Misdiagnosis of bradyarrhythmias in clinical practice in Iraq
Background and objective: Bradyarrhythmias are one of the many causes of syncope, pre-syncope, and dizzy spells. Missing the diagnosis of bradyarrhythmias, an underlying etiology of those symptoms, may lead to serious complications and even mortality. This study aimed to set a standard case definition of bradyarrhythmias, which will improve patient survival.
Methods: Patients presented with partial or total loss of consciousness, who were misdiagnosed as other non-arrhythmic etiologies and later diagnosed as bradyarrhythmia, were included in this study. Diagnosis of bradyarrhythmias was reached by either 12 leads electrocardiography, Holter monitor, or electrophysiological study.
Results: A total of 150 patients who fulfilled the definition of missed diagnosis of bradyarrhythmias were included. A total of 100 males and 50 females were collected over 10 years. The pre arrhythmic over-diagnosis included transient ischemic attacks in 35 patients, vertebrobasilar insufficiency in 40 patients, vertigo in 30 patients, and other nonspecific diagnoses in 45 patients. The final diagnosis of bradyarrhythmias was reached by electrocardiogram only in 45, Holter recording in 75, and electrophysiological study in 30. All the diagnosed cases of bradyarrhythmias received permanent pacemaker therapy.
Conclusion: Misdiagnosis of bradyarrhythmias in patients presenting with syncope is not uncommon in clinical practice in Iraq, which may have a bad impact on patients' morbidity and mortality. Understanding the causative factors for the missed diagnosis can help set up an educational program to minimize this problem.
Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circul 2019; 140(8):e382–482.
Deal N. Evaluation of bradyarrhythmias in the emergency department. Emerg Med Pract 2013; 15(9):2–11.
BurriH, DayalN. Acute management of bradycardia in the emergency setting. Cardiovasc Med 2018; 21(04):98–104.
Weberndörfer V, Russi I, Kobza R. Bradyarrhythmias. Cardiovasc Med 2018; 21(09):218–26.
Sidhu S, Marine JE. Evaluating and managing bradycardia. Trends Cardiovasc Med 2019; 13:11.
Vogler J, Breithardt G, Eckardt L. Bradyarrhythmias and conduction blocks. Rev Esp Cardiol (English edition) 2012; 65(7):656–67.
Chiesa V, Vignoli A, Paola Canevini M. Cardiac asystoles misdiagnosed as epileptic seizures. BMJ Case Rep 2015; 2015:bcr2014206969.
Breitenstein A. Long-term ECG recording system useful in patients with infrequent symptoms. Implantable loop recorders. Cardiovasc Med 2018; 21(03):66–8.
Bisignani A, De Bonis S, Mancuso L, Ceravolo G, Bisignani G. Implantable loop recorder in clinical practice. J Arrhythm 2018; 35(1):25–32.
Benditt DG. Syncope: an overview of diagnosis and treatment. Rev Urug Cardiol 2011; 26(1):38–45.
Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circul 2017; 136:e60–122.
Brignole M, Moya A, Lange FJ, Deharo JC, Elliott PM, Fanciulli A. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39, 21(1):1883–948.
Patel PR, Quinn JV. Syncope: a review of emergency department management and disposition. Clin Exp Emerg Med 2015; 2(2):67–74.
Krahn A, Klein G. Syncope. Circ 2013; 127:1330–9.
Grossman SA, Badireddy M. Syncope. Emerg Med J 2019; 36(2):108–16.
Lisboa Da Silva RMF. Syncope: Epidemiology, etiology, and prognosis. Front Physiol 2014; 5:471.
Runser LA, Gauer RL, Houser A. Syncope: Evaluation and differential diagnosis. Am Fam Physician 2017; 95(5):303–12.
Albassam OT, Redelmeier RJ, Shadowitz S, Husain AM, Simel D, Etchells EE. Did this patient have cardiac syncope? The rational clinical examination systematic review. JAMA 2019; 321(24):2448.
O’Brien H, Anne Kenny R. Syncope in the elderly. ECR 2014; 9(1):28–36.
Khan T, Stecker MA, Stecker M. Evaluating the patient with loss of consciousness. Surg Neuro Int 2015; 6(Suppl 6):S262–5.
Semelka M, Gera J, Usman S. Sick sinus syndrome: A review. Am Fam Physician 2013; 87(10):691–6.
Martin-Almor J, Cladellas M, Bazan V, Delclos J. Novel predictors of progression of atrioventricular block in patients with chronic bifascicular block. Rev Espa de Cardiol 2010; 63(4):400–8.
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