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Rao BH, Gowlikar V, Vooturi S, Raj JP, Surath M. Management of patients with Reflex Vasovagal syncope with a protocol involving a yoga maneuver Tadasana. Int J Cardiol 2024; 412:132302. [PMID: 38945370 DOI: 10.1016/j.ijcard.2024.132302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND There is no universally followed protocol for managing Reflex Vasovagal syncope (VVS). METHODS VVS patients were treated with a 2 step protocol. Step I - counseling, hydration, physiotherapy, and Tadasana Yoga maneuver. Patients with ≥2 VVS recurrences were given step II care - intensification of step I, elastic stockings,and pharmacotherapy. Follow-up included assessment by periodic functional status questionnaires. RESULTS 157 patients (103 males & 54 females,mean age - 53 ± 20 years & mean LVEF - 62 ± 5%.) experienced 867 total events - 382 syncopal, and 485 near syncopal episodes over 14 ± 9 months. After step I protocol, the mean total, syncopal and near syncopal events declined from 5 ± 7 to 0.3 ± 1.2 (P < 0.0001), 3 ± 2 to 0.1 ± 0.4 (P < 0.0001) and 3 ± 6 to 0.2 ± 1.1 (P < 0.0001) respectively. Twenty (12.7%) patients had 53 event recurrences, 15- syncopal episodes in 7 and 38 near syncope events in 13. After step II, 5 patients had 14 events. At 33 ± 15 months, in 152 patients (96.8%) there were no recurrences and syncope was prevented in all (100%). The median total, syncopal and near syncopal events declined from 3 to 0,(p < 0.001) 2 to 0 (p < 0.001) and 1 to 0 (p < 0.001) respectively. There was an improvement in all the 3 quality of life parameters. CONCLUSION We demonstrate a simple and effective protocol that can be universally adopted to prevent VVS recurrences,with improvement in quality of life.
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Affiliation(s)
- B Hygriv Rao
- Department of Cardiology, KIMS Hospitals, b Arrythmia Research & Training Society (ARTS), India.
| | | | - Sudhindra Vooturi
- Department of Cardiac Rehabilitation & Physiotherapy, KIMS Hospitals, India
| | - Jeffrey Predeep Raj
- Department of Pharmacology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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Salari N, Karimi Z, Hemmati M, Mohammadi A, Shohaimi S, Mohammadi M. Global prevalence of vasovagal syncope: A systematic review and meta-analysis. GLOBAL EPIDEMIOLOGY 2024; 7:100136. [PMID: 38283939 PMCID: PMC10821537 DOI: 10.1016/j.gloepi.2024.100136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/18/2023] [Accepted: 01/04/2024] [Indexed: 01/30/2024] Open
Abstract
Background Today, vasovagal syncope is a common problem that has become a significant health and social challenge. The present study investigated the global prevalence of vasovagal syncope using a systematic review and meta-analysis.Methods: In this systematic review and meta-analysis study, the global prevalence of vasovagal syncope using the keywords Prevalence, Epidemiology, Vasovagal syncope, and Reflex syncope in PubMed, WoS, Scopus, ScienceDirect databases, and Google scholar search engine without time limit until July 20, 2022, was extracted and transferred to the information management software (EndNote). Then the repeated studies were excluded, and researchers evaluated the remaining studies during three stages (i.e., screening, eligibility, and qualitative assessment). The heterogeneity of studies was investigated using the I2 index, and the analysis of eligible studies was performed using the random effects model. Results In the review of 12 studies with a sample size of 36,156 people, the global prevalence of vasovagal syncope was reported as 16.4 (95%CI: 6-37.5), and the study of publication bias in the studies through the Egger test shows the absence of publication bias in the studies. Conclusion The prevalence reported in the studies shows a high prevalence of vasovagal syncope, which requires serious intervention and preventive, diagnostic, and therapeutic measures. It is necessary for health policymakers to take effective measures in this field.
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Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Zohre Karimi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mahvan Hemmati
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Mohammadi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- Department of Biology, Faculty of Science, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Masoud Mohammadi
- Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran
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Aksu T, Chung MK. Cardioneuroablation for Cardioinhibitory Vasovagal Syncope: Rationale, Approaches, and Its Role in Long-Term Management. CURRENT CARDIOVASCULAR RISK REPORTS 2024; 18:55-64. [PMID: 38707611 PMCID: PMC11064987 DOI: 10.1007/s12170-024-00736-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024]
Abstract
Purpose of Review Cardioneuroablation (CNA) has emerged as a potential alternative to pacemaker therapy in well-selected cases with vasovagal syncope (VVS). In recent years, the number of CNA procedures performed by electrophysiologists has considerably risen. However, some important questions, including proper patient selection and long-term results, remain unanswered. The present article aims to critically review and interpret latest scientific evidence for clinical indications and how to approach long-term management. Recent Findings CNA is a new approach that has been supported mainly by retrospective or observational data for its use in syncope. Overall, in mixed population studies treated with CNA, 83.3 to 100% have been reported to be free of syncope over follow-up periods of 6 to 52.1 months. For studies including patients who underwent CNA with pure VVS, 73.2 to 100% have been reported to be syncope-free over follow-up periods of 4 to 45.1 months. One large meta-analysis showed 91.9% freedom from syncope after CAN. To date, only one randomized controlled trial with small case number has been performed of CNA compared to non-pharmacological treatment in VVS. In this study of 48 patients with an average of 10 ± 9 spontaneous syncopal episodes prior to study enrollment and 3 ± 2 episodes in the year prior to CNA. After CNA, 92% were free of syncope compared with 46% treated with optimal non-pharmacological treatment to prevent new syncope episodes (P = 0.0004). To date, most studies have included younger patients (< 60 years of age). There are only limited data in patients older than 60, and some studies suggest less of an effect in relatively older patients. Summary Cardioneuroablation can be performed to decrease syncope recurrence in adult patients aged < 60 years, with severe or recurrent cardioinhibitory syncope without prodromal symptoms, after proven failure of conventional therapies. Due to a paucity of data supporting efficacy in older individuals or for vasodepressor components, CNA in adult patients aged > 60 years or in the presence of a dominant vasodepressor should be considered investigational in severely symptomatic patients after proven failure of pharmacological and non-pharmacological therapies.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Faculty of Medicine, Yeditepe University Hospital, Istanbul 34742, Turkey
| | - Mina K. Chung
- Heart, Vascular, and Thoracic Institute, and Lerner Research Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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van Zanten S, Sutton R, Hamrefors V, Fedorowski A, de Lange FJ. Tilt table testing, methodology and practical insights for the clinic. Clin Physiol Funct Imaging 2024; 44:119-130. [PMID: 37839043 DOI: 10.1111/cpf.12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value.
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Affiliation(s)
- Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Russo V, Parente E, Comune A, Laezza N, Rago A, Nigro G, Brignole M. Clinical features and response at head-up tilt test of patients with situational syncope. Heart 2023; 110:35-39. [PMID: 37527918 DOI: 10.1136/heartjnl-2023-322943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/13/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVE The study compared clinical characteristics and response at head-up tilt test (HUTT) between situational (SS) and vasovagal syncope (VVS). METHODS Consecutive patients who underwent nitroglycerin-potentiated HUTT were retrospectively dichotomised into two groups: those with a history of SS and those with a history of VVS. The patients with SS were further subdivided into patients with SS alone and with SS and at least one episode of VVS. RESULTS 1285 patients were enrolled: 246 (19.1%) had SS (SS alone in 121 and SS+VVS in 125). Patients with SS were older (48.8±20.0 vs 44.4±19.1, p=0.007) and more frequently male (57.3% vs 47.7%, p=0.001). At multivariable analysis, smoking habit (OR 2.28; p<0.0001), history of traumatic syncope (OR 2.29; p=0.0001) and ACE inhibitors/angiotensin II receptor blockers (OR 4.74; p<0.0001) were independently associated with SS. HUTT was positive in 175 (71.1%) patients with SS and in 737 (70.9%) patients with VVS (p=0.9). Patients with SS showed more mixed (42.3% vs 32.0%, p=0.002) and vasodepressor forms (10.6% vs 6.1%, p=0.01) and less cardioinhibitory responses compared with others (18.3% vs 32.8%, p<0.0001). CONCLUSIONS Compared with VVS, patients with SS have different clinical characteristics and a higher prevalence of hypotensive drugs leading to hypotensive susceptibility. The positivity rate of HUTT is high and similar to that of VVS, although patients with SS show a higher prevalence of hypotensive responses.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Nunzia Laezza
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Napoli, Italy
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Traykov V, Shalganov T. Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life. Curr Cardiol Rep 2023; 25:1839-1849. [PMID: 37982935 DOI: 10.1007/s11886-023-01997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE OF REVIEW Vasovagal syncope (VVS) is a common entity causing transient loss of consciousness and affecting quality of life. Guideline-recommended therapy involves conservative measures and pacing in selected patients. Cardioneuroablation (CNA) targeting the ganglionated plexi in the heart has been shown to reduce excessive vagal excitation, which plays a major role in the pathophysiology of VVS and functional bradycardia. RECENT FINDINGS The introduction of CNA has fueled research into its value for the treatment of VVS. Multiple observational studies and one randomized trial have demonstrated the safety and efficacy of CNA and the positive impact on quality of life. This review describes the rationale and CNA procedural techniques and outcomes. Patient selection and future directions have also been described. Cardioneuroablation is a promising treatment for patients with recurrent VVS and functional bradycardia. Further large-scale randomized studies are needed to further verify the safety and efficacy of this approach.
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Affiliation(s)
- Vassil Traykov
- Department of Invasive Electrophysiology, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, 1407 N. Vaptzarov blvd 51B, Sofia, Bulgaria.
| | - Tchavdar Shalganov
- Department of Electrophysiology, Clinic of Cardiology, National Heart Hospital, Sofia, Bulgaria
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Cooper PN, Sutton R. Tilt testing. Pract Neurol 2023; 23:493-500. [PMID: 37726165 DOI: 10.1136/pn-2023-003749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 09/21/2023]
Abstract
Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving sublingual nitroglycerine after 15 min, while monitoring beat-to-beat blood pressure (BP) and recording on video. Tilt testing is time-consuming but it is clinically useful and can guide therapy. Complications are rare. Syncope types include vasovagal syncope where BP falls after >3 min of tilt-up and later the heart rate falls; classic orthostatic hypotension where there is an immediate, progressive BP fall with minimal heart rate change; delayed orthostatic hypotension with a late BP fall after a stable phase but little or no heart rate rise; psychogenic pseudosyncope with apparent loss of consciousness, but no BP fall and a moderate heart rate rise; and postural orthostatic tachycardia syndrome where there is a significant heart rate rise but no BP fall.
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Affiliation(s)
- Paul N Cooper
- Department of Neurology, Manchester Centre for Clinical Neurosciences: Salford Royal Hospital, Salford, UK
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - Richard Sutton
- Department of Cardiology, Imperial College London, London, UK
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Cai S, Zheng L, Yao Y. Cardioneuroablation for vasovagal syncope alters head-up tilt test response and reduces cardiac deceleration capacity. HeartRhythm Case Rep 2023; 9:773-778. [PMID: 38047189 PMCID: PMC10691945 DOI: 10.1016/j.hrcr.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Simin Cai
- Center of Arrhythmia, Huazhong Fuwai Hospital, Heart Center, Henan Provincial People’s Hospital, The People’s Hospital of Zhengzhou University, Henan, China
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Meglič B, Danieli A. Glyceryl trinitrate-induced blood pressure variability decrease during head-up tilt test predicts vasovagal response. Blood Press Monit 2023; 28:236-243. [PMID: 37334541 DOI: 10.1097/mbp.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
PURPOSE Glyceryl trinitrate (GTN) provoked cardioinhibitory syncope during the head-up tilt test is preceded by a period of disrupted blood pressure variability (BPV). Endogenous nitric oxide (NO) attenuates BPV independently of blood pressure (BP). We hypothesized that exogenous NO donor GTN might decrease BPV during the presyncope period. A decrease in BPV may predict the tilt outcome. METHODS We analyzed 29 tilt test recordings of subjects with GTN-induced cardioinhibitory syncope and 30 recordings of negative subjects. A recursive autoregressive model of BPV after GTN was performed; powers of the respiratory (0.15-0.45 Hz) and nonrespiratory frequency (0.01-0.15 Hz) bands were calculated for each of the 20 normalized time periods. The post-GTN relative changes in heart rate, BP, and BPV were calculated. RESULTS In the syncope group, spectral power of nonrespiratory frequency systolic and diastolic BPV progressively felt for 30% after GTN application and stabilized after 180 s. BP started to fall 240 s after the GTN application. Decrease in nonrespiratory frequency power of diastolic BPV 20 s after GTN administration predicted cardioinhibitory syncope (area under the curve 0.811; 77% sensitivity; 70% specificity; cutoff value > 7%). CONCLUSION GTN application during the tilt test attenuates systolic and diastolic nonrespiratory frequency BPV during the presyncope period, independent of BP. A decrease in nonrespiratory frequency diastolic BPV 20 s after GTN application predicts cardioinhibitory syncope with good sensitivity and moderate specificity.
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Affiliation(s)
- Bernard Meglič
- Department of Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
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Francia P, Viveros D, Falasconi G, Penela D, Soto-Iglesias D, Martí-Almor J, Alderete J, Saglietto A, Bellido AF, Franco-Ocaña P, Zaraket F, Matiello M, Fernández-Armenta J, San Antonio R, Berruezo A. Clinical impact of aging on outcomes of cardioneuroablation for reflex syncope or functional bradycardia: Results from the cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs-The ELEGANCE multicenter study. Heart Rhythm 2023; 20:1279-1286. [PMID: 37329936 DOI: 10.1016/j.hrthm.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/27/2023] [Accepted: 06/09/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Cardioneuroablation (CNA) is a novel treatment for reflex syncope. The effect of aging on CNA efficacy is not fully understood. OBJECTIVE The purpose of this study was to assess the impact of aging on candidacy and efficacy of CNA for treating vasovagal syncope (VVS), carotid sinus syndrome (CSS), and functional bradyarrhythmia. METHODS The ELEGANCE (cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs) multicenter study assessed CNA in patients with reflex syncope or severe functional bradyarrhythmia. Patients underwent pre-CNA Holter electrocardiography (ECG), head-up tilt testing (HUT), and electrophysiological study. CNA candidacy and efficacy was assessed in 14 young (18-40 years), 26 middle-aged (41-60 years), and 20 older (>60 years) patients. RESULTS Sixty patients (37 men; mean age 51 ± 16 years) underwent CNA. The majority (80%) had VVS, 8% had CSS, and 12% had functional bradycardia/atrioventricular block. Pre-CNA Holter ECG, HUT, and electrophysiological findings did not differ across age groups. Acute CNA success was 93%, without differences between age groups (P = .42). Post-CNA HUT response was negative in 53%, vasodepressor in 38%, cardioinhibitory in 7%, and mixed in 2%, without differences across age groups (P = .59). At follow-up (8 months, interquartile range 4-15), 53 patients (88%) were free of symptoms. Kaplan-Meier curves did not show differences in event-free survival between age groups (P = .29). The negative predictive value of a negative HUT was 91.7%. CONCLUSION CNA is a viable treatment for reflex syncope and functional bradyarrhythmia in all ages, and is highly effective in mixed VVS. HUT is a key step in postablation clinical assessment.
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Affiliation(s)
- Pietro Francia
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain; Cardiology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Daniel Viveros
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Giulio Falasconi
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Diego Penela
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - David Soto-Iglesias
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Julio Martí-Almor
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - José Alderete
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Andrea Saglietto
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | | | - Paula Franco-Ocaña
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Fatima Zaraket
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain; Clínica del Pilar, Barcelona, Spain
| | | | | | - Rodolfo San Antonio
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain; Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Antonio Berruezo
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, Barcelona, Spain.
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Fedorowski A, Kulakowski P, Brignole M, de Lange FJ, Kenny RA, Moya A, Rivasi G, Sheldon R, Van Dijk G, Sutton R, Deharo JC. Twenty-five years of research on syncope. Europace 2023; 25:euad163. [PMID: 37622579 PMCID: PMC10450792 DOI: 10.1093/europace/euad163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last 25 years, the Europace journal has greatly contributed to dissemination of research and knowledge in the field of syncope. More than 400 manuscripts have been published in the journal. They undoubtedly improved our understanding of syncope. This symptom is now clearly differentiated from other forms of transient loss of consciousness. The critical role of vasodepression and/or cardioinhibition as final mechanisms of reflex syncope is emphasized. Current diagnostic approach sharply separates between cardiac and autonomic pathways. Physiologic insights have been translated, through rigorously designed clinical trials, into non-pharmacological or pharmacological interventions and interventional therapies. The following manuscript is intended to give the reader the current state of the art of knowledge of syncope by highlighting landmark contributions of the Europace journal.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Piotr Kulakowski
- Department of Cardiology, Medical Centre for Postgraduate Education, Grochowski Hospital, Ul. Grenadierow 51/59, 04-073 Warsaw, Poland
| | - Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Piazzale Brescia 20, 20149 Milan, Italy
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, 152-160 Pearse St, Dublin, Ireland
- Mercer Institute for Successful Ageing, St. James Hospital, James St, Dublin 8, D08 NHY1Ireland
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, Carrer de Sabino Arana 5-19, 08028 Barcelona, Spain
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Robert Sheldon
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute, 3310 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Gert Van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, Du Cane Road, London, W12 0HS, United Kingdom
| | - Jean-Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France and Aix Marseille Université, C2VN, 264 Rue Saint-Pierre, 13005 Marseille, France
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Lin J, Liu Q, Jiang R, Chen S, Yu L, Jiang C. Selective anatomical catheter ablation of left atrial ganglionated plexus for vasovagal syncope: Left superior and right anterior ganglionated plexus ablation. Pacing Clin Electrophysiol 2023; 46:1010-1018. [PMID: 37377409 DOI: 10.1111/pace.14769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Vasovagal syncope (VVS) is one of the most common causes of syncope. Traditional treatment has not achieved satisfactory results. The purpose of this study was to assess the feasibility and efficacy of selective anatomical catheter ablation of left atrial ganglionated plexus (GP) as a therapeutic strategy for the patients of symptomatic VVS. METHODS A total of 70 patients with at least once recurrent syncopal episode of VVS with a positive head-up tilt test were enrolled. They were divided into GP ablation group and control group. Patients in GP ablation group received anatomical catheter ablation of left superior ganglionated plexus (LSGP) and right anterior ganglionated plexus (RAGP). Patients in the control group were guideline-directed conventional therapy. The primary endpoint was VVS recurrences. The secondary endpoint was the recurrence of syncope and prodrome events. RESULTS There were no statistical differences in clinical characteristics between the ablation group (n = 35) and the control group (n = 35). Over a follow-up of 12 months, the ablation group had significantly lower syncope recurrence compared with the control group (5.7% vs. 25.7%, p = .02), and the ablation group had significantly lower syncope and prodrome recurrence compared with the control group (11.4% vs. 51.4%, p < .001). In GP ablation, 88.6% of the patients showed significant vagal response during LSGP ablation, and 88.6% of the patients showed significantly increased heart rate during RAGP ablation. CONCLUSIONS For patients with recurrent VVS, selective anatomical catheter ablation of LSGP and RAGP is superior to conventional therapy in reducing syncope recurrence.
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Affiliation(s)
- Jianwei Lin
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Shiquan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
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Prakash A, Sutton R. Prospective randomized study comparing permanent pacing with rate drop response and closed loop stimulation in patients with vasovagal syncope where permanent pacing is indicated and selected as the appropriate treatment option. J Cardiovasc Electrophysiol 2023; 34:1744-1749. [PMID: 37393604 DOI: 10.1111/jce.15991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/10/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Pacing for vasovagal syncope is established. Two pacing algorithms are available. The rate-drop-response (RDR-Medtronic) is triggered by falling heart rate acting with modified rate-hysteresis. The closed loop stimulation or system (CLS-Biotronik) is triggered by impedance changes in the right ventricle reflecting falling volume and rising contractility. These are very different physiologically. Both algorithms carry favorable reports in clinical use. METHODS A randomized-controlled superiority trial is proposed to compare the two algorithms for the control of vasovagal syncope in patients for whom pacing is indicated by current guidelines in North America and Europe. Available recent evidence may be seen as supporting superiority of CLS. No comparison between the two algorithms has been made. In this trial, patients will be centrally randomized to one or other algorithm on a 1:1 basis. Two-hundred-seventy-six patients in each group will be recruited. Sample size is determined using a confidence interval of 95%, a power of 90%, and a drop-out rate of 10% to detect an 11% difference between CLS and RDR. Recurrent symptom comparison will be made by an independent committee. The Co-primary endpoints will be recurrent syncope burden compared with that in 24-months preimplant, and occurrence of syncope in 24-months follow-up. Each outcome will be compared between the two algorithms. Secondary endpoints will be program and drug therapy changes over 24-months follow-up and quality of life by questionnaire at baseline,1 and 2 years. RESULTS AND CONCLUSIONS These are anticipated to clarify the device algorithm choice and, therefore, to improve patient care.
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Affiliation(s)
- Atul Prakash
- Rutgers Medical School, Newark, New Jersey, USA
- Prime Health Care, Newark, New Jersey, USA
- St Mary's General Hospital, Passaic, New Jersey, USA
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital Campus of National Heart & Lung Institute, Imperial College, London, UK
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Li L, Po S, Yao Y. Cardioneuroablation for Treating Vasovagal Syncope: Current Status and Future Directions. Arrhythm Electrophysiol Rev 2023; 12:e18. [PMID: 37457436 PMCID: PMC10345939 DOI: 10.15420/aer.2023.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/05/2023] [Indexed: 07/18/2023] Open
Abstract
Syncope is defined by transient and spontaneous loss of consciousness with rapid recovery. Vasovagal syncope (VVS) is the most common form of syncope and is strongly associated with hypervagotonia. There is, however, a lack of effective therapies for VVS. Cardioneuroablation (CNA) is an emerging and promising intervention for VVS with favourable outcomes. CNA has been shown to suppress excessive excitation of vagal activity through ablating the cardiac ganglionated plexi. CNA in the management of VVS requires more structured and comprehensive studies and several issues concerning patient selection, selection of ablation targets, ablation endpoints and the long-term effect of CNA are yet to be determined. This review describes its clinical applications and future directions based on current research data and the authors' own experiences.
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Affiliation(s)
- Le Li
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Sunny Po
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, US
| | - Yan Yao
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
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15
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Russo V, Parente E, Comune A, Laezza N, Rago A, Golino P, Nigro G, Brignole M. The clinical presentation of syncope influences the head-up tilt test responses. Eur J Intern Med 2023; 110:41-47. [PMID: 36639324 DOI: 10.1016/j.ejim.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/08/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Little is still known about the positivity rate of nitroglycerin (NTG) potentiated head-up tilt test (HUTT) according to the history-based clinical features of syncope. The study aimed to compare the HUTT positivity rate and type of responses in patients with classical and non-classical vasovagal syncope (VVS). MATERIALS AND METHODS We retrospectively evaluated all consecutive patients who underwent NTG-potentiated HUTT for VVS. The study population was dichotomized into classical and non-classical VVS. RESULTS A total of 1285 VVS patients (45± 19.1 years; 49.6% male) were enrolled: 627 (48.8%) had a history of classical VVS and 658 (51.2%) of non-classical VVS. HUTT was positive in 866 (67.4%) patients. The positivity rate was significantly higher in patients with classical compared to those with non-classical VVS (81.5% vs 54%; P< 0.0001). Cardioinhibitory response showed similar total positivity rate (27.6% vs 31%; P= 0.17), but higher relative prevalence among positive tests (57.7% vs 33.9%, P< 0.0001) in patients with non-classical VVS. At multivariable analysis, classical reflex syncope, male sex, history of traumatic syncope and use of diuretics were independent predictors of HUTT positivity. CONCLUSION The clinical presentation of syncope influences the overall HUTT positivity rate and the type of responses. Cardioinhibitory response and traumatic syncope are more likely in patients with non-classical VVS.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy.
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Nunzia Laezza
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Paolo Golino
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
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Tajdini M, Hosseinsabet A, Tofighi S, Yadangi S. Left atrial function evaluation by 2D speckle-tracking echocardiography in patients with vasovagal syncope. Pacing Clin Electrophysiol 2023; 46:300-308. [PMID: 36912282 DOI: 10.1111/pace.14689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 02/05/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVES Evidence indicates left atrial (LA) involvement in vasovagal syncope (VVS). The LA regulates left ventricular filling during the cardiac cycle. We aimed to assess LA function in patients with VVS by 2D speckle-tracking echocardiography. METHODS Sixty-nine consecutive patients with VVS were recruited. Based on the head-up tilt test (HUTT) results, the study population was divided into two groups: HUTT+ (n = 45) and HUTT- (n = 24). Fifty-one consecutive subjects were enrolled as the control group. LA myocardial deformation parameters were measured by 2D speckle-tracking echocardiography to evaluate LA function. RESULTS Maximal, minimal, and pre-P LA volumes were lower in patients with VVS. Strain and strain rate during reservoir, conduit, and contraction phases in VVS patients with HUTT+ or HUTT- were not statistically significantly different from those in the control group. Additionally, the volumetric parameters of LA function showed no difference in statistical significance between the three study groups. CONCLUSIONS While LA phasic function was not different between the two groups of VVS patients with HUTT+ or HUTT- and the control group, LA size during the three LA phases was smaller in patients with VVS.
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Affiliation(s)
- Masih Tajdini
- Cardiology Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinsabet
- Cardiology Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Tofighi
- Cardiology Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Yadangi
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Pachon-M J, Pachon E, Aksu T, Gopinathannair R, Kautzner J, Yao Y, Kusumoto F. Cardioneuroablation: where are we at? Heart Rhythm O2 2023. [DOI: 10.1016/j.hroo.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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Krzesiński P, Marczyk J, Wolszczak B, Gielerak GG, Accardi F. Quantitative Complexity Theory (QCT) in Integrative Analysis of Cardiovascular Hemodynamic Response to Posture Change. Life (Basel) 2023; 13:life13030632. [PMID: 36983787 PMCID: PMC10052206 DOI: 10.3390/life13030632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/19/2023] [Accepted: 02/22/2023] [Indexed: 03/30/2023] Open
Abstract
The explanation of physiological mechanisms involved in adaptation of the cardiovascular system to intrinsic and environmental demands is crucial for both basic science and clinical research. Computational algorithms integrating multivariable data that comprehensively depict complex mechanisms of cardiovascular reactivity are currently being intensively researched. Quantitative Complexity Theory (QCT) provides quantitative and holistic information on the state of multi-functional dynamic systems. The present paper aimed to describe the application of QCT in an integrative analysis of the cardiovascular hemodynamic response to posture change. Three subjects that underwent head-up tilt testing under beat-by-beat hemodynamic monitoring (impedance cardiography) were discussed in relation to the complexity trends calculated using QCT software. Complexity has been shown to be a sensitive marker of a cardiovascular hemodynamic response to orthostatic stress and vasodilator administration, and its increase has preceded changes in standard cardiovascular parameters. Complexity profiling has provided a detailed assessment of individual hemodynamic patterns of syncope. Different stimuli and complexity settings produce results of different clinical usability.
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Affiliation(s)
- Paweł Krzesiński
- Departament of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland
| | | | | | - Grzegorz Gerard Gielerak
- Departament of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland
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Russo V, Parente E, Groppelli A, Rivasi G, Tomaino M, Gargaro A, Giacopelli D, Ungar A, Parati G, Fedorowski A, Sutton R, van Dijk JG, Brignole M. Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology. Europace 2023; 25:263-269. [PMID: 36796797 PMCID: PMC10103574 DOI: 10.1093/europace/euac154] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
This review addresses tilt-testing methodology by searching the literature which reports timing of asystole and loss of consciousness (LOC). Despite the Italian protocol being the most widely adopted, its stipulations are not always followed to the letter of the European Society of Cardiology guidelines. The discrepancies permit reassessment of the incidence of asystole when tilt-down is early, impending syncope, compared with late, established LOC. Asystole is uncommon with early tilt down and diminishes with increasing age. However, if LOC is established as test-end, asystole is more common, and it is age-independent. Thus, the implications are that asystole is commonly under-diagnosed by early tilt-down. The prevalence of asystolic responses observed using the Italian protocol with a rigorous tilt down time is numerically close to that observed during spontaneous attacks by electrocardiogram loop recorder. Recently, tilt-testing has been questioned as to its validity but, in selection of pacemaker therapy in older highly symptomatic vasovagal syncope patients, the occurrence of asystole has been shown to be an effective guide for treatment. The use of head-up tilt test as an indication for cardiac pacing therapy requires pursuing the test until complete LOC. This review offers explanations for the findings and their applicability to practice. A novel interpretation is offered to explain why pacing induced earlier may combat vasodepression by raising the heart rate when sufficient blood remains in the heart.
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Affiliation(s)
- Vincenzo Russo
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Erika Parente
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Marco Tomaino
- Ospedale Generale Regionale, Via Lorenz Böhler, 5, 39100 Bolzano, Italy
| | - Alessio Gargaro
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Daniele Giacopelli
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
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20
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Pawłowski R, Zalewski P, Newton J, Piątkowska A, Koźluk E, Opolski G, Buszko K. An assessment of heart rate and blood pressure asymmetry in the diagnosis of vasovagal syncope in females. Front Physiol 2023; 13:1087837. [PMID: 36699671 PMCID: PMC9868761 DOI: 10.3389/fphys.2022.1087837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/20/2022] [Indexed: 01/10/2023] Open
Abstract
Introduction: Heart Rate Asymmetry (HRA) describes a phenomenon of differences between accelerations and decelerations in human heart rate. Methods used for HRA assessment can be further implemented in the evaluation of asymmetry in blood pressure variations (Blood Pressure Asymmetry-BPA). Methods: We have analyzed retrospectively the series of heartbeat intervals extracted from ECG and beat-to-beat blood pressure signals from 16 vasovagal patients (age: 32.1 ± 13.3; BMI: 21.6 ± 3.8; all female) and 19 healthy subjects (age: 34.6 ± 7.6; BMI: 22.1 ± 3.4; all female) who have undergone tilt test (70°). Asymmetry was evaluated with Poincaré plot-based methods for 5 min recordings from supine and tilt stages of the test. The analyzed biosignals were heart rate (RR), diastolic (dBP) and systolic Blood Pressure (sBP) and Pulse Pressure (PP). In the paper we explored the differences between healthy and vasovagal women. Results: The changes of HRA indicators between supine and tilt were observed only in the control group (Porta Index p = 0.026 and Guzik Index p = 0.005). No significant differences in beat-to-beat variability (i.e. spread of points across the line of identity in Poincaré plot-SD1) of dBP was noted between supine and tilt in the vasovagal group (p = 0.433 in comparison to p = 0.014 in healthy females). Moreover, in vasovagal patients the PP was significantly different (supine: 41.47; tilt: 39.27 mmHg) comparing to healthy subjects (supine: 35.87; tilt: 33.50 mmHg) in supine (p = 0.019) and in tilt (p = 0.014). Discussion: Analysis of HRA and BPA represents a promising method for the evaluation of cardiovascular response to orthostatic stressors, however currently it is difficult to determine a subject's underlying health condition based only on these parameters.
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Affiliation(s)
- Rafał Pawłowski
- Department of Biostatistics and Biomedical Systems Theory, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland,*Correspondence: Rafał Pawłowski,
| | - Paweł Zalewski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Torun, Bydgoszcz, Poland,Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Julia Newton
- Population Health Sciences Institute, The Medical School, Newcastle University, Newcastle, United Kingdom
| | - Agnieszka Piątkowska
- Department of Emergency Medicine, Wroclaw Medical University, Wroclaw, Poland,1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Edward Koźluk
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Buszko
- Department of Biostatistics and Biomedical Systems Theory, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Gopinathannair R, Olshansky B, Turagam MK, Gautam S, Futyma P, Akella K, Tanboga HI, Bozyel S, Yalin K, Padmanabhan D, Shenthar J, Lakkireddy D, Aksu T. Permanent pacing versus cardioneuroablation for cardioinhibitory vasovagal syncope. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01456-x. [PMID: 36562915 DOI: 10.1007/s10840-022-01456-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND We compared the efficacy and safety of cardioneuroablation (CNA) vs. permanent pacing (PM) for recurrent cardioinhibitory vasovagal syncope (CI-VVS). METHODS One hundred sixty-two patients (CNA = 61, PM = 101), age 36 + 11 years) with syncope frequency of 6.7 ± 3.9/year were included in this multicenter study. All patients with CNA were provided by a single center, while patients with PM were provided by 4 other centers. In the CNA arm, an electroanatomic mapping guided approach was used to detect and ablate ganglionated plexus sites. Dual chamber rate drop response (RDR) or close loop stimulation (CLS) transvenous and leadless pacemakers were implanted using standard technique. The primary endpoint was freedom from syncope. RESULTS Of 101 patients in the PM group, 39 received dual-chamber pacemaker implants with the CLS algorithm, 38 received dual-chamber pacemakers with the RDR algorithm, and 24 received a leadless pacemaker. At 1-year follow-up, 97% and 89% in the CNA and PM group met the primary endpoint (adjusted HR = 0.27, 95% CI 0.06-1.24, p = 0.09). No significant differences in adverse events were noted between groups. There was no significant association between age (HR:1.01, 95% CI 0.96-1.06, p = 0.655), sex (HR:1.15, 95% CI 0.38-3.51, p = 0.809), and syncope frequency in the past year (HR:1.10, 95% CI 0.97-1.25, p = 0.122) and the primary outcome in univariable analyses. CONCLUSIONS After adjustment for patient characteristics, the medium-term syncope recurrence risk of CI-VVS patients who underwent CNA was similar to that of a population of patients undergoing pacemaker implantation with a similar safety profile.
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Affiliation(s)
- Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute and Research Foundation, 5100 W 110Th St, Ste 200, Overland Park, KS, 66211, USA.
| | - Brian Olshansky
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mohit K Turagam
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sandeep Gautam
- Division of Cardiovascular Medicine, University of Missouri-Columbia, Columbia, MO, USA
| | - Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszow, Poland
| | | | - Halil Ibrahim Tanboga
- Department of Cardiology, Nisantasi University & Hisar Intercontinental Hospital, Istanbul, Turkey
| | - Serdar Bozyel
- University of Health Sciences, Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey
| | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Deepak Padmanabhan
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Jayaprakash Shenthar
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, 5100 W 110Th St, Ste 200, Overland Park, KS, 66211, USA
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Muacevic A, Adler JR, Chaudhuri D, Khan KI, Al Shouli R, Allakky A, Ferguson AA, Khan AI, Hamid P. Anxiety and Depression as Risk Factors for Vasovagal Syncope and Potential Treatment Targets: A Systematic Review. Cureus 2022; 14:e32793. [PMID: 36694488 PMCID: PMC9858696 DOI: 10.7759/cureus.32793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Vasovagal syncope (VVS) is a transient, sudden loss of consciousness followed by complete resolution, usually due to a paradoxical autonomic reaction that results in hypotension and/or bradycardia. In this study, we assessed the correlation between VVS and a patient's psychiatric status, as well as if this association could be a target in the treatment of those patients. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched the available literature using the following databases: PubMed, Google Scholar, and ScienceDirect, with last access on July 21, 2022. The search resulted in 1691 articles, and inclusion and exclusion criteria were applied to nine remaining articles, all of which were accepted after using the quality assessment tools, four observational and four randomized controlled trials (RCTs). Four of the included studies assessed the correlation among vasovagal syncope, psychosocial impairment, and quality of life. We found a consistent correlation among VVS, psychosocial impairment, and quality of life (QoL), meaning that VVS patients usually have some degree of psychosocial impairment, especially in the form of anxiety and depression, and a poorer QoL in comparison to their healthy counterparts. The use of psychotherapy and antidepressants was proven to be effective in VVS in RCTs, but further evidence is needed.
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Comparison of pain-provoked versus standard 40-min tilt table test for the conformation of vasovagal syncope. Neurol Sci 2022; 43:4847-4851. [DOI: 10.1007/s10072-022-06079-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/15/2022] [Indexed: 10/18/2022]
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Influence of Age on Magnitude and Timing of Vasodepression and Cardioinhibition in Tilt-Induced Vasovagal Syncope. JACC Clin Electrophysiol 2022; 8:997-1009. [DOI: 10.1016/j.jacep.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/09/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022]
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Lisboa da Silva RMF, Oliveira PML, Tonelli HAF, Alves Meira ZM, Mota CDCC. Neurally Mediated Syncope in Children and Adolescents: An Updated Narrative Review. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2205110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Syncope presents a proportion of up to 25% among children and adolescents and accounts for 0.9% of emergency room visits. Its most frequent aetiology is neurally mediated syncope, which includes vasovagal syncope and orthostatic hypotension. Up to 70% of the paediatric population with reflex syncope is female. There are usually precipitating factors and prodromes. This mini-review will discuss the particularities of the clinical presentation, diagnosis, modified Calgary score, indications and accuracy of the head-up tilt test, classification, and pathophysiology in four sequential phases. Prognostic data and the non-pharmacological and pharmacological approaches will also be reviewed and differences regarding reflex syncope in adults will be discussed.
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LAZUROVA Z, HABALOVA V, MITRO P. Association of Polymorphisms in Endothelin-1 and Endothelin Receptor A Genes With Vasovagal Syncope. Physiol Res 2022; 71:93-101. [DOI: 10.33549/physiolres.934689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The endothelin system may play a role in the pathogenesis of vasovagal syncope (VVS) because it is implicated in blood pressure regulation. We hypothesized that endothelin-related genetic polymorphisms might modulate susceptibility to VVS. This study aimed to evaluate the possible influence of endothelin-1 (EDN1) and endothelin receptor A (EDNRA) gene variants on the occurrence of tilt-induced VVS and autonomic nervous system activity during the head-up tilt test (HUT). Results were expressed as mean ± SEM. In 254 patients with recurrent syncope (age 45.33±1.22 years, 94 males, 160 females), heart rate variability (HRV) was measured during HUT. EDN1 rs5370 G>T and EDNRA rs5333 T>C gene polymorphisms were assessed using high-resolution melting analysis. There was no statistically significant association between polymorphisms EDN1 rs5370 and EDNRA rs5333 and positivity of HUT or hemodynamic types of VVS. Patients with GT or TT genotypes at the rs5370 locus of the EDN1 had significantly higher values of high-frequency (HF) and the standard deviation of the average NN intervals at the time of the syncope, and they tended to have lower low-frequency (LF) and LF/HF ratio when compared to homozygotes (GG). No statistically significant differences were found in HRV parameters concerning the EDNRA rs5333 genotypes. Our findings suggest the potential role of EDN1 rs5370 variants in regulating autonomic nervous activity and pathogenesis of VVS.
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Affiliation(s)
- Z LAZUROVA
- Fourth Department of Internal Medicine, Medical Faculty of University of P.J. Safarik, Kosice, Slovak, Republic
| | - V HABALOVA
- Department of Medical Biology, Medical Faculty of University of P.J. Safarik, Kosice, Slovak Republic
| | - P MITRO
- First Department of Cardiology, Medical Faculty of University of P.J. Safarik, Kosice, Slovak Republic
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Yuan P, Li X, Tao C, Du X, Zhang C, Du J, Huang Y, Liao Y. Poincaré Plot Can Be a Useful Tool to Select Potential Responders to Metoprolol Therapy in Children with Vasovagal Syncope. Int J Gen Med 2022; 15:2681-2693. [PMID: 35300141 PMCID: PMC8922042 DOI: 10.2147/ijgm.s352928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Piaoliu Yuan
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xueying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Chunyan Tao
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xiaojuan Du
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, People’s Republic of China
| | - Yaqian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
- Correspondence: Ying Liao; Yaqian Huang, Department of Pediatrics, Peking University First Hospital, Xi-An Men Street No. 1, West District, Beijing, 100034, People’s Republic of China, Tel +8610-83573238; +8610-83575807, Fax +8610-66530532, Email ;
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Hockin BCD, Heeney ND, Whitehurst DGT, Claydon VE. Evaluating the Impact of Orthostatic Syncope and Presyncope on Quality of Life: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:834879. [PMID: 35224062 PMCID: PMC8866568 DOI: 10.3389/fcvm.2022.834879] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/17/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose Syncope (transient loss of consciousness and postural tone) and presyncope are common manifestations of autonomic dysfunction that are usually triggered by orthostasis. The global impact of syncope on quality of life (QoL) is unclear. In this systematic review, we report evidence on the impact of syncope and presyncope on QoL and QoL domains, identify key factors influencing QoL in patients with syncopal disorders, and combine available data to compare QoL between syncopal disorders and to population normative data. Methods A comprehensive literature search of academic databases (MEDLINE (PubMed), Web of Science, CINAHL, PsycINFO, and Embase) was conducted (February 2021) to identify peer-reviewed publications that evaluated the impact of vasovagal syncope (VVS), postural orthostatic tachycardia syndrome (POTS), or orthostatic hypotension (OH) on QoL. Two team members independently screened records for inclusion and extracted data relevant to the study objectives. Results From 12,258 unique records identified by the search, 36 studies met the inclusion criteria (VVS: n = 20; POTS: n = 13; VVS and POTS: n = 1; OH: n = 2); 12 distinct QoL instruments were used. Comparisons of QoL scores between patients with syncope/presyncope and a control group were performed in 16 studies; significant QoL impairments in patients with syncope/presyncope were observed in all studies. Increased syncopal event frequency, increased autonomic symptom severity, and the presence of mental health disorders and/or comorbidities were associated with lower QoL scores. Conclusion This review synthesizes the negative impact of syncope/presyncope on QoL and identifies research priorities to reduce the burden of these debilitating disorders and improve patient QoL.
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Affiliation(s)
- Brooke C. D. Hockin
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
- International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Natalie D. Heeney
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
- International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - David G. T. Whitehurst
- International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Victoria E. Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
- International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Victoria E. Claydon
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Kawano H, Sakai K, Kudo T, Arakawa S, Doi Y, Takei A, Fukae S, Maemura K. Sympathetic nerve abnormality in an adolescent patient with cardioinhibitory vasovagal syncope. J Cardiol Cases 2021; 24:230-233. [PMID: 34868403 DOI: 10.1016/j.jccase.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022] Open
Abstract
A 15 year-old-Japanese girl was admitted to our ward because of syncope. Electrocardiography (ECG) demonstrated sinus bradycardia with heart rate of 52/min. Holter ECG showed no arrhythmia related to syncope. Coronary enhanced computed tomography and cardiac magnetic resonance imaging showed no abnormal findings. Head-up tilt test revealed syncope with sinus arrest. 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy revealed focally decreased uptake on the anterior wall of the left ventricle but generally maintained uptake of MIBG. Finally, she was diagnosed with cardioinhibitory vasovagal syncope (CIVS). Sympathetic nerve abnormalities seemed to be related to CIVS in this patient. <Learning objective: Vasovagal syncope (VVS) is a common clinical event and is the most common type of syncope. A decrease in sympathetic nervous system activity as indicated by HRV and disturbance in myocardial adrenergic innervation may be one of the pivotal factors in some type 2B (cardioinhibition type) VVS patients without other diseases.>.
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Affiliation(s)
- Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, 852-8501 Nagasaki, Japan
| | - Kenji Sakai
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, 852-8501 Nagasaki, Japan
| | - Takashi Kudo
- Department of radioisotope medicine, Atomic bomb disease institute Nagasaki University. Nagasaki, Japan
| | - Shuji Arakawa
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, 852-8501 Nagasaki, Japan
| | - Yoshiyuki Doi
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, 852-8501 Nagasaki, Japan
| | - Asumi Takei
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, 852-8501 Nagasaki, Japan
| | - Satoki Fukae
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, 852-8501 Nagasaki, Japan
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, 852-8501 Nagasaki, Japan
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van Dijk JG, van Rossum IA, Thijs RD. The pathophysiology of vasovagal syncope: Novel insights. Auton Neurosci 2021; 236:102899. [PMID: 34688189 DOI: 10.1016/j.autneu.2021.102899] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 12/16/2022]
Abstract
The pathophysiology of vasovagal syncope (VVS) is reviewed, focusing on hemodynamic aspects. Much more is known about orthostatic than about emotional VVS, probably because the former can be studied using a tilt table test (TTT). Recent advances made it possible to quantify the relative contributions of the three factors that control blood pressure: heart rate (HR), stroke volume (SV) and total peripheral resistance (TPR). Orthostatic VVS starts with venous pooling, reflected in a decrease of SV. This is followed by cardioinhibition (CI), which is a decrease of HR that accelerates the ongoing decrease of BP, making the start of CI a literal as well as fundamental turning point. The role of hormonal and other humoral factors, respiration and of psychological influences is reviewed in short, leading to the conclusion that a multidisciplinary approach to the study of the pathophysiology of VVS may yield new insights.
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Affiliation(s)
- J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Ineke A van Rossum
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands
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Quantitative Complexity Theory Used in the Prediction of Head-Up Tilt Testing Outcome. Cardiol Res Pract 2021; 2021:8882498. [PMID: 34603772 PMCID: PMC8486546 DOI: 10.1155/2021/8882498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 05/29/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background Head-up tilt testing (HUTT), a well-established tool in the diagnosis of vasovagal syncope, is time-consuming, and every provoked vasovagal reaction may result in consolidating the reflex mechanism. Therefore, identification of parameters that could shorten the duration of HUTT and prevent fainting is desirable. Quantitative complexity theory (QCT) may provide holistic information on the cardiovascular reaction in HUTT. The aim of the present article was to evaluate the prognostic value of complexity in comparison with traditional haemodynamic parameters (HR and BP) in predicting the HUTT outcome. Methods Eighty-one healthy volunteers (74 men; mean age: 37.8 years) were included in this retrospective analysis of data collected within the project realized in Department of Cardiology and Internal Diseases, Military Institute of Medicine between January 2012 and October 2014. The subjects underwent HUTT, with beat-to-beat haemodynamic monitoring with a Niccomo™. The chosen haemodynamic parameters (including BP, HR, stroke volume, cardiac output, systemic vascular resistance) have been used in complexity analysis. Results HUTT was positive in 54 (66.7%) study participants. The values of complexity were already higher in fainting subjects than those were in nonfainting ones 300 s before HUTT termination (HUTT_end), with a significant upward trend starting 150 s before (pre)syncope. An area under the curve (AUC) over 0.700 was observed for complexity from 120 s before HUTT_end, with a sensitivity of 63% and specificity of 78% at this time point. The prognostic value of complexity was superior to that of the HR and mean arterial pressure (MAP). Conclusions Complexity has been shown to be a sensitive marker of cardiovascular haemodynamic response to orthostatic stress and proved to be superior over HR and BP in predicting HUTT outcomes.
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Matveeva N, Titov B, Bazyleva E, Pevzner A, Favorova O. Towards Understanding the Genetic Nature of Vasovagal Syncope. Int J Mol Sci 2021; 22:10316. [PMID: 34638656 PMCID: PMC8508958 DOI: 10.3390/ijms221910316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 11/17/2022] Open
Abstract
Syncope, defined as a transient loss of consciousness caused by transient global cerebral hypoperfusion, affects 30-40% of humans during their lifetime. Vasovagal syncope (VVS) is the most common cause of syncope, the etiology of which is still unclear. This review summarizes data on the genetics of VVS, describing the inheritance pattern of the disorder, candidate gene association studies and genome-wide studies. According to this evidence, VVS is a complex disorder, which can be caused by the interplay between genetic factors, whose contribution varies from monogenic Mendelian inheritance to polygenic inherited predisposition, and external factors affecting the monogenic (resulting in incomplete penetrance) and polygenic syncope types.
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Affiliation(s)
- Natalia Matveeva
- National Medical Research Center for Cardiology, 121552 Moscow, Russia; (N.M.); (B.T.); (E.B.); (A.P.)
- Department of Molecular Biology and Medical Biotechnology, Pirogov Russian National Research Medical University, 117997 Moscow, Russia
| | - Boris Titov
- National Medical Research Center for Cardiology, 121552 Moscow, Russia; (N.M.); (B.T.); (E.B.); (A.P.)
- Department of Molecular Biology and Medical Biotechnology, Pirogov Russian National Research Medical University, 117997 Moscow, Russia
| | - Elizabeth Bazyleva
- National Medical Research Center for Cardiology, 121552 Moscow, Russia; (N.M.); (B.T.); (E.B.); (A.P.)
| | - Alexander Pevzner
- National Medical Research Center for Cardiology, 121552 Moscow, Russia; (N.M.); (B.T.); (E.B.); (A.P.)
| | - Olga Favorova
- National Medical Research Center for Cardiology, 121552 Moscow, Russia; (N.M.); (B.T.); (E.B.); (A.P.)
- Department of Molecular Biology and Medical Biotechnology, Pirogov Russian National Research Medical University, 117997 Moscow, Russia
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Clinical Significance of the Head-Up Tilt Test in Improving Prognosis in Patients with Possible Neurally Mediated Syncope. BIOLOGY 2021; 10:biology10090919. [PMID: 34571796 PMCID: PMC8493797 DOI: 10.3390/biology10090919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/20/2022]
Abstract
Simple Summary Several diseases can cause syncope, which is commonly known as fainting; however, syncope triggered by a reflex mechanism, also termed neurally mediated syncope (NMS), is one of the most common forms. While NMS is considered a benign disease, it can cause critical clinical events, such as severe trauma due to syncope. The head-up tilt test (HUTT) is one of the modalities for the diagnosis of NMS. The clinical significance of HUTT in the prognosis of NMS, such as recurrence rate of syncope and mortality, are still to be elucidated. This research aimed to clarify the value of HUTT for the diagnosis of NMS, and to investigate the prognosis of patients with NMS by analyzing the data of 101 patients with syncope and their close long-term (four years at the longest) follow-up. Furthermore, as insertable cardiac monitors (ICMs) are considered effective in patients with syncope, this study also aimed to evaluate the usefulness of ICM in patients with negative HUTT results. Finally, our research contributes to the improvement of the clinical management for patients with syncope. Abstract Syncope is commonly encountered in daily clinical practice. Depending on its etiology (benign or life-threatening conditions or environmental triggers), syncope can be neurally mediated (reflex), cardiac, or orthostatic. Furthermore, neurologic disease can cause symptoms that mimic syncope. However, there is limited research on neurally mediated syncope (NMS), which is considered a benign disorder, and close follow-ups are rarely performed. NMS can cause serious clinical events, including severe trauma and car accidents. The head-up tilt test (HUTT) is the gold standard for diagnosing NMS; however, its clinical significance remains unknown, and its relevance to NMS prognosis requires further research. This retrospective study aimed to assess the clinical significance of the HUTT for NMS. We reviewed the charts of 101 patients who underwent HUTT at Tokai University Hospital in Japan between January 2016 and March 2019. During the HUTT, 72 patients (69.2%) experienced syncope. Patients were followed up for 886.1 ± 457.7 days (interquartile range: 518–1293 days). The syncope recurrence rate was 16.9%; however, no significant difference was observed between the two groups (HUTT positive vs. negative) (13.8% vs. 18.1%, p = 0.772). Four of 29 (13.9%) and two of 72 (2.8%) patients in the negative and positive HUTT groups, respectively, experienced cardiac events (p = 0.019). Negative HUTT results may assist in anticipating unexpected clinical events within a few years. A negative HUTT result may allow us to reconsider the NMS diagnosis based on clinical information. Close outpatient follow-up of patients with negative HUTT results is warranted.
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Akıncı S, Çoner A, Balcıoğlu AS, Akbay E, Müderrisoğlu İH. Heart rate variability and heart rate turbulence in patients with vasovagal syncope. ACTA ACUST UNITED AC 2021; 61:54-59. [PMID: 34549694 DOI: 10.18087/cardio.2021.8.n1523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022]
Abstract
Aim The autonomic nervous system plays an important role in the pathogenesis of vasovagal syncope, but studies on the effect of basal autonomic tone have found confusing results. The aim of this study was to investigate the effect of basal autonomic functions, as assessed by heart rate variability (HRV) and heart rate turbulence (HRT), in patients with vasovagal syncope.Material and methods Patients who underwent head-up tilt test (HUTT) due to unexplained syncope and who had a 24 hr Holter ECG recording in the same period were retrospectively analyzed. Patients with diabetes, a history of myocardial infarction, heart failure, orthostatic hypotension, atrial fibrillation, or use of vasoactive drugs, such as beta blockers, were excluded from the study. 161 patients who met these criteria were included in the study. Time domain HRV parameters from Holter ECG recordings and HRT parameters from patients with sufficient number of ventricular premature contractions were measured.Results The age of the patients varied from 16 to 75 yrs (mean: 44.8±18.5 yrs). HUTT results of 60 (37.2 %) patients were evaluated as positive. There were no significant differences in the basal demographic, clinical, or laboratory findings of the tilt-positive and tilt-negative patient groups. Likewise, there were no significant differences between the time domain HRV parameters and HRT parameters of both groups.Conclusion HRV and HRT parameters reflecting basal autonomic function were not different between HUTT positive and HUTT negative patient groups. These findings suggest that basal autonomic functions have no effect on vasovagal syncope pathogenesis.
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Affiliation(s)
- Sinan Akıncı
- Baskent University Faculty of Medicine, Alanya Application and Research Center, Department of Cardiology, Antalya, Turkey
| | - Ali Çoner
- Baskent University Faculty of Medicine, Alanya Application and Research Center, Department of Cardiology, Antalya, Turkey
| | - Akif Serhat Balcıoğlu
- Kahramanmaraş Sütçü İmam University Faculty of Medicine, Department of Cardiology, Kahramanmaraş, Turkey
| | - Ertan Akbay
- Başkent University Faculty of Medicine, Alanya Application and Research Center, Department of Cardiology, Antalya, Turkey
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Rivasi G, Torabi P, Secco G, Ungar A, Sutton R, Brignole M, Fedorowski A. Age-related tilt test responses in patients with suspected reflex syncope. Europace 2021; 23:1100-1105. [PMID: 33564843 DOI: 10.1093/europace/euab024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/19/2021] [Indexed: 12/17/2022] Open
Abstract
AIMS Tilt testing (TT) is recognized to be a valuable contribution to the diagnosis and the pathophysiology of vasovagal syncope (VVS). This study aimed to assess the influence of age on TT responses by examination of a large patient cohort. METHODS AND RESULTS Retrospective data from three experienced European Syncope Units were merged to include 5236 patients investigated for suspected VVS by the Italian TT protocol. Tilt testing-positivity rates and haemodynamics were analysed across age-decade subgroups. Of 5236 investigated patients, 3129 (60%) had a positive TT. Cardioinhibitory responses accounted for 16.5% of positive tests and were more common in younger patients, decreasing from the age of 50-59 years. Vasodepressor (VD) responses accounted for 24.4% of positive tests and prevailed in older patients, starting from the age of 50-59. Mixed responses (59.1% of cases) declined slightly with increasing age. Overall, TT positivity showed a similar age-related trend (P = 0.0001) and was significantly related to baseline systolic blood pressure (P < 0.001). Tilt testing was positive during passive phase in 18% and during nitroglycerine (TNG)-potentiated phase in 82% of cases. Positivity rate of passive phase declined with age (P = 0.001), whereas positivity rate during TNG remained quite stable. The prevalence of cardioinhibitory and VD responses was similar during passive and TNG-potentiated TT, when age-adjusted. CONCLUSIONS Age significantly impacts the haemodynamic pattern of TT responses, starting from the age of 50. Conversely, TT phase-passive or TNG-potentiated-does not significantly influence the type of response, when age-adjusted. Vagal hyperactivity dominates in younger patients, older patients show tendency to vasodepression.
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Affiliation(s)
- Giulia Rivasi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Gianmarco Secco
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy.,Emergency Medicine Unit, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital, London, UK.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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Electrocardiographic Patterns in Patients with Neurally Mediated Syncope. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57080808. [PMID: 34441014 PMCID: PMC8399501 DOI: 10.3390/medicina57080808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022]
Abstract
The baseline electrocardiogram (ECG) is less informative in neurally mediated syncope (NMS) than in arrhythmic syncope. However, some of the ECG patterns present in NMS can have diagnostic and prognostic value in such patients. Electrocardiographic documentation of a syncopal spell and thus identification of the ECG changes can be performed during tilt table test (TTT) or during prolonged ECG monitoring. This work reviews the specific ECG patterns in NMS, which are primarily related to the cardioinhibitory reflex. In addition, there are other ECG findings present in patients with NMS that are being analyzed, such as increased heart rate variability as well as specific QRS voltage patterns. In addition to the diagnostic and prognostic value, these ECG patterns in NMS may help improving the selection of patients for pacemaker implant.
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Catheter-Based Cardio-Neural Ablation for Refractory Vasovagal Syncope: First U.S. Report. JACC Case Rep 2021; 2:1161-1165. [PMID: 34317439 PMCID: PMC8311716 DOI: 10.1016/j.jaccas.2020.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/07/2020] [Accepted: 04/15/2020] [Indexed: 11/20/2022]
Abstract
We highlight the feasibility and efficacy of a new application for catheter ablation to target atrial ganglionated plexi in a patient with refractory vasovagal syncope. We describe a physiologically guided technique and demonstrate 18-month freedom from syncope with 2 tilt-table tests to objectively assess reproducible elimination of symptomatology and underlying pathophysiology. (Level of Difficulty: Beginner.)
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Key Words
- AV, atrioventricular
- BP, blood pressure
- CS, coronary sinus
- GP, ganglionated plexus
- HFS, high-frequency stimulation
- HR, heart rate
- LA, left atrial/atrium
- LSGP, left superior ganglionated plexus
- RA, right atrial/atrium
- RAGP, right anterior ganglionated plexus
- RF, radiofrequency
- SVC, superior vena cava
- VVS, vasovagal syncope
- cardioinhibitory
- denervation
- ganglionated plexus ablation
- syncope
- vasodepressor
- vasovagal
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Abstract
SUMMARY This review recapitulates the head-up tilt test, which is commonly used for evaluation of orthostatic syndromes and dysautonomia. Tilt test evaluates autonomic system responses to orthostatic stress. Established tilt testing includes monitoring of heart rate and blood pressure; adding capnography and cerebral blood flow monitoring expands its diagnostic yield and allows assessing cerebral blood flow regulation. Common syndromes detectable by the tilt test are neurally mediated syncope (vasodepressor, cardiovagal, or mixed), orthostatic hypotension, postural orthostatic tachycardia syndrome, hypocapnic cerebral hypoperfusion, and orthostatic cerebral hypoperfusion syndrome. This review describes relevant physiology, tilt test protocols, diagnostic criteria for orthostatic syndromes, grading test results, diagnostic accuracy, limitations of the tilt test, and safety considerations.
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Piotrowski R, Żuk A, Baran J, Sikorska A, Kryński T, Kułakowski P. Cardioneuroablation changes the type of vasovagal response in patients with asystolic reflex syncope. Auton Neurosci 2021; 235:102838. [PMID: 34186273 DOI: 10.1016/j.autneu.2021.102838] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 05/18/2021] [Accepted: 06/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardioneuroablation (CNA) has been recently proposed as a new therapy in patients with asystolic vasovagal syncope (VVS) caused by parasympathetic overactivity. OBJECTIVE To assess the impact of CNA on the type of VV response during tilt testing (TT). METHODS The study group consisted of 20 patients (7 males, mean age 38 ± 9). All patients had a history of syncope due to asystole and confirmed asystolic VVS at baseline TT (TT1). CNA was performed in the right and left atrium. The second TT (TT2) and Holter ECG were performed three months later. All patients completed one-year follow up. RESULTS At TT1, twenty patients had cardioinhibitory syncope and 1 had mixed VVS with asystole > 3 s. During one-year follow-up no spontaneous syncopal episodes were noted. At TT2, 6 patients had no syncope whereas the remaining 13 had syncope - twelve due to vasodepressor mechanism and only one due to asystole. Mean heart rate after CNA was significantly faster and heart rate variability parameter (SDNN) lower than before the procedure (82 ± 9 vs 69 ± 11 beats/min, p = 0.0003 and 74 ± 22 vs 143 ± 40 ms, p = 000001, respectively). These changes were similar in those who fainted during TT2 and those who did not (84 ± 10 vs 81 ± 5 beats/min, p = NS and 72 ± 24 vs 72 ± 19 ms, p = NS, respectively). CONCLUSIONS CNA profoundly affects type of VV reaction causing normalization of the response to tilting or changing cardiodepression to vasodepression. Changes in heart rate and heart rate variability are consistent with attenuation of parasympathetic activity.
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Affiliation(s)
- Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Anna Żuk
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Jakub Baran
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland.
| | - Agnieszka Sikorska
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Tomasz Kryński
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Piotr Kułakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
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Ghariq M, Kerkhof FI, Reijntjes RH, Thijs RD, van Dijk JG. New hemodynamic criteria to separate classical orthostatic hypotension from vasovagal syncope. Ann Clin Transl Neurol 2021; 8:1635-1645. [PMID: 34166574 PMCID: PMC8351382 DOI: 10.1002/acn3.51412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/20/2021] [Accepted: 06/07/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To define and evaluate hemodynamic criteria to distinguish between classical orthostatic hypotension (cOH) and vasovagal syncope (VVS) in tilt table testing (TTT). METHODS Inclusion criteria for VVS were a history of VVS and tilt-induced syncope defined as a blood pressure (BP) decrease and electroencephalographic changes during syncope with complaint recognition. Criteria for cOH were a history of cOH and a BP decrease meeting published criteria. Clinical diagnoses were established prior to TTT. We assessed (1) whether the decrease of systolic BP accelerated, "convex," or decelerated, "concave"; (2) the time from head-up tilt to when BP reached one-half its maximal decrease; (3) the difference between baseline heart rate (HR) and HR at BP nadir. We calculated the diagnostic yield of optimized thresholds of these features and their combinations. RESULTS We included 82 VVS cases (40% men, median age 44 years) and 65 cOH cases (66% men, median age 70 years). BP decrease was concave in cOH in 79% and convex in VVS in 94% (p < 0.001). The time to reach half the BP decrease was shorter in cOH (median 34 sec, interquartile range (IQR) 19-98 sec) than in VVS (median 1571 sec, IQR 1381-1775 sec, p < 0.001). Mean HR increased by 11 ± 11 bpm in cOH and decreased by 20 ± 19 bpm in VVS (p < 0.001). When all three features pointed to VVS, sensitivity for VVS was 82% and specificity was 100%. When all three pointed to cOH, sensitivity for cOH was 71% and specificity was 100%. INTERPRETATION These new hemodynamic criteria reliably differentiate cOH from VVS.
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Affiliation(s)
- Maryam Ghariq
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Fabian I Kerkhof
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert H Reijntjes
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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Tajdini M, Aminorroaya A, Tavolinejad H, Tofighi S, Jalali A, Sadeghian S, Vasheghani-Farahani A, Yadangi S, Shahmansouri N, Akhondzadeh S, Bozorgi A. Atomoxetine as an adjunct to nonpharmacological treatments for preventing vasovagal attacks in patients with recurrent vasovagal syncope: A pilot randomized-controlled trial. IJC HEART & VASCULATURE 2021; 34:100789. [PMID: 34027030 PMCID: PMC8129927 DOI: 10.1016/j.ijcha.2021.100789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Despite the reduced quality of life in patients with recurrent vasovagal syncope (VVS), pharmacologic treatment options remain limited. Studies indicate that norepinephrine reuptake inhibition reduces tilt-induced syncope/pre-syncope. This study aimed to evaluate the effects of atomoxetine on syncopal/pre-syncopal episodes in patients with recurrent VVS. METHODS In a placebo-controlled trial, we randomized patients with newly diagnosed VVS who experienced ≥3 syncopal episodes in the past three months to receive either atomoxetine (20 mg daily for two weeks followed by 40 mg daily for two weeks) or placebo. The primary endpoint was the combined number of syncopal and pre-syncopal episodes. RESULTS Among 843 patients initially screened, 46 were randomized (N = 23 in each group) and reevaluated at one and three months. Compared to placebo, atomoxetine significantly reduced the primary endpoint after three months (P < 0.001). In the atomoxetine arm, the median time to first pre-syncopal episode was 55 days (95% confidence interval (CI): 41.21-68.79), while this was 27 days (95% CI: 14.48-39.52) for the placebo group (P < 0.001). In a subgroup analysis of patients with systolic blood pressure < 110 mmHg, atomoxetine reduced the primary endpoint, and the number of syncopal and pre-syncopal episodes after one and three months. In this subgroup, the median time to first pre-syncopal attack was 56 days in the atomoxetine group as opposed to 9 days in the placebo group. CONCLUSIONS In this pilot study, the promising effects of atomoxetine in reducing syncopal/pre-syncopal episodes in recurrent VVS, especially with low blood pressure phenotype, warrant the conduction of future randomized trials.
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Affiliation(s)
- Masih Tajdini
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arya Aminorroaya
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Tavolinejad
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Tofighi
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Sadeghian
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Somayeh Yadangi
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Bozorgi
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Shenthar J, Gangwar RS, Banavalikar B, Benditt DG, Lakkireddy D, Padmanabhan D. A randomized study of yoga therapy for the prevention of recurrent reflex vasovagal syncope. Europace 2021; 23:1479-1486. [PMID: 34015829 DOI: 10.1093/europace/euab054] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Vasovagal syncope (VVS) is a common cardiovascular dysautonomic disorder that significantly impacts health and quality of life (QoL). Yoga has been shown to have a positive influence on cardiovascular autonomics. This study assessed the effectiveness of yoga therapy on the recurrence of VVS and QoL. METHODS AND RESULTS We randomized subjects with recurrent reflex VVS (>3 episodes in the past 1 year) and positive head-up tilt test to guideline-directed therapy (Group 1) or yoga therapy (Group 2). Patients in Group 1 were advised guideline-directed treatment and Group 2 was taught yoga by a certified instructor. The primary endpoint was VVS recurrences and QoL. Between June 2015 and February 2017, 97 highly symptomatic VVS patients were randomized (Group 1: 47 and Group 2: 50). The mean age was 33.1 ± 16.6 years, male:female of 40:57, symptom duration of 17.1 ± 20.7 months, with a mean of 6.4 ± 6.1 syncope episodes. Over a follow-up of 14.3 ± 2.1 months Group 2 had significantly lower syncope burden compared with Group 1 at 3 (0.8 ± 0.9 vs. 1.8 ± 1.4, P < 0.001), 6 (1.0 ± 1.2 vs. 3.4 ± 3.0, P < 0.001), and at 12 months (1.1 ± 0.8 vs. 3.8 ± 3.2, P < 0.001). The Syncope functional score questionnaire was significantly lower in Group 2 compared with Group 1 at 3 (31.4 ± 7.2 vs. 64.1 ± 11.5, P < 0.001), 6 (26.4 ± 6.3 vs. 61.4 ± 10.7, P < 0.001), and 12 months (22.2 ± 4.7 vs. 68.3 ± 11.4, P < 0.001). CONCLUSION For patients with recurrent VVS, guided yoga therapy is superior to conventional therapy in reducing symptom burden and improving QoL.
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Affiliation(s)
- Jayaprakash Shenthar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bangalore, Karnataka 560069, India
| | - Ritesh Singh Gangwar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bangalore, Karnataka 560069, India
| | - Bharatraj Banavalikar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bangalore, Karnataka 560069, India
| | - David G Benditt
- Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Dhanunjaya Lakkireddy
- Cardiovascular Division, Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS, USA
| | - Deepak Padmanabhan
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bangalore, Karnataka 560069, India
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Debruyne P, Rossenbacker T, Janssens L, Collienne C, Ector J, Haemers P, le Polain de Waroux JB, Bazelmans C, Boussy T, Wijns W. Durable Physiological Changes and Decreased Syncope Burden 12 Months After Unifocal Right-Sided Ablation Under Computed Tomographic Guidance in Patients With Neurally Mediated Syncope or Functional Sinus Node Dysfunction. CIRCULATION. ARRHYTHMIA AND ELECTROPHYSIOLOGY 2021; 14:e009747. [PMID: 33999698 PMCID: PMC8208097 DOI: 10.1161/circep.120.009747] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Philippe Debruyne
- Department of Cardiology, Imeldaziekenhuis, Bonheiden, Belgium (P.D., T.R., L.J.)
| | - Tom Rossenbacker
- Department of Cardiology, Imeldaziekenhuis, Bonheiden, Belgium (P.D., T.R., L.J.)
| | - Luc Janssens
- Department of Cardiology, Imeldaziekenhuis, Bonheiden, Belgium (P.D., T.R., L.J.)
| | - Christine Collienne
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Woluwe, Belgium (C.C.)
| | - Joris Ector
- Department of Cardiology, University of Leuven, Belgium (J.E., P.H.)
| | - Peter Haemers
- Department of Cardiology, University of Leuven, Belgium (J.E., P.H.)
| | | | | | - Tim Boussy
- Department of Cardiology, AZ Groeninge, Kortrijk, Belgium (T.B.)
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway and Saolta University Healthcare Group (W.W.)
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Pevzner AV, Kuchinskaya EA, Kiktev VG, Kheimets GI. Treatment of Vasovagal Syncope Associated with Asystole: Literature Review and Case Report of Long-term Follow-up. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-04-09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Vasovagal syncope (VVS) can occur in every third of human population. Clinical symptoms of VVS areas a result of arterial hypotension with critical global cerebral hypoperfusion due to vasodilatation and bradicardia. Bradicardia is manifested as sinus node dysfunction and atrioventricular conduction disturbances due to activation of nervus vagus. Asystole can take place in some cases. Lack of efficacy of permanent pacemaker founds in patients to prevent of VVS. The results of double blind placebo controlled studies, European and American expert's opinions, probable causes of lack of efficacy of pacemakers in such category of patients and way of solution of this problem are discussed in the review. Syncope recurrences in spite of pacemaker implantation, risk of surgery complications and good life prognosis are arguments for therapeutic approach, now suitable for the most of patients with VVS. Case report (VVS with asystole but without of pacemaker implantation) with successful follow-up is analyzed in the article.
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45
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Myrovali E, Fragakis N, Vassilikos V, Hadjileontiadis LJ. Efficient syncope prediction from resting state clinical data using wavelet bispectrum and multilayer perceptron neural network. Med Biol Eng Comput 2021; 59:1311-1324. [PMID: 33959855 DOI: 10.1007/s11517-021-02353-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 03/19/2021] [Indexed: 11/28/2022]
Abstract
Neurally mediated syncope (NMS) is the most common type of syncope, and head up tilt test (HUTT) is, so far, the most appropriate tool to identify NMS. In this work, an effort to predict the NMS before performing the HUTT is attempted. To achieve this, the heart rate variability (HRV) at rest and during the first minutes of tilting position during HUTT was analyzed using both time and frequency domains. Various features from HRV regularity and complexity, along with wavelet higher-order spectrum (WHOS) analysis in low-frequency (LF) and high-frequency (HF) bands were examined. The experimental results from 26 patients with history of NMS have shown that at rest, a time domain entropy measure and WHOS-based features in LF band exhibit significant differences between positive and negative HUTT as well as among 10 healthy subjects and NMS patients. The best performance of multilayer perceptron neural network (MPNN) was achieved by using an input vector consisted of WHOS-based HRV features in the LF zone and systolic blood pressure from the resting period, yielding an accuracy of 89.7%, assessed by 5-fold cross-validation. The promising results presented here pave the way for an early prediction of the HUTT outcome from resting state, contributing to the identification of patients at higher risk NMS. The HRV analysis along with systolic blood pressure at rest predict NMS using a multilayer perceptron neural network.
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Affiliation(s)
- Evangelia Myrovali
- Department of Electrical and Computer Engineering, Aristotle University of Thessaloniki, GR 54645, Thessaloniki, Greece.
| | - Nikolaos Fragakis
- 3rd Cardiology Department, Aristotle University of Thessaloniki, Hippokration General Hospital, 49 Konstantinoupoleos str, 54642, Thessaloniki, Greece
| | - Vassilios Vassilikos
- 3rd Cardiology Department, Aristotle University of Thessaloniki, Hippokration General Hospital, 49 Konstantinoupoleos str, 54642, Thessaloniki, Greece
| | - Leontios J Hadjileontiadis
- Department of Electrical and Computer Engineering, Aristotle University of Thessaloniki, GR 54645, Thessaloniki, Greece.,Department of Electrical and Computer Engineering, Khalifa University of Science and Technology, PO BOX 127788, Abu Dhabi, UAE
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46
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Zheng L, Sun W, Qiao Y, Hou B, Guo J, Killu A, Yao Y. Symptomatic Premature Ventricular Contractions in Vasovagal Syncope Patients: Autonomic Modulation and Catheter Ablation. Front Physiol 2021; 12:653225. [PMID: 34012407 PMCID: PMC8126685 DOI: 10.3389/fphys.2021.653225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction There has been limited reports about the comorbid premature ventricular contractions (PVCs) and vasovagal syncope (VVS). Deceleration capacity (DC) was demonstrated to be a quantitative evaluation to assess the cardiac vagal activity. This study sought to report the impact of autonomic modulation on symptomatic PVCs in VVS patients. Methods and Results Twenty-six VVS patients with symptomatic idiopathic PVCs were consecutively enrolled. Identification and catheter ablation of left atrial ganglionated plexi (GP) and PVCs were performed in 26 and 20 patients, respectively. Holter 24 h-electrocardiograms were performed before and after the procedure to evaluate DC and PVCs occurrence. Eighteen patients were subtyped as DC-dependent PVCs (D-PVCs) and eight as DC-independent PVCs groups (I-PVCs). In D-PVCs group, circadian rhythm of hourly PVCs was positively correlated with hourly DC (P < 0.05) while there was no correlation in I-PVCs group (P > 0.05). Fifty-three GPs with positive vagal response were successfully elicited (2.0 ± 0.8 per patient). PVCs failed to occur spontaneously nor to be induced in six patients. In the remaining 20 patients, PVCs foci identified were all located in the ventricular outflow tract region. Post-ablation DC decreased significantly from baseline (P < 0.05). During mean follow-up of 10.64 ± 6.84 months, syncope recurred in one patient and PVCs recurred in another. PVCs burden of the six patients in whom neither catheter ablation nor antiarrhythmic drugs were applied demonstrated a significant decrease during follow-up (P = 0.037). Conclusion Autonomic activities were involved in the occurrence of symptomatic idiopathic PVCs in some VVS patients. D-PVCs might be facilitated by increased vagal activities. Catheter ablation of GP and PVCs foci may be an effective, safe treatment in patients with concomitant VVS and idiopathic PVCs.
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Affiliation(s)
- Lihui Zheng
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Sun
- Department of General Medicine, Monash Health, Melbourne, VIC, Australia
| | - Yu Qiao
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bingbo Hou
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinrui Guo
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ammar Killu
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, United States
| | - Yan Yao
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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47
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Evaluation of atrial fibrillation risk in patients with vasovagal syncope. Herz 2021; 47:79-84. [PMID: 33890135 DOI: 10.1007/s00059-021-05038-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/22/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study aimed to determine whether autonomic dysfunction in patients with vasovagal syncope with a positive tilt test may cause an alteration in atrial electromechanical properties and pose a risk for subsequent atrial arrhythmias, especially atrial fibrillation. METHODS The data of 27 patients with vasovagal syncope and a matched control group comprising 28 healthy individuals were compared. All patients underwent a tilt table test. Atrial electromechanical intervals (PA) were measured from the mitral lateral annulus, mitral septal annulus, and tricuspid annulus with tissue Doppler imaging. Left atrium volumes were measured with the disc method in apical four-chamber imaging. RESULTS Although atrial electromechanical intervals such as lateral PA, septal PA, and tricuspid PA durations were significantly longer (p = 0.009, p = 0.002, p = 0.011, respectively), interatrial, right intra-atrial, and left intra-atrial durations were similar in the vasovagal syncope group and the control group (p = 0.298, p = 0.388, p = 0.069, respectively). Left atrial volumes (maximum, minimum, and presystolic) were significantly increased in the vasovagal syncope group when compared with the control group (p = 0.001, p = 0.001, p = 0.007, respectively). There was no difference between vasovagal syncope types in terms of atrial electromechanical intervals. CONCLUSION Interatrial and intra-atrial intervals were similar in the vasovagal syncope group and the control group. However, an increase in atrial volumes and a prolongation of certain atrial electromechanical intervals were observed in patients with vasovagal syncope. These findings suggest an alteration in atrial electromechanics caused by autonomic dysfunction that can lead to subsequent atrial arrhythmias, especially atrial fibrillation.
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Jug J, Bradić L, Levicki R, Benčić ML. PR interval as a predictor of syncope in tilt-up testing in adolescents and young adults. Egypt Heart J 2021; 73:28. [PMID: 33743104 PMCID: PMC7981354 DOI: 10.1186/s43044-021-00149-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Syncope, as the most frequent consciousness disorder, is very common in young individuals. The aim of this study was to analyze ECG parameters and clinical properties obtained during tilt-up testing in 12 to 30-year-old subjects. We enrolled a total of 142 patients from our outpatient clinic (39 males, 103 females) with a true positive tilt-up test and analyzed ECG records obtained during tilt-testing. Data were stratified according to the age, gender, and type of syncope. RESULTS PR interval shortening preceding syncope was found in all syncope types, irrespective of the gender. All types of syncope were more frequent in women (72.5%). Mixed syncope type was found to be the most common (47.18%). Male and female subjects differed in initial heart rate (71.56 vs 76.23/min, p=0.05), as well as heart rate dynamics during tilt-up testing. A gender difference was also found in systolic blood pressure (116.92 vs 110.44 mmHg, p<0.01), time to syncope onset (20.77 vs. 16.44 min, p=0.03), and the total number of syncopal episodes in patient history (2.79 vs. 4.62, p<0.05). Subjects with cardioinhibitory syncope had the longest PR interval (average 154.3 ms). PR interval prolongation and loss of variability during tilt-up testing positively correlated with aging (r=0.22, p<0.05). Nodal rhythm was found in 8 patients. CONCLUSION PR interval shortening on ECG tracings during a tilt-up test can be found in all subtypes of vasovagal syncope, thereby contrasting previous reports that these changes are a hallmark of the cardioinhibitory type of syncope. PR shortening, if observed during ECG monitoring, could be a potential predictor of syncope.
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Affiliation(s)
- Juraj Jug
- University of Zagreb School of Medicine, Zagreb, Croatia.
| | | | | | - Martina Lovrić Benčić
- University of Zagreb School of Medicine, Zagreb, Croatia.,University Hospital Zagreb, Zagreb, Croatia
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Saal DP, Thijs RD, Bootsma M, Brignole M, van Dijk JG. Five cases of complete atrioventricular block induced by bending forward: unusual but not unique. Europace 2021; 23:1487-1492. [PMID: 33693701 DOI: 10.1093/europace/euab044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS We describe five patients with syncope caused by a complete atrioventricular block (AVB) while they were bending forward, not rising after bending, and aim to describe the occurrence and the association between bending forward and AVB. METHODS AND RESULTS In two patients, bending forward was the exclusive trigger for syncope, while in the remaining three, other postural changes (sitting down, standing up, and exertion) could also provoke syncope. Complete AVB as the cause of syncope was documented using ECG monitoring in two cases and an implantable loop recorder in the other three. Ectopic beats without preceding sinus slowing occurred before syncope in four cases. Two cases had a left bundle branch block. All patients responded favourably to cardiac pacing. CONCLUSION This is the first case series on complete AVB provoked by bending forward. Syncope during bending forward should suggest a search for an AVB. Arguments in favour of a vagal mechanism were syncope triggered by bending forward, and that other triggers could also evoke syncope. However, the absence of sinus slowing before syncope in some cases and the fact that bending forward did not seem to provoke reflex syncope without AVB, cast doubts on a reflex mechanism. There were also arguments favouring conduction disorder: i.e. ectopic beats before syncope and pre-existing conduction disturbances in two cases. The cases are reminiscent of paroxysmal AVB. Discrimination between paroxysmal AVB and vagal AVB is important because a pacemaker is warranted in arrhythmic complete AVB, while the benefit is limited or absent in reflex AVB.
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Affiliation(s)
- Dirk P Saal
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Neurology, Franciscus Gasthuis en Vlietland Hospital, PO 215, 3100 AE Rotterdam/Schiedam, The Netherlands
| | - Roland D Thijs
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Marianne Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - J Gert van Dijk
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands
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The benefit of cardioneuroablation to reduce syncope recurrence in vasovagal syncope patients: a case-control study. J Interv Card Electrophysiol 2021; 63:77-86. [PMID: 33527216 DOI: 10.1007/s10840-020-00938-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Adequate and effective therapy for resistant vasovagal syncope patients is lacking and the benefit of cardioneuroablation (CNA) in this cohort is still debated. The aim of this study is to assess the long-term effect of CNA versus conservative therapy (CT) in a retrospectively followed cohort. METHODS A total of 2874 patients underwent head-up tilt test (HUT) and 554 (19.2 %) were reported as positive, with VASIS type 2B response or > 3 s asystole in 130 patients. After exclusion of 29 patients under 18 years and over 65 years of age, 101 patients were included final analysis. Fifty-one patients (50.4%) underwent CNA and 50 (49.6%) patients received CT. After propensity score matching, 19 pairs of patients were successfully matched. The recurrence rate of syncope was compared between groups. RESULTS During a median follow-up of 22 months (IQR, 13-35), syncope was seen in 12 (11.8%) cases. In the 19 propensity-matched patients, recurrent syncope was observed in 8 patients in the CT group and in 2 patients in the CNA group, respectively. In mixed effect Cox regression analysis, CNA was associated with less syncope recurrence risk at follow-up (HR 0.23, 95% CI 0.03-0.99, p = 0.049). The 4-year Kaplan-Meier syncope free rate was 0.86 (95% CI, 0.63-1.00) for CNA group and 0.50 (95% CI, 0.30-0.82) for CT group in the matched cohort. CONCLUSIONS In highly selected patients with HUT-induced cardioinhibitory response, CNA is associated with a significant reduction in syncope recurrence during follow-up when compared to CT.
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