent of suicides occurred within the first year of onset of the primary disorder, 67% had a history of previous admission to a mental health service, and 63% had a history of self-harm. One hundred eighty-six of the 2,177 cases considered occurred in outpatient settings before the first scheduled follow-up appointment, with the highest incidence being in the week after discharge from an inpatient facility. During the final contact before suicide, 84% of patients were felt by providers to be at low or no risk of suicide. Although this questionnaire-based study lacked case controls and probably incorporated bias on the part of reporting clinicians, the authors noted several interventions that could lower the incidence of suicide. Inpatient cases suggested that structural considerations to reduce hangings and minimize barriers to direct observation would result in fewer deaths. Closer supervision, including immediate follow-up and improved medication compliance, was identified as being most likelyto reduce the frequency of outpatient suicides.
Long-term outcome of patients with syncope associated with coronary artery disease and a nondiagnostic electrophysiologic evaluation Link MS, Kyong-Mee SK, Homoud MK, et al Am J Cardiol 83:1334-1337 May 1999 This article represents a longitudinal survey of outcomes in patients with coronary artery disease (CAD)and negative electrophysiologic (EPS)testing. Sixty-eight patients with syncope, CAD, and a nondiagnostic EPStest were enrolled and followed for an average of 30 months (range 1 to 65 months). During that time 17 patients (25%) had recurrent symptoms. Eight of these patients were subsequently found to have symptomatic bradycardia or heart block. Eighty-eight percent of these had a bundle branch block on initial presentation. Medication reactions (2), seizures (1), and supraventriculartachycardia (1)accounted for 4 of the remaining syncopal events. The remaining recurrent syncope remained undiagnosed. Three patients had implanted cardioverter/defibrillators (ICDs) placed on presentation despite a negative workup and 2 of these patients demonstrated ventricular arrhythmias during the follow-up period. There were 7 (10%) deaths during the follow-up period; 2 from sudden cardiac death and 3 from heart failure.
[Editor's note: Only 13% of individuals who committed suicide were thought to be at moderate risk at the time of final contact, whereas only2% were categorized as high risk. A Io wer threshold for inclusion in these categories appears to be needed in order to identify at-risk patients.]
[Editor's note: The authors conclude that patients with CAD and syncope have a high risk for recurrent events even in the face of negative EPS studies. Although many of these events (12%) were relatively benign bradycardias or heart blocks, a significant percentage (6%) were sudden cardiac death or ventricular arrhythmias. The authors do not conclude that pacemaker/ /CO devices should be implanted prophylactically in all of these pa tients, but they do make the point that further studies should attempt to delineate a subgroup of patients who might benefit from this therapy.]
Bruce Evans, MD
Kevin Merrell, MD, PhD
ANNALS OF EMERGENCY MEDICINE
57 1