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  • This approach is similar to that suggested by the

    2019-08-13

    This approach is similar to that suggested by the previous edition of the GL [6]. Not surprisingly, the questions to be answered are the same (i.e., was the event TLOC? In cases of TLOC, is this sphingosine 1-phosphate receptor modulator of syncopal or non-syncopal origin? In cases of suspected syncope, is there a clear aetiological diagnosis? Is there evidence to suggest a high risk of cardiovascular events or death?). According to ESC GL [5] the primary aim of emergency physicians (EPs) is to identify syncopal episodes that hide acute underlying diseases, especially those associated with risk of rapid deterioration. Only after excluding these conditions, patients should be managed with initial evaluation and risk stratification, as earlier discussed (see Supplemental Fig. 1). Notably, short-term serious events are most frequently identified within the first 72 h, mainly in the ED, and these mainly coincided with the acute disease causing the syncope or with serious related injuries [7]. This approach appears hence crucial for focusing priorities in ED management of patients with syncope. Compared to the previous edition of the GL [6], this updated version provides a table of non-syncopal causes of TLOC that should be ruled out, also showing the clinical features which may help differentiating them from syncope (seizures, metabolic disorders, intoxications, cerebrovascular diseases, etc.). Regarding risk stratification, ESC GL include a detailed table, which contains features for stratifying patients as being at high- and low-risk. Subjects without these characteristics should be considered neither high- nor low-risk, and the inclusion of this additional group is another important novelty, as dealing with these patients is challenging, because their risk is still indeterminate [8] and there is limited guidance for their management [9]. According to this classification, ESC GL provide clear indications for each group: i) patients with low-risk features should be discharged directly from the ED, with fast-tracking to a Syncope Unit (SU) in case of recurrent syncope; ii) patients neither at high- or low-risk shall be managed in an ED observation unit (EDOU), rather than being discharged; iii) patients at high risk should be admitted for diagnostic or therapeutic purposes, except cases without potentially severe coexisting conditions or severe injuries, who could then be managed as those neither at high- or low-risk [5]. The attempt to make a selection among high-risk patients represents a further advancement, since it has been observed that cardiovascular diseases are not associated with an enhanced risk of severe short-term events, if in a stable condition [10] or after an initial negative ED workup [11].
    Points for further improvement
    Conclusions The following are the supplementary data related to this article.
    Declarations of interest
    Financial disclosure
    Introduction Overwhelming evidence documents the strong association of plasma low-density lipoprotein (LDL)-cholesterol with risk of coronary artery disease (CAD) events and the effectiveness of lipid lowering therapy on the reduction of cardiovascular events in secondary prevention [[1], [2], [3], [4], [5], [6], [7]]. Following the growing evidence, the European Society of Cardiology (ESC) first incorporated low-density lipoprotein targets, using a target of <100 mg/dl for patients with known CAD in 1994 [8]. In 2011, the LDL-target was reduced to <70 mg/dl, which is also recommended according current guidelines [9,10]. While statins are the first-line lipid-modifying treatment for patients with CAD as reducing both LDL-cholesterol levels and cardiovascular events [[11], [12], [13], [14], [15]], several studies in clinical practice have shown a gap between the recommendations in clinical guidelines and the actual lipid profile of high risk populations, especially in Europe [[16], [17], [18], [19], [20]]. However, whether the change in LDL-targets in ESC-guidelines resulted in a reduction of LDL in patients with CAD over time has not been evaluated. Therefore, we set out to evaluate the change in patterns of lipid lowering therapy and its success in achieving LDL-targets over time in a real-world registry cohort of patients with manifest CAD.