[Diagnostic algorithm of syncope: integrative approach]. / Diagnostický algoritmus synkop: integrativní prístup.

Syncope is a symptom, defined as transient loss of consciousness and postural tone with spontaneous and mostly prompt recovery. At first it is necessary to differentiate other non-syncopal transient loss of consciousness and simple falls, where thorough history taking is pivotal. EGSYS and OESIL risk scores seem to be contributional in initial risk stratification, however they are neither widely accepted nor a part of national guidelines. They are part of the European society of cardiology guidelines, though. Next it is essential expert ECG evaluation, thorough physical status examination, supine and standing blood pressure measurement and carotid sinus massage, if not contraindicated. Successively one has to decide if hospitalization or outpatient management is more suitable. Recently it has been shown, that so-called syncope management units (aimed for short-term hospitalization or fast outpatient examination, including vital function monitoring, echocardiography and facile cathlab access) are effective in fast syncope evaluation. Echocardiography, ECG monitoring and head-up tilt test should be a part of complex diagnostic evaluation. If syncope is not clarified by upon stated methods moreover syncope is recurrent, electrophysiological study, ILR implantation or both are justified. Despite of entire health practitioner's effort, more than 1/3 of syncopes remain unexplained.

[Head-up tilt test--do we really know all about it?]. / Polohový test--víme o nem opravdu vsechno?

Head-up tilt test (HUTT) falls within the competence of functional cardiological examination. Most often it is being used for the diagnostical approach to possibly neurally-mediated syncope, less is known about the possibility of using tilt table test in the treatment of vasovagal syncope. The main goal of this article is to make clear the principles, appropriate indication, performance and subsumption of HUTT in the algorithm of syncope investigation. Moreover it will be marginally mentioned how HUTT can be used in predicting cardiovascular risk of patients with coronary artery disease.

[Comparison of two types of devices for long-term Holter monitoring of the ECG in detection of heart arrhythmias]. / Srovnání pouzití dvou typu prístroju pro dlouhodobou Holterovu monitoraci EKG pri vysetrování srdecních arytmií.

UNLABELLED: The objective of the work was to compare the use of two types of long-term ECG monitors in examinations of cardiac arrhythmias and to find out whether their yields differed significantly when patients with a history of palpitations and syncope are examined. Two recorders, King of Heart with manual operation of the ECG tracing were used and the R test with continuous recording of the ECG tracing. For statistical processing contingence tables were used. For examination by the King of Heart recorders 111 patients (40 men and 71 women) were indicated, average age 48 years (14-84 years). 108 patients were examined. Yield I (number of patients with complaints)--89%. Yield II (number of patients with pathological ECG)--50%. In indications for palpitation pathological findings were recorded in 52% patients. In indication for syncope or presyncope pathological findings were recorded in 46% patients. Yield II in these two groups does not differ significantly (p = 0.9). For examination with an R test recorders 74 patients (30 men and 44 women) were indicated with a mean age of 52 years (18-85). Yield I (number of patients with complaints)--66%. Yield II (number of patients with complaints and a pathological ECG)--40%. Yield III (total number of pathological ECG findings)--79%. Yield IV (number of patients without complaints with a pathological ECG)--29%. In indication on account of palpitation there were pathological findings in 69% patients. In indication on account of syncope and presyncope pathological findings were recorded in 71% patients. Yield II does not differ significantly in these sub-groups (p = 1.0). Statistical comparison of the yield of the two instruments: in the basic indication on account of palpitation the yield of these methods does not differ significantly (p = 0.09). In the basic indication on account of syncope and presyncope the yield of the two methods does not differ significantly (p = 0.33). CONCLUSION: The yield of the two instruments for long-term Holter monitoring does not differ significantly, both can be recommended for examination of patients with suspected cardiac arrhythmias. The future belongs to instruments with continual ECG recording because of detection of asymptomatic arrhythmias.

[ECG Holter monitoring in the detection of cardiac arrhythmias yesterday, today and tomorrow]. / Holterova monitorace EKG pri vysetrování srdecních arytmií vcera, dnes a zítra.

The paper summarizes contemporary knowledge and technical possibilities of the use of Holter systems of 24-hour and long-term ECG monitoring in the diagnosis of cardiac arrhythmias. It evaluates the development of different types of equipment and indications for their use. It summarizes the yield of different types and mentions detailed limitations for their use and deals with the economic evaluation of different methods. Finally it summarizes contemporary technical possibilities and future perspectives such as transmission of data over the internet and combination of ECG monitoring with other non-invasive examinations.

Incidence and significance of chronotropic incompetence in patients with indications for primary pacemaker implantation or pacemaker replacement.

This prospective study was undertaken to evaluate the incidence and significance of chronotropic incompetence in 211 patients [age 71.1 6 10.6 years (mean 6 SD)] by means of maximum exercise test in order to determine the indication for rate-responsive pacing before primary pacemaker implantation (147 patients) or pacemaker replacement (64 patients). There were 112 (53%) patients with second- or third-degree AV block, 63 (30%) with sick sinus syndrome, and 36 (17%) with chronic atrial fibrillation. Chronotropic incompetence was defined as maximum heart rate lower than age-adjusted norm calculated by the formula: 0.7x(220 - age) and its significance as the difference between the two rates. The overall incidence of chronotropic incompetence was 42%. The incidence was significantly higher in patients with atrial fibrillation (67%, P<0.0005) and sick sinus syndrome (49%, P<0.012) than in those with AV block (30%). The mean difference between maximum heart rate and the age-adjusted norm was 18% (range 2%-63%). The mean difference was significantly higher in patients with atrial fibrillation (27%, range 8-63%) than in those with sick sinus syndrome (19%, range 2%-45%, P<0.01), or with AV block (12%, range 6%-26%, P<0.000001). The rate-responsive pacemakers were implanted in 44% of 211 patients studied and in 43% of 196 patients excluded from the study due to the apparent (contra)indication of rate-responsive pacing (NS). Thus, chronotropic incompetence seems to be common in the pacemaker patient population. The highest incidence and significance was found in patients with chronic atrial fibrillation. Systematic evaluation of chronotropic competence can double the rate of implantation of rate-responsive pacemakers; however, further studies are needed to clarify relation between the significance of chronotropic incompetence and functional benefit of rate-responsive pacing.

[Latent tetany in patients with a negative coronarographic finding]. / Výskyt latentní tetanie u pacientu s negativním koronarografickým nálezem.

UNLABELLED: Chest pain, constriction of the throat and palpitations are symptoms common to tetany and ischaemic heart disease. The objective of the work was to assess the latent prevalence of tetany in patients with typical chest pain and a negative outcome of coronarographic examination. The group comprised 20 patients (5 men and 15 women), mean age 54 years (28-74) with a history of chest pain, who had selective coronarography with a negative or minimal (up to 30% stenosis) outcome. In this group EMG, the ischaemic and hyperventilation test for latent tetany was made. A metabolic cause of tetany was ruled out. The results of the EMG test were positive in 10 patients (50%, 8 women, 2 men). Patients with a positive finding were treated with magnesium lactate by the oral route. All patients reported after one month regression of complaints. CONCLUSION: With regard to the high rate of positive EMG tests in patients with a history of chest pain and a negative coronarographic finding the authors recommend to add this simple test to the algorithm of examinations of these patients and supplement treatment according to its results.

[New trends in ECG Holter monitoring]. / Novejsí smery v Holterove monitorování EKG.

The authors review contemporary possibilities of Holter ECG monitoring. In the first group of patients they emphasize possibilities and the yield of long-term ambulatory ECG monitoring by means of an apparatus started by the patient. The second group of patients was examined by Holter monitoring, using an oesophageal lead. It is a method hitherto not used in the Czech Republic, which if properly indicated, improves the non-invasive diagnosis of cardiac arrhythmias.

Quality-of-life during DDD and dual sensor VVIR pacing.

Twenty-one patients (mean age 68 +/- 8 years) with dual-sensor (QT+activity) DDDR pacemaker were randomly assigned to a crossover, double-blind study in order to evaluate their quality-of-life scores. All pacemakers were implanted for sick sinus syndrome (8 patients) or complete heart block (13 patients). The pacemakers were randomly programmed to VVIR or DDD pacing modes for 2-week periods and then the pacing mode was switched for another 2-week period. At the end of each period, the quality-of-life was evaluated by a questionnaire with regard to cardiovascular symptoms, physical activity, psychosocial and emotional functioning, and self-perceived health. Nineteen questions were scored 0-5 points each. Significant improvement in the mean total quality-of-life score (20.5 +/- 14.9 vs 34.8 +/- 17.4) as well as in dyspnea on effort, dizzy spells, palpitation, sweating, fatigue, lethargy, emotional functioning, and self-perceived health was observed during DDD compared to VVIR pacing. No question was scored in favor of VVIR pacing mode. Significant improvements during DDD pacing was demonstrated in all subgroups of patients (sick sinus syndrome, chronotropically competent and incompetent patients, and patients with high degree AV block). Eighteen patients preferred DDD pacing mode, while only one preferred VVIR pacing mode. Two remaining patients expressed no preference. The results suggest that DDD pacing offers better quality-of-life than dual sensor VVIR pacing in all subgroups of patients commonly indicated for pacemaker implantation.

[Atrial rate and increased work capacity during DDD pacing in patients with a high level atrioventricular block]. / Sínová frekvence a zvýsení maximální pracovní kapacity DDD stimulací u nemocných s vyssím stupnem sínokomorové blokády.

Though the benefits of DDD pacing in patients with high-degree atrioventricular (AV) block are undisputable, it is desirable to identify--because of economic aspects--the subgroups of patients with maximum benefit from DDD pacing. An attempt has been made in the presented study to identify the subgroups of patients with a high increase in maximum working capacity during DDD pacing. The predictability of artificial pacemaker block based on atrial rate behaviour during exercise in heart block and VVI pacing has also been determined. The results are presented obtained in 26 patients with high-degree AV block and normal sinus function, who underwent exercise testing during AV block, VVI and DDD pacing. The benefit from DDD pacing in maximum working capacity was higher in patients with a lower resting atrial rate, steeper slope and a higher mean increase of atrial rate in the course of exercise during VVI pacing only. On the other hand, the maximum atrial rate during AV block is a good predictor of the incidence of artificial pacemaker block during exercise during DDD pacing and provides useful information for setting the upper rate limit of DDD pacemaker.

[Dual-cavity pacing for maximal work capacity in patients with a chronic high-grade atrioventricular block]. / Prínos dvoudutinové stimulace pro maximální pracovní kapacitu nemocných s chronickou sínokomorovou blokádou vyssího stupne.

Twenty-eight patients with a grade 2 and 3 atrioventricular block and an implanted DDD pacemaker were repeatedly subjected to a bicycle ergometric test with a maximum load of the AV block (VV30), ventricular stimulation (VVI70) and DDD stimulation. The maximum work capacity and maximum heart rate achieved on VVI30 were 92 + xi 38 W and 61 +/- 27/min. The maximum work capacity increased on DDD by 49% while on VVI70 only by 22% (p < 0.00001) and the maximum heart rate increased on DDD by 185%, while on VVI70 only by 41% (p < 0.00001). The authors found a significant correlation between the increment of the maximum work capacity on DDD, as compared with that on VVI70 (d maximum work capacity) and maximum work capacity at VVI70 (r = -0.53, p < 0.01), maximum work capacity on VVI30 (r = -0.437, p > 0.03), maximum heart rate at VVI70 (r = -0.415, p < 0.004) and age (r = 0.56, p < 0.005). The d maximum work capacity was significantly higher in patients without their own ventricular activity during the load on VVI70 (28 +/- 24% vs. 13 +/- 8%, p < 0.05 (in patients who did not attain the upper frequency limit of DDD stimulation (30 +/- 25% vs. 14 +/- 9%, p < 0.004) and in patients above 60 years of age (37 +/- 26% vs. 14 +/- 10%, p < 0.002).

[Permanent variable frequency cardiac pacing: which patients with chronic complete atrioventricular block profit most?]. / Trvalá kardiostimulace s promenlivou frekvencí: kterým nemocným s chronickou úplnou sínokomorovou blokádou nejvíce prospívá?

The authors examined 27 patients with chronic complete atrioventricular block (AVIII) and an implanted pacemaker with rate responsive pacing (RRP), controlled by atrial frequency (DDD stimulation--19 patients) or the length of the QT interval (VVIR pacing--8 patients). The loading test in AVIII ventricular stimulation 70/min (VVI 70) and RRP proved a more than double asset of MKP in RRP, as compared with VVI 70 (55.5 +/- 43.3% vs. 24.3 +/- 34.1%, p less than 0.001). The difference was greater in acquired than in congenital AVIII (27.7 +/- 18.5% vs. 8.4 +/- 4.1%, p less than 0.002) and in patients where the maximum heart rate on VVI did not exceed 70/min, as compared with the remainder (29.3 +/- 19.1% vs. 12.7 +/- 8.1%, p less than 0.002). The difference of MPK in RRP and VVI 70 was inversely correlated with MPK on VVI 70 (r = -0.412, p less than 0.03). MPK on AVIII and MTF on VVI 70 (r = -0.386, p less than 0.05). RRP in patients with AVIII thus causes a double increase of MPK, as compared with VVI pacing. A greater asset can be expected in patients with acquired AVIII, with a lower working capacity and heart rate recorded during the loading test before implantation.