Clinical characteristics and hemodynamic responses to head-up tilt test in children and adolescents with unexplained sighing

Relationship between syncopal symptoms and head-up tilt test modes

OBJECTIVE

Head-up tilt test (HUTT) is an important tool in the diagnosis of pediatric vasovagal syncope. This research will explore the relationship between syncopal symptoms and HUTT modes in pediatric vasovagal syncope.

METHODS

A retrospective analysis was performed on the clinical data of 2513 children aged 3-18 years, who were diagnosed with vasovagal syncope, from Jan. 2001 to Dec. 2021 due to unexplained syncope or pre-syncope. The average age was 11.76 ± 2.83 years, including 1124 males and 1389 females. The patients were divided into the basic head-up tilt test (BHUT) group (596 patients) and the sublingual nitroglycerine head-up tilt test (SNHUT) group (1917 patients) according to the mode of positive HUTT at the time of confirmed pediatric vasovagal syncope.

RESULTS

(1) Baseline characteristics: Age, height, weight, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and composition ratio of syncope at baseline status were higher in the BHUT group than in the SNHUT group (all P < 0.05). (2) Univariate analysis: Age, height, weight, HR, SBP, DBP, and syncope were potential risk factors for BHUT positive (all P < 0.05). (3) Multivariate analysis: syncope was an independent risk factor for BHUT positive, with a probability increase of 121% compared to pre-syncope (P<0.001).

CONCLUSION

The probability of BHUT positivity was significantly higher than SNHUT in pediatric vasovagal syncope with previous syncopal episodes.

Clinical and Autonomic Profile, and Modified Calgary Score for Children and Adolescents with Presumed Vasovagal Syncope Submitted to the Tilt Test

BACKGROUND

In the pediatric population, syncope is mainly from vasovagal (VVS) origin. Its evaluation must be done by clinical methods, and the tilt test (TT) can contribute to the diagnosis.

OBJECTIVES

To analyze the clinical profile, Calgary and modified Calgary scores, response to TT and heart rate variability (HRV) of patients aged ≤ 18 years with presumed VVS. To compare the variables between patients with positive and negative responses to TT.

METHOD

Observational and prospective study, with 73 patients aged between 6 and 18 years, submitted to clinical evaluation and calculation of scores without previous knowledge of the TT. It was done at 70º under monitoring for HRV analysis. P-value < 0.05 was the statistical significance criterion.

RESULTS

Median age was 14.0 years; 52% of participants were female, 72 had Calgary ≥ -2 (mean 1.80), and 69 had modified Calgary ≥ -3 (mean 1.38). Prodromes were observed in 59 patients, recurrence in 50 and trauma in 19. The response to TT was positive in 54 participants (49 vasovagal, with 39 vasodepressor responses), with an increase in the low frequency (LF) component and a decrease in the high frequency (HF) component (p < 0,0001). In the supine position, LF was 33.6 in females and 47.4 in normalized units for males (p = 0.02). When applying the operating characteristic curve for positive TT, there was no statistical significance for HRV and scores.

CONCLUSION

Most children and adolescents with a presumed diagnosis of VVS presented a typical clinical scenario, with a Calgary score ≥ -2, and a predominant vasodepressor response to TT. Greater sympathetic activation was observed in the supine position in males. Calgary scores and sympathetic activation did not predict the response to TT.

Neurally Mediated Syncope in Children and Adolescents: An Updated Narrative Review

Syncope presents a proportion of up to 25% among children and adolescents and accounts for 0.9% of emergency room visits. Its most frequent aetiology is neurally mediated syncope, which includes vasovagal syncope and orthostatic hypotension. Up to 70% of the paediatric population with reflex syncope is female. There are usually precipitating factors and prodromes. This mini-review will discuss the particularities of the clinical presentation, diagnosis, modified Calgary score, indications and accuracy of the head-up tilt test, classification, and pathophysiology in four sequential phases. Prognostic data and the non-pharmacological and pharmacological approaches will also be reviewed and differences regarding reflex syncope in adults will be discussed.

The Relationship Between Unexplained Chest Pain in Children and Head-Up Tilt Test

BACKGROUND

To explore the relationship between unexplained chest pain in children and head-up tilt test (HUTT).

MATERIALS AND METHODS

A total of 825 children with the main symptom of unexplained chest pain were admitted to the Specialist Outpatient Clinic of Children's Cardiovascular Disease from October 2000 to November 2021 at The Second Xiangya Hospital, Central South University. Among them, 473 were male and 352 were female, with a mean age of 10.61 ± 2.21 years. The control group included 58 cases, comprising 35 males and 23 females, with a mean age of 10.26 ± 2.66 years. The detailed history, physical examinations, conventional 12-lead electrocardiogram, chest X-ray, echocardiography, myocardial enzymes, electroencephalogram, and blood series were all examined. Disorders of the chest wall, lung, heart, mediastinum, and esophageal reflux, as well as drug effects, were ruled out. All the children underwent HUTT. Demographic description, univariate analysis, and multivariate logistic regression analysis were used to explore the possible linear or non-linear relationships between the children's unexplained chest pain and HUTT.

RESULTS

Among the 825 chest pain cases, 301 (36.48%) were HUTT positive and 524 (63.52%) were HUTT negative. HUTT-positive patients were older than HUTT-negative patients (11.04 ± 2.03 vs. 10.34 ± 2.31 years, P < 0.001). The logistic regression results showed that each year of age increased the probability of being HUTT positive by 17.90% (P < 0.000), and females were 91.30% more likely to be HUTT positive than males (P < 0.000).

CONCLUSION

Clinically unexplained chest pain in children is mainly caused by unbalanced autonomic nervous function. HUTT can help clear the cause of unexplained chest pain.

Autonomic dysfunction in SARS-COV-2 infection acute and long-term implications COVID-19 editor's page series

Abstract

The autonomic nervous system (ANS) is a complex network of nerves originating in the brain, brain stem, spinal cord, heart and extracardiac organs that regulates neural and physiological responses to internal and external environments and conditions. A common observation among patients with the 2019 Coronavirus (CoV) (SARS-severe acute respiratory syndrome CoV-2) (SARS-CoV-2) or COVID-19 [CO for corona, VI for virus, D for disease and 19 for when the outbreak was first identified (31 December 2019)] in the acute and chronic phases of the disease is tachycardia, labile blood pressure, muscular fatigue and shortness of breath. Because abnormalities in the ANS can contribute to each of these symptoms, herein a review of autonomic dysfunction in SARS-COV-2 infection is provided to guide diagnostic testing, patient care and research initiatives.

Graphic abstract

The autonomic nervous system is a complex network of nerves originating in the brain, brain stem, spinal cord, heart and extracardiac organs that regulates neural and physiological responses to internal and external environments and conditions. A common collection of signs and symptoms among patients with the 2019 Coronavirus (CoV) (SARS-severe acute respiratory syndrome CoV-2) (SARS-CoV-2) or COVID-19 [CO for corona, VI for virus, D for disease and 19 for when the outbreak was first identified (31 December 2019)] is tachycardia, labile blood pressure, muscular fatigue and shortness of breath. Abnormalities in the autonomic nervous system (ANS) can contribute to each of these identifiers, potentially offering a unifying pathobiology for acute, subacute and the long-term sequelae of SARS-CoV-2 infection (PASC) and a target for intervention.