Elderly adults who have recurrent, unexplained falls, attributing them to old age, weak joints or other causes, actually may suffer from a heart condition that can be effectively treated by cardiac pacing, according to an article in a recent issue of the Journal of the American College of Cardiology (JACC). The article, titled "Carotid Sinus Syndrome: A Modifiable Risk Factor for Nonaccidental Falls in Older Adults," says these unexplained falls may be caused by a condition called carotid sinus syndrome (CSS), which results in syncope.

Carotid sinus syndrome in the elderly is manifested by extremely slow heart rates and abnormally low blood pressure. A specific type of CSS, known as cardioinhibitory, is characterized by asystole (stoppage of the heart beat) when pressure is applied or sensed near the carotid artery in the neck. People with this tendency are at higher risk for further syncope and falls. The study also says that patients with this type of syndrome can benefit from dual-chamber pacing, which has been proven to reduce falls and associated injuries by 70% and episodes of syncope by 50%.

Guidelines by the American Heart Association (Dallas, Texas) and American College of Cardiology (Bethesda, Maryland), as well as the European Society of Cardiology (Sophia Antipolis, France), recommend pacemaker therapy for patients with cardioinhibitory CSS, who have had repeated syncope. In routine practice, however, most elderly patients who have suffered falls do not receive further evaluation by a cardiac specialist.

Based on following 175 patients in the United Kingdom, the study found "a strong association between non-accidental falls and cardioinhibitory CSS" and suggested that these types of patients should be referred to a specialist for a cardiovascular assessment. "This study clearly shows that for patients with non-accidental falls and cardioinhibitory CSS, cardiac pacing significantly reduces subsequent falls," wrote Rose Anne Kenny, MD, lead investigator of the SAFE-PACE (Syncope and Falls in the Elderly-Pacing and Carotid sinus Evaluation) study. "No other single intervention for falls has demonstrated this magnitude of benefit."

Falls are the sixth-leading cause of death in older adults, and in 40% to 60%, falls or syncope episodes are unwitnessed, making diagnosis of syncope more challenging. Falls among those 50 or older are the most common single reason for visits to physicians and emergency departments in the UK and are a major health care and cost priority. In the UK each year, an estimated 30% of those over age 65 will experience falls or syncope, with 15% of these falls being unexplained. This figure rises to 60% in nursing homes.

Women underestimate heart disease threat

Evidence continues to accumulate that American women do not understand their risk for heart problems and that they seriously underestimate cardiovascular disease as a risk for death. A new poll – conducted by Harris Interactive and commissioned by the American Heart Association – showed that only one-third of the women polled identified heart disease as the No. 1 killer of women, and less than 10% identified it as their greatest health problem. "Although many women die unnecessarily every year from heart disease, women are not aware that they are at risk," said AHA President Rose Marie Robertson, MD. The AHA commissioned the poll to assess women's perceptions and sources of information regarding general health risks as well as heart disease and stroke. An update of a previous poll completed in 1997, the national survey involved over 1,000 women over the age of 25 who were interviewed by telephone in June and July 2000.

The researchers found that although cardiovascular disease kills more American men and women than any other illness, over 60% of women believed cancer is their leading health problem – a figure basically unchanged from three years prior. Specific knowledge about heart disease was found to be uneven. In spite of the fact that almost 70% of the women said they were concerned about stroke, and 65% knew that chest pain is a warning sign of an attack, only 36% recognized that sudden weakness or numbness on one side of the body or face is a symptom. Over one-quarter said that they thought aromatherapy was an adequate protection against heart disease, with the AHA calling that belief "mistaken."

Other findings from the survey were that only one-fifth of the women had discussed the issue of heart problems with a health care professional in the past year. Most said they had informed themselves on the subject either through reading magazines (43%) or watching television (21%). Somewhat more than a third (35%) said that they viewed heart disease as something that can suddenly develop between the ages of 35 and 49, rather than realizing that it is widely known to develop gradually, perhaps at a very early age.

On the good news side, most of the women polled could identify the seven activities that can best prevent or reduce the risk of developing heart disease. These include exercise, weight and stress reduction, quitting smoking and reducing consumption of cholesterol, sodium and animal products. And the researchers also pointed to the encouraging fact that three-quarters of women reported having received some information on heart disease in the prior year.

Commenting on the results in an editorial published in the May 15 issue of Circulation, Robertson cautioned that despite high levels of general awareness and concern, adequate prevention and risk reduction will not be seen if physicians and patients don't discuss the disease more often. She noted that the less than 40% of physicians currently talking to their patients about heart disease is insufficient, given the fact that more than 90% of women said they are comfortable discussing disease prevention and treatment with their doctors.

Dentist can ID women's stroke risk

Surprisingly, one of the health professionals that may be best able to identify risk of stroke in women is the dentist, according to a new report in the Journal of the American Dental Association. The published research says that X-ray technology known as "wide-angle radiography" provides a panoramic view of the neck, as well as the mouth, and that this technology is currently being used by about half of all U.S. dentists. Viewing of the neck area allows the imaging of neck arteries which are blocked by hardened fatty tissues, known as atheromas, with the blockage leading to stroke.

In the study, researchers reviewed the X-rays and medical records of 52 female military veterans who averaged 70 years of age and had no symptoms of neurological disease or illness. Overall, 16 of the women (31%) had atheromas in the neck. Because they were asymptomatic, the women probably would not have been diagnosed until they had developed more dangerous symptoms, according to Arthur Friedlander, MD, lead author and associate chief of staff and director of graduate medical education at the Veterans Affairs Greater Los Angeles Healthcare System (Los Angeles, California). Friedlander emphasized that the technique should only be used when a patient already needs an X-ray for some dental purpose. Also, he said that ultrasound screenings should then be used to determine the nature of the atheroma, the extent of the blockage and the necessary treatment.

"There are more sensitive imaging systems which can pick up much earlier lesions than we're picking up with these X-rays," Friedlander says. "So, if a person was interested in finding out whether they were at risk, they are best advised to go see a doctor first. There needs to be a dental rationale and a need. Once that's been met, then since it's already there, the dentist needs to review the entirety of the radiograph and not just the teeth."

Atheromas occur more often in post-menopausal women than men as estrogen levels decline. When the blockage is less than 60%, the treatment normally consists of medications, such as hypertension drugs, plus lifestyle changes to deal with obesity or diabetes. Symptoms of an atheroma include short-term loss of strength in a hand, an arm, a leg or a foot, as well as short-term difficulty in speaking, says Dr. Richard Latchaw, chief of the department of neuroradiology at the University of Pittsburgh Medical Center (Pittsburgh, Pennsylvania).

Framingham recruits 3rd generation

The Framingham Heart Study, currently in its 53rd year, has begun recruiting participants in the third generation of this trend-setting research. Letters were sent last month to the grandchildren of the original participants, inviting them to take part in the longest epidemiological project in medicine. "The future success of the study depends on your participation in this newest phase," according to the letter. The Framingham study, funded by the National Heart, Lung and Blood Institute (Bethesda, Maryland), is staffed largely by doctors from Boston University (Boston, Massachusetts). It began in the Boston suburb of Framingham in 1948. The new recruitment drive is the first since 1971.

More than 10,000 people have participated in the study, and the organizers hope to recruit about 3,500 more from the third generation. Three generations of every family's medical history, combined with new medical technology, could mean enormous gains for the study, said its director, Dr. Daniel Levy. "I think it will allow us to advance our understanding of the genetic basis of a number of common conditions," Levy said.

Volunteers in the Framingham Heart Study agree to extensive physical exams every three or four years. They also provide information about their eating and living habits. In return, they get thousands of dollars worth of free tests and a chance to be part of research that has already produced most of what is known about the causes of heart attacks and strokes.

Framingham, which is located 20 miles west of Boston, was chosen because of its economic and ethnic mix and proximity to Boston's medical centers. About 5,200 residents signed up. Second- and third-generation participants do not have to live in Framingham. Adults as young as 20 will be added to a sample with people as old as 90, enabling researchers in the study to chart family risk factors such as obesity, high cholesterol, diabetes and asthma through the generations and perhaps determine the role played by genetics and lifestyle in various diseases.

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