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Syncope in advanced heart failure: High risk of sudden death regardless of origin of syncope
Open accessAbstract
Objectives The purpose of this study was to assess the importance of syncope as a warning sign for sudden death in advanced heart failure and to determine the relative importance of cardiac syncope and syncope from other causes.Background Despite remarkable advances in the pharmacologic approach to advanced heart failure, 20% to 40% of patients with advanced heart failure will die each year. In such patients, the relation between sudden death and the etiology of syncope has not been evaluated.Methods The relation of syncope to sudden death was evaluated in 491 consecutive patients with advanced heart failure (New York Heart Association functional class III or IV), no history of cardiac arrest and a mean left ventricular ejection fraction of 0.20 +/- 0.07. Patients were evaluated for the presence and origin of syncope. The severity of heart failure was assessed from serum sodium levels, ejection fraction, functional class and echocardiographic and hemodynamic variables.Results Sixty patients (12%) had a history of syncope; the condition had a cardiac origin in 29 (48%) and was due to other causes in 31 (52%). The origin of heart failure was coronary artery disease in 234 patients (48%) and dilated cardiomyopathy in 253 (51%) and its severity was similar in patients with and without syncope. During a mean follow-up interval of 365 +/- 419 days, 69 patients (14%) died suddenly and 66 patients (13%) died of progressive heart failure. The actuarial incidence of sudden death by 1 year was significantly greater in patients with (45%) than in those without (12%, p < 0.00001) syncope. In the Cox proportional hazards model, syncope predicted sudden death independent of atrial fibrillation, serum sodium, cardiac index, angiotensin-converting enzyme inhibition and patient age. The actuarial risk of sudden death by 1 year was similarly high in patients with either cardiac syncope or syncope from other causes (49% vs. 39%, p = NS).Conclusions Patients with advanced heart failure are at especially high risk for sudden death regardless of the etiology of syncope.
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“Arrhythmic syncope is highly probable when the ECG shows 25-39 : • Persistent sinus bradycardia <40 b.p.m. or sinus pauses >3 s in awake state and in absence of physical training; • Mobitz II second- and third-degree AV block; • Alternating left and right BBB; • VT or rapid paroxysmal SVT;”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [27]
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“Cardiac ischaemia-related syncope is confirmed when syncope presents with evidence of acute myocardial ischaemia with or without myocardial infarction. 25-39”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [27]
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“Structural heart disease 25-27,31,35,36,45 and primary electrical disease 46 are major risk factors for sudden cardiac death (SCD) and overall mortality in patients with syncope.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [27]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“Data from observational studies in selected cohorts show a high rate of occurrence of ventricular arrhythmias, ICD discharge, and death in patients with a history of unexplained syncope but, owing to a lack of control groups, are unable to show the benefit of an ICD. 27,28,359,360”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [27]
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“In patients with New York Heart Association class III–IV HF, syncope is present in 12% to 14% of patients (46,47).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [47]
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Metadata
- Authors
- Middlekauff, H. R., Stevenson, W. G., Stevenson, L. W., & Saxon, L. A.
- Affiliations
- University of California, Los Angeles (US)
- Corresponding author
- Middlekauff, Holly R.
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 1993-01
- Volume
- 21
- Issue
- 1
- Pages
- 110-116
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W1994239059
- Cited by
- 311
- References
- 37
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 1 · 2023: 5 · 2022: 8 · 2021: 5 · 2020: 7 · 2019: 9 · 2018: 15 · 2017: 15 · 2016: 8 · 2015: 8 · 2014: 14 · 2013: 12 · 2012: 7
- FWCI
- 8.08
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- syncope, sudden death, advanced heart failure, cardiac syncope, dilated cardiomyopathy, coronary artery disease, mortality risk, prognostic factors, left ventricular ejection fraction
- MeSH terms
- Adult, Cardiac Pacing, Artificial, Female, Heart Failure, Humans, Male, Middle Aged, Risk Factors, Syncope, Los Angeles, Incidence, Chi-Square Distribution, Logistic Models, Proportional Hazards Models, Survival Analysis, Death, Sudden, Cardiac
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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