Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms.

INTRODUCTION: We evaluated emergency physicians' (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients. METHODS: We administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule. RESULTS: The response rate was 68% (366/535). Respondents' median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests' bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful. CONCLUSION: EPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

'Cardiogenic vertigo'--true vertigo as the presenting manifestation of primary cardiac disease.

BACKGROUND: A 90-year-old woman presented to a hospital emergency department with a brief loss of consciousness that was heralded by spinning vertigo lasting approximately 2 min. She had a long history of intermittent brief episodes of rotatory vertigo, presyncope, and non-vertiginous dizziness, occurring either with or without loss of consciousness. Although initially attributed to symptomatic carotid artery stenosis, these episodes persisted, despite surgical restoration of carotid artery blood flow 1 year after her first syncope. Her medical history was otherwise notable for hypertension, mild depression and a gradual decline in gait and balance function attributed to left hip arthritis and older age. INVESTIGATIONS: Bedside history and examination, non-contrast head CT scan, electrocardiogram, transthoracic echocardiogram, and bedside cardiac telemetry. DIAGNOSIS: Sick sinus syndrome or severe reflex bradycardia with asystole causing recurrent, episodic vertigo, presyncope, non-vertiginous dizziness and syncope (Stokes-Adams attacks). MANAGEMENT: Placement of a temporary pacing wire, followed by surgical implantation of a single-chamber ventricular (VVI) pacemaker.

William Osler: slow pulse, stokes-adams disease, and sudden death in families.

In 1903, William Osler, then at Johns Hopkins University, published "On the So-Called Stokes-Adams Disease (Slow Pulse with Syncopal Attacks, etc.)" in The Lancet, classifying a syndrome in evolution. There are thinly disguised references to a brother and to himself in the article, suggesting that Osler was concerned about a family and personal predisposition. Osler's decision to move to Oxford was triggered in part by his personal concerns about cardiac disease. Then, in 1909, Osler contributed a chapter on Stokes-Adams disease to Allbutt and Rolleston's A System of Medicine, complemented by a brilliant pathologic section by the renowned anatomist-morphologist, Arthur Keith. Osler's original contributions involved his emphasis on the importance of family history, his careful clinical and natural history observations, and his recognition of the familial occurrence of bradycardia, Stokes-Adams disease, sudden death, and cardiomyopathy.

[Variant angina pectoris associated with Morgagni-Adams-Stokes syndrome--case report]. / Wazospastyczna postac dusznicy bolesnej z towarzyszacym zespolem Morgagniego- Adamsa-Stokesa--opis przypadku.

We report a case of Prinzmetal angina initially manifested with short losses of consciousness in a 55-year-old man hospitalized in the Department of Coronary Artery Disease, Institute of Cardiology, Jagiellonian University Medical College in Cracow. Clinical symptomatology of the presented case, causes and mechanism of loss of consciousness in variant angina as well as treatment methods are discussed.

[Complete atrioventricular block (with Adams-Stokes syndrome) in systemic connective tissue disease. Electrocardiographic development in three patients]. / Uplná sínokomorová blokáda (s Adams-Stokesovým syndromem) u systémových onemocnení pojivové tkáne. Elektrokardiografický vývoj u trí pozorovaných nemocných.

The association of high grade atrioventricular heart block with systemic connective tissue diseases is very rare. To date, only sporadic case reports or reviews appeared in the literature. Three cases of such association observed by the author are described here. The patients were a 51 years old man with systemic sclerosis and two women, a 64 years old patient with visceral nodous seropositive rheumatoid arthritis, and second was a 74 years old patient with systemic lupus erythematosus, the oldest of the group of patients with this disease. In two of the three patients, Adams-Stokes attack was a cause of death. The author did not observe this high grade atrioventricular block in patients with systemic connective tissue diseases the last 32 years. First and second grade heart blocks were, however, o chi asionally seen and responded well to the treatment of the systemic disease. Thus, in patients with systemic connective tissue diseases and emergency symptoms, it is recommended to consider also this rare association. While, two decades ago, patients frequently died after the Adams-Stokes attack, the treatment of the high grade block is now successful due the permanent cardiostimulator. In the last years, there are almost no reports about the association of systemic connective tissue diseases with high grade heart block, presumably because of the efficient new treatment approached to systemic diseases including modern immunomodulation drugs.

[Prinzmetal angina pectoris associated with 3rd degree atrioventricular block]. / Teljes atrioventricularis blokkal szövódött Prinzmetal-angina pectoris.

The authors report on the case of a 61 year-old female patient who was repeatedly taken to hospital because of chest pain and temporary loss of consciousness. During her hospitalization there was no ST elevation on the ECG, sinus bradycardia, other times atrial fibrillation was detected. The diagnosis was made by Holter monitoring three years after the onset of complaints. At this time chest pain set in after midnight, which was followed by loss of consciousness. Significant ST elevation and IIIrd degree AV block were detected. The coronarography showed non-significant coronary stenosis. According to the vasospastic patomechanism nitrate, calcium antagonist and acetylsalicylic acid therapy was administered and because of the complete AV block leading to syncope a VVI, M pacemaker was implanted. During the two years passed since the implantation of the pacemaker the patient had chest pain only once and it was not accompanied by syncope.

El vértigo en las urgencias médicas / Vertigo in medical emergency

El autor propone una revisión del síndrome vertiginoso dirigido a médicos residentes y generalistas que atiendan pacientes en los servicios de urgencias. Tras un breve repaso de todas las posibilidades etiológicas, se centra en la exploración básica urgente. Analiza de forma detenida los diferentes cuadros vertiginosos, propone un diagnóstico diferencial y sugiere un enfoque terapéutico inicial en cada caso (AU)

[The use of an implantable ECG recorder in the diagnosis of puzzling sporadic syncopes]. / Gebruik van een implanteerbare ECG-recorder bij de diagnostiek van onbegrepen wegrakingen.

A 70-year-old man had passed out three times in six years, and was suspected of having a rhythm or conduction disturbance. Repeated hospitalization with telemetric monitoring had not revealed any disease. An implantable ECG recorder finally revealed the occurrence of symptomatic sinus arrest (Adams-Stokes attack), a month after discharge from the hospital. The patient was treated with a pacemaker. The cause of recurrent syncope can be difficult to diagnose. There is always a danger of overdiagnosis or under-treatment. Prospective study and cost effectiveness analysis are needed to determine the proper place of the implantable ECG recorder in the diagnosis of this disease.

Recovery from congenital complete atrioventricular block.

Congenital complete atrioventricular block without any other intracardiac anomaly reverted to sinus rhythm at the age of 7 years. The girl had had heart failure and Adams-Stokes attacks when aged 1 year, requiring pacemaker implantation. Electrocardiography confirmed sinus rhythm for the first time at the age of 7 years. At the same time, a treadmill test yielded a normal tracing without any arrhythmias.

Complete heart block in Reiter's syndrome.

Complete heart block with Stokes-Adams attacks was diagnosed in a 30 year old male, who had suffered from a Reiter's syndrome for only 3 1/2 years. The heart block was unaffected by treatment with high dose corticosteroids, and a permanent pacemaker was implanted. There were no signs of concomitant aortic insufficiency or spondylitis/sacroiliitis.