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Veazie S, Peterson K, Ansari Y, Chung KA, Gibbons CH, Raj SR, Helfand M. Fludrocortisone for orthostatic hypotension. Cochrane Database Syst Rev 2021; 5:CD012868. [PMID: 34000076 PMCID: PMC8128337 DOI: 10.1002/14651858.cd012868.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Orthostatic hypotension is an excessive fall in blood pressure (BP) while standing and is the result of a decrease in cardiac output or defective or inadequate vasoconstrictor mechanisms. Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure. Fludrocortisone is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures such as increasing fluid and salt intake and venous compression methods. However, there has been no Cochrane Review of the benefits and harms of this drug for this condition. OBJECTIVES To identify and evaluate the benefits and harms of fludrocortisone for orthostatic hypotension. SEARCH METHODS We searched the following databases on 11 November 2019: Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL. We also searched trials registries. SELECTION CRITERIA We included all studies evaluating the benefits and harms of fludrocortisone compared to placebo, another drug for orthostatic hypotension, or studies without comparators, including randomized controlled trials (RCTs), quasi-RCTs and observational studies. We included studies in people with orthostatic hypotension due to a chronic peripheral neuropathy, a central autonomic neuropathy, or autonomic failure from other causes, but not medication-induced orthostatic hypotension or orthostatic hypotension from acute volume depletion or blood loss. DATA COLLECTION AND ANALYSIS We used Cochrane methodological procedures for most of the review. We developed and used a tool to prioritize observational studies that offered the best available evidence where there are gaps in the evidence from RCTs. We assessed the certainty of evidence for fludrocortisone versus placebo using GRADE. MAIN RESULTS We included 13 studies of 513 participants, including three cross-over RCTs and 10 observational studies (three cohort studies, six case series and one case-control study). The included RCTs were small (total of 28 participants in RCTs), short term (two to three weeks), only examined fludrocortisone for orthostatic hypotension in people with two conditions (diabetes and Parkinson disease), and had variable risk of bias (two had unclear risk of bias and one had low risk of bias). Heterogeneity in participant populations, comparators and outcome assessment methods prevented meta-analyses of the RCTs. We found very low-certainty evidence about the effects of fludrocortisone versus placebo on drop in BP in people with diabetes (-26 mmHg versus -39 mmHg systolic; -7 mmHg versus -11 mmHg diastolic; 1 cross-over study, 6 participants). For people with Parkinson disease, we found very-low certainty evidence about the effects of fludrocortisone on drop in BP compared to pyridostigmine (-14 mmHg versus -22.1 mmHg diastolic; P = 0.036; 1 cross-over study, 9 participants) and domperidone (no change after treatment in either group; 1 cross-over study, 13 participants). For orthostatic symptoms, we found very low-certainty evidence for fludrocortisone versus placebo in people with diabetes (4 out of 5 analyzed participants had improvements in orthostatic symptoms, 1 cross-over study, 6 participants), for fludrocortisone versus pyridostigmine in people with Parkinson disease (orthostatic symptoms unchanged; 1 cross-over study, 9 participants) or fludrocortisone versus domperidone (improvement to 6 for both interventions on the Composite Autonomic Symptom Scale-Orthostatic Domain (COMPASS-OD); 1 cross-over study, 13 participants). Evidence on adverse events was also very low-certainty in both populations, but indicated side effects were minimal. Observational studies filled some gaps in evidence by examining the effects in larger groups of participants, with more diverse conditions, over longer periods of time. One cohort study (341 people studied retrospectively) found fludrocortisone may not be harmful in the long term for familial dysautonomia. However, it is unclear if this translates to long-term improvements in BP drop or a meaningful improvement in orthostatic symptoms. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of fludrocortisone on blood pressure, orthostatic symptoms or adverse events in people with orthostatic hypotension and diabetes or Parkinson disease. There is a lack of information on long-term treatment and treatment of orthostatic hypotension in other disease states. There is a need for standardized reporting of outcomes and for standardization of measurements of blood pressure in orthostatic hypotension.
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Affiliation(s)
- Stephanie Veazie
- Scientific Resource Center, VA Portland Health Care System, Portland, Oregon, USA
| | - Kim Peterson
- Evidence-based Synthesis Program Coordinating Center, VA Portland Health Care System, Portland, Oregon, USA
| | - Yasmin Ansari
- Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Kathryn A Chung
- Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Canada
| | - Mark Helfand
- Medicine, Medical Informatics & Clinical Epidemiology, Oregon Health Sciences University, Portland, Oregon, USA
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Liao Y, Du J. Pathophysiology and Individualized Management of Vasovagal Syncope and Postural Tachycardia Syndrome in Children and Adolescents: An Update. Neurosci Bull 2020; 36:667-681. [PMID: 32367250 PMCID: PMC7271077 DOI: 10.1007/s12264-020-00497-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/31/2020] [Indexed: 12/12/2022] Open
Abstract
Vasovagal syncope (VVS) and postural tachycardia syndrome (POTS) are the main forms of orthostatic intolerance in pediatrics and both are underlying causes of neurally-mediated syncope. In recent years, increasing attention has been paid to the management of VVS and POTS in children and adolescents. A number of potential mechanisms are involved in their pathophysiology, but the leading cause of symptoms varies among patients. A few studies thus have focused on the individualized treatment of VVS or POTS based on selected hemodynamic parameters or biomarkers that can predict the therapeutic effect of certain therapies and improve their effectiveness. This review summarizes the latest developments in individualized treatment of VVS and POTS in children and indicates directions for further research in this field.
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Affiliation(s)
- Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China.
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Müller MJ, Paul T. [Syncope in children and adolescents]. Herzschrittmacherther Elektrophysiol 2018; 29:204-207. [PMID: 29761336 DOI: 10.1007/s00399-018-0562-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/03/2018] [Indexed: 10/16/2022]
Abstract
Syncope is common in children and adolescents. Neurally mediated syncope including pallid and cyanotic breath holding spells, vagovasal syncope and neurocardiogenic syncope is based on a common pathomechanism and accounts for approximately 75% of cases. A potentially life-threatening cardiac cause of syncope may be present in up to 6%. Detailed history, physical examination and 12-lead electrocardiogram (ECG) allow discrimination between benign and serious syncope in the majority of pediatric patients. Tilt-testing can be useful when diagnosis is unclear. In neurally mediated syncope, education on awareness of prodromes, modification of life-style and reassurance of the family on benign character of the disease is sufficient for preventing further syncopal episodes in the majority of cases. In pediatric patients unresponsive to these measures midodrine is often effective. Fludrocortisone and cardiac pacing may be considered in selected patients. β‑Blockers are not beneficial in pediatric neurally mediated syncope. Cardiac causes need specific disease-targeted therapy.
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Affiliation(s)
- Matthias J Müller
- Klinik für Pädiatrische Kardiologie und Intensivmedizin, Universitätsklinikum Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Thomas Paul
- Klinik für Pädiatrische Kardiologie und Intensivmedizin, Universitätsklinikum Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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6
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2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: Executive summary. Heart Rhythm 2017; 14:e218-e254. [DOI: 10.1016/j.hrthm.2017.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 01/05/2023]
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2017; 14:e155-e217. [PMID: 28286247 DOI: 10.1016/j.hrthm.2017.03.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 12/26/2022]
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8
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017; 70:620-663. [PMID: 28286222 DOI: 10.1016/j.jacc.2017.03.002] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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9
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e25-e59. [PMID: 28280232 DOI: 10.1161/cir.0000000000000498] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison.,Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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Anderson JB, Willis M, Lancaster H, Leonard K, Thomas C. The Evaluation and Management of Pediatric Syncope. Pediatr Neurol 2016; 55:6-13. [PMID: 26706050 DOI: 10.1016/j.pediatrneurol.2015.10.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 10/27/2015] [Accepted: 10/31/2015] [Indexed: 11/16/2022]
Abstract
Syncope is a common problem in children and adolescents. It is typically caused by benign neurally mediated hypotension, but other, more concerning, etiologies of syncope must be considered. In most instances, the underlying cause of syncope in the pediatric patient can be determined by obtaining a thorough history and physical examination. Attention to the cardiac, neurological, and psychological history and examination can rule out more rare causes of loss of consciousness. Most individuals with neurally mediated hypotension can be treated with lifestyle measures including aggressive hydration, dietary salt, and an exercise program. In instances where lifestyle modification fails, medications may offer symptomatic improvement.
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Affiliation(s)
- Jeffrey B Anderson
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Syncope Clinic, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Martha Willis
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Syncope Clinic, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Heidi Lancaster
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Syncope Clinic, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karen Leonard
- Syncope Clinic, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cameron Thomas
- Syncope Clinic, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Courtheix M, Jalal Z, Bordachar P, Iriart X, Pillois X, Escobedo C, Rabot C, Tribout L, Thambo JB. Syncope unit in the paediatric population: A single-centre experience. Arch Cardiovasc Dis 2016; 109:199-206. [PMID: 26782626 DOI: 10.1016/j.acvd.2015.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 11/01/2015] [Accepted: 11/05/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Syncopes are frequent in the paediatric population. Most are benign, but rare cases are caused by cardiac life-threatening diseases. Syncope units developed in the adult population have demonstrated improvement in evaluation and treatment, with a reduction in hospitalization. AIMS We report our experience of paediatric syncope management in a dedicated unit, and analyse the value of different elements in the identification of cardiac causes. METHODS This prospective study included 97 consecutive patients (mean age: 12.1±3.3 years) referred between January 2011 and June 2013 to a syncope unit with a paediatric cardiologist, a nurse, a physiotherapist and a psychologist. Patients were classified into diagnostic categories after an initial evaluation that included history, physical examination, electrocardiography, echocardiography and Holter monitoring. RESULTS The most common diagnosis was neurocardiogenic syncope (n=69, 70.4%). Fifty-two cases (81.3%) had no or less recurrence after specific management that included physiotherapy and psychological support (follow-up: 11.5±5.4 months). Psychogenic pseudosyncopes affected 20 children (20.6%). Two patients had epileptic seizures. There were five cases of cardiac syncope (5.1%): two long QT syndromes and a catecholaminergic polymorphic ventricular tachycardia received beta-blockers; two atrioventricular complete blocks required pacemakers. One case was of indeterminate cause and received an insertable loop recorder after exhaustive investigations. Exercise-induced syncopes were significantly associated with cardiac origins (P=0.003), such as electrocardiographic abnormalities (P<0.001), whereas echocardiography was not contributive. CONCLUSION Syncope units in the paediatric population may be useful in the diagnostic process, to help identify rare cardiac aetiologies, and could decrease recurrence through specific management.
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Affiliation(s)
- Mathieu Courtheix
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France.
| | - Zakaria Jalal
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Pierre Bordachar
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Xavier Iriart
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Xavier Pillois
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Cécile Escobedo
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Catherine Rabot
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Laetitia Tribout
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
| | - Jean-Benoit Thambo
- Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France
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Role of yoga as an adjunctive therapy in patients with neurocardiogenic syncope: a pilot study. J Interv Card Electrophysiol 2015; 43:105-10. [PMID: 25863799 DOI: 10.1007/s10840-015-9996-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 03/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neurocardiogenic syncope (NCS) is a common clinical condition characterized by abrupt cardiovascular autonomic changes resulting in syncope. This is a recurring condition with mixed results from current strategies of treatment. METHODS Subjects with a diagnosis of NCS were screened and enrolled. All the participants were given a DVD containing yoga videos and were instructed to practice yoga therapy for 60 min, three times a week for 3 consecutive months. Syncope functional status questionnaire score (SFSQS) was administered at the beginning and the end of the study. The subjects were followed for 3 months and underwent repeat tilt table testing at the end of the study. RESULTS Of the 60 patients screened, 44 subjects were enrolled, 21 in the intervention group and 23 in the control group. Most of the participants were females, and the mean age was 21 ± 3 years. In the intervention group, who finished the yoga regimen, there was a statistically significant improvement from control phase to the intervention phase, in number of episodes of syncope (4 ± 1 vs 1.3 ± 0.7, p < 0.001) and presyncope (4.7 ± 1.5 vs 1.5 ± 0.5, p < 0.001). The mean SFSQS also decreased from 67 ± 7.8 to 29.8 ± 4.6 (p < 0.001). All subjects had positive head up tilt table (HUTT) study at the time of enrollment compared to only six patients at the completion of intervention phase (10/100 vs 6/28 %, p < 0.0001). CONCLUSION Yoga therapy can potentially improve the symptoms of presyncope and syncope in young female patients with NCS.
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Schleifer JW, Shen W. Vasovagal syncope: an update on the latest pharmacological therapies. Expert Opin Pharmacother 2014; 16:501-13. [DOI: 10.1517/14656566.2015.996129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Coffin ST, Raj SR. Non-invasive management of vasovagal syncope. Auton Neurosci 2014; 184:27-32. [PMID: 24996861 DOI: 10.1016/j.autneu.2014.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/06/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
Vasovagal syncope (VVS) is a common disorder of the autonomic nervous system. While recurrent syncope can cause very impaired quality of life, the spells are not generally life-threatening. Both non-pharmacological and pharmacological approaches can be used to treat patients. Conservative management with education, exercise and physical maneuvers, and aggressive volume repletion is adequate for controlling symptoms in most patients. Unfortunately, a minority of patients will continue to have recurrent syncope despite conservative therapy, and they may require medications. These could include vasopressor agents, beta-blockers, or neurohormonal agents. Some patients may require more aggressive device based therapy with pacemakers or radiofrequency ablation, which are emerging therapies for VVS. This paper will review non-procedure based treatments for VVS.
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Affiliation(s)
- Samuel T Coffin
- Autonomic Dysfunction Center, Vanderbilt University School of Medicine, USA; Department of Medicine, Vanderbilt University School of Medicine, USA
| | - Satish R Raj
- Autonomic Dysfunction Center, Vanderbilt University School of Medicine, USA; Department of Medicine, Vanderbilt University School of Medicine, USA; Department of Pharmacology, Vanderbilt University School of Medicine, USA.
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Abstract
Vasovagal syncope is a common disorder that affects at least 20% of people at some time in their lives. Probably half of these patients faint recurrently; for many this causes physical trauma, a substantial reduction in quality of life, and difficulties with driving, employment and education. The last 15 years have seen striking advances in diagnostic approaches and prognostic understanding. A number of physiological, pharmacological and electrical therapies have been developed and tested to various degrees in patients. These include counterpressure manoeuvres, salt and fluid recommendations, and attempted treatment with fludrocortisone, midodrine, beta-blockers, serotonin reuptake inhibitors, and permanent pacemakers. This review highlights the most important of these advances and suggests strategies for managing this often difficult problem.
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Affiliation(s)
- Robert Sheldon
- University of Calgary, Libin Cardiovascular Institute of Alberta, Faculty of Medicine, 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1, Canada.
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17
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Walsh EP, Dick M. Research accomplishments in pediatric electrophysiology: a historical review. CONGENIT HEART DIS 2013; 8:362-9. [PMID: 23947822 DOI: 10.1111/chd.12126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 11/27/2022]
Abstract
Arrhythmia management in young patients plays a small but important role within the broader discipline of cardiac electrophysiology (EP). By virtue of its sharp focus on developmental cardiology, congenital heart defects, and hereditary channelopathies, pediatric EP has contributed in significant ways to improved understanding of rhythm disorders in patients of all ages. Scientific progress in the field was recently reviewed at the 2012 meeting of the Heart Rhythm Society, where historical details of pioneering investigations in pediatric EP were highlighted. In this article, we hope to summarize those details and acknowledge the roles of individuals and organizations that were instrumental in developing the subspecialty.
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Affiliation(s)
- Edward P Walsh
- Boston Children's Hospital, Harvard Medical School, Boston, Mass, USA
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18
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Medical therapy and physical maneuvers in the treatment of the vasovagal syncope and orthostatic hypotension. Prog Cardiovasc Dis 2013; 55:425-33. [PMID: 23472781 DOI: 10.1016/j.pcad.2012.11.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patients with vasovagal syncope and neurogenic orthostatic hypotension can both present with pre-syncope and syncope resulting from systemic hypotension. While not directly responsible for increased mortality, both of these conditions can have a tremendous deleterious impact on the daily lives of patients. This negative impact can take the form of both physical symptoms and injury, but also a psychological impact from living in fear of the next syncopal episode. Despite these similarities, these are different disorders with fixed damage to the autonomic nerves in neurogenic orthostatic hypotension, as opposed to a transient reflex hypotension in "neurally mediated" vasovagal syncope. The treatment approaches for both disorders are parallel. The first step is to educate the patient about the pathophysiology and prognosis of their disorder. Next, offending medications should be withdrawn when possible. Non-pharmacological therapies and maneuvers can be used, both in an effort to prevent the symptoms and to prevent syncope at the onset of presyncope. This is all that is required in many patients with vasovagal syncope. If needed, pharmacological options are also available for both vasovagal syncope and neurogenic orthostatic hypotension, many of which are focused on blood volume expansion, increasing cardiac venous return, or pressor agents to increase vascular tone. There is a paucity of high-quality clinical trial data to support the use of these pharmacological agents. We aim to review the literature on these different therapy choices and to give recommendations on tailored approaches to the treatment of these conditions.
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Hicks CW, Sweeney DA, Danner RL, Eichacker PQ, Suffredini AF, Feng J, Sun J, Moriyama B, Wesley R, Behrend EN, Solomon SB, Natanson C. Beneficial effects of stress-dose corticosteroid therapy in canines depend on the severity of staphylococcal pneumonia. Intensive Care Med 2012; 38:2063-71. [PMID: 23111805 DOI: 10.1007/s00134-012-2735-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 10/03/2012] [Indexed: 12/15/2022]
Abstract
PURPOSE The effects of stress-dose corticosteroid therapy were studied in a canine staphylococcal pneumonia model of septic shock. METHODS Immediately following intrabronchial bacterial challenge, purpose-bred beagles were treated with stress doses of desoxycorticosterone (DOC), a mineralocorticoid agonist, and dexamethasone (DEX), a glucocorticoid agonist, or with placebo for 96 h. Oxacillin (30 mg/kg every 8 h) was started 4 h after infection onset. Bacterial dose was titrated to achieve 80-90 % lethality (n = 20) using an adaptive design; additional animals (n = 18) were investigated using the highest bacterial dose. RESULTS Initial analysis of all animals (n = 38) demonstrated that the effects of DOC + DEX were significantly altered by bacterial dose (p = 0.04). The treatment effects of DOC + DEX were different in animals administered high or relatively lower bacterial doses in terms of survival (p = 0.05), shock reversal (p = 0.02), interleukin-6 levels (p = 0.02), and temperature (p = 0.01). DOC + DEX significantly improved the above parameters (p ≤ 0.03 for all) and lung injury scores (p = 0.02) after high-dose bacterial challenges, but not after lower challenges (p = not significant for all). Oxacillin trough levels were below the minimum inhibitory concentration of the infecting organism, and DOC + DEX increased the frequency of persistent staphylococcal bacteremia (odds ratio 3.09; 95 % confidence interval 1.05-9.11; p = 0.04). CONCLUSIONS Stress-dose corticosteroids were only beneficial in cases of sepsis with high risk for death and even short courses may interfere with host mechanisms of bacterial clearance.
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Affiliation(s)
- Caitlin W Hicks
- Department of General Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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Midodrine hydrochloride in the management of older adults with neurocardiogenic syncope and orthostatic hypotension: A prospective observational study. Eur Geriatr Med 2012. [DOI: 10.1016/j.eurger.2012.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Uhm JS, Youn HJ, Chung WB, Choi YS, Park CS, Oh YS, Chung WS, Park KI, Kim TS. Positive result in the early passive phase of the tilt-table test: a predictor of neurocardiogenic syncope in young men. Korean J Intern Med 2012; 27:60-5. [PMID: 22403501 PMCID: PMC3295990 DOI: 10.3904/kjim.2012.27.1.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 06/17/2011] [Accepted: 10/05/2011] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS This study elucidated the prognostic factors for neurocardiogenic syncope in males in their late teens and early twenties. METHODS Tilt-table testing (TTT) was performed on 665 males (age range, 17 to 27 years) following the Italian protocol. The subjects were tilted head-up at a 70° angle on a table for 30 minutes during the passive phase. If the passive phase was negative, the subjects were given sublingual nitroglycerin and tilted to the same angle for 20 minutes during the drug-provocation phase. The subjects with positive results were followed without medication. We analyzed factors related to the recurrence rate of syncope. RESULTS Of 305 subjects (45.8%) with positive results, 223 (age range, 18 to 26 years) were followed for 12 months. The frequency of previous syncopal episodes ≥ 4 (p = 0.001) and a positive result during the passive phase (p = 0.022) were significantly related to a high recurrence rate. A positive result during the early passive phase (≤ 12 minutes) was significantly related to a higher recurrence rate than was that during the late passive phase (> 12 minutes; p = 0.011). CONCLUSIONS A positive result during the early passive phase of TTT and frequent previous syncopal episodes were prognostic factors for neurocardiogenic syncope in men in their late teens and early twenties.
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Affiliation(s)
- Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Ho-Joong Youn
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Woo-Baek Chung
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Yun-Seok Choi
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Chul-Soo Park
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Wook-Sung Chung
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Kyung-Il Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-Suk Kim
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
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Rosanio S, Schwarz ER, Ware DL, Vitarelli A. Syncope in adults: systematic review and proposal of a diagnostic and therapeutic algorithm. Int J Cardiol 2011; 162:149-57. [PMID: 22188993 DOI: 10.1016/j.ijcard.2011.11.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Revised: 10/28/2011] [Accepted: 11/24/2011] [Indexed: 10/14/2022]
Abstract
This review aims to provide a practical and up-to-date description on the relevance and classification of syncope in adults as well as a guidance on the optimal evaluation, management and treatment of this very common clinical and socioeconomic medical problem. We have summarized recent active research and emphasized the value for physicians to adhere current guidelines. A modern management of syncope should take into account 1) use of risk stratification algorithms and implementation of syncope management units to increase the diagnostic yield and reduce costs; 2) early implantable loop recorders rather than late in the evaluation of unexplained syncope; and 3) isometric physical counter-pressure maneuvers as first-line treatment for patients with neurally-mediated reflex syncope and prodromal symptoms.
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Affiliation(s)
- Salvatore Rosanio
- University of North Texas Health Science Center, Department of Internal Medicine, Division of Cardiology 855 Montgomery Street 76107 Fort Worth, TX, United States.
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23
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Abstract
Traditionally, antihypertensive medications were used in few children or adolescents, usually just those with underlying renal or other organ system disease. However, with recent data suggesting that the incidence of primary hypertension may be increasing in the young, it is possible that more children and adolescents will be prescribed antihypertensive agents. This article will review currently available pediatric data on the use of calcium channel blockers, agents affecting the renin-angiotensin-aldosterone system and other classes of antihypertensive medications in children, highlighting appropriate indications and safety considerations. Guidelines for use of antihypertensive medications, including choice of initial agent and how to prescribe appropriately, will be presented.
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Eltahawy EA, Grubb BP. Neurocardiogenic syncope: mechanisms, evaluation and treatment. Future Cardiol 2010; 2:325-34. [PMID: 19804090 DOI: 10.2217/14796678.2.3.325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Syncope is the abrupt and transient loss of consciousness due to a temporary reduction in cerebral blood flow, associated with an absence of postural tone, followed by a rapid and usually complete recovery. It may result from several possible etiologies, ranging from the benign to the potentially fatal. Neurocardiogenic (vasovagal) syncope is the most common of a group of neurally mediated syncopes, characterized by a sudden failure of autonomic regulatory mechanisms to maintain adequate blood pressure and, occasionally, heart rate, to sustain cerebral perfusion and consciousness. The diagnosis may be suggested by a characteristic history and by exclusion of other causes of syncope; however, in some cases, upright tilt table testing may be required to provoke typical hemodynamic responses. Cardiologists and cardiac electrophysiologists are frequently expected to manage patients with suspected neurocardiogenic syncope. The following review aims to provide a basic framework for understanding its pathophysiology, clinical presentations, diagnosis and treatment.
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Affiliation(s)
- Ehab A Eltahawy
- Department of Cardiovascular Diseases, Medical University of Ohio, 3000 Arlington Avenue, Toledo, OH 43614, USA
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25
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Kelley RE. Neurologic Presentations of Cardiac Disease. Neurol Clin 2010; 28:17-36. [DOI: 10.1016/j.ncl.2009.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Benditt DG, Nguyen JT. Syncope. J Am Coll Cardiol 2009; 53:1741-51. [DOI: 10.1016/j.jacc.2008.12.065] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Revised: 12/01/2008] [Accepted: 12/15/2008] [Indexed: 10/20/2022]
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Kuo FY, Hsiao HC, Chiou CW, Liu CP. Recurrent syncope due to carotid sinus hypersensitivity and sick sinus syndrome. J Chin Med Assoc 2008; 71:532-5. [PMID: 18955189 DOI: 10.1016/s1726-4901(08)70163-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Syncope is a sudden and brief loss of consciousness with postural tone. Its recovery is usually spontaneous. There are various causes of syncope including cardiac, vascular, neurologic, metabolic and miscellaneous origins. The tracing is usually time-consuming and costly. The diagnosis of carotid sinus syncope may sometimes be difficult since the symptoms are nonspecific, especially in older persons. Here, we report the case of a 72-year-old woman who sought medical attention at our hospital due to repeated syncope episodes over the previous 5 years. Neurologic examinations showed negative results (including brain computed tomography). Twenty-four-hour ambulatory electrocardiogram monitoring showed atrial and ventricular premature contractions only. Electrophysiologic study disclosed prolonged corrected sinus node recovery time (1,737 ms) with poor atrioventricular conduction. Drop of blood pressure together with sinus bradycardia developed after left side carotid sinus massage. Both carotid sinus hypersensitivity with sick sinus syndrome contributed to this patient's syncope, and after pacemaker placement together with selective serotonin reuptake inhibitor treatment, she was free from syncope thereafter.
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Affiliation(s)
- Feng-Yu Kuo
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
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Gould PA, Klein GJ, Yee R, Skanes AC, Gula LJ, Krahn AD. Syncope. HANDBOOK OF CLINICAL NEUROLOGY 2008; 90:247-263. [PMID: 18631827 DOI: 10.1016/s0072-9752(07)01714-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Paul A Gould
- London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
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Abstract
Syncope is defined as transient loss of consciousness as a result of inadequate cerebral perfusion. The causes of syncope fall into five broad categories: neurally mediated, orthostatic (the most frequent causes), cardiac arrhythmias, structural cardiovascular (relatively uncommon cause), and cerebrovascular (very rare). The initial evaluation of the syncope patient includes a detailed medical history and physical exam, and usually an ECG and echocardiogram. Thereafter, selected additional testing (e.g. ambulatory ECG recording, autonomic function testing, electrophysiologic study) may be needed on a case-by-case basis. Neurally mediated and orthostatic syncope should first be treated by conservative therapies including hydration/volume expanders and physical counter-maneuvers. Various drugs may play a role as second-line of treatment. However, apart from midodrine, randomized studies of drug therapy are largely lacking, and most agents have not proved to be predictably effective. For syncope due to cardiac arrhythmias, treatment options (depending on the specific circumstance) include ablation of the arrhythmia origin, antiarrhythmic drugs, and/or implantable devices (pacemakers and defibrillators). In the case of syncope due to structural cardiovascular defects (e.g. acute myocardial ischemia, pulmonary hypertension, obstructive cardiomyopathy), treatment is aimed at ameliorating the underlying structural defect. In brief, establishing a specific cause(s) for syncope is crucial. Only then can a potentially effective treatment strategy be contemplated.
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Affiliation(s)
- Deviprasad Venugopal
- Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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Ponciroli KM, Jureidini SB, Dempsher D, Balfour I. Fludrocortisone in the management of an infant with a single ventricle and an overly tightened pulmonary artery band. Pediatr Cardiol 2006; 27:640-2. [PMID: 16933074 DOI: 10.1007/s00246-005-1120-3] [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] [Indexed: 10/24/2022]
Abstract
We describe a 2-month-old female infant with a univentricular heart and overly tightened pulmonary artery band (PAB) resulting in hypercyanotic episodes. Despite adequate doses of morphine and a beta-blocker, she continued to have multiple hypercyanotic events per day. Treatment with fludrocortisone resulted in resolution of these episodes and allowed performance of a Glenn shunt at 3 half months of age. We conclude that fludrocortisone may be beneficial in the management of an overly tightened PAB until the patient is suitable for surgical intervention.
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Affiliation(s)
- K M Ponciroli
- Department of Pediatric Cardiology and Endocrinology, St. Louis University, School of Medicine, Cardinal Glennon Children's Hospital, 1465 South Grand Boulevard, St. Louis, MO 63104, USA
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Raj SR, Rose S, Ritchie D, Sheldon RS. The Second Prevention of Syncope Trial (POST II)--a randomized clinical trial of fludrocortisone for the prevention of neurally mediated syncope: rationale and study design. Am Heart J 2006; 151:1186.e11-7. [PMID: 16781217 DOI: 10.1016/j.ahj.2006.03.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Accepted: 03/20/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND Neurally mediated syncope is a common and frequently distressing problem. It is associated with a poor quality of life, which improves when the frequency of syncope is reduced. Few therapies for neurally mediated syncope have been proven effective. Fludrocortisone is commonly used to prevent recurrences of syncope but with little evidence to support its use. A placebo-controlled clinical trial of fludrocortisone for the prevention of neurally mediated syncope is needed. STRUCTURE OF STUDY POST II is a multicenter, international, randomized, placebo-controlled study of fludrocortisone in the prevention of neurally mediated syncope. The primary end point is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive fludrocortisone 0.05 to 0.2 mg or matching placebo and followed for 1 year. Secondary end points include syncope frequency, presyncope, and quality of life. Primary analysis will be performed with an intention-to-treat approach, with a secondary on-treatment analysis. POWER CALCULATIONS Assuming a 40% risk of syncope in the control arm, a relative reduction of 40% by fludrocortisone, and a dropout rate of 20%, the enrollment of 310 patients will give an 80% power of reaching a positive conclusion about fludrocortisone therapy, with P = .05. REGISTRATION POST II is registered with both (ISRCTN 51802652) and (NCT00118482). IMPLICATIONS This study will be the first adequately powered trial to determine whether fludrocortisone is effective in preventing neurally mediated syncope. If it is effective, then fludrocortisone may become the first-line medical therapy for this condition.
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Affiliation(s)
- Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
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Abstract
Neurocardiogenic syncope is a neurally mediated disorder and is a common cause of syncope. The goal of treatment is to prevent recurrences with the aim of improving quality of life and reducing morbidity. Reassurance, in some cases, may suffice. In others, augmenting central blood volume by increasing fluid and/or salt intake is effective. The role of non-pharmacological physical manoeuvres is increasingly recognised, given the increasing clinical trial data supporting their efficacy. This review summarises the clinical evidence for a variety of pharmacological agents. Of these, midodrine appears to have yielded the most consistent favourable outcome. Its use, however, should be reserved for patients with recurrent and refractory syncope.
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Affiliation(s)
- Lin Y Chen
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota, MN 55905, USA.
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Sheldon R, Connolly S, Rose S, Klingenheben T, Krahn A, Morillo C, Talajic M, Ku T, Fouad-Tarazi F, Ritchie D, Koshman ML. Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation 2006; 113:1164-70. [PMID: 16505178 DOI: 10.1161/circulationaha.105.535161] [Citation(s) in RCA: 170] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous studies that assessed the effects of beta-blockers in preventing vasovagal syncope provided mixed results. Our goal was to determine whether treatment with metoprolol reduces the risk of syncope in patients with vasovagal syncope. METHODS AND RESULTS The multicenter Prevention of Syncope Trial (POST) was a randomized, placebo-controlled, double-blind, trial designed to assess the effects of metoprolol in vasovagal syncope over a 1-year treatment period. Two prespecified analyses included the relationships of age and initial tilt-test results to any benefit from metoprolol. All patients had >2 syncopal spells and a positive tilt test. Randomization was stratified according to ages <42 and > or =42 years. Patients received either metoprolol or matching placebo at highest-tolerated doses from 25 to 200 mg daily. The main outcome measure was the first recurrence of syncope. A total of 208 patients (mean age 42+/-18 years) with a median of 9 syncopal spells over a median of 11 years were randomized, 108 to receive metoprolol and 100 to the placebo group. There were 75 patients with > or =1 recurrence of syncope. The likelihood of recurrent syncope was not significantly different between groups. Neither the age of the patient nor the need for isoproterenol to produce a positive tilt test predicted subsequent significant benefit from metoprolol. CONCLUSIONS Metoprolol was not effective in preventing vasovagal syncope in the study population.
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Affiliation(s)
- Robert Sheldon
- University of Calgary, Calgary, Alberta T2N 4N1, Canada.
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Abstract
Syncope is a common symptom in children, particularly in the teenage years. Although most often benign, it can be a symptom of serious underlying conditions and may result in sudden death. It is estimated that approximately 1% to 2% of children presenting with syncope have a serious underlying disorder. Therefore, it is important to assess patients logically and be able to separate those with serious pathology from those without. A good history is the most important step in this regard, and can save a significant amount of anxiety, time, and money for the patient and for the health care system. Most patients can be determined to have vasovagal syncope on the basis of a good history, physical examination, and standard electrocardiogram. Other tests, such as echocardiography and electrocardiogram monitoring (eg, Holter/event monitors, including implantable event monitors), may be reserved for those with abnormalities in the initial workup. Therapy depends on the underlying disorder. Vasovagal syncope may only need reassurance and volume loading with increase in salt and water intake.
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Affiliation(s)
- Anjan S Batra
- Pediatric Cardiology, Oregon Health & Science University, 707 SW Gaines Road, CDRC-P, Portland, OR 97239, USA
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35
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Salim MA, Di Sessa TG. Effectiveness of fludrocortisone and salt in preventing syncope recurrence in children: a double-blind, placebo-controlled, randomized trial. J Am Coll Cardiol 2005; 45:484-8. [PMID: 15708690 DOI: 10.1016/j.jacc.2004.11.033] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Revised: 10/28/2004] [Accepted: 11/02/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVES We sought to evaluate the effectiveness of salt and fludrocortisone versus placebo in the prevention of syncope recurrence in children. BACKGROUND Intravascular volume expansion with fludrocortisone and salt has been reported to be effective in the treatment of syncope in children. However, no pediatric placebo-controlled data are available on the effectiveness of this mode of therapy. METHODS Thirty-three children with syncope or severe presyncope were randomized in a double-blinded fashion to receive either fludrocortisone 0.1 mg/day and salt 1 g/day or placebo two capsules per day for one year. All children had a positive tilt test before enrollment. RESULTS Thirty-two children (20 female) had follow-up. Their age was (mean +/- SD) 13.9 +/- 2.5 years. The number of syncopal episodes before therapy was 4.4 +/- 4.8. Therapy was continued for 176 +/- 117 days, and follow-up including time after discontinuation of medications was 1.2 +/- 0.8 years. The demographics were similar in the 18 children treated with fludrocortisone and salt compared with the 14 children on placebo. Data for up to one year of randomization were included in analyses. Symptoms recurred in 10 of 18 children on fludrocortisone and salt and in 5 of 14 children on placebo (p < 0.04). Children on placebo had no symptoms until they discontinued their study medications. CONCLUSIONS These data, coupled with the reported comparable effect of many medications used in the treatment of syncope, raise the potential of a significant placebo effect with pharmacologic therapy.
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Affiliation(s)
- Mubadda A Salim
- Division of Pediatric Cardiology, Department of Pediatrics, the University of Tennessee, Memphis, USA.
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Affiliation(s)
- Blair P Grubb
- Division of Cardiology, Department of Medicine, Medical College of Ohio, Toledo 43614, USA.
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37
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Abstract
Syncope, defined as the temporary loss of consiousness and postural tone resulting from an abrupt transient decrease in cerebral blood flow, is a common usually benign self-limiting event. However, rarely, it may be the first warning sign of a serious condition including arrhythmias, structural heart disease, or non-cardiac disease. This article presents a differential diagnosis of syncope in children with an emphasis on neurocardiogenic syncope, details important positives and negatives in the history and physical exam that would suggest cardiac syncope and gives recommendations on when to refer a child for syncope to a pediatric cardiologist.
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Affiliation(s)
- Margaret J Strieper
- Pacing and Electrophysiology, Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, GA 30329, USA.
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38
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Abstract
Patient education, identification of possible triggers of syncope and reassurance are a central feature of the management of patients with reflex syncope. Patients should be advised as to the importance of adequate hydration and taught physical countermaneuvers to enhance cardiac venous return. These maneuvers are sufficient for most patients, however, for a small number of patients who continue to have recurrent syncopal events, pharmacological intervention may be considered. Volume expansion can be enhanced with salt and fludrocortisone. Agents from diverse pharmacological classes have been used to attenuate the reflex response, enhance vasoconstriction and attenuate vagal outflow. Alpha adrenoreceptor agonists, anticholinergic agents, theophylline, beta adrenoreceptor antagonists, serotonin reuptake inhibitors and disopyramide are the most widely studied. None of these agents has shown a consistent therapeutic benefit in clinical trials.
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Affiliation(s)
- Horacio Kaufmann
- Mount Sinai School of Medicine, Box 1052, New York, NY 10029, USA.
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Morillo CA, Baranchuk A. Current Management of Syncope: Treatment Alternatives. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:371-383. [PMID: 15324613 DOI: 10.1007/s11936-004-0021-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Syncope, defined as a transient loss of consciousness and postural tone with spontaneous recovery and no neurologic sequelae, is among one of the most common causes of consultation with a physician. The diagnostic workup is complex but can be simplified if focused on the underlying condition. Prognosis is highly dependent on the presence or absence of structural heart disease, primarily the presence of cardiomyopathy regardless of etiology, particularly if the left ventricular (LV) function is less than 35%. The diagnostic approach to the patient with recurrent syncope and no structural heart disease is targeted to rule out neurally mediated causes. This approach usually includes a tilt table test (ie, head-up tilt), carotid sinus massage in patients older than 55 years, and an adenosine challenge test in patients who remain with unexplained syncope. Unexplained syncope in patients with reduced LV function (< 35%) may be potentially life-threatening. Infrequent causes of syncope should be sought in younger patients with a family history of sudden cardiac death. Channelopathies such as the long QT syndrome, Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia are among this variety. Therapy should address the potential mechanism of syncope. In neurally mediated causes, restoration of orthostatic tolerance, primarily by increasing volume during orthostatic stress, is recommended. Physiologic countermaneuvers and increase in salt and water intake are usually the initial therapy. With syncope in patients with an LV dysfunction (< 35%), an ICD is frequently recommended after ruling out common causes of syncope. Syncope in the elderly is usually multifactorial and therapy should include reassessment of multiple medications, which can promote neurally mediated syncope as well as searching for bradycardic causes. Empiric pacing may be used in this complex group of patients.
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Affiliation(s)
- Carlos A. Morillo
- Arrhythmia Service-Cardiology Division, McMaster University, HGH-McMaster Clinic 5th Floor, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
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40
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Affiliation(s)
- Carol Chen-Scarabelli
- VA Ann Arbor Healthcare System, Division of Cardiology (111A), 2215 Fuller Road, Ann Arbor, MI 48105, USA.
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41
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Abstract
PURPOSE OF REVIEW Syncope is a common symptom in adolescents. The vast majority of cases are the result of benign neurocardiogenic syncope, without associated risk of sudden death. This paper reviews the mainstays of diagnosis and treatment for syncopal episodes, differentiation of syncope from life-threatening arrhythmia and aborted sudden cardiac death, and the patient populations at highest risk for cardiac symptoms and cardiac disease. RECENT FINDINGS A detailed history (including past medical history and family history that focus on cardiac disease) combined with dynamic physical examination and electrocardiogram identifies the vast majority of adolescents with significant heart disease. Further diagnostic modalities have limited utility. Reassurance and supportive measures remain the treatment of choice, although drug therapy can sometimes be helpful, even if data are limited. Divergent approaches to the screening of the young competitive athlete exist. Particular attention is required in adolescents and young adults with exercise-associated syncope, eating disorders, chronic fatigue syndrome, or history of congenital heart disease. Their symptoms may be either more serious or challenging to manage. SUMMARY Syncope in the adolescent patient is very common; true cardiac disease is not. The traditional diagnostic screen of history and physical combined with an electrocardiogram will identify the overwhelming majority of patients with significant disease. Patients with abnormalities on this initial office evaluation, history of cardiac disease, or complicating medical illness may benefit from referral to a cardiologist. Even within this patient subset, many will prove to have benign disease.
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Affiliation(s)
- Amy Desrochers DiVasta
- Division of Adolescent and Young Adult Medicine, Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA.
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42
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Abstract
A wide variety of pharmacologic agents are currently used for the prevention of recurrent neurocardiogenic syncope in children and adolescents. Significant advances in the understanding of this syncopal disorder have occurred in the past decade, and the list of medications recommended has changed, reflecting the evolving understanding of the pathophysiology and development of agents with enhanced efficacy and fewer adverse effects. Clinicians have few randomized controlled trials available to guide their decisions about treating neurocardiogenic syncope, and even fewer when it comes to medications targeting the pediatric population. At the present time, beta-adrenergic receptor blockers, fludrocortisone, and also specific serotonin reuptake inhibitors and midodrine, appear to be favored treatment options. Ideally, specific therapy would be tailored to specific pathophysiologic mechanisms. Unfortunately, at present, specific treatments based on those abnormalities have not been identified.
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Affiliation(s)
- Martial Massin
- Division of Pediatric Cardiology, University of Liège at Regional Hospital Centre La Citadelle, Liège, Belgium.
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Alegria JR, Gersh BJ, Scott CG, Hodge DO, Hammill SC, Shen WK. Comparison of frequency of recurrent syncope after beta-blocker therapy versus conservative management for patients with vasovagal syncope. Am J Cardiol 2003; 92:82-4. [PMID: 12842256 DOI: 10.1016/s0002-9149(03)00475-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jorge R Alegria
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Maule S, Tredici M, Del Colle S, Chiandussi L. Treatment of Patients with Neurogenic Orthostatic Hypotension. High Blood Press Cardiovasc Prev 2003. [DOI: 10.2165/00151642-200310020-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Abstract
Patients with frequent vasovagal syncope have a poor quality of life and often resist treatment with standard pharmacologic approaches. Clinical vasovagal syncope may be associated with some degree of bradycardia. Studies of temporary pacing during tilt table tests showed that pacing prevented syncope in a little more than half of patients who developed a vasovagal response. Six open-label studies of permanent pacing show that permanent pacemaker therapy is associated with substantial improvement over medical therapy. The roles of specific pacemaker modes have not been determined, although there is some evidence that rate-drop responsiveness helps. The second Vasovagal Pacemaker Study will quantify the true benefits of pacing for vasovagal syncope and assess the role of rate-drop response algorithms.
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Affiliation(s)
- Satish R Raj
- Cardiovascular Research Group, University of Calgary, Calgary, Alberta, Canada
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Abstract
Syncope is a common condition that can be both disabling and expensive to treat. Although investigative modalities are sometimes required, a diagnosis can often be made with a good history and physical exam. Recent reports have identified specific historic features that are more suggestive of cardiac syncope as compared with vasovagal syncope and seizures. Advances in ambulatory electrocardiography (in particular the implantable loop recorder) have proven invaluable in both difficult-to-diagnose syncope, and in advancing our knowledge of its mechanisms. When clear dysrhythmias are manifest, appropriate therapies are self-evident. However, recurrent vasovagal syncope continues to be a condition that can be difficult to treat. Fortunately, there are well-conducted trials of both pharmacologic therapies (b-blockers, alpha agonists, and selective serotonin reuptake inhibitors) and nonpharmacologic treatments (orthostatic physical training and dual-chamber pacemakers) that should provide more guidance in the near future.
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Affiliation(s)
- Satish R Raj
- Faculty of Medicine, University of Calgary, Health Sciences Centre, 3330 Hospital Drive, NW, Calgary, Alberta, T2N 4N1, Canada.
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Flevari P, Livanis EG, Theodorakis GN, Zarvalis E, Mesiskli T, Kremastinos DT. Vasovagal syncope: a prospective, randomized, crossover evaluation of the effect of propranolol, nadolol and placebo on syncope recurrence and patients' well-being. J Am Coll Cardiol 2002; 40:499-504. [PMID: 12142117 DOI: 10.1016/s0735-1097(02)01974-5] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to assess the relative therapeutic efficacy of propranolol, nadolol and placebo in recurrent vasovagal syncope (VVS). BACKGROUND Central and peripheral mechanisms have been implicated in the pathogenesis of VVS. Propranolol, nadolol and placebo have different sites of action on central and/or peripheral mechanisms. It has not yet been clarified whether one of the aforementioned treatments is more efficient than the others in reducing clinical episodes and exerting a beneficial effect on patients' well-being. METHODS We studied 30 consecutive patients with recurrent VVS and a positive head-up tilt test. All were serially and randomly assigned to propranolol, nadolol or placebo. Therapy with each drug lasted three months. On the day of drug crossover, patients reported the total number of syncopal and presyncopal attacks during the previous period. They also gave a general assessment of their quality of life, taking into account: 1) symptom recurrence; 2) drug side effects; and 3) their personal well-being during therapy (scale 0 to 4: 0 = very bad/discontinuation; 1 = bad; 2 = good; 3 = very good; 4 = excellent). At the end of the nine-month follow-up period, they reported whether they preferred a specific treatment over the others. RESULTS Spontaneous syncopal and presyncopal episode recurrence during each three-month follow-up period was reduced by all drugs tested (analysis of variance [ANOVA]: chi-square = 67.4, p < 0.0001 for syncopal attacks; chi-square = 60.1, p < 0.0001 for presyncopal attacks) No differences were observed in the recurrence of syncope and presyncope among the three drugs. All drugs improved the patients' well-being (ANOVA: chi-square = 61.9, p < 0.0001). CONCLUSIONS Propranolol, nadolol and placebo are equally effective treatments in VVS, as demonstrated by a reduction in the recurrence of syncope and presyncope, as well as an improvement in the patients' well-being.
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Affiliation(s)
- Panagiota Flevari
- Second Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece.
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48
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Abstract
The disorders of autonomic control associated with orthostatic intolerance are a diverse group of syndromes that can result in syncope and near-syncope. A basic understanding of the pathophysiology of these disorders is essential to diagnosis and proper treatment. It is especially important to recognise the difference between the effect of prolonged upright posture on a failing autonomic nervous system (a hyposensitive or dysautonomic response) and the vasovagal response (which may be a hypersensitive response). Vasovagal syncope is the most common abnormal response to upright posture and occurs in all age groups. The advent of tilt table testing has helped define a population with an objective finding during provocative testing that has enabled researchers to study the mechanism of vasovagal syncope and to evaluate the efficacy of treatments. In most patients, vasovagal syncope occurs infrequently and only under exceptional circumstances and treatment is not needed. Treatment may be indicated in patients with recurrent syncope or with syncope that has been associated with physical injury or potential occupational hazard. Based on study data, patients with vasovagal syncope can now be risk stratified into a high-risk group likely to have recurrent syncope and a low-risk group. Many patients with vasovagal syncope can be effectively treated with education, reassurance and a simple increase in dietary salt and fluid intake. In others, treatment involves removal or avoidance of agents that predispose to hypotension or dehydration. However, when these measures fail to prevent the recurrence of symptoms, pharmacological therapy is usually recommended. Although many pharmacological agents have been proposed and/or demonstrated to be effective based on nonrandomised clinical trials, there is a remarkable absence of data from large prospective clinical trials. Data from randomised placebo-controlled studies support the efficacy of beta-blockers, midodrine, serotonin reuptake inhibitors and ACE inhibitors. There is also considerable clinical experience and a consensus suggesting that fludrocortisone is effective. Encouraging new data suggest that a programme involving tilt training can effectively prevent vasovagal syncope. For patients with recurrent vasovagal syncope that is refractory to these treatments, implantation of a permanent pacemaker with specialised sensing/pacing algorithms appears to be effective. A number of larger clinical trials are underway which should help further define the efficacy of a number of different treatments for vasovagal syncope.
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Affiliation(s)
- Daniel M Bloomfield
- Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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49
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Dendi R, Goldstein DS. Meta-analysis of nonselective versus beta-1 adrenoceptor-selective blockade in prevention of tilt-induced neurocardiogenic syncope. Am J Cardiol 2002; 89:1319-21. [PMID: 12031740 DOI: 10.1016/s0002-9149(02)02338-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Raghuveer Dendi
- University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.
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50
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Abstract
Neurocardiogenic syncope is the most common cause of syncope presenting in the outpatient setting. It is usually encountered among individuals without an underlying heart disease, but not uncommonly participates in the syncope mechanism of patients with an obstructive or an arrhythmic cardiac cause for syncope as well. The vasovagal event is caused by a transient profound hypotensive reaction most commonly associated with inappropriate bradycardia resulting from activation of a complex autonomic reflex. The pathophysiology of neurocardiogenic syncope has been elucidated by tilt table testing, a noninvasive and well-tolerated method for reproducing the event in susceptible individuals. Although the majority of people with vasovagal fainting need no specific treatment, treatment is required for those presenting with problematic features such as frequent events accompanied by trauma or accidents, and occasionally by a severe cardioinhibitory pattern response. A number of different drugs have been proposed to favourably act on different aspects of the neurocardiogenic reflex but only a few randomised, placebo-controlled, drug-specific trials are currently available. Alternatively, cardiac pacing has also been introduced for patients who have symptoms that are drug-refractory or for those with a severe cardioinhibitory hypotensive response. The selection of the appropriate treatment plan should be individualised after consideration of patient history, clinical characteristics and preference, results of the baseline tilting study, and the existing evidence from the few randomised, controlled studies performed so far.
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Affiliation(s)
- K A Gatzoulis
- University Department of Cardiology, Hippokration General Hospital, Athens, Greece
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