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Dr. Neil Doherty is Associate Professor of Cardiology at Western University of Health Sciences in Pomona. As part of this pursuit Dr. Doherty participates in the following: 1. CLINICAL CLERKSHIPS, Four (4) week rotation, 8:30am-12:30pm office, and some hospital work, for 4th year and late 3rd year students. No call. Please contact Jeff Day, two months in advance for phone or office interview. Clinical exam, given the final week includes: - History & Physical with auscultation, including doing and interpreting EKG, and complete written discussion of new patient seen in office, typed, with references, within 24 hours.
Nightly reading, including current Braunwald’s Heart Disease (text provided, on loan). 2. SYNCOPE LECTURE (2nd Year Medical Students): 19 September 2006 at 1:00 - 2:00 pmRequired Reading (Exam Questions)- AHA/ACCF Scientific Statement on the Evaluation of Syncope.
Circulation. 2006; 113; 316-327.
- Connolly, S. et al. The North American vasovagal pacemaker study: A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope. Journal of the American College of Cardiology. 1999, 33: 16-20. (VPS-1).
- Connolly, S. et al, Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II). Journal of the American Medical Association. 2003; 289: 2224-2229.
- Glatter, K. et al, Malignant Micturition Syncope. Circulation. 2003; 107: 2987-2988.
- Grubb, B. Neurocardiogenic Syncope. New England Journal of Medicine. 2005; 352: 1004-1010.
- Sheldon, R., et al. Historical criteria that distinguish syncope from seizures. Journal of the American College of Cardiology. 2002; 40: 142-148.
- Krahn, A. et al. Cost implications of testing strategy in patients with syncope. Journal of the American College of Cardiology. 2003; 42: 495-501.
- Krahn, A. et al. Use of an extended monitoring strategy in patients with problematic syncope. Circulation. 1999; 99: 406-410.
Suggested Reading:- Ammirati, F., et al. Permanent cardiac pacing versus medical treatment for the prevention of recurrent vasovagal syncope. Circulation. 2001, 104: 52-57. (SYDIT).
- Moya, A. et al. Mechanism of syncope in patients with isolated syncope and in patients with tilt-positive syncope. Circulation. 2001; 104: 1261-1267.
- Blair P. Grubb and Brian Olshansky (Editors), Syncope Mechanisms and Management, 2d edition, 2005. Blackwell Publishing, Malden, MA 02148-5018.
- Sutton, R. et al. Dual Chamber Pacing in the Treatment of Neurally Mediated Tilt-Positive Cardioinhibitory Syncope. Circulation. 2000; 102: 294-299.
- Brignole, M., et al. Guidelines on management (diagnosis and treatment) of syncope. European Heart Journal. 2001; 22: 1256-1306.
- Bigger, J. Expanding indications for implantable cardiac defibrillators (editorial). New England Journal of Medicine. 2002; 346: 931-933.
- Moss, AJ, et.al. ECG T Wave Patterns in Long QT Syndrome. Circulation, 1995; 92: 2929.
3. Pacemaker and ICD Lecture (2nd Year Medical Students) 21 September 2006 at 1:00 -2:00 pm
Recommended Reading (before lecture)Required Reading (Exam Questions):- Bardy, G. et al. for The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) investigators. Amiodarone or an Implantable Cardioverter-Defibrillator for Congestive Heart Failure. New England Journal of Medicine. 2005: 352: 225-237.
- Toff, W. et al., for the UKPACE Trial Investigators. Single-Chamber versus Dual-Chamber Pacing for High-Grade Atrioventricular Block. New England Journal of Medicine. 2005; 353,: 145-155.
- Verma, A.and Natale A. Why Atrial Fibrillation Ablation Should be Considered First-Line Therapy for Some Patients. Circulation. 2005; 112: 1214-1231.
Suggested Reading:- Montgomery, Kathryn. How Doctors Think. Oxford Press; Copywrite 2006.
- Zipes, Libby, Bonow, Braunwald. Heart Disease. Elsevier/Saunders, Philadelphia. 7th edition, 2005; Chapter 31: Cardiac Pacemakers and Cardioverter-Defibrillators, pages 767-787.
- Moss, AJ. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction-MADIT II. New England Journal of Medicine. 2002; 346: 877-883.
- Solomon, S. et al. Sudden Death in Patients with Myocardial Infarction and Left Ventricular Dysfunction, Heart Failure, or Both. New England Journal of Medicine. 2005; 352: 2581-2588.
- Lau CP et al. Dual-site atrial pacing for atrial fibrillation in patients without bradycardia. American Journal of Cardiology, 2001; 88: 371-375.
- Mitchell, AR. Effect of atrial antitachycardia pacing treatments: randomized study comparing subthreshold and nominal pacing outputs. Heart. 2002; 87: 433-437.
- Furman, S. et al. A Practice of Cardiac Pacing, Futura Publishing, Mount Kisco, NY. 3rd edition, 1993.
- Barold, Stroobrand, Sinnaeve. Cardiac Pacing Step by Step. Blackwell Press, Malden, MA. 2004-2005.
- Pendapudi, N. et. al. Patients' Perspectives on Ideal Physician Behaviors. Mayo Clinic Proceedings. 2006; 81(3): 338-344.
Question #1Which of the following is correct? A. VPS II – Phase 1, showed that ODO pacing reduces the risk of syncope in patients with recurrent, refractory, highly-symptomatic, cardioinhibitory vasovagal syncope. (23rd Annual Scientific Sessions of the North American Society of Pacing and Electrophysiology Late Breaking Clinical Trials, May 11, 2002).
B. SYDIT and VPS-1 showed that DDD pacing reduces the risk of syncope in patients with recurrent, refractory, highly-symptomatic, vasoinhibitory vasovagal syncope. (Anmitrati, F. et al. Circulation. 2001; 104:52-57).
C. VPS-1 and SYDIT showed that DDD pacing, with rate drop response, reduces the risk of syncope in patients with recurrent, refractory, highly-symptomatic, cardio inhibitory vasovagal syncope. (Connolly, S, et al.; VPS-1. Journal of the American College of Cardiology. 1999, 33 : 16-20).
D. VPS-1 and SYDIT showed the VVI pacing with hysteresis pacing reduces the risk of syncope in patients with recurrent, refractory, highly-symptomatic, cardioinhibitory vasovagal syncope.
E. SYDIT showed EPS testing was superior to 30 day external loop recorders to diagnose Torsades de pointes. (Ammirati, F., et al. SYDIT. Circulation. 2001, 104 : 52-57).
Question #2 A holter monitor, shown below, shows long asystolic pauses that were correlated with syncope during micturition. The most effective treatment would be: (Glatter, K., et al. Malignant micturition syncope. Circulation. 2003; 107: 2987-2988. A. Amiodarone
B. Dual Chamber Pacemaker
C. Defibrillator
D. Midodrine
E. Prozac Question #3 According to historical criteria, useful criteria to distinguish seizures from syncope include: (Reference: Sheldon et al. Journal of the American College of Cardiology . 2002; 40 : 142-148) A. Jamais vu and déjà vu experiences precede syncope.
B. Loss of consciousness does not occur with seizures.
C. Receiver – operating curve analysis showed prodromal diaphoresis, palpitations, and nausea provoked by prolonged sitting and standing did not help distinguish syncope from seizures.
D. EEG is always normal, even between seizures.
E. Seizures are often characterized by waking with cut tongue, tonic-clonic movements or other abnormal behaviors, post-ictal confusion, and head turning to one side during loss of consciousness. Question #4 Randomized Assessment of Syncope Trial (RAST) found that in patients with unexplained syncope and ejection fraction above 35%: (Reference: Krahn, A., et al. Journal of the American College of Cardiology . 2003; 42 : 495-501.) A. A primary implanted loop recorder in 30 patients obtained diagnosis due to bradycardia in 10 patients, supraventricular tachycardia in 1 patient, and neurocardiogenic syncope in 3 patients. In 30 other patients, a “conventional” strategy of two to four week external loop recorder, followed by tilt table test and electrophysiology (EP) testing obtained diagnosis in 6 patients before cross-over. The authors concluded that a diagnostic strategy of prolonged monitoring is more cost effective than “conventional” testing algorithm, in patients with recurrent, unexplained syncope with preserved LV function.
B. As a result of the RAST Trial, Medicare reimburses implanted loop recorders in patients who have not had tilt table tests.
C. The RAST Trial showed EP testing was cost effective.
D. Complications with implanted loop recorders include endocarditis and stroke.
E. If the patient does not activate the device, the implanted loop recorder can not ever retrieve the heart rate and rhythm associated with syncope.
Question #5 Krahn, A., (1991) showed that: (Reference: Krahn, A., Use of an Extended Monitoring Strategy in Patients with Problematic Syncope. Circulation . 1999; 99 : 406-410.) A. Reveal loop recorders must be placed in an operating room setting.
B. Ventricular tachycardia was the most common diagnosis for syncope in a group of 85 patients with previously undiagnosed syncope.
C. Head up tilt-test gave diagnosis in 70% of patients.
D. Reveal loop recorders may be placed left inframammary or left pectoral position. 4 of 85 patients (4.7%) had local infection, pain at implant site, or local erosion with infection.
E. 29% of patients failed to properly activate the loop recorder. Question #6 Krahn (1991) showed that: (Reference: Krahn, A., Use of an Extended Monitoring Strategy in Patients with Problematic Syncope. Circulation . 1999; 99 : 406-410.) A. There were no complications with implanted loop recorders.
B. Devices must be placed in the operating room.
C. In this study, all patients received pre-operative antibiotic prophylaxis.
D. This study showed that reveal loop recorders should not be placed in the right pectoral position.
E. Of 85 patients receiving an Implanted Loop Recorder, two who had not received prophylactic antibiotics developed local infection requiring treatment. A second device was reimplanted in another site, a third had persistent pain at the left inframammary implant site, and was moved to the left pectoral position. A fourth developed local erosion with infection 13 weeks after implantation. Anwers to Syncope Questions: Answer to Question 1: C Answer to Question 2: B Answer to Question 3: E Answer to Question 4: A Answer to Question 5: D Answer to Question 6: E [Top of Page] - [Top of Article]
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