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Tilt testing

EEG = electroencephalogram; OH = orthostatic hypotension; POTS = postural orthostatic tachycardia syndrome; PPS = psychogenic pseudosyncope; VVS = vasovagal syncope.


Tilt testing

EEG = electroencephalogram; OH = orthostatic hypotension; POTS = postural orthostatic tachycardia syndrome; PPS = psychogenic pseudosyncope; VVS = vasovagal syncope.

Figure 7
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Rates of tilt testing positivity in different clinical conditions. These studies used the Westminster protocol for passive tilt, the Italian protocol for trinitroglycerin tilt, and the clomipramine protocol, for a total of 1453 syncope patients and 407 controls without syncope. Studies using other tilt protocols, e.g. isoproterenol challenge, were not included. Clom = clomipramine; TNG = trinitroglycerin; VVS = vasovagal syncope.

Figure 7
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Rates of tilt testing positivity in different clinical conditions. These studies used the Westminster protocol for passive tilt, the Italian protocol for trinitroglycerin tilt, and the clomipramine protocol, for a total of 1453 syncope patients and 407 controls without syncope. Studies using other tilt protocols, e.g. isoproterenol challenge, were not included. Clom = clomipramine; TNG = trinitroglycerin; VVS = vasovagal syncope.

Autonomic function assessment helps to identify autonomic failure as the underlying cause of syncope.

The methodology of the Valsalva manoeuvre is described in section 7.1.1 of the
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. There is strong evidence that the absence of a BP overshoot and an absence of a HR increase during the Valsalva is pathognomonic for neurogenic OH, occurring in primary and secondary autonomic failure, and the degree of hypotension and/or lack of compensation during forced expiration usually correlate with the degree of autonomic dysfunction and related symptoms. 138–143 In contrast, a pronounced BP fall beyond what is normally expected during forced expiration, but a normal chronotropic response during the manoeuvre, may occur in patients with suspected situational syncope, i.e. syncope occurring during some forms of situational syncope, e.g. coughing, brass instrument playing, singing, and weightlifting. 144

on symptomatic grounds in patients with persistent limiting symptoms (angina or angina equivalent) despite OMT and/or

on prognostic grounds in certain anatomical patterns of disease or a proven significant ischaemic territory (even in asymptomatic patients). Significant LM stenosis, and significant proximal LAD disease, especially in the presence of multivessel CAD, are strong indications for revascularization. In the most severe patterns of CAD, CABG appears to offer a survival advantage as well as a marked reduction in the need for repeat revascularization, albeit at a higher risk of CVA, especially in LM disease.

Recognizing that visual attempts to estimate the severity of stenoses on angiography may either under- or overestimate the severity of lesions, the increasing use of FFR measurements to identify functionally more important lesions is a significant development (Section 5.4).

It is not feasible to provide specific recommendations for the preferred method of revascularization for every possible clinical scenario. Indeed it has been estimated that there are > 4000 possible clinical and anatomical permutations. Nevertheless, in comparing outcomes between PCI and CABG, Tables 8 and 9 should form the basis of recommendations by the Heart Team in informing patients and guiding the approach to informed consent. However, these recommendations must be interpreted according to individual patient preferences and clinical characteristics. For example, even if a patient has a typical prognostic indication for CABG, this should be modified according to individual clinical circumstances such as very advanced age or significant concomitant comorbidity.

NSTE-ACS is the most frequent manifestation of ACS and represents the largest group of patients undergoing PCI. Despite advances in medical and interventional treatments, the mortality and morbidity remain high and equivalent to that of patients with STEMI after the initial month. However, patients with NSTE-ACS constitute a very heterogeneous group of patients with a highly variable prognosis. Therefore, early risk stratification is essential for selection of medical as well as interventional treatment strategies. The ultimate goals of coronary angiography and revascularization are mainly two-fold: symptom relief, and improvement of prognosis in the short and long term. Overall quality of life, duration of hospital stay, and potential risks associated with invasive and pharmacological treatments should also be considered when deciding on treatment strategy.

RCTs have shown that an early invasive strategy reduces ischaemic endpoints mainly by reducing severe recurrent ischaemia and the clinical need for rehospitalization and revascularization. These trials have also shown a clear reduction in mortality and MI in the medium term, while the reduction in mortality in the long term has been moderate and MI rates during the initial hospital stay have increased (early hazard) [ 58 ]. The most recent meta-analysis confirms that an early invasive strategy reduces cardiovascular death and MI at up to 5 years of follow-up [ 59 ].

What is already known on this topic

What does this study add

Despite the non-contact nature of volleyball, this sport has a high injury incidence. Previous studies on volleyball injuries have shown that ankle sprains account for up to one half of all acute injuries in volleyball, with an estimate of one sprain per 1000 playing hours.

Studies on volleyball injury incidence during training and match play have mainly been retrospective, and reliable information from season-long prospective studies is scarce. The current study overcomes the drawbacks of the few previous prospective studies, and thereby strengthens data and theories from previous work.

The overall injury incidence in volleyball was 2.6 per 1000 playing hours. The incidence of acute and overuse injuries was 2.0 and 0.6 per 1000 playing hours, respectively. The ankle sprain is clearly the most common injury in volleyball, accounting for 41% of all volleyball related injuries, with an injury incidence of 1.0 per 1000 playing hours. Although our study was limited to injuries causing absence from volleyball, ankle sprains should be of particular interest in studies on prevention strategies. Previous injury seems to be an important risk factor for ankle sprains. Thus if an initial ankle sprain can be prevented the most important risk factor has been eliminated.


This study was financially supported by the Netherlands Organisation for Health Research and Development (ZonMw; grant No 2200.0068), and the project group Sport Blessure Vrij (SBV) of the Dutch National Olympic Committee (NOC*NSF). We would also like to thank the Dutch Volleyball Association for their cooperation and specifically R H M Vesters MD and H J P A du Bois MD for their willingness to give their expertise by diagnosing all registered injuries, and their help in the organisation of the study. We are also very grateful with the help given by M Inklaar in collecting the data.

Federation Internationale de Volleyball (FIVB)
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The procedure-specific risks of stroke, silent stroke, and bleeding emphasize the importance of acquiring data from randomized trials comparing NOAC therapy and VKAs in patients undergoing AF ablation. In a randomized trial with rivaroxaban (VENTURE-AF), 248 patients scheduled for ablation were randomly assigned to uninterrupted therapy with warfarin or rivaroxaban. 42 The incidence of thromboembolic and major bleedings events was low in both treatment arms (one patient in each).

Ongoing trials [AXAFA with apixaban (NCT02227550) and RE-CIRCUIT (NCT02348723) with dabigatran] will provide prospectively collected data on outcomes, including silent ischaemic brain lesions in patients undergoing AF ablation on uninterrupted NOAC therapy compared with uninterrupted warfarin. These trials are exploratory for outcomes such as stroke because of the low event rates, but they should shed some light on major bleeding rates and possibly provide information about the effect of NOAC therapy on silent strokes in patients undergoing AF ablation.

Although the use of transcatheter aortic valve implantation is increasing, surgical valve replacement with either bioprosthetic or mechanical valves is the more common approach, with mechanical prostheses having the advantage of durability but the disadvantages of thrombogenicity and need for life-long anticoagulation. An alternative to VKAs is needed and there was the hope that NOACs might fill the role, but the RE-ALIGN trial found even high-dose dabigatran neither safe nor effective. 43 In that trial, 252 patients with recent or remote valve replacement were randomly assigned to a VKA (guideline-directed INR target range) or to dabigatran adjusted to a trough plasma level of ≥50 ng/mL. The trial was stopped early due to excess stroke (nine patients in the dabigatran group and none in the warfarin group) and major bleeding (seven patients in the dabigatran vs. two in the warfarin group). There was also excess valve thrombosis with dabigatran. This small study, although not definitive, suggests that dabigatran is not effective and that NOACs should not be selected for patients with mechanical prosthetic valves.

The term ‘non-valvular AF’ was developed to define patient eligibility for enrolment in the historical warfarin trials, excluding individuals with rheumatic mitral stenosis and AF, which was associated with a high risk of stroke. Since these patients were not included in the trials that established the non-inferiority boundaries, they were excluded from the NOAC trials and therefore from the labelling indications for NOAC use. We have little or no data on the efficacy of NOACs in this population, and patients with mitral stenosis should not be treated with NOACs, although the threshold of severity warranting this prohibition has not been established.

Other types of valvular heart disease (VHD), such as mitral or tricuspid insufficiency and aortic stenosis or insufficiency, occur commonly in patients with AF. In the ROCKET AF trial, 43 14% of enrolled patients had clinically significant VHD, as did 26% in ARISTOTLE. 44 , 45 In each of these trials, the treatment effect of the NOAC compared with warfarin was similar in patients with and without VHD, but rivaroxaban was associated with a higher risk of bleeding than warfarin in patients with VHD. 44 In ARISTOTLE apixaban was associated with fewer bleeding complications in patients with and without VHD. 45 Patients in the ROCKET-AF 44 and ARISTOTLE 45 trials with VHD differed with regard to age, stroke risks, and history of previous stroke or systemic embolism. Thus, NOACs may be prescribed for patients with VHD other than mitral stenosis or mechanical valve prostheses. A few hundred patients with bioprosthetic valves were included in the ARISTOTLE and ENGAGE AF trials, but the results in these subgroups have not been reported. It may be reasonable to treat patients who have bioprosthetic valves with NOACs unless intracardiac thrombus or other features placing the patient at an unusually high risk of thromboembolism or bleeding are present.

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