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In general, a TIA concerns a focal neurological deficit without LOC, and syncope the opposite. Subclavian steal refers to the rerouting of blood flow to the arm through the vertebral artery due to proximal stenosis or occlusion of the subclavian artery. A TIA may occur when flow through the vertebral artery cannot supply both the arm and part of the brain during forceful use of the arm. Steal most often affects the left side. When detected with ultrasound, steal is asymptomatic in 64% of cases. 422 A TIA is likely due to steal only when it is vertebrobasilar (see below) and associated with exercise of one arm. There are no reliable reports of isolated LOC without focal neurological symptoms and signs in subclavian steal.

A TIA related to a carotid artery does not usually cause TLOC. An exception concerns orthostatic TIAs , concerning a combination of multiple stenoses of cerebral arteries and OH. This may rarely result in repetitive, orthostatic, short-lasting, and stereotyped TIAs. 423 , 424

A TIA of the vertebrobasilar system can cause LOC, but there are always focal signs, usually limb weakness, gait and limb ataxia, vertigo, diplopia, nystagmus, dysarthria, and oropharyngeal dysfunction. Fewer than 1% of patients with vertebrobasilar ischaemia present with a single presenting symptom. 425

Syncope, presumable VVS, and orthostatic intolerance occur more often in patients with migraine, who have a higher lifetime prevalence of syncope and often frequent syncope. 426 In migraineurs, syncope and migraine attacks rarely occur simultaneously.

Cataplexy concerns paresis or paralysis triggered by emotions, usually laughter, but also by a range of other triggers. 427 Patients are conscious even when considered unconscious by eyewitnesses, and there is no amnesia. Cataplexy is a key feature of narcolepsy; other cardinal symptoms are excessive daytime sleepiness, sleep-onset paralysis, and hypnagogic hallucinations. Cataplexy may be mistaken for syncope, but also for PPS: a partial awareness of events may be present in PPS, and the falls of cataplexy are partly controlled because paralysis need not be immediately complete.

The term drop attacks is confusing as it is variably used for Menière's disease, atonic epileptic seizures, and unexplained falls. 387 A specific condition also labelled drop attacks concerns middle-aged women (rarely men) who suddenly find themselves falling. 428 They usually remember hitting the floor and can stand up immediately afterwards.

Neurological evaluation

TLOC = transient loss of consciousness.

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Neurological evaluation

TLOC = transient loss of consciousness.

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A schematic comprehensive figure of neurological tests used for autonomic failure is shown in Figure 17 .

Exercise testing

AV = atrioventricular.

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Exercise testing

AV = atrioventricular.

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In patients presenting with syncope and obstructive coronary artery disease, percutaneous coronary intervention is not associated with a significant reduction in readmission for syncope. 258 Angiography alone is not diagnostic of the cause of syncope. Therefore, cardiac catheterization techniques should be carried out in suspected myocardial ischaemia or infarction with the same indications as for patients without syncope.

Coronary angiography

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Coronary angiography

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The general framework of treatment is based on risk stratification and the identification of specific mechanisms when possible ( Figure 8 ).

Figure 8
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General framework of treatment is based on risk stratification and the identification of specific mechanisms when possible. ARVC = arrhythmogenic right ventricular cardiomyopathy; CAD = coronary artery disease; DCM = dilated cardiomyopathy; ECG = electrocardiographic; HCM = hypertrophic cardiomyopathy; ICD = implantable cardioverter defibrillator; LQTS = long QT syndrome; SCD = sudden cardiac death.

Figure 8
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General framework of treatment is based on risk stratification and the identification of specific mechanisms when possible. ARVC = arrhythmogenic right ventricular cardiomyopathy; CAD = coronary artery disease; DCM = dilated cardiomyopathy; ECG = electrocardiographic; HCM = hypertrophic cardiomyopathy; ICD = implantable cardioverter defibrillator; LQTS = long QT syndrome; SCD = sudden cardiac death.

The following three general principles should be considered:

The efficacy of therapy aimed at preventing syncope recurrence is largely determined by the mechanism of syncope rather than its aetiology. Bradycardia is a frequent mechanism of syncope. Cardiac pacing is the most powerful therapy for bradycardia but its efficacy is less if hypotension coexists (see Table 9 and Supplementary Data Table 9 ). The treatment of syncope due to a hypotensive reflex or to OH is more challenging because specific therapies are less effective.

In pooled data from nine studies 179 performed in 506 patients with unexplained syncope at the end of complete negative work-up, a correlation between syncope and ECG was found in 176 patients (35%); of these, 56% had asystole (or bradycardia in a few cases) at the time of the recorded event, 11% had tachycardia, and 33% had no arrhythmia. Presyncope was much less likely to be associated with an arrhythmia than syncope. Similar findings were subsequently observed with ILR use expanded in an early phase of evaluation in patients with recurrent syncope of uncertain origin, in the absence of high-risk criteria and structural heart disease, 176 , 180–183 and in suspected reflex syncope. 184–186 In particular, an asystolic pause was present during syncope in about 50% of these patients.

There are several areas of interest other than unexplained syncope in which ILRs have been investigated:

Patients with bundle branch block (BBB) in whom paroxysmal atrioventricular (AV) block is likely despite negative complete EPS: an arrhythmia was observed in 41% of these patients (being paroxysmal AV block in 70%) under ILR observation, based on pooled data from three studies 174 , 187 , 188 (see Fitflop Women’s Ritzy BackStrap Open Toe Sandals Black Black free shipping sale online shop online sale great deals 0DrY9sK
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Patients in whom epilepsy was suspected but the treatment has proven ineffective: in pooled data, an attack could have been documented by ILR in 62% of patients, with an arrhythmic cause being responsible in 26% 137 , 189–191 (see Supplementary Data Table 7 ).

Patients with unexplained falls: in pooled data, an attack could have been documented by ILR in 70% of patients, with an arrhythmic cause being responsible in 14% 191–194 (see Supplementary Data Table 8 ).

Table5

Odds ratio of 30 day all-cause mortality, according to time of admission

Patient characteristics: type of fracture, fracture positioning, type of operation, age, sex, body-mass index, Charlson comorbidity index, marital status, housing, domicile region, native country, level of income and year of admission. Hospital characteristics: hospital region, type of unit and unit volume.

Adjusted for clustering by unit.

Adjusted for clustering by unit and patient characteristics.

Adjusted for clustering by unit, patient characteristics and hospital characteristics.

Adjusted for clustering by unit, patient characteristics and delay >48 h.

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Table5

Odds ratio of 30 day all-cause mortality, according to time of admission

Patient characteristics: type of fracture, fracture positioning, type of operation, age, sex, body-mass index, Charlson comorbidity index, marital status, housing, domicile region, native country, level of income and year of admission. Hospital characteristics: hospital region, type of unit and unit volume.

Adjusted for clustering by unit.

Adjusted for clustering by unit and patient characteristics.

Adjusted for clustering by unit, patient characteristics and hospital characteristics.

Adjusted for clustering by unit, patient characteristics and delay >48 h.

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We found that patients admitted with hip fractures during on-hours and off-hours were comparable. Furthermore, the admission time had no influence on compliance with performance measures for hip fracture care. However, the risk of surgical delay was lower for patients admitted off-hours compared with patients admitted on-hours. Additional analyses showed that this effect was driven by observations for patients admitted on weekdays during evening and night shifts; indeed the risk of delay was higher for patients admitted during weekends. We found no influence of the time of admission on the 30-day mortality risk in the primary pooled analyses, but additional analyses did reveal an increased mortality risk related to weekend admission.

The strengths included the study size, the nationwide design, the detailed prospective data collection, the complete follow-up and the extensive control for confounding. Only patients without contraindications for the specific performance measure were included in the analyses of the quality of care. This approach reduced the risk of confounding, e.g. by disease severity or by indication, and have also been used in similar studies in other patient groups [ 33 ]. Detailed registration of the exact time of admission enabled the definition of off-hours to reflect the work flow in every day clinical practice.

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