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Parsons IT, Ellwood J, Stacey MJ, Gall N, Chowienczyk P, Woods DR. Risk factors for reflex syncope in the British Army. BMJ Mil Health 2023; 169:548-553. [PMID: 35177430 DOI: 10.1136/bmjmilitary-2021-002040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/29/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Reflex syncope in the UK Armed Forces is reportedly higher than comparable militaries and civilian populations and is significantly more common in soldiers who take part in State Ceremonial and Public Duties (SCPD) compared with other British Army service personnel (SP). This study aimed to investigate individual susceptibility factors for syncope in soldiers who regularly take part in SCPD. METHODS A retrospective cohort study was performed in 200 soldiers who perform SCPD. A questionnaire was undertaken reviewing soldiers' medical history and circumstances of any fainting episodes. A consented review of participants' electronic primary healthcare medical record was also performed. Participants were divided into two groups (syncope, n=80; control, n=120) based on whether they had previously fainted. RESULTS In the syncope group orthostasis (61%) and heat (35%) were the most common precipitating factors. The most common interventions used by soldiers were to maintain hydration (59%) and purposeful movements (predominantly 'toe wiggling'; 55%). 30% of participants who had previously fainted did not seek definitive medical attention. A history of migraines/headaches was found to increase the risk of reflex syncope (OR 8.880, 1.214-218.8), while a history of antihistamine prescription (OR 0.07144, 0.003671-0.4236), non-white ethnicity (OR 0.03401, 0.0007419-0.3972) and male sex (OR 0.2640, 0.08891-0.6915) were protective. CONCLUSION This is the first study, in the British Army, to describe, categorise and establish potential risk factors for reflex syncope. Orthostatic-mediated reflex syncope is the most common cause in soldiers who regularly perform SCPD and this is further exacerbated by heat exposure. Soldiers do not use evidence-based methods to avoid reflex syncope. These data could be used to target interventions for SP who have previously fainted or to prevent fainting during SCPD.
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Affiliation(s)
- Iain T Parsons
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- School of Life Sciences and Medicine, King's College London, London, UK
| | - J Ellwood
- Defence Primary Healthcare, George Guthrie Medical Centre, Wellington Barracks, London, UK
| | - M J Stacey
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - N Gall
- Department of Cardiology, King's College Hospital, London, UK
| | - P Chowienczyk
- School of Life Sciences and Medicine, King's College London, London, UK
| | - D R Woods
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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Russo V, Parente E, Comune A, Laezza N, Rago A, Golino P, Nigro G, Brignole M. The clinical presentation of syncope influences the head-up tilt test responses. Eur J Intern Med 2023; 110:41-47. [PMID: 36639324 DOI: 10.1016/j.ejim.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/08/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Little is still known about the positivity rate of nitroglycerin (NTG) potentiated head-up tilt test (HUTT) according to the history-based clinical features of syncope. The study aimed to compare the HUTT positivity rate and type of responses in patients with classical and non-classical vasovagal syncope (VVS). MATERIALS AND METHODS We retrospectively evaluated all consecutive patients who underwent NTG-potentiated HUTT for VVS. The study population was dichotomized into classical and non-classical VVS. RESULTS A total of 1285 VVS patients (45± 19.1 years; 49.6% male) were enrolled: 627 (48.8%) had a history of classical VVS and 658 (51.2%) of non-classical VVS. HUTT was positive in 866 (67.4%) patients. The positivity rate was significantly higher in patients with classical compared to those with non-classical VVS (81.5% vs 54%; P< 0.0001). Cardioinhibitory response showed similar total positivity rate (27.6% vs 31%; P= 0.17), but higher relative prevalence among positive tests (57.7% vs 33.9%, P< 0.0001) in patients with non-classical VVS. At multivariable analysis, classical reflex syncope, male sex, history of traumatic syncope and use of diuretics were independent predictors of HUTT positivity. CONCLUSION The clinical presentation of syncope influences the overall HUTT positivity rate and the type of responses. Cardioinhibitory response and traumatic syncope are more likely in patients with non-classical VVS.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy.
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Nunzia Laezza
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Paolo Golino
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
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Cardioinhibitory syncope with asystole during nitroglycerin potentiated head up tilt test: prevalence and clinical predictors. Clin Auton Res 2022; 32:167-173. [PMID: 35524080 PMCID: PMC9236999 DOI: 10.1007/s10286-022-00864-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/04/2022] [Indexed: 11/21/2022]
Abstract
Aims The aim of our study was to evaluate the prevalence and clinical predictors of cardioinhibitory (CI) responses with asystole at the nitroglycerin (NTG)-potentiated head-up tilt test (HUTT) in patients with a history of syncope admitted to a tertiary referral syncope unit. Methods We retrospectively evaluated all consecutive patients who underwent NTG-potentiated HUTT for suspected reflex syncope at our institution from March 1 2017 to May 1 2020. The prevalence of HUTT-induced CI syncope was assessed. Univariate and multivariate analyses were performed to test the association of asystolic response to HUTT with a set of clinical covariates. Results We enrolled 1285 patients (45 ± 19.1 years; 49.6% male); 368 (28.6%) showed HUTT-induced CI response with asystole. A multivariate analysis revealed that the following factors were independently associated with HUTT-induced CI syncope: male sex (OR 1.48; ConInt 1.14–1.92; P = 0.003), smoking (OR 2.22; ConInt 1.56–3.115; P < 0.001), traumatic syncope (OR: 2.81; ConInt 1.79–4.42; P < 0.001), situational syncope (OR 0.45; ConInt 0.27–0.73; P = 0.002), and the use of diuretics (OR 9.94; ConInt 3.83–25.76; P < 0.001). Conclusions The cardioinhibitory syncope with asystole induced by NTG-potentiated HUTT is more frequent than previously reported. The male gender, smoking habit, history of traumatic syncope, and use of diuretics were independent predictors of HUTT-induced CI responses. Conversely, the history of situational syncope seems to reduce this probability.
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Alboni P, Messop AC, Lauri A, Furlan R. Are women really more affected by vasovagal syncope than men? J Cardiovasc Med (Hagerstown) 2021; 22:69-78. [PMID: 32925389 DOI: 10.2459/jcm.0000000000001009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It is commonly reported that vasovagal syncope (VVS) is more frequent in women. Presently, this issue has never been investigated. The purpose of this review was to evaluate, through an extensive review of the literature, whether women are really more affected by VVS than men. The gender distribution was investigated in individuals with classical and nonclassical VVS. The database PubMed was searched using the terms 'syncope', 'vasovagal syncope', 'neurally mediated syncope' and 'tilt testing'. Twelve studies dealing with classical and 75 with nonclassical VVS were eligible. In the individuals with classical (N = 1861) and nonclassical VVS (N = 9696), a trend towards a greater percentage of women emerged (P = 0.14 and 0.07, respectively). In the total population with VVS (N = 11 557), the percentage of women was significantly higher than that of men (58 versus 42%, P = 0.03). Most of the individuals were young or middle-aged. In 84% of the studies, the percentage of women was greater than that of men. A separate analysis was carried out in older VVS patients (≥60 years) and only two studies were eligible to be evaluated. Considering that almost all the studies were carried out in the western nations, where the number of men and women is almost superimposable until the age of 65 years and a bias by gender has never been reported in the management of VVS, these data strongly suggest that young and middle-aged women are more affected by VVS than their male counterparts. At present, data are too scant to draw a definitive conclusion in older VVS patients.
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Affiliation(s)
| | | | - Alessandro Lauri
- Section of Economics and Statistics, Ospedale Privato Quisisana, Ferrara
| | - Raffaello Furlan
- Internal Medicine, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, Italy
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A higher proportion of men than of women fainted in the phase without nitroglycerin in tilt-induced vasovagal syncope. Clin Auton Res 2020; 30:441-447. [PMID: 31953616 PMCID: PMC7561535 DOI: 10.1007/s10286-020-00666-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/06/2020] [Indexed: 11/25/2022]
Abstract
Purpose Vasovagal syncope (VVS) affects more women than men. We determined whether this sex ratio affects tilt table test (TTT) results. Methods We retrospectively studied TTT outcomes in suspected VVS. TTT consisted of supine rest, a maximum 20 min of head-up tilt without and, if nitroglycerin was needed, a further maximum 20 min after nitroglycerin administration. TTT was terminated if VVS occurred. We used binary logistic regression for the entire TTT and for each phase, with VVS as outcome and age and sex as predictors. Results TTT provoked vasovagal (pre)syncope in 494 out of 766 tests (64%). The proportion of men and women who fainted during the entire TTT did not differ significantly between the sexes (p = 0.13, corrected for age). A lower proportion of women than men had VVS in the phase without nitroglycerin (odds ratio 0.54; 95% confidence interval 0.37–0.79; p = 0.002, corrected for age), whereas a higher proportion of women than men fainted after nitroglycerin (odds ratio 1.58; 95% confidence interval 1.13–2.21; p = 0.008, corrected for age). These sex differences remained significant after correction for a history of orthostatic versus emotional triggers. The effect of sex on TTT outcome was closely associated with differences of blood pressure change upon tilt-up (lower in men in both TTT phases: without nitroglycerin p = 0.003; with nitroglycerin p = 0.05), but not with heart rate changes. Conclusion Men were more susceptible to induction of VVS without nitroglycerin and women after it. The unexpected findings may be due to sex-specific pathophysiological differences. Electronic supplementary material The online version of this article (10.1007/s10286-020-00666-5) contains supplementary material, which is available to authorized users.
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Russo V, Rago A, De Rosa M, Papa AA, Simova I, Petrov I, Bonev N, Gargaro A, Golino P, Nigro G. Does cardiac pacing reduce syncopal recurrences in cardioinhibitory vasovagal syncope patients selected with head-up tilt test? Analysis of a 5-year follow-up database. Int J Cardiol 2018; 270:149-153. [PMID: 29980368 DOI: 10.1016/j.ijcard.2018.06.063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/05/2018] [Accepted: 06/18/2018] [Indexed: 12/18/2022]
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Christou GA, Kouidi EJ, Anifanti MA, Sotiriou PG, Koutlianos NA, Deligiannis AP. Pathophysiological mechanisms of noncardiac syncope in athletes. Int J Cardiol 2016; 224:20-26. [DOI: 10.1016/j.ijcard.2016.08.308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/19/2016] [Indexed: 11/29/2022]
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RUSSO VINCENZO, PAPA ANDREAANTONIO, CIARDIELLO CARMINE, RAGO ANNA, PROIETTI RICCARDO, CALABRÒ PAOLO, RUSSO MARIAGIOVANNA, NIGRO GERARDO. Which Hemodynamic Parameter Predicts Nitroglycerin-Potentiated Head-Up Tilt Test Response? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:507-13. [PMID: 25684414 DOI: 10.1111/pace.12593] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 01/07/2015] [Accepted: 01/07/2015] [Indexed: 01/14/2023]
Affiliation(s)
- VINCENZO RUSSO
- Department of Cardiothoracic and Respiratory Sciences; Second University of Naples, Monaldi Hospital; Naples Italy
| | - ANDREA ANTONIO PAPA
- Department of Cardiothoracic and Respiratory Sciences; Second University of Naples, Monaldi Hospital; Naples Italy
| | | | - ANNA RAGO
- Department of Cardiothoracic and Respiratory Sciences; Second University of Naples, Monaldi Hospital; Naples Italy
| | - RICCARDO PROIETTI
- Cardiac Electrophysiology Service; McGill University Health Center; Montreal Canada
| | - PAOLO CALABRÒ
- Department of Cardiothoracic and Respiratory Sciences; Second University of Naples, Monaldi Hospital; Naples Italy
| | - MARIA GIOVANNA RUSSO
- Department of Cardiothoracic and Respiratory Sciences; Second University of Naples, Monaldi Hospital; Naples Italy
| | - GERARDO NIGRO
- Department of Cardiothoracic and Respiratory Sciences; Second University of Naples, Monaldi Hospital; Naples Italy
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LUIZ LUZ LEIRIA TIAGO, BARCELLOS SÔNIAREGINA, MORAES MARIAANTONIETA, LIMA GUSTAVOGLOTZDE, KUS TERESA, BARBISAN JUAREZNEHAUS. Low Body Mass Index Is Associated with a Positive Response during a Head-Up Tilt Test. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 36:37-41. [DOI: 10.1111/pace.12006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 07/11/2012] [Accepted: 07/21/2012] [Indexed: 12/26/2022]
Affiliation(s)
- TIAGO LUIZ LUZ LEIRIA
- From the Electrophysiology and Tilt Department; Instituto de Cardiologia do Rio Grande do Sul - Fundação Universitária de Cardiologia do Rio Grande do Sul; Porto Alegre; Brazil
| | - SÔNIA REGINA BARCELLOS
- From the Electrophysiology and Tilt Department; Instituto de Cardiologia do Rio Grande do Sul - Fundação Universitária de Cardiologia do Rio Grande do Sul; Porto Alegre; Brazil
| | - MARIA ANTONIETA MORAES
- From the Electrophysiology and Tilt Department; Instituto de Cardiologia do Rio Grande do Sul - Fundação Universitária de Cardiologia do Rio Grande do Sul; Porto Alegre; Brazil
| | - GUSTAVO GLOTZ DE LIMA
- From the Electrophysiology and Tilt Department; Instituto de Cardiologia do Rio Grande do Sul - Fundação Universitária de Cardiologia do Rio Grande do Sul; Porto Alegre; Brazil
| | - TERESA KUS
- Arrhythmia Department; Hôpital du Sacré-Coeur (HSC) de Montréal; Montréal; Canada
| | - JUAREZ NEHAUS BARBISAN
- From the Electrophysiology and Tilt Department; Instituto de Cardiologia do Rio Grande do Sul - Fundação Universitária de Cardiologia do Rio Grande do Sul; Porto Alegre; Brazil
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Elbey MA, Atilgan Z, Cil H, Kaya H, Ertas F, Aydın M, Ozaydogdu N. Carotid artery stiffness in patients with neurally mediated syncope. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1431-1435. [PMID: 22922623 DOI: 10.7863/jum.2012.31.9.1431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Neurally mediated syncope is defined as a transient loss of blood flow to the brain, resulting in vasodilatation, bradycardia, or both. The pathophysiologic mechanisms of neurally mediated syncope are not clear. In this study, we investigated carotid artery elasticity parameters in patients with neurally mediated syncope. METHODS The study was conducted on 41 patients who were examined by the tilt table test. Group 1 constituted of 21 patients who had a positive response to the tilt table test. Clinical and hemodynamic parameters were compared with patients in a negative tilt table test group (group 2). The systolic and diastolic diameters of the carotid arteries, carotid distensibility, carotid strain, carotid stiffness index, and carotid elastic modulus of the left carotid arteries were calculated by a high-resolution ultrasound device. RESULTS No differences in hemodynamic variables or clinical parameters were detected between the groups. Carotid distensibility (mean ± SD, 1.6 ± 0.6 versus 2.2 ± 0.8 cm(2) × dyne(-1) × 10(-6); P = .044) and strain (6.8% ± 1.7% versus 8.2% ± 1.9%; P = .026) were lower in group 1 than in group 2. The carotid elastic modulus (0.88 ± 0.33 versus 0.74 ± 0.25 cm(2) × dyne(-1) × 10(-6); P = .002) and stiffness index (6.7 ± 0.4 versus 6.2 ± 0.5; P = .038) were higher in group 1. CONCLUSIONS In this study, we concluded that elastic properties of the carotid artery are impaired in patients with neurally mediated syncope. This finding suggests that impaired carotid arterial elasticity may be a factor in the pathophysiologic mechanisms of neurally mediated syncope.
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Affiliation(s)
- Mehmet Ali Elbey
- Department of Cardiology, Dicle University School of Medicine, 21280 Diyarbakır, Turkey.
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