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Thomas C, Mandilaras G, Rabenhorst D, Oberhoffer FS, Fischer M, Haas NA, Fernandez Rodriguez S. Vagal Asystoles in a Boy With Prader-Willi Syndrome. Pediatrics 2023; 152:e2022058216. [PMID: 37539482 DOI: 10.1542/peds.2022-058216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 08/05/2023] Open
Abstract
Prader-Willi syndrome (PWS) is a genetic hormonal disorder of the hypothalamic-pituitary-axis resulting in mental retardation, muscle hypotonia, hypogonadism, and hyperphagia leading to significant obesity. Cardiovascular morbidity and mortality in adult patients with PWS is higher than in healthy controls and mainly secondary to massive obesity. In childhood, mortality may result from respiratory or gastrointestinal illnesses. We present a case of a 10-year-old boy with PWS who experienced recurrent and asymptomatic episodes of sinus pauses caused by the ingestion of large gulps of apple juice, which could be provoked and reproduced. The asystoles could not be provoked by any other vagal maneuvers and an initial diagnostic workup revealed no indication for structural heart disease. Because of the asymptomatic character of the asystoles, no treatment was initially provided. When he re-presented 3 months later after a clinically relevant syncope at school, pacemaker therapy was initiated, and he has demonstrated no subsequent sinus pauses or syncopes. Regarding the rising awareness of subtle cardiac alterations including autonomic dysfunction and electrocardiogram changes in young patients with PWS and especially the occurrence of unexplained sudden deaths in childhood that may be precipitated by arrhythmia, we suggest that the utility of periodic screening for arrhythmia risk should be evaluated in children with PWS.
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Affiliation(s)
- Clara Thomas
- Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig Maximilians University Munich, Munich, Germany
| | - Guido Mandilaras
- Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig Maximilians University Munich, Munich, Germany
| | - Dorothee Rabenhorst
- Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig Maximilians University Munich, Munich, Germany
| | - Felix S Oberhoffer
- Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig Maximilians University Munich, Munich, Germany
| | - Marcus Fischer
- Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig Maximilians University Munich, Munich, Germany
| | - Nikolaus A Haas
- Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig Maximilians University Munich, Munich, Germany
| | - Silvia Fernandez Rodriguez
- Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig Maximilians University Munich, Munich, Germany
- med4kidz Kinder- und Jugendmedizinisches Zentrum, Herz und Lungenzentrum Bayreuth, Bayreuth, Germany
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Alegbeleye BJ. Sudden cardiac arrest under spinal anesthesia in a mission hospital: a case report and review of the literature. J Med Case Rep 2018; 12:144. [PMID: 29792218 PMCID: PMC5966884 DOI: 10.1186/s13256-018-1648-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/07/2018] [Indexed: 11/23/2022] Open
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Kumari A, Gupta R, Bajwa SJS, Singh A. Unanticipated cardiac arrest under spinal anesthesia: An unavoidable mystery with review of current literature. Anesth Essays Res 2015; 8:99-102. [PMID: 25886115 PMCID: PMC4173580 DOI: 10.4103/0259-1162.128923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cardiac arrest during anesthesia and perioperative period is a matter of grave concern for any anesthesiologist. But such mishaps have been reported for one reason or the other in the literary sciences. We are reporting the occurrence of unanticipated delayed cardiac arrest following spinal anesthesia in two young and healthy patients. Fortunately, these patients were successfully resuscitated with timely and appropriate cardiopulmonary resuscitative measures. Occurrence of such cases needs timely reporting and exploring all the possible causes of these unusual and possibly avoidable events. The present case reports are an important addition to a series of recently published mishaps that occurred during spinal anesthesia in young and healthy patients.
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Affiliation(s)
- Anita Kumari
- Department of Anaesthesiology and Intensive Care, Sri Guru Ram Das Institute of Medical sciences, Vallah, Amritsar, India
| | - Ruchi Gupta
- Department of Anaesthesiology and Intensive Care, Sri Guru Ram Das Institute of Medical sciences, Vallah, Amritsar, India
| | - Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
| | - Amrinder Singh
- Department of Anaesthesiology and Intensive Care, Sri Guru Ram Das Institute of Medical sciences, Vallah, Amritsar, India
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McCord JL, Halliwill JR. H1 and H2 receptors mediate postexercise hyperemia in sedentary and endurance exercise-trained men and women. J Appl Physiol (1985) 2006; 101:1693-701. [PMID: 16888049 DOI: 10.1152/japplphysiol.00441.2006] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In sedentary individuals, H(1) receptors mediate the early portion of postexercise skeletal muscle hyperemia, whereas H(2) receptors mediate the later portion. It is not known whether postexercise hyperemia also presents in endurance-trained individuals. We hypothesized that the postexercise skeletal muscle hyperemia would also exist in endurance-trained individuals and that combined blockade of H(1) and H(2) receptors would abolish the long-lasting postexercise hyperemia in trained and sedentary individuals. We studied 28 sedentary and endurance trained men and women before and through 90 min after a 60-min bout of cycling at 60% peak O(2) uptake on control and combined H(1)- and H(2)-receptor antagonist days (fexofenadine and ranitidine). We measured arterial pressure (brachial auscultation) and femoral blood flow (Doppler ultrasound). On the control day, femoral vascular conductance (calculated as flow/pressure) was elevated in all groups 60 min after exercise (sedentary men: Delta86 +/- 35%, trained men, Delta65 +/- 18%; sedentary women, Delta61 +/- 19%, trained women: Delta59 +/- 23%, where Delta is change; all P < 0.05 vs. preexercise). In contrast, on the histamine antagonist day, femoral vascular conductance was not elevated in any of the groups after exercise (sedentary men: Delta21 +/- 17%, trained men: Delta9 +/- 5%, sedentary women: Delta19 +/- 4%, trained women: Delta11 +/- 11%; all P > 0.16 vs. preexercise; all P < 0.05 vs. control day). These data suggest postexercise skeletal muscle hyperemia exists in endurance trained men and women. Furthermore, histaminergic mechanisms produce the long-lasting hyperemia in sedentary and endurance-trained individuals.
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Affiliation(s)
- Jennifer L McCord
- Department of Human Physiology, University of Oregon, Eugene, Oregon 97403, USA
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5
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Nei M, Ho RT, Abou-Khalil BW, Drislane FW, Liporace J, Romeo A, Sperling MR. EEG and ECG in Sudden Unexplained Death in Epilepsy. Epilepsia 2004; 45:338-45. [PMID: 15030496 DOI: 10.1111/j.0013-9580.2004.05503.x] [Citation(s) in RCA: 173] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality for patients with epilepsy. Cardiac factors may be involved and were evaluated in this study. METHODS EEG and ECG data for 21 patients with definite (n = 6) or probable (n = 15) SUDEP were compared with data from a group of 43 patients with refractory partial epilepsy. ECG abnormalities and heart rate (HR) changes were correlated with clinical data. RESULTS Fourteen patients died in their sleep; two were awake. Ictal maximal HR (90 seizures from 16 of 21 patients) was significantly higher in SUDEP (mean, 149 beats/min, BPM) than in comparison patients (mean, 126 BPM; p < 0.001). Greater increases in HR were associated with seizures arising from sleep (78 BPM increase) than from wakefulness (47 BPM; p < 0.001) in SUDEP, as compared with the non-SUDEP group (52 BPM in sleep, 43 BPM in wakefulness; p = 0.27). Ictal cardiac repolarization and rhythm abnormalities occurred in 56% of SUDEP (including two atrial fibrillation, two ventricular premature depolarizations, two marked sinus arrhythmia, two atrial premature depolarizations, one junctional escape, one ST-segment elevation), and 39% of comparison patients (p = 0.39). No specific seizure onset (laterality or lobe) was associated with SUDEP. CONCLUSIONS This study reveals, for the first time, evidence of increased autonomic stimulation (as measured by HR) associated with seizures, particularly in sleep, in patients with SUDEP, as compared with a clinically similar group of patients with refractory epilepsy.
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Affiliation(s)
- Maromi Nei
- Jefferson Comprehensive Epilepsy Center, Department of Neurology, Jefferson Medical College, Philadelphia, Pennsylvania, USA.
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6
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Pollard JB. Common mechanisms and strategies for prevention and treatment of cardiac arrest during epidural anesthesia. J Clin Anesth 2002; 14:52-6. [PMID: 11880024 DOI: 10.1016/s0952-8180(01)00355-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cardiac arrests continue to occur during epidural anesthesia and frequently result in death or brain damage. Although unintentional "total spinal" anesthesia, respiratory depression, myocardial ischemia, and local anesthetic toxicity can also lead to cardiac arrest, often the arrests do not fit any of these four categories. Many of the unexplained arrests may be attributed to vagal predominance. The evidence for a vagal-linked circulatory mechanism for these arrests is reviewed, and the characteristics that are associated with an increased risk for cardiac arrest during epidural anesthesia are identified. Specific strategies to forestall vagal predominance are discussed. In case these strategies fail, multiple interventions are discussed that should increase the likelihood of a successful resuscitation in the setting of extensive sympathetic blockade.
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Affiliation(s)
- John B Pollard
- Department of Anesthesiology, Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, Stanford, CA 94304-1207, USA.
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Abstract
Although there are a variety of neurologic disease processes that the emergency physician should be aware of the most common of these include seizures, closed head injury, headache, and syncope. When one is evaluating a patient who has had a seizure, differentiating between febrile seizures, afebrile seizures, and SE helps to determine the extent of the work-up. Febrile seizures are typically benign, although a diagnosis of meningitis must not be missed. Educating parents regarding the likelihood of future seizures, and precautions to be taken should a subsequent seizure be witnessed, is important. The etiology of a first-time afebrile seizure varies with the patient's age at presentation, and this age-specific differential drives the diagnostic work-up. A follow-up EEG is often indicated, and imaging studies can appropriate on a nonurgent basis. Appropriate management of SE requires a paradigm of escalating pharmacologic therapy, and early consideration of transport for pediatric intensive care services if the seizure cannot be controlled with conventional three-tiered therapy. Closed head injury frequently is seen in the pediatric emergency care setting. The absence of specific clinical criteria to guide the need for imaging makes management of these children more difficult. A thorough history and physical examination is important to uncover risk factors that prompt emergent imaging. Headaches are best approached by assessing the temporal course, associated symptoms, and the presence of persistent neurologic signs. Most patients ultimately are diagnosed with either a tension or migraine headache; however, in those patients with a chronic progressive headache course, an intracranial process must be addressed and pursued with appropriate imaging. Syncope has multiple causes but can generally be categorized as autonomic, cardiac, or noncardiac. Although vasovagal syncope is the most common cause of syncope, vigilance is required to identify those patients with a potentially fatal arrhythmia or with heart disease that predisposes to hypoperfusion. As such, all patients who present with syncope should have an ECG. Additional work-up studies are guided by the results of individual history and physical examination.
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Affiliation(s)
- David Reuter
- Department of Emergency Sciences, Children's Hospital and Regional Medical Center, Seattle, Washington, USA
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Pollard JB. Cardiac arrest during spinal anesthesia: common mechanisms and strategies for prevention. Anesth Analg 2001; 92:252-6. [PMID: 11133639 DOI: 10.1097/00000539-200101000-00050] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J B Pollard
- Department of Anesthesiology, Veterans Affairs Palo Alto Health Care System, California 94304-1207, USA.
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Deal BJ, Strieper M, Scagliotti D, Hulse E, Auld D, Campbell R, Strasburger JF, Benson DW. The medical therapy of cardioinhibitory syncope in pediatric patients. Pacing Clin Electrophysiol 1997; 20:1759-61. [PMID: 9249828 DOI: 10.1111/j.1540-8159.1997.tb03563.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A small percentage of pediatric patients with neurally mediated syncope will have an asystolic response during upright tilt table testing. The purpose of this study is to evaluate the incidence of asystole during tilt table testing, and to assess the outcome of medical management of such patients. Of 398 patients undergoing evaluation for recurrent syncope between January 1989 and 1994, 18 (4.5%) experienced asystole lasting > or = 5 seconds during baseline tilt test. Patients had experienced a mean of four episodes of syncope, with a mean age at the time of tilt test of 11.1 +/- 4.0 years. The median duration of asystole was 10 seconds (range 5-40 s). Treatment was individualized to increased fluids and salt intake (3 patients), metoprolol (8 patients), pseudoephedrine (4 patients), disopyramide (1 patient), or combination therapy with fludrohydrocortisone (2 patients). During a median duration of follow-up of 31 months, no additional syncope was experienced by 78% of patients. Recurrent syncope in 4 patients was associated with either noncompliance or discontinuation of therapy in 3 patients; in 1 patient, increasing the dose of metoprolol was effective in preventing recurrences. We conclude that young patients with recurrent syncope and asystole during tilt test may be safely and effectively managed with pharmacological therapy, without resorting to pacemaker implantation.
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Affiliation(s)
- B J Deal
- Division of Cardiology, Children's Memorial Hospital, Northwestern University Medical School, Chicago, Illinois, USA
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10
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Abstract
A number of studies have evaluated the effect of cardiac pacing for prevention of tilt induced vasovagal syncope. The findings are relatively consistent. Pacing does not prevent the onset of vasovagal syncope. This is predictable since hypotension (vasodepressor effect) typically occurs prior to bradycardia. However, dual chamber may prolong the presyncopal period in patients with a prominent cardioinhibitory component. Further, the relation of laboratory observations to spontaneous events is uncertain. In the largest retrospective assessment of pacing efficacy, 89% of patients reported improved symptoms and 62% remained free of symptom recurrence over 50 months.
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Affiliation(s)
- M E Petersen
- Chelsea and Westminster Hospital, London, United Kingdom
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11
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Calvert CA, Jacobs GJ, Pickus CW. Bradycardia-associated episodic weakness, syncope, and aborted sudden death in cardiomyopathic Doberman Pinschers. J Vet Intern Med 1996; 10:88-93. [PMID: 8683487 DOI: 10.1111/j.1939-1676.1996.tb02034.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Paradoxical sinus bradycardia and cardiac asystole resulted in episodic weakness, syncope, or aborted sudden cardiac death during exertion in 8 cardiomyopathic Doberman Pinschers. Bradycardias persisted for 1 to 2 minutes in 5 of 8 dogs, and were often followed by sinus tachycardia. Syncope was prolonged on multiple occasions in 5 dogs, and was accompanied by white, then cyanotic mucous membranes, mydriasis, and apparent sudden death.
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Affiliation(s)
- C A Calvert
- Department of Small Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens 30602, USA
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12
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Petersen ME, Price D, Williams T, Jensen N, Riff K, Sutton R, Rift K [corrected to Riff K]. Short AV interval VDD pacing does not prevent tilt induced vasovagal syncope in patients with cardioinhibitory vasovagal syndrome. Pacing Clin Electrophysiol 1994; 17:882-91. [PMID: 7517523 DOI: 10.1111/j.1540-8159.1994.tb01429.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Eleven subjects (mean age 50 years, range 33-71 years), who had previously received permanent dual chamber pacemakers for cardioinhibitory vasovagal syncope, underwent paired Westminster protocol tilt tests, one with short AV delay VDD pacing and one without pacing, to test the hypothesis that continuous ventricular pacing would prevent the cardiac initiation of vasovagal syncope. Nine (82%) of the paced tilts produced positive vasovagal outcomes compared with seven (64%) of the unpaced tilts. No important differences in the heart rate or blood pressure behavior during tilt or the time to positive vasovagal outcomes were observed between the paired tilts. There was more accelerated syncope/presyncope once symptoms had developed during the paced tilts of subjects in whom both study tilts were positive, although this did not reach statistical significance (P = 0.054). This study shows that atrial synchronous ventricular pacing does not prevent the initiation, or progression, of tilt induced vasovagal syncope in predisposed subjects.
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Affiliation(s)
- M E Petersen
- Department of Cardiology, Chelsea and Westminster Hospital, London, United Kingdom
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13
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Petersen ME, Chamberlain-Webber R, Fitzpatrick AP, Ingram A, Williams T, Sutton R. Permanent pacing for cardioinhibitory malignant vasovagal syndrome. Heart 1994; 71:274-81. [PMID: 8142198 PMCID: PMC483666 DOI: 10.1136/hrt.71.3.274] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To evaluate the effect of permanent pacing in cardioinhibitory malignant vasovagal syndrome. PATIENTS AND METHODS 37 patients with permanent pacemakers for cardioinhibitory malignant vasovagal syndrome. All presented with syncope (median six episodes, median frequency two episodes a year) and after conventional investigation and invasive electrophysiological assessment they remained undiagnosed, and without a generally accepted indication for pacemaker implantation. In all vasovagal syncope with cardioinhibition (heart rate at syncope < 60 beats/min) developed during tilt tests performed according to the Westminster protocol (head up tilt at 60 degrees with a footplate support for 45 minutes or until syncope intervenes). Dual chamber pacemakers were implanted in 35 (95%) and VVI pacemakers in the remaining two (5%). RESULTS Over a mean (SD) follow up since implantation of 50.2 (23.9) months symptomatic improvement occurred in 89%: 62% remained free of syncope and 27% were completely symptom free. The collective syncopal burden of these 37 patients was reduced from 136 to 11 episodes each year. During follow up three patients died from unrelated causes. Patients who become asystolic during the tilt test (sinus pause of at least four seconds) experienced no greater benefit from pacing than those with less extreme cardioinhibition. Patients who remained free of syncope since implantation were younger than those who continued to experience syncope. Patients who remained completely symptom free after implantation were younger, more likely to be male, and had had fewer syncopal episodes before implantation than those who continued to experience syncope or presyncope. No other demographic, clinical, investigative, or pacing variable suggested a more favourable outcome after implant. CONCLUSIONS This retrospective and uncontrolled experience suggests a possible role for permanent pacing in selected patients with cardioinhibitory malignant vasovagal syndrome. Improved acquisition of tilt test data may enable better selection of patients who are suitable for permanent pacing. A randomised prospective study to compare permanent pacing with no treatment or with medical treatment in cardioinhibitory malignant vasovagal syndrome is indicated.
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Oslizlok P, Allen M, Griffin M, Gillette P. Clinical features and management of young patients with cardioinhibitory response during orthostatic testing. Am J Cardiol 1992; 69:1363-5. [PMID: 1585875 DOI: 10.1016/0002-9149(92)91238-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- P Oslizlok
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston 29425
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Abstract
Syncope is a multifactorial disorder; however, most pediatric syncopal episodes result from vasodepressor syndrome or the simple faint. A very detailed history and physical examination should indicate the etiology in the majority of cases. Extensive diagnostic studies are rarely necessary. Tilt table testing is a reliable way of identifying individuals predisposed to vasodepressor syncope, and may provide a means of assessing the efficacy of therapeutic interventions in those who require treatment. Treatment for syncope from etiologies other than vasodepressor syndrome is directed at the underlying cause.
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Affiliation(s)
- W A Scott
- Department of Pediatrics, University of Texas, Southwestern Medical Center, Dallas 75235-9063
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Jaeger FJ, Schneider L, Maloney JD, Cruse RP, Fouad-Tarazi FM. Vasovagal syncope: diagnostic role of head-up tilt test in patients with positive ocular compression test. Pacing Clin Electrophysiol 1990; 13:1416-23. [PMID: 1701896 DOI: 10.1111/j.1540-8159.1990.tb04017.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We investigated the relative merits of the ocular compression test and the head-up tilt test to aid differentiation of syncope and seizures in young patients. Sixteen patients (10 males and 6 females) with a mean age of 14 +/- 4.7 (SD) years (range 7-22 years) underwent graded head-up tilt (15 degrees, 30 degrees, and 45 degrees for 2 minutes each, then 60 degrees for 20 minutes) following positive ocular compression testing defined as precipitation of asystole for at least 3 seconds (mean 5 seconds +/- 2 seconds, range 3-12 seconds). Each patient presented with recurrent unexplained loss of consciousness (mean number of episodes 30 +/- 45, mean duration of illness 52 +/- 40 months), and seven patients were receiving anticonvulsant medications, three of these had normal EEGs. Eleven patients (69%) developed vasovagal syncope during head-up tilt, reproducing their clinical episodes (systolic blood pressure decreased from 105 +/- 10 mmHg to 84 +/- 13 mmHg, diastolic blood pressure from 75 +/- 9 to 22 +/- 25 mmHg, and heart rate from 89 +/- 13 beats/min to 37 +/- 20 beats/min). Asystole occurred in two patients during vasovagal syncope lasting 11 seconds in one and 16 seconds in the other, and, it was associated with myoclonic movements in both (convulsive syncope). Based on these findings, and given the perceived potential hazards of the ocular compression test, the head-up tilt test may be a safer procedure that adds useful information to the diagnostic evaluation of these patients.
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Affiliation(s)
- F J Jaeger
- Department of Heart and Hypertension Research, Cleveland Clinic Foundation, Ohio 44195-5069
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Almquist A, Goldenberg IF, Milstein S, Chen MY, Chen XC, Hansen R, Gornick CC, Benditt DG. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med 1989; 320:346-51. [PMID: 2913492 DOI: 10.1056/nejm198902093200603] [Citation(s) in RCA: 518] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Neurally mediated hypotension and bradycardia are believed to be common causes of syncope. We used the "upright-tilt test" (duration, less than or equal to 10 minutes) with or without an infusion of exogenous catecholamine (isoproterenol [1 to 5 micrograms per minute], given intravenously) to elicit bradycardia, hypotension, or both in 24 patients with recurrent syncope and in 18 control subjects. A conventional electrophysiologic test performed before the tilt test was positive in 9 of the 24 patients, revealing arrhythmias that may have caused recurrent syncope, but was negative and thus nondiagnostic in 15 patients. The tilt test alone (i.e., without isoproterenol) induced symptomatic bradycardia or hypotension in 1 of the 9 patients with positive electrophysiologic tests (11 percent), 4 of the 15 patients with negative electrophysiologic tests (27 percent), and none of the controls. When the isoproterenol infusion was administered during the tilt test, 9 of the 11 patients with negative electrophysiologic and tilt tests had syncope, marked slowing of the heart rate, and hypotension. In contrast, isoproterenol was associated with tachycardia and only a slight decline in arterial pressure in the 8 remaining patients with positive electrophysiologic tests and the 18 control subjects, and syncope developed in only 1 of the 8 patients with positive electrophysiologic tests and negative tilt tests (13 percent) and 2 of the 18 control subjects (11 percent). We conclude that an isoproterenol infusion administered in conjunction with the upright-tilt test may be useful for identifying susceptibility to neurally mediated recurrent syncope.
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Affiliation(s)
- A Almquist
- Department of Medicine, University of Minnesota Medical School, Minneapolis
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Lack EE. Microanatomy of vagal body paraganglia in infancy including victims of sudden infant death syndrome. PEDIATRIC PATHOLOGY 1989; 9:373-86. [PMID: 2798265 DOI: 10.3109/15513818909022360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The microanatomy of vagal body paraganglia (VBP) in the cephalic segment of both vagus nerves was evaluated in an autopsy study of 32 infants one year of age or younger. The study group included 14 victims of sudden infant death syndrome (SIDS) and 18 non-SIDS cases. VBP in both groups were located at or below the lower border of the ganglion nodosum, and were histologically identical to carotid body chemoreceptors, although spatially dispersed and much smaller in size. Using a combined step and serial sectioning technique, there were no significant differences between the two groups (i.e. SIDS vs. non-SIDS) with regard to microanatomy, number, distribution and size of VBP. The proportion of chief and sustentacular cells was similar to carotid body paraganglia. For the study group as a whole, VBP were present in 89% of vagus nerves, and were typically multiple with good correlation between the number of separate paraganglia on the two sides. Small collections of ectopic parathyroid chief cells were identified in 6% of nerve segments, and histologically should be distinguished from VBP. Although the microanatomy of VBP in the SIDS group was identical to that of non-SIDS, one cannot exclude an underlying functional abnormality with autonomic malregulation.
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Affiliation(s)
- E E Lack
- Georgetown University School of Medicine, Washington, D.C. 20007
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19
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Milstein S, Reyes WJ, Benditt DG. Upright body tilt for evaluation of patients with recurrent, unexplained syncope. Pacing Clin Electrophysiol 1989; 12:117-24. [PMID: 2464804 DOI: 10.1111/pace.1989.12.p1.117] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- S Milstein
- Department of Medicine, University Medical School, Minneapolis, Minnesota
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20
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Vagotonia as a cause of syncope. J Pediatr 1986; 109:394-5. [PMID: 3734984 DOI: 10.1016/s0022-3476(86)80422-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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22
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Editorial note Vagotonia/reflex anoxic seizures — is pacemaker therapy justified? Int J Cardiol 1985. [DOI: 10.1016/0167-5273(85)90201-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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