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Ventricular tachycardia/fibrillation (VT/VF) may occur in autoimmune rheumatic diseases (ARDs). We hypothesized that cardiovascular magnetic resonance (CMR) can identify arrhythmogenic substrates in ARD patients.Using a 1.5 T system, we evaluated 61 consecutive patients with various types of ARDs and normal left ventricular ejection fraction (LVEF) on echocardiography. A comparison of patients with recent VT/VF and those that never experienced VT/VF was performed. CMR parameters included left and right ventricular (LV and RV) end-systolic and end-diastolic volumes (ESV and EDV), T2 signal ratio of myocardium over skeletal muscle, early/late gadolinium enhancement (EGE and LGE), T1/T2-mapping and extracellular volume fraction (ECV).21 (34%) patients had a history of recent, electrocardiographically identified, VT/VF. No demographic or functional CMR variables differed significantly between groups. The same was the case for T2 signal ratio and EGE/LGE. Median native T1 mapping values were significantly higher in patients with VT/VF compared to those without [1135.0 (1076.0, 1201.0) vs. 1050.0 (1025.0, 1078.0), p 0.001], as was the case for mean T2 mapping [60.4 (6.6) vs. 55.0 (7.9), p = 0.009] and median ECV values [32.0 (30.0, 32.0) vs. 29.0 (28.0, 31.5), p = 0.001]. After multivariate corrections for age, LVEDV, LVEF, RVEDV, RVEF, T2 signal ratio, EGE and LGE, these remained significant predictors of having experienced VT/VF in the past.T1/T2-mapping and ECV offer incremental value as identifiers of arrhythmogenic substrates in ARD patients, beyond traditionally used indices. They can thus guide implantable cardiac defibrillator (ICD) implantation in ARD patients presenting with VT/VF and normal LVEF.

Sudden cardiac death (SCD) is due to ventricular tachycardia/fibrillation (VT/VF) and may occur with or without any structural or functional heart disease. The presence of myocardial edema, ischemia and/or fibrosis plays a crucial role in the pathogenesis of VT/VF, irrespective of the pathophysiologic background of the disease. Specifically, in autoimmune rheumatic diseases (ARDs), various entities such as myocardial/vascular inflammation, ischemia and fibrosis may lead to VT/VF. Furthermore, autonomic dysfunction, commonly found in ARDs, may also contribute to SCD in these patients. The only non-invasive, radiation-free imaging modality that can perform functional assessment and tissue characterization is cardiovascular magnetic resonance (CMR). Due to its capability to detect and quantify edema, ischemia and fibrosis in parallel with ventricular function assessment, CMR has the great potential to identify ARD patients at high risk for VT/VF, thus influencing both cardiac and anti-rheumatic treatment and modifying perhaps the criteria for implantation of cardioverter defibrillators.

Background/objectives Acute coronary syndromes (ACS) continue to pose a significant medical and socioeconomic burden worldwide. Optimal management strategy aims to improve short and long-term outcome. The present study aims to assess short-term outcome of real-world ACS patients and evaluate the achievement rate of secondary prevention goals. Methods The TARGET study is an observational study enrolling 418 consecutive ACS patients from 17 centers countrywide (78.0% males, 63.9±12.9years). After the in-hospital phase, patients were followed for 6months. In total, 366 patients were included in the prospective phase of the study. At the end of the follow-up, mortality, major adverse cardiovascular events (MACE), prescription pattern of cardiovascular medications, lipid levels, adherence rate to treatment and behavioral recommendations were measured. Results The overall mortality was 4.8% and the rate of MACE was 17.5%. At 6months, a significantly lower proportion of patients received antiplatelet agents and statins as compared to hospital discharge. At the end of the follow-up, 87.7% of patients remained on statin treatment, yet only 18.2% of patients had LDL cholesterol levels less than 70mg/dL. The adherence pattern to lifestyle and dietary recommendations remained low (66.2% quit smoking, 55.8% and 81.3% followed physical activity and dietary recommendations respectively). Conclusion Despite the low rate of mortality and MACE occurrence rate in this countrywide observational study, the attainment rate of secondary prevention goals is relatively poor. Improvement interventions focusing in these gaps of optimal care provision are expected to have a favorable impact on the prognosis of real world ACS patients.

Ventricular tachycardia (VT) is the commonest cause of sudden cardiac death (SCD) in developed countries. Coronary artery disease (CAD) is the most frequent cause of VT in individuals over the age of 30, while hypertrophic cardiomyopathy (HCM), myocarditis and congenital heart disease in those below 30 years of age. Cardiac magnetic resonance (CMR), a non-invasive, non-radiating technique, can reliably detect the changes in ventricular volumes and the ejection fraction that can be predictive of VT/SCD. Furthermore, the capability of CMR to perform tissue characterization and detect oedema, fat and fibrotic substrate, using late gadolinium enhanced images (LGE), can predict VT/SCD in both ischaemic and non-ischaemic cardiomyopathy. The extent of LGE in HCM is correlated with risk factors of SCD and the likelihood of inducible VT. In idiopathic-dilated cardiomyopathy, the presence of midwall fibrosis, assessed by CMR, also predicts SCD/VT. Additionally, in arrhythmogenic right ventricle (RV) dysplasia/cardiomyopathy, CMR has an excellent correlation with histopathology and predicted inducible VT on programmed electrical stimulation, suggesting a possible role in evaluation and diagnosis of these patients. A direct correlation between LGE and VT prediction has been identified only in chronic Chagas' heart disease, but not in viral myocarditis. In CAD, infarct size is the strongest predictor of VT inducibility. The peri-infarct zone may also play a role; however, further studies are needed for definite conclusions. Left ventricle, RV, right ventricular outflow tract (RVOT) function, pulmonary regurgitation and LGE around the infundibular patch and RV anterior wall play an important role in the VT prediction in repaired Tetralogy of Fallot. Finally, in treated transposition of great arteries, the extent of LGE in the systemic RV correlates with age, ventricular dysfunction, electrophysiological parameters and adverse clinical events, suggesting prognostic importance.

Rhythm disturbances and sudden cardiac death (SCD) are important manifestations of cardiac involvement in systemic inflammatory diseases (SID). The commonest events demanding the implantation of a device include ventricular tachycardia and atrioventricular block, mainly diagnosed in sarcoidosis, systemic lupus erythematosus and scleroderma. In SCD, cardiac magnetic resonance (CMR) identified areas of late gadolinium enhancement (LGE) in 71% and provided an arrhythmic substrate in 76%, while during the follow-up, the extent of LGE identified a subgroup at increased risk for future adverse events. CMR has been successfully used for detection of cardiac disease in SID, including myocarditis, coronary, microvascular and valvular disease. Additionally, SIDs have a higher probability to need MRI scanning of other organs, due to their systemic disease. These reasons support the necessity of an MRI conditional device in SIDs. A broad selection of devices, approved for the MRI environment under defined conditions allows the safe and accurate scanning of SID patients.

Ventricular tachycardia (VT) and sudden cardiac death (SCD) are deleterious manifestations of cardiac involvement in connective tissue diseases (CTD). In rheumatoid arthritis (RA), the commonest cause of SCD is coronary artery disease that may lead to acute coronary syndrome and VT. In systemic lupus erythematosus (SLE), VT is due either to coronary artery disease or to acute myocarditis. VT/SCD can be also assessed in polymyostis (PM) and dermatomyositis (DM). Finally, VT was described in 7-13%, while SCD in 5-21% of unselected SSc patients. Cardiovascular magnetic resonance (CMR) has been already used as screening tool in CTDs, because of its capability to evaluate noninvasively and without radiation, function, inflammation, perfusion defects and fibrosis. Apart of the impaired ventricular function, which can be by itself a predisposing factor for VT/SCD, the commonest causes that can potentially lead to VT/SCD in CTDs are myocarditis, coronary artery disease with ischemic type fibrosis, microvascular disease, nonischemic type fibrosis and heart failure. The detection of perfusion defects by CMR can be served as a tool to select those patients, who should undergo x ray coronary angiography and/or angioplasty. The location and extent of myocardial scar can guide further electrophysiologic study and/or intervention. On the other hand, in those with myocarditis, microvascular disease and/or heart failure, a modification in both cardiac and rheumatic medication may be recommended after evaluation of CMR findings. CMR in CTDs with VT/SCD may guide risk stratification, rheumatic and cardiac therapeutic decision making and therefore it should be included as a reliable adjunct in the evaluation of these patients.

Background:We aimed at evaluating the long-term effects of cardiac resynchronization therapy (CRT) in nonambulatory New York Heart Association (NYHA) IV heart failure patients (NAIVHFP). Methods:Eighteen patients, 15 men and three women, eight with ischemic and 10 with nonischemic cardiomyopathy, who underwent biventricular pacemaker implantation while they were in nonambulatory NYHA IV class, were studied. Patients’ age was 58 ± 9 years and left ventricular ejection fraction (LVEF) 18 ± 3 %. Follow-up data were obtained through review of follow-up visits notes, stored echocardiographic studies, device interrogation data, and death certificates. Results:After a mean duration of 1223 ± 846 days, 11 patients were alive, including five patients who underwent heart transplantation (OCT) and seven dead. Three of 11 patients who received a CRT-defibrillator, experienced at least one appropriate discharge, but eventually they either died or received an OCT during follow-up. Sustained improvements in NYHA class (Z = 2.4, P = 0.015) and 6-minute walk distance (0 vs 212 ± 95 m, P ≪ 0.001) were documented after a median duration of 855 days postimplantation. Cumulative proportion of death or OCT at 18 months—when full follow-up data were available—was 18%, which compared favorably with historical controls. Full echocardiographic and clinical follow-up data at 12-months postimplantation were available for 10 patients, documenting a significant reduction in end-systolic volume (248 ± 82 vs 269 ± 97 mL, P = 0.039). Conclusions:CRT can be safely applied in this subset of extreme severity heart failure patients, achieving encouraging survival rates and reverse remodeling effects. These observations can form an evidence-based rationale for including NAIVHFP in randomized CRT trials. (PACE 2011; 34:1553–1560)

Transseptal catheterization is used by interventional cardiologists to gain access in the left atrium. This technique was initially introduced for left-sided pressure measurements and has been integrated in a variety of procedures including left atrial ablations and percutaneous mitral valvuloplasties. The establishment of catheter ablation of atrial fibrillation as an effective treatment strategy has brought transseptal catheterization back to the limelight. Technique refinements, introduction of adjunctive imaging tools, and enrichment of available technical equipment have simplified the procedure. In the present article we review the technique of transseptal catheterization, presenting tips and caveats that could be of value for safe and successful transseptal punctures.

Portal hypertension (PHT) is a complication of liver cirrhosis and directly increases mortality and morbidity by increasing the propensity of venous hemorrhage. There are two main underlying causations for PHT, increased hepatic resistance and systemic hyperdynamic circulation. Both are related to localized aberrations in endothelial nitric oxide synthase (eNOS) function and NO biosynthesis. This study investigates the importance of eNOS and systemic hyperdynamic-associated hyperemia to better understand the pathophysiology of PHT. Wild-type and eNOS−/− mice were given the hepatotoxin CCl4 for 4–12 wk. Hepatic fibrosis was determined histologically following collagen staining. Portal venous pressure, hepatic resistance, and hyperemia were determined by measuring splenic pulp pressure (SPP), hepatic portal-venous perfusion pressure (HPVPP), abdominal aortic flow (Qao), and portal venous flow (Qpv). Hepatic fibrosis developed equally in wild-type and eNOS−/− CCl4-exposed mice. SPP, Qao, and Qpv increased rapidly in wild-type CCl4-exposed mice, but HPVPP did not. In eNOS−/− CCl4 mice, Qao was not increased, SPP was partially increased, and HPVPP and Qpv were increased nonsignificantly. We concluded that the systemic hyperemia component of hyperdynamic circulation is eNOS dependent and precedes increased changes in hepatic resistance. Alternative mechanisms, possibly involving cyclooxygenase, may contribute. eNOS maintains normal hepatic resistance following CCl4-induced fibrosis. Consequently, increased portal pressure following chronic CCl4 exposure is linked to hyperdynamic circulation in wild-type mice and increased hepatic resistance in eNOS−/− mice.

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have recently published, in both the Journal of the American College of Cardiology (JACC) and Circulation, a Scientific Statement on the Evaluation of Syncope ('Statement'). This Scientific Statement was commissioned to provide guidance for clinicians regarding the evaluation of patients who present with 'syncope'. The Statement was not intended to be a formal set of practice guidelines. However, in the absence of generally accepted practice guidelines in North America, the Statement's potential impact on clinical care may be more far-reaching than expected; it may erroneously be considered to be the authoritative 'de-facto' guideline document. This commentary, submitted by a multidisciplinary consortium of more than 60 physicians with expertise in the management of transient loss of consciousness (TLOC), points out that in many respects the ACCF/AHA Syncope Statement fails to address long-standing clinical errors associated with the evaluation of episodes of apparent TLOC, including syncope. If not appropriately revised, the current Statement may lead to both inadequate patient care as well as a potentially damaging legal environment for physicians undertaking evaluation of patients who present with transient loss of consciousness.

Executive Summary ESC Committee for Practice Guidelines (CPG): Silvia G. Priori (Chairperson) (Italy), Maria Angeles Alonso Garcia (Spain), Jean-Jacques Blanc (France), Andrzej Budaj (Poland), Martin Cowie (UK), Jaap Deckers (The Netherlands), Enrique Fernandez Burgos (Spain), John Lekakis (Greece), Bertil Lindhal (Sweden), Gianfranco Mazzotta (Italy), JoA£o Morais (Portugal), Ali Oto (Turkey), Otto Smiseth (Norway) Document reviewers: Silvia G. Priori (CPG Review Coordinator) (Italy), Martin Cowie (UK), Carlo Menozzi (Italy), Hugo Ector (Belgium), Ali Oto (Turkey), Panos Vardas (Greece) Guidelines and Expert Consensus documents aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and by different organisations and other related societies. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents. In spite of the fact that standards for issuing good quality Guidelines and Expert Consensus Documents are well defined, recent surveys of Guidelines and Expert Consensus Documents published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilization of health resources. The ESC Committee for …

IMPLICATIONS The symptomatic obstruction of a pulmonary arterial branch secondary to the intravascular migration of a pigtail ureteral stent is reported. This iatrogenic complication may cause dyspnea, chest pain, or both after uneventful urologic procedures involving ureteral stents.

Table of contents Preamble Scope of the document 1256 Method 1257 Part 1. Classification, epidemiology and prognosis Definition 1258 Brief overview of pathophysiology of syncope 1258 Classification 1259 Epidemiological considerations 1259 Prognostic stratification: identification of factors predictive of adverse outcome 1260 Part 2. Diagnosis Strategy of evaluation (flow chart) 1262 Initial evaluation (history, physical examination, baseline electrocardiogram) 1264 Echocardiogram 1266 Carotid sinus massage 1266 Tilt testing 1268 Electrocardiographic monitoring (non-invasive and invasive) 1271 Electrophysiological testing 1273 ATP test 1277 Ventricular signal-averaged electrocardiogram 1278 Exercise testing 1278 Cardiac catheterization and angiography 1279 Neurological and psychiatric evaluation 1279 Diagnostic yield and prevalence of causes of syncope 1282

The impact of ranolazine, an anti-ishemic agent with antiarrhythmic properties, on paroxysmal atrial fibrillation (PAF) in patients with coronary artery disease (CAD) remains unclear. Pacing devices can be useful tools for disclosing even asymptomatic PAF. Purpose of this study is to assess the effect of ranolazine on atrial fibrillation (AF), in patients with CAD, PAF and a dual-chamber pacemaker. We studied 74 patients with CAD, PAF, and sick sinus syndrome or atrio-ventricular block, treated with pacemakers capable to detect PAF episodes. The total time in AF, AF burden, and the number of PAF episodes within the last 6 months before enrolment in the study, mean AF duration per episode, and the QTc interval were initially assessed. Subsequently, patients were randomized into additional treatment with ranolazine (375 mg twice daily) or placebo. Following six months of treatment, all parameters were reassessed and compared to those before treatment. Ranolazine was associated with shorter total AF duration (81.56±45.24 hours versus 68.71±34.84 hours, p=0.002), decreased AF burden (1.89±1.05% versus 1.59±0.81%, p=0.002), and shortened mean AF duration (1.15±0.41 hours versus 0.92±0.35 hours, p=0.01). In the placebo group no such differences were observed. In both groups, no significant differences in the number of PAF episodes and QTc duration were observed. We conclude that in patients with CAD and PAF, ranolazine reduces the total time in AF, AF burden, and mean AF duration. These findings may imply additional antiarrhythmic properties of ranolazine on atrial myocardium and might indicate the necessity of its use in ischemic patients with PAF.

A 44-year-old male patient with known Becker muscular dystrophy and concomitant non-ischemic dilated cardiomyopathy presented to our department because of worsening heart failure and presyncope. Upon admission, the patient was in New York Heart Association functional class III despite optimal pharmacological treatment; his ECG showed sinus rhythm with left bundle branch block and a wide QRS complex. Non-sustained ventricular tachycardia was recorded during 24-hour Holter monitoring. A complete three-dimensional echocardiographic study was performed and documented the dilatation and concomitant hypertrabeculation of the left ventricle (LV), with severely depressed systolic LV performance (ejection fraction 20%), as well as mechanical dyssynchrony--mainly in terms of intraventricular delay. A biventricular cardioverter-defibrillator (CRT-D) was implanted in this patient, with the LV lead in a lateral vein and the right ventricular defibrillating lead in the apical part of the interventricular septum. Echocardiography-guided device programming was performed in order to achieve the optimal atrio-, inter-, and intraventricular resynchronization. The patient's clinical condition was substantially improved within one month after the implantation.

Conduction of national surveys is needed to depict temporal trends in the risk profile, type of implemented treatment strategy and outcome of patients with acute coronary syndromes (ACS). The TARGET study is a multicenter, observational study that aimed to evaluate the epidemiological characteristics, management pattern and outcome of ACS patients in Greece.A total of 418 consecutive patients with ACS (44.7% STEMI, 34.2% NSTEMI, 21.1% unstable angina) from 17 centers (52.9% with catheterization facilities) were enrolled in the study (78.0% males, 63.9 ± 12.9 years).Overall, 67.9% of the patients had hypertension, 27.5% were diabetics and 57.4% had dyslipidemia. Thrombolytic therapy (60.7% tenecteplase, 38.2% reteplase) was administered in 22.7% of the study population, while invasive management was performed in 40.2% of patients (27.0% PCI and 1.0% CABG) during the index hospitalization. In-hospital all-cause mortality was 1.9%, with 12.2% of patients experiencing adverse clinical events. Evidence-based medications were prescribed to the majority of enrolled patients during hospitalization and upon discharge (97% and 94% received aspirin, 93% and 84% clopidogrel, 87% and 86% beta-blockers, 96% and 93% statins, respectively).The prevalence of modifiable risk factors exhibits an increasing trend among ACS patients in Greece. The prescription pattern of evidence-based medications has improved considerably, while there remains considerable room for improvement in expanding the implementation of invasive management in realworld clinical practice.

Coronary artery disease is the most frequent cause of SCD in individuals over the age of 30, while hypertrophic cardiomyopathy in those below 30 years of age. Cardiac magnetic resonance (CMR), a noninvasive, non-radiating technique, can reliably perform evaluation of 1) cardiac function through assessment of ventricular volumes and ejection fraction and 2) tissue characterization through oedema, fat and fibrotic substrate assessment. The presence of scar has been linked to ventricular arrhythmias, which is believed to be the major cause of SCD in both ischemic and nonischemic cardiomyopathy. The extent of late gadolinium enhancement (LGE) in hypertrophic cardiomyopathy is correlated with risk factors of SCD. In idiopathic dilated cardiomyopathy, the presence of midwall fibrosis, assessed by CMR, also predicts SCD. In coronary artery disease, infarct size is the strongest predictor of SCD. LGE around infundibular patch and RV anterior wall, among other functional parameters, also play an important role in SCD prediction in repaired Tetralogy of Fallot (TOF). Finally, in treated transposition of great arteries (TGA), the extent of LGE in systemic RV also correlates with SCD development.

We aimed at evaluating the long-term effects of cardiac resynchronization therapy (CRT) in nonambulatory New York Heart Association (NYHA) IV heart failure patients (NAIVHFP).Eighteen patients, 15 men and three women, eight with ischemic and 10 with nonischemic cardiomyopathy, who underwent biventricular pacemaker implantation while they were in nonambulatory NYHA IV class, were studied. Patients' age was 58 ± 9 years and left ventricular ejection fraction (LVEF) 18 ± 3%. Follow-up data were obtained through review of follow-up visits notes, stored echocardiographic studies, device interrogation data, and death certificates.After a mean duration of 1223 ± 846 days, 11 patients were alive, including five patients who underwent heart transplantation (OCT) and seven dead. Three of 11 patients who received a CRT-defibrillator, experienced at least one appropriate discharge, but eventually they either died or received an OCT during follow-up. Sustained improvements in NYHA class (Z = 2.4, P = 0.015) and 6-minute walk distance (0 vs 212 ± 95 m, P 0.001) were documented after a median duration of 855 days postimplantation. Cumulative proportion of death or OCT at 18 months-when full follow-up data were available-was 18%, which compared favorably with historical controls. Full echocardiographic and clinical follow-up data at 12-months postimplantation were available for 10 patients, documenting a significant reduction in end-systolic volume (248 ± 82 vs 269 ± 97 mL, P = 0.039).CRT can be safely applied in this subset of extreme severity heart failure patients, achieving encouraging survival rates and reverse remodeling effects. These observations can form an evidence-based rationale for including NAIVHFP in randomized CRT trials.

Antitachycardia therapies administered by implantable cardioverter defibrillators (ICDs) can occasionally prove proarrhythmic due to induction of ventricular tachyarrhythmias. In this report we present the case of a tachycardia induction as a result of inappropriate therapy delivery in an ICD recipient. Detailed analysis of the stored electrograms facilitated the delineation of the underlying mechanism of the recorded tachycardia.

We report the case of a dual-chamber cardioverter defibrillator (ICD) implantation in a young patient with a persistent left superior vena cava. The patient had biventricular dilatation, pulmonary hypertension and severely depressed left ventricular ejection fraction due to non-ischemic cardiomyopathy. Appropriate use of currently available, low profile active fixation leads allowed safe implantation of both leads through the left subclavian vein.

BACKGROUND Heart rate turbulence (HRT) following isolated premature complexes is a baroreceptor-mediated prognostic marker. Short runs of spontaneous, nonsustained ventricular tachycardia (nsVT) exert a greater hemodynamic effect than extrasystoles and may trigger a more potent turbulence-like response (HRT(VT)), possibly related to other risk-related markers, such as heart rate variability (HRV), left ventricular ejection fraction (EF), and original HRT parameters (turbulence slope [TS] and turbulence onset [TO]). METHODS We studied 27 patients with heart failure (HF) and nsVT (4-7 beats) on 24-hour Holter electrocardiographic recordings (mean age 58 +/- 3.6 years, EF 36%+/- 5.0%). Following nsVT, TS(VT) and TO(VT) were measured according to the original definitions. HRV, TS, and TO were also assessed. RESULTS HRT(VT) parameters were related to HRV. A significant relation existed between TS(VT) and EF (r= 0.66, P < 0.05). HRT(VT) parameters were related to the originally described (TS and TO), whereas TO(VT) was higher than TO (1.63 +/- 1.6 vs -1.7 +/- 0.65, P < 0.05). CONCLUSIONS In mild-to-moderate HF, turbulence is observed following short nsVT runs and is related to prognostically important HRV indexes and EF. HRT(VT) is similar to HRT but TO(VT) is shifted toward more positive values than TO. HRT(VT) might be prognostically significant.

We reviewed 322 patients with recurrent syncope between 1984 and 1988. Investigation included limited intracardiac electrophysiological study in all cases with programmed extra-stimulus studies in 48 cases. In 93 patients (29%), all investigations were normal, (including negative extrastimulus in 30). In the other 229 cases syncope was explained by AV-block (n = 111, 34%), sinus node disease (n = 68, 21%), carotid sinus syndrome (n = 32, 10%) and inducible sustained tachyarrhythmia (n = 18, 6%). Prolonged 60 degrees head-up tilt was performed in 71 out of 93 patients with unexplained syncope, and reproduced vasovagal syncope and presenting symptoms in 53 (75%), or 16% of the whole population reported. These patients were diagnosed as having malignant vasovagal syndrome. Positive tilts were significantly less common in a group of 27 subjects of similar age without a history of syncope (7%), and a random sample of 37 patients with atrioventricular block (n = 16), sick sinus syndrome (n = 18) and inducible tachyarrhythmia (n = 3), (19%, 11% and 0% respectively, P less than 0.01). From this retrospective review it appears, therefore, that tilt testing is a valuable provocative tool for vasovagal syncope and may reduce the number of syncopal patients that remain undiagnosed, although these early observations do not allow an exact appraisal of the sensitivity and specificity of the tilt test.

Summarization: In order to effectively exploit the wealth of content in Learning Object Repositories several issues should be addressed including the “closed corpus” problem as identified in the field of Adaptive Hypermedia as well as the “one size fits all” problem. Both are related to personalization. The creation of personalized learning experiences is considered as a necessity to cope with the overwhelming amount of available learning material. This paper presents a personalization framework that allows for the automatic creation of pedagogically-sound learning experiences taking into account the variety of the Learners and their individual needs. This framework defines a model for the representation of abstract training scenarios (Learning Designs) encoded in an instructional ontology. This ontology clearly separates pedagogy from content allowing this way the construction of real personalized learning experiences where learning objects are bound to the learning scenario at run-time taking into account information encoded in Learner Profiles. Presented on