RESUMO
A 67-year-old woman presented to the Emergency Department (ED) of a Level 4 Hospital with a history of "dizziness" on standing. The front-door frailty team, including a consultant geriatrician, reviewed her in the ED. An Active Stand test was performed on the day of attendance, identifying Postural Orthostatic Tachycardia Syndrome (POTS). This was attributed to underlying adrenal insufficiency and managed with oral steroids. "Dizziness" is a common presentation to Emergency Departments and can be challenging to investigate. This case report describes the application of Comprehensive Geriatric Assessment, the novel use of beat-to-beat non-invasive blood pressure monitoring in an Emergency Department setting, and the benefits for an individual patient presenting with a complaint of "dizziness". While the benefits of Comprehensive Geriatric Assessment have previously been described, our case report suggests that Active Stand testing in an ED setting may help clarify this presentation. Further research in this area could prove beneficial to patients.
RESUMO
OBJECTIVES: An assessment of the comparative incidence of fatal or disabling stroke may influence choice of intervention for patients with severe aortic stenosis. We explored whether transcatheter aortic valve implantation (TAVI) is associated with a lower incidence of fatal or disabling stroke, compared to surgical aortic valve replacement (SAVR). MATERIALS & METHODS: We classified stroke into two categories; fatal or disabling, or non-disabling, and completed meta-analyses for each. We explored randomised controlled trials to assess the effect publication year, predicted operative risk, and route of TAVI access. RESULTS: There was no difference between treatment groups per 100 person years of follow up for disabling or non-disabling stroke outcomes. In a stratified analysis by year of publication, there was a lower rate of fatal or disabling stroke with TAVI in trials published after 2015, compared to those published in 2015 or before (p-interaction = 0.01 at 30 days). Higher proportions of transfemoral route access (>90%), more common in recent trials, were associated with a lower rate of fatal or disabling stroke (p-interaction = 0.03 at 30 days). Lower average surgical risk scores were associated with lower rates of fatal or disabling stroke (p = 0.02 at 30 days). CONCLUSION: We found that treatment of aortic stenosis with TAVI compared with SAVR was not associated with an overall reduced risk in fatal or disabling stroke. Subgroup analyses suggested a lower risk of fatal or disabling stroke with TAVI in situations which reflect contemporary practice.
