Alternating anterior and posterior fascicular block and left septal fascicular block.

Electrocardiogram of a patient affected by hypertensive cardiomyopathy showed an anterior fascicular block pattern and in right precordial leads an anterior displacement of QRS complex, characterised by a well evident jump of r wave from V1 to V2. Lead V2 showed qR morphology with embryonic q wave and very tall R wave. Septal q waves were not present in leads I and aVL. A subsequent electrocardiogram showed a posterior fascicular block pattern and the same findings in right precordial leads. Septal q waves were not present in inferior leads. Other causes of anterior displacement of QRS complex were ruled out by clinical/instrumental investigation. These findings are highly suggestive of left septal (middle) fascicular block coexisting with anterior and posterior fascicular block.

Different degrees of anterior displacement of QRS complex.

Electrocardiogram of a patient affected by hypertrophic cardiomyopathy showed normal PR and QRS intervals and signs of left ventricular hypertrophy. In leads I,V5 and V6 the initial q waves were absent. A subsequent electrocardiogram revealed the appearance of prominent anterior QRS forces expressed by a change from rS to R pattern in leads V2 and V3 with a tall R wave in V2. PR and QRS intervals and QRS axis remained substantially unchanged. Other electrocardiograms showed day-to-day variations of the anterior displacement of QRS complex. The different degrees of anterior displacement appear to be an expression of an underlying left septal fascicular block, but a diagnosis cannot be made with certainty.

The Rate of Asystolic Reflex Syncope Is Not Influenced by Age.

BACKGROUND: The head-up tilt test (HUT) and other evidence suggest that the vagal effect on the heart decreases with age. OBJECTIVES: The main aim of the study was to assess whether this age effect also affects the rate of asystole in spontaneous reflex syncope (RS). METHOD: We performed an analysis of pooled individual data from 4 studies that recruited patients ≥40 years of age affected by certain or suspected RS who received an implantable loop recorder (ILR) and reported follow-up data on syncope recurrence. We assessed the presence of asystolic syncope of >3 seconds or nonsyncopal asystole of >6 seconds recorded by ILR and compared the findings to tilt test results on the same patients. RESULTS: A total of 1,046 patients received ILR because of unexplained syncope. Of these, 201 (19.2%) had a documentation of an asystolic event of 10-second (Q1-Q3: 6- to 15-second) duration. They were subdivided in 3 age tertiles: ≤60 years (n = 64), 61 to 72 years (n = 72), and ≥73 years (n = 65). The rate of asystolic events was similar in the 3 subgroups (50.1%, 50.1%, and 49.2%, respectively; P = 0.99). Conversely, the rate of asystolic syncope induced during HUT (performed in 169 of 201) was greatly age dependent (31.0%, 12.1%, and 11.1% in increasing age tertiles, respectively; P = 0.009). CONCLUSIONS: The rate of the spontaneous asystolic form of RS documented by ILR is constant at any age >40 years. Conversely, the rate of asystolic syncope induced by HUT is higher in younger patients and decreases with age. The contrasting results between spontaneous and tilt-induced events cast doubt on the concept that asystole in RS is less common in older patients.

[Tall R waves in the right precordial leads as a possible expression of left septal fascicular block]. / Ampie onde R nelle derivazioni precordiali destre quale possibile espressione di un blocco del fascicolo settale della branca sinistra.

Histological, physiological and pathophysiological studies have shown that the left bundle branch mainly divides into three fascicles, and a septal (middle) fascicle is present in over half of human hearts. Electrocardiographic criteria for the diagnosis of the block of this fascicle have been suggested by some authors: tall R waves in lead V2 and sometimes in V1 in the absence of a right bundle branch block pattern or a well evident jump of R waves from V1 to V2, absence of initial septal q waves and/or possible small q waves in the right precordial leads, normal QRS duration and normal QRS axis. At present, this intraventricular block can only be suspected but not diagnosed with certainty even after clinical/instrumental exclusion of pathological situations associated with tall R waves in leads V1 and V2 (right ventricular hypertrophy, lateral infarction, severe septal hypertrophy) because of the marked variability of normal ECG and the potential presence of confounding diseases.

Intermittent isolated anterior displacement of QRS complex - Differential diagnosis.

BACKGROUND: The proposed criteria for diagnosis of left septal (middle) fascicular block (LSFB) appear to be conflicting. Moreover, it has been claimed that isolated anterior displacement (AD) of QRS complex could be a manifestation of a conduction delay of the right bundle branch, besides of LSFB. The purpose of the present study was to better define the etiology of AD through an analysis of the case reports dealing with intermittent AD, published up to now. METHODS: PubMed search was performed to include all case reports dealing with intermittent AD occurring spontaneously, with an available 12­lead electrocardiographic recording. Pertinent data were extracted from the papers for further analysis. RESULTS: Eighteen case reports were found in the literature; in all cases intermittent AD was attributed to LSFB. In all cases AD was associated to changes of initial QRS forces, characterized by disappearance of septal q waves (in I and V6) and/or appearance of a small q wave in leads V1-V3. Morphology of terminal QRS forces, analysed for the first time, was unchanged in 90% of cases. Some Isolated ADs observed during induction of premature atrial extra-stimuli and recorded by vectorcardiographic tracing and some electrocardiographic leads were attributed to a conduction delay of the right bundle branch. In this case, initial QRS forces did not change and terminal QRS forces shifted to the right. CONCLUSIONS: In the presence of intermittent isolated AD, a differential diagnosis between LSFB and a conduction delay of the right bundle branch appears to be possible by the analysis of initial and terminal QRS forces. Instead, the diagnosis of permanent LSFB remains a challenge.

[Neurally mediated syncope starting in young or in old age: different prognostic significance?] / La sincope neuromediata ad esordio nel giovane o nell'anziano: diverso significato prognostico?

Neurally mediated syncope (NMS) is the clinical manifestation of the vasovagal reflex activation. Prognosis of this type of syncope is reported as "benign", mainly on the basis of the results of the Framingham study, in which the incidence of mortality, cardiovascular and cerebrovascular events did not differ from that of the control population. However, in this study NMS starting in young age and that starting in advanced age were investigated together, but some elements suggest that we are dealing with two different clinical entities, even if the efferent pathways of the reflex circuit appear to be the same. While it is largely accepted that NMS starting in young age is a manifestation of a non-pathological trait, some lines of evidence suggest that NMS starting in old age is the expression of a pathological process of the autonomic nervous system, up to now not well defined from the nosological point of view: (i) onset in old age per se, (ii) absence of triggers, which means "abnormal activation" (pathological) of the vasovagal reflex, (iii) frequent overlap with situational syncope, carotid sinus hypersensitivity, orthostatic or post-prandial hypotension and other dysautonomic symptoms, and (iiii) it appears to be the human homologue of a recently described syncope starting in dogs in advanced age; in other words, humans and dogs seem to suffer from the same disease. On the basis of these considerations, in future studies the prognostic significance of NMS starting in old age should be investigated separately. At present, the prognosis of NMS, in relation to hard events, remains undefined in the elderly.

Role of new drug therapies and innovative procedures in older patients with heart failure: from trials to clinical practice.

During earliest years, new drug-therapies and novel interventional therapies have been tested to modify the detrimental effect of secondary valve diseases, adverse ventricular remodelling and persistent fluid overload in HF patients. However, the increased prevalence of older or very old patients with HF has made their widespread implementation more problematic due to complex comorbidity, frailty, or overt disability. This growing older population, often excluded by randomized trials, but with elevated risk of hospitalization, required a different clinical and management approach that allows clinicians to take full advantage in reducing mortality and morbidity from these new pharmacological and instrumental therapies. In this perspective, the role of multidisciplinary Heart Team is mandatory for better define a correct decision-making process and tailoring the best pharmacological therapy in each patient and to program a continuum care in a post-acute phase of treatment. In addition, the possibility to plan multicentre registries of several complex cases evaluated by Heart Team could become a very important source of real world data to further refine indications and contraindications of different highly technological therapeutic approach, today based often on randomized clinical trials that do not represent faithfully the current clinical practice population.

The older patient with cardiovascular disease: background and clinical implications of the comprehensive geriatric assessment.

Principles and processes of comprehensive geriatric assessment (CGA) are increasingly being applied to subspecialties and subspecialty conditions, including cardiovascular patients (i.e., infective endocarditis; considerations of surgery or transcatheter aortic valve replacement, TAVR, for patients with aortic stenosis; vascular surgery) and postoperative mortality risk. In cardiovascular field CGA has mainly the aim to define ideal management according to the different typology of older adult patients (e.g., robust versus intermediate versus physical and cognitively disabled versus end-stage or dying), allowing physicians to select different therapeutic goals according to life expectancy; Aspect to be valued are by CGA are global health status and patient's decision-making capacity: CGA allows the individualized treatment definition and optimize the preprocedure condition.

Hypertension in the elderly: why one size does not fit all.

Over recent years, managing hypertension in older people has gained increasing attention, with reference to very old, frailer individuals. In these patients, hypertension treatment may be challenging due to a higher risk of hypotension-related adverse events which commonly overlaps with a higher cardiovascular risk. Additionally, frailer older adults rarely satisfy inclusion criteria of randomized clinical trials, which determines a substantial lack of scientific data. Although limited, available evidence suggests that the association between blood pressure and adverse outcomes significantly varies at advanced age according to frailty status. In particular, the negative prognostic impact of hypertension seems to attenuate or even revert in individuals with older biological age, e.g., patients with disability, cognitive impairment, and poor physical performance. Consequently, "one size does not fit all" and personalized treatment strategies are needed, customized to individuals' frailty and functional status. Similar to other cardiovascular diseases, hypertension management in older people should be characterized by a geriatric approach based on biological rather than chronological age and a geriatric comprehensive evaluation including frailty assessment is required to provide the most appropriate treatment, tailored to patients' prognosis and health care goals. The aim of this review was to illustrate the importance of a patient-centered geriatric approach to hypertension management in older people with the final purpose to promote a wider implementation of frailty assessment in routine practice.

Evidence and uncertainties in the management of atrial fibrillation in the elderly.

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to most patients affected from AF. Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications. Scientific literature focused on the three items will be discussed. Practical treatment of older AF patients is presented, including approach and management of patients with geriatric syndromes, selection of the most appropriate individualized drug treatment, clinical indications, and potential clinical benefit of LAAO and CA in selected older AF patients. Older people carry the greatest burden of AF in real world practice. Within a shared decision-making process, the patient centered approach needs to be put in the context of a comprehensive assessment, in order to gain maximal net clinical benefit and avoid futility or harm.

Severe aortic stenosis and transcatheter aortic valve replacement in elderly patients: utility vs. futility.

Recently, transcatheter aortic valve replacement (TAVR) has emerged as established standard treatment for symptomatic severe aortic stenosis, providing an effective, less-invasive alternative to open cardiac surgery for inoperable or high-risk older patients. In order to assess the anticipated benefit of aortic replacement, considerable interest now lies in better identifying factors likely to predict outcome. In the elderly population frailty and medical comorbidities have been shown to significantly predict mortality, functional recovery and quality of life after transcatheter aortic valve replacement. Scientific literature focused on the three items will be discussed. High likelihood of futility is described in patients with severe chronic lung, kidney, liver disease and/or frailty. The addition of frailty components to conventional risk prediction has been shown to result in improved discrimination for death and disability following the procedure and identifies those individuals least likely to derive benefit. Several dedicated risk score have been proposed to provide new insights into predicted "futile" outcome. However, assessment of frailty according to a limited number of variables is not sufficient, while a multi-dimensional geriatric assessment significantly improves risk prediction. A multidisciplinary heart team that includes geriatricians can allow the customization of therapeutic interventions in elderly patients to optimise care and avoid futility.

[Anticoagulant treatment in patients with non-valvular atrial fibrillation and chronic anemia: still a grey area]. / Il trattamento anticoagulante nei pazienti con fibrillazione atriale non valvolare e anemia cronica: ancora zone grigie.

Anemia has been associated with a higher risk of major bleeding among atrial fibrillation patients on oral anticoagulation and is therefore included in most bleeding risk scores. In contrast, much less evidence exists regarding the association between anemia and stroke risk in atrial fibrillation patients. The purpose of this review was to re-evaluate the efficacy and safety of anticoagulant treatment, in particular of new oral anticoagulants, in patients with non-valvular atrial fibrillation and chronic anemia. Five observational studies were found in the literature that specifically investigated this issue; the results can be synthetized as follows: (i) the progressive decrease in hemoglobin level was associated with an increased incidence of major hemorrhages, already evident in mild anemia and very high in more severe anemia (hemoglobin level <~10 g/dl), up to >10% per year. In contrast, the association between anemia and stroke risk appears to be weak; (ii) warfarin seems to be effective in stroke prevention in patients with mild anemia, with a moderate increase in major hemorrhages, whereas it seems to be ineffective and associated with a high incidence of hemorrhagic complications in patients with more severe anemia; (iii) new oral anticoagulants, in particular apixaban, seem to induce a lower incidence of major hemorrhages in comparison with warfarin in patients with both mild and severe anemia. However, when hemoglobin level is <~10 g/dl, the incidence of major hemorrhages remains high, also in patients treated with the new anticoagulants. These data suggest that in patients with atrial fibrillation and mild anemia, anticoagulant treatment appears to be effective, but requires close monitoring during follow-up, whereas in patients with more severe anemia the choice of whether or not to prescribe an anticoagulant treatment should be made on a case by case basis, considering the thromboembolic risk, the etiology of chronic anemia and the history and general condition of the patient. New oral anticoagulants should be preferred to warfarin.

Are women really more affected by vasovagal syncope than men?

It is commonly reported that vasovagal syncope (VVS) is more frequent in women. Presently, this issue has never been investigated. The purpose of this review was to evaluate, through an extensive review of the literature, whether women are really more affected by VVS than men. The gender distribution was investigated in individuals with classical and nonclassical VVS. The database PubMed was searched using the terms 'syncope', 'vasovagal syncope', 'neurally mediated syncope' and 'tilt testing'. Twelve studies dealing with classical and 75 with nonclassical VVS were eligible. In the individuals with classical (N = 1861) and nonclassical VVS (N = 9696), a trend towards a greater percentage of women emerged (P = 0.14 and 0.07, respectively). In the total population with VVS (N = 11 557), the percentage of women was significantly higher than that of men (58 versus 42%, P = 0.03). Most of the individuals were young or middle-aged. In 84% of the studies, the percentage of women was greater than that of men. A separate analysis was carried out in older VVS patients (≥60 years) and only two studies were eligible to be evaluated. Considering that almost all the studies were carried out in the western nations, where the number of men and women is almost superimposable until the age of 65 years and a bias by gender has never been reported in the management of VVS, these data strongly suggest that young and middle-aged women are more affected by VVS than their male counterparts. At present, data are too scant to draw a definitive conclusion in older VVS patients.

[Major gastrointestinal hemorrhage during anticoagulant therapy in patients with atrial fibrillation: when should treatment be resumed?] / Emorragia gastrointestinale maggiore in corso di terapia anticoagulante nei pazienti con fibrillazione atriale: quando riprendere il trattamento?

In patients with atrial fibrillation (AF) under oral anticoagulant therapy (OAT), over half of the hemorrhagic complications occur in the gastrointestinal (GI) tract, with an incidence of 1-4% per year. This complication mainly involves older patients, often very compromised from the clinical point of view; mortality rates are not negligible, varying between 4% and 15%. The purpose of the present review was to evaluate the utility of resuming OAT after a major GI hemorrhage in patients with AF. Four observational studies were found in the literature that specifically investigated this issue; three of them had a retrospective design. In these studies almost exclusively warfarin was utilized. OAT was discontinued in all patients at the beginning of GI hemorrhage; in about half of the patients anticoagulation was then restarted and in the other half it was definitively stopped. The results of these studies suggest a beneficial effect of OAT resumption, since it reduced the incidence of thromboembolic events and mortality with a not marked increase in hemorrhagic recurrences. However, these results should be interpreted with caution since, very likely, OAT was resumed in patients in good clinical condition - as suggested by the very low mortality rate during hemorrhagic recurrences (0.7%) - and not in those with very severe hemorrhage and/or very compromised from the clinical point of view. Because of this type of patient selection, we do not know the real hemorrhagic risk in patients resuming OAT after GI hemorrhage. This is a strong limitation in the decision making; in order to acquire this knowledge, randomized studies should be carried out. The evaluation whether or not to restart OAT should be made in the clinical context by a team including the gastroenterologist (or the physician taking care of the GI pathology) and the cardiologist. At present, clinical variables such as site and/or cause of GI bleeding, severity of the anemia and the degree of prolongation of the international normalized ratio, do not appear useful for decision making. The available data suggest that OAT should be resumed in "robust" elderly patients, if the source of bleeding has been identified and corrected, whereas in frail patients and/or with multiple comorbidities, the doubt often remains. The available literature does not offer clear data on the optimal duration of OAT discontinuation after an episode of major GI bleeding. The evaluation should be made in the clinical context; however, therapy discontinuation between 1 week and 1 month appears to be adequate in most cases. On the basis of indirect comparisons, which show many limitations, the most appropriate anticoagulants after GI hemorrhage appear to be warfarin, apixaban and low-dose edoxaban.

[Sinus bradycardia and syncope: what pathophysiological mechanism and what management of the patient?] / Bradicardia sinusale e sincope: quale fisiopatologia e quale gestione del paziente?

Sick sinus syndrome (SSS) can be diagnosed only when there is a clear correlation between symptoms and sinus node dysfunction. In the absence of such correlation, the mechanism of undocumented intermittent symptoms such as syncopal spells in patients with permanent mild sinus bradycardia remains uncertain. Some clinical data suggest that a reflex mechanism is likely to be involved in many patients with syncope and sinus bradycardia: the course of syncopal recurrences is very variable from patient to patient and transient loss of consciousness does not recur in more than half of unpaced patients during an observation period of several years. The results of some studies seem to confirm a reflex mechanism as the cause of syncope in most cases: in patients with SSS and syncope the prevalence of positive response to tilt testing was high (~60%) and significantly higher than in patients with SSS without syncope and in other control groups. However, a depressed sinus node automaticity, roughly expressed by very prolonged sinus node recovery time, suggests a role of sinus node dysfunction in the origin of syncope. Patients with permanent mild sinus bradycardia and syncope as an isolated symptom should undergo tilt testing and electrophysiological study. In the presence of positive tilt test without very prolonged sinus node recovery time, the patient should be managed as the patients with neurally mediated syncope and normal sinus rate.

Typical vasovagal syncope as a "defense mechanism" for the heart by contrasting sympathetic overactivity.

Many observations suggest that typical (emotional or orthostatic) vasovagal syncope (VVS) is not a disease, but rather a manifestation of a non-pathological trait. Some authors have hypothesized this type of syncope as a "defense mechanism" for the organism and a few theories have been postulated. Under the human violent conflicts theory, the VVS evolved during the Paleolithic era only in the human lineage. In this evolutionary period, a predominant cause of death was wounding by a sharp object. This theory could explain the occurrence of emotional VVS, but not of the orthostatic one. The clot production theory suggests that the vasovagal reflex is a defense mechanism against hemorrhage in mammals. This theory could explain orthostatic VVS, but not emotional VVS. The brain self-preservation theory is mainly based on the observation that during tilt testing a decrease in cerebral blood flow often precedes the drop in blood pressure and heart rate. The faint causes the body to take on a gravitationally neutral position, and thereby provides a better chance of restoring brain blood supply. However, a decrease in cerebral blood flow has not been demonstrated during negative emotions, which trigger emotional VVS. Under the heart defense theory, the vasovagal reflex seems to be a protective mechanism against sympathetic overactivity and the heart is the most vulnerable organ during this condition. This appears to be the only unifying theory able to explain the occurrence of the vasovagal reflex and its associated selective advantage, during both orthostatic and emotional stress.

[Efficacy and safety of oral anticoagulants in frail elderly patients with atrial fibrillation: an unsolved problem]. / Efficacia e sicurezza degli anticoagulanti orali nell'anziano fragile con fibrillazione atriale: problema ancora aperto.

At present, the efficacy and safety of anticoagulants, warfarin, or new oral anticoagulants in frail patients remain unknown, as these patients have largely been excluded from both randomized trials and "real-world" studies; as a result, the guidelines do not provide guidance for the management of this population. Frail patients with atrial fibrillation (AF) are significantly less likely to receive oral anticoagulants compared to their nonfrail counterparts; is that an expression of reasonable prudence or malpractice? In this regard, some aspects of physical frailty should be considered: (i) increased vulnerability to stressors, including pharmacological agents with potential severe adverse effects; (ii) frail elderly patients are at high risk of falls and, therefore, of severe traumatic hemorrhages on oral anticoagulation; (iii) frail patients are more likely to have complications during intercurrent affections, potentially responsible for hemorrhages. Prospective "real-world" studies including frail AF patients are necessary. Waiting for more evidence, the doubt whether to prescribe or not an oral anticoagulant to frail AF patients remains legitimate.

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

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.