This article appeared in a journal published by Elsevier.

The attached
copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
http://www.elsevier.com/authorsrights
 Author's personal copy

266 Letters to the Editor

Correlation of syncopal burden with anxiety symptoms score in recurrent

vasovagal syncope
Abel Lerma, Claudia Lerma, Manlio F. Márquez, Manuel Cárdenas, Antonio G. Hermosillo ⁎
Electrocardiology Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
Electromechanical Instrumentation Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico

a r t i c l e i n f o symptoms in 23 subjects (45%). Anxiety symptoms score was

directly associated with the syncopal burden: patients with high
Article history: syncopal burden had a higher anxiety score than subjects with low
Received 23 July 2012
syncopal burden. No significant differences were observed in gender
Accepted 16 September 2012
Available online 6 October 2012 or depression symptoms score among subjects with high or low
syncopal burden.
Keywords: It is clinically relevant to correctly discriminate anxiety related to VVS
Anxiety from anxiety as a part of a psychopathology that will need, by itself,
Depression
Vasovagal syncope
specific treatment. Subjects with a psychiatric disorder usually do not
Neurally-mediated syncope respond to conventional treatment of VVS, have a higher severity of
Fainting syncope, more prodromal symptoms and higher recurrence of syncope
than patients without a psychiatric illness [9]. On the other hand, subjects
without psychopathology can develop anxiety related to recurrence of
Vasovagal syncope (VVS) is the transitory loss of consciousness VVS. In them, anxiety may be the result, not the cause of VVS and could be
secondary to generalized cerebral hypoperfusion due to arterial hypoten- solved by avoiding the recurrence of the events. Our finding of higher
sion with or without a concomitant reduction of heart rate [1]. Subjects levels of anxiety, but not depression, in subjects with VVS and a higher
suffering from recurrent VVS can have a high psychological stress syncopal burden is relevant for two reasons: (1) it supports the
including anxiety, depression, concern, and somatic complaints [2,3]. In hypothesis of a bidirectional relationship between cognitive/affective
previous studies, syncopal burden has been inversely correlated with factors and syncopal symptoms in subjects with VVS [10], and (2)
quality of life but no significant correlation was observed between because, as suggested by many investigators, the diagnosis and treatment
anxiety, depression and the patient's syncopal burden [2,3]. The aim of of these minor psychiatric disorders may be crucial for the effective
this study was to correlate syncopal burden with symptoms score of treatment of VVS. The subgroup of patients with a high syncopal burden
anxiety and depression in subjects with VVS and no psychiatric could be the most benefited by early intervention aimed to acquire skills
disorders. for functional coping with their distressing symptoms. Also relevant, the
The study included 51 patients (27 females, median age 17 years, age present finding could explain the reported benefit of clonazepam, a drug
range 15 to 45 years old) attending a syncope unit. All patients were with anxiolytic effects, in subjects with VVS [11,12].
evaluated by an expert physician. Diagnosis was established in the In conclusion, higher levels of anxiety were observed in subjects with
presence of a clinical history characteristic of VVS (simple fainting of very a clinical diagnosis of VVS and a high recurrence of syncopal episodes,
brief duration that occurs with the subject standing or at the moment of supporting a bidirectional relationship between cognitive/affective factors
stand-up) with one or more of the following prodromal symptoms: and syncopal symptoms in VVS.
dizziness, pallor, visual blurring, diaphoresis, dysesthesia, sighing The authors thank Alma Delia Ferreira Vidal for her assistance during
dyspnea, tremor in fingers, or nausea [4,5]. All participants filled out the recruitment of participants, and Ms Betty Lou Chin R.N. for her
the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI) support in the preparation of the manuscript.
and a cognitive function test [6–8]. Syncopal burden was classified as
follows: low burden (≤3 events in the last 6 months), high syncopal
burden (N3 events). No significant differences were observed in
cognitive function and educational grade among subjects with high or Table 1
low syncopal burden (data not shown). Exclusion criteria were: Anxiety and depression symptoms in 51 patients with history of syncope, according to
orthostatic hypotension, suspected or confirmed heart disease, other syncopal burden (Low = up to 3 events, High = more than 3 events).
specific causes of neurally mediated syncope (situational or associated Study population Syncopal burden
to coughing, swallowing or brisk neck movements), metabolic or (n = 51) Low (n = 33) High (N = 18) pa
neurological disorders, any concurrent disease or treatment that Age (years) 17 (16–26) 16 (16–20) 21 (17–31) 0.026
affects the autonomic nervous system, or known psychiatric disorder. Gender
All subjects gave informed written consent to participate. The study Female 27 (53%) 16 (49%) 11 (61%) 0.285
complies with the ethical guidelines of the 1975 Declaration of Anxiety symptoms
Absent b 34 (67%) 26 (79%) 8 (44%) 0.013
Helsinki, as well as the standards established by the Ethics
Present c 17 (33%) 7 (21%) 10 (56%)
Committee of the Instituto Nacional de Cardiologia Ignacio Chavez. Symptoms score 14 (7–22) 11 (4–19) 22 (12–27) 0.023
The authors of this manuscript have certified that they comply with Depression symptoms
the Principles of Ethical Publishing in the International Journal of Absent b 28 (55%) 20 (61%) 8 (44%) 0.268
Cardiology. Present c 23 (45%) 13 (39%) 10 (56%)
Symptoms score 8 (4–14) 7 (4–12) 15 (7–22) 0.112
Results are shown in Table 1. In the total study group, anxiety
symptoms were present in 17 patients (33%), and depression Results are shown as median (percentile 25 to percentile 75) or absolute frequency
(percentage).
a
Significant difference (p b 0.05, Mann–Whitey U test or Chi-squared test), high
⁎ Corresponding author at: Instituto Nacional de Cardiología Ignacio Chávez, Juan versus low syncopal burden.
b
Badiano 1, Col. Sección XVI, Tlalpan 14080, México, D.F., Mexico. Tel.: + 52 55 This grade corresponds to normal scores in general population.
c
55732911x1477; fax: + 52 55 56 55 70 59. This grade includes mild, moderate or severe symptoms according to cut-off values
E-mail address: sincope39@yahoo.com.mx (A.G. Hermosillo). standardized for Mexican population [6,7].
 Author's personal copy
Letters to the Editor
References
[1] Brignole M, Alboni P, Benditt DG, et al. Guidelines on management (diagnosis and
treatment) of syncope—update 2004. Europace 2004;6(6):467–537.
[2] D'Antono B, Dupuis G, St-Jean K, et al. Prospective evaluation of psychological distress
and psychiatric morbidity in recurrent vasovagal and unexplained syncope. J Psychosom
Res 2009;67(3):213–22.
[3] Giada F, Silvestri I, Rossillo A, et al. Psychiatric profile, quality of life and risk of syncopal
recurrence in patients with tilt-induced vasovagal syncope. Europace
2005;7(5):465–71.
[4] Asensio E, Oseguera J, Loria A, et al. Clinical findings as predictors of positivity of head-up
tilt table test in neurocardiogenic syncope. Arch Med Res 2003;34(4):287–91.
[5] Vallejo M, Hermosillo AG, Marquez MF, et al. Value of symptoms to predict tilt testing
outcome in patients with clinical suspicion of vasovagal syncope. Arch Med Res
2007;38(5):579–83.
[6] Jurado S, Villegas M, Méndez L, et al. La estandarización del inventario de depresión de
Beck para residentes de la Ciudad de México. Salud Ment 1998;21(3):26–31.
0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijcard.2012.09.105
Respiratory ventricular area changes measured with real-time cardiac magnetic
resonance: A new, accurate, and reproducible approach for the diagnosis of
pericardial constriction☆
Jesus G. Mirelis a,b,⁎, Ana Garcia-Alvarez a,b, Leticia Fernandez-Friera a,b, Simonette Sawit a, Rocio Hinojar a,
Valentin Fuster a,b, Mario J. García a, Javier Sanz a
a
The Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, USA
b
Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
a r t i c l e i n f o
Article history:
Received 10 July 2012
Accepted 16 September 2012
Available online 3 October 2012
Keywords:
Cardiovascular magnetic resonance
Real-time imaging
Pericardial constriction
Demonstration of pericardial pathology and/or constrictive
physiology remains the basis for the diagnosis of pericardial
constriction (PC). Cardiovascular magnetic resonance (CMR) is
increasingly used to depict pericardial abnormalities [1–6]. More-
over, the Society of CMR endorses visual determination of
abnormal respiratory septal motion characteristic of constrictive
physiology on real-time cine imaging [7], and preliminary CMR
studies have attempted to quantify this sign of increased
ventricular interdependence [8,9] (Fig. 1). Our goal was to develop
a simple, accurate, and reproducible method for the quantification
of ventricular interdependence with free-breathing CMR for PC
diagnosis.
We included 69 consecutive patients with suspected PC who
underwent a CMR study that included real-time free-breathing cine
imaging. Two clinical cardiologists, blinded to CMR quantification of
☆ Funding Information: This work was partially supported by the Centro Nacional de
Investigaciones Cardiovasculares (CNIC), Madrid, Spain (CARDIOJOVEN Program to
A.G.A. and CARDIOIMAGEN to J.G.M.); Instituto de Formación en Investigación ‘Marqués
de Valdecilla’, Santander, Spain (Post-MIR Wenceslao López Albo grant to L.F.F.) and the
Spanish Society of Cardiology (Post-Residency Grant to L.F.F. and A.G.A.).
⁎ Corresponding author at: Melchor Fernandez Almagro, 3, 28029 Madrid, Spain.
Tel.: + 34 667393212.
E-mail address: jesus.gmirelis@telefonica.net (J.G. Mirelis).
267
[7] Robles R, Varela R, Jurado S, Páez F. Versión mexicana del inventario de ansiedad de
Beck: propiedades psicométricas. Rev Mex Psicol 2001;18(2):211–7.
[8] Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA:
a brief screening tool for mild cognitive impairment. J Am Geriatr Soc
2005;53(4):695–9.
[9] Kapoor WN, Fortunato M, Hanusa BH, Schulberg HC. Psychiatric illnesses in patients
with syncope. Am J Med 1995;99(5):505–12.
[10] Beacher FD, Gray MA, Mathias CJ, Critchley HD. Vulnerability to simple faints is
predicted by regional differences in brain anatomy. Neuroimage 2009;47(3):937–45.
[11] Kadri NN, Hee TT, Rovang KS, et al. Efficacy and safety of clonazepam in refractory
neurally mediated syncope. Pacing Clin Electrophysiol 1999;22(2):307–14.
[12] Marquez MF, Urias-Medina K, Gomez-Flores J, et al. Comparison of metoprolol vs
clonazepam as a first treatment choice among patients with neurocardiogenic syncope.
Gac Med Mex 2008;144(6):503–7.
interdependence and based on available clinical, hemodynamic,
imaging, and surgical data, adjudicated the diagnosis of PC,
restrictive cardiomyopathy (RCM), or other diagnoses (“Control
group”) by consensus. The institutional Internal Review Board
approved the study. The authors of this manuscript have certified
that they comply with the Principles of Ethical Publishing in the
International Journal of Cardiology.
For CMR studies we used either a 1.5-T (Magnetom Sonata©;
n = 45), or a 3.0-T magnet (Philips Achieva©; n = 24). Standard
steady-state free precession cine views, axial fast spin echo images,
real-time free-breathing cine imaging in a basal-to-mid left ven-
tricular (LV) short-axis orientation, and standard late gadolinium
enhancement (LGE) imaging were performed.
Images were analyzed on a dedicated workstation (Philips
Workspace©). Biventricular volumes were quantified by Simpson's
method. Pericardial thickness was measured from spin echo
images, and abnormal thickening was defined as N4 mm [1]. On
real-time cine images, septal flattening was first assessed visually
and defined as severe if complete inspiratory flattening was observed.
Additionally, three early-diastolic indexes, each providing a ratio for
which higher values indicate increasing interdependence, were
quantified:
1. Respiratory-related septal excursion (diameter method): LV and right
ventricular diameters were measured as described by Francone et al.
[9] (Fig. 2A).
2. Respiratory-related LV curvature change (curvature method): the
curvature radii of the interventricular septum and LV free wall were
measured with the method used by Brinker et al. [10] and others
[11,12] (Fig. 2B).
3. Respiratory-related ventricular area change (area method):
Biventricular cavity areas were measured (Fig. 2C).
To assess intra- and inter-observer reproducibility, ten imaging
studies were randomly selected and reanalyzed by the first reader