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Cardioinhibition Can Be the Unique Manifestation of Epilepsy-Like Syncope. J Clin Neurophysiol 2015; 32:e1-3. [DOI: 10.1097/wnp.0000000000000106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Subbiah R, Chia PL, Gula LJ, Klein GJ, Skanes AC, Yee R, Krahn AD. Cardiac monitoring in patients with syncope: making that elusive diagnosis. Curr Cardiol Rev 2014; 9:299-307. [PMID: 23228074 PMCID: PMC3941093 DOI: 10.2174/1573403x10666140214120056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 11/27/2012] [Accepted: 11/28/2012] [Indexed: 11/25/2022] Open
Abstract
Elucidating the cause of syncope is often a diagnostic challenge. At present, there is a myriad of ambulatory
cardiac monitoring modalities available for recording cardiac rhythm during spontaneous symptoms. We provide a comprehensive
review of these devices and discuss strategies on how to reach the elusive diagnosis based on current evidencebased
recommendations.
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Affiliation(s)
| | | | | | | | | | | | - Andrew D Krahn
- London Health Sciences Centre, University Campus, C6-113, 339 Windermere Road, London, Ontario, Canada, N6A 5A5.
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Subbiah R, Gula LJ, Klein GJ, Skanes AC, Yee R, Krahn AD. Syncope: review of monitoring modalities. Curr Cardiol Rev 2011; 4:41-8. [PMID: 19924276 PMCID: PMC2774584 DOI: 10.2174/157340308783565447] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Revised: 12/05/2007] [Accepted: 12/08/2007] [Indexed: 11/29/2022] Open
Abstract
Elucidating the underlying cause of unexplained syncope, palpitations or other possible arrhythmia-related symptoms is a formidable clinical challenge. Cardiac monitoring supplements the most important “test” in patients with syncope or palpitations, that of a thoughtful history and physical examination. Ideally, comprehensive physiologic monitoring during spontaneous symptoms would constitute what, at present, is an unattainable gold standard test for establishing a cause. Short of that goal, establishing an accurate symptom-rhythm correlation can often provide a diagnosis. Ambulatory outpatient monitoring is a powerful diagnostic tool for the evaluation of cardiac arrhythmias. Evolving technologies have provided a vast array of monitoring options for patients suspected of having cardiac arrhythmias, with each modality differing in duration of monitoring, quality of recording, convenience and invasiveness. Holter monitors, event monitors and external loop recorders are non-invasive and provide easily accessible short-term monitoring solutions. In instances where the diagnosis remains elusive, a more long-term strategy with an implantable loop recorder may be the preferred path.
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Affiliation(s)
- Rajesh Subbiah
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada
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Clinically significant bradyarrhythmias in video-EEG patients. Seizure 2011; 20:225-30. [DOI: 10.1016/j.seizure.2010.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 10/01/2010] [Accepted: 11/22/2010] [Indexed: 11/22/2022] Open
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Kanjwal K, Kanjwal Y, Karabin B, Grubb BP. Psychogenic syncope? A cautionary note. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:862-5. [PMID: 19572860 DOI: 10.1111/j.1540-8159.2009.02400.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In some patients with recurrent syncope, the etiology may remain unclear despite extensive evaluation. These patients may sometimes be labeled as having a "psychogenic" cause for their syncope. METHODS We report on three patients with recurrent unexplained syncope (despite extensive evaluation) who were labeled as having a psychogenic cause for their events. In each patient following placement of an implantable loop recorder, their syncopal events were found to be due to periods of prolonged asystole and/or complete heart block. One patient had prolonged asystole for 44 seconds. In each patient, episodes of syncope were eliminated following permanent pacemaker implantation. CONCLUSION We conclude that physicians should exercise great caution before labeling any patient's syncope as psychogenic and that prolonged monitoring may be necessary to exclude a potential cardiac rhythm-related etiology.
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Affiliation(s)
- Khalil Kanjwal
- Department of Medicine, Division of Cardiovascular Medicine, Center for Autonomic Disorders, the University of Toledo Medical Center, Toledo, Ohio 43614, USA
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DRIVER KEVIN, GILLIAM FRANK, DIZON JOSE, WHANG WILLIAM, EHLERT FREDERICK, HICKEY KATHLEEN, GARAN HASAN, BIVIANO ANGELOB. Utility of Noninvasive, Mobile, Continuous Outpatient Rhythm Monitoring to Diagnose Seizure-Related Arrhythmias. Pacing Clin Electrophysiol 2009; 32:959-62. [DOI: 10.1111/j.1540-8159.2009.02417.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kanjwal K, Kanjwal Y, Karabin B, Grubb BP. Clinical symptoms associated with asystolic or bradycardic responses on implantable loop recorder monitoring in patients with recurrent syncope. Int J Med Sci 2009; 6:106-10. [PMID: 19381350 PMCID: PMC2669599 DOI: 10.7150/ijms.6.106] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 04/08/2009] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Implantable loop recorders (ILR) have been found to be useful in the diagnosis and management of syncope of unclear etiology. The clinical symptoms of abnormalities seen during ILR monitoring have not been adequately studied. AIM The aim of this retrospective study was to determine the clinical symptoms which were the best predictors of asystolic or bradycardic responses during ILR monitoring. METHODS Patients with either asystole or bradycardia recorded during ILR monitoring were analyzed from our database. The clinical characteristics of these patients were compared to the patients with ILR's who did not have recorded bradycardic episodes. The episodes were characterized as being convulsive or nonconvulsive, brief (<5 minutes) or prolonged (> 5 minutes), and having had a prodrome or no prodrome. RESULTS Eleven patients (4 males and 7 females; age 39 +/-11 years) had asystole or bradycardia on ILR monitoring. Eleven patients (2 males and 9 females; age 46+/-23) had no bradycardiac events. Palpitations, convulsive syncope, prolonged episode, and prodrome were present in 37% vs. 74% (P = 0.125), 62% vs. 0% (P = 0.002), 87% vs. 0% (P=0), and 73% vs. 13% (P=0.009) patients, respectively, in the asystole/bradycardia and non-bradycardia groups. In the asystole/bradycardia group eight patients had bradycardia (HR < 20) for > 10 seconds and three patients had asystole >10 seconds. CONCLUSION Convulsive syncope, prolonged loss of consciousness during syncopal episode, and absence of prodrome or aura are clinical predictors of asystole or bradycardia on ILR monitoring.
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Affiliation(s)
- Khalil Kanjwal
- Department of Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA
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Gould PA, Klein GJ, Yee R, Skanes AC, Gula LJ, Krahn AD. Syncope. HANDBOOK OF CLINICAL NEUROLOGY 2008; 90:247-263. [PMID: 18631827 DOI: 10.1016/s0072-9752(07)01714-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Paul A Gould
- London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
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Abstract
PURPOSE OF REVIEW This review focuses on recent literature on the cardiovascular investigation of syncope. RECENT FINDINGS Syncope is a common and complex clinical entity with many varied etiologies, the diagnosis of which can often be elusive. Recent advances in the area of investigation in syncope include improvements in technologies for arrhythmia event monitoring and an increase in applicability and efficacy of traditional investigations. These advances have increased our ability to manage syncope. SUMMARY A better understanding of the etiology of syncope in certain cohorts has allowed tailoring of investigations and management of syncope. This is evident when syncope occurs in the presence of structural heart disease, which is associated with a higher incidence of arrhythmias and an increased 1-year mortality. Patients with left-ventricular dysfunction should be considered candidates for an implantable cardioverter defibrillator based on heart function and syncopal presentation. In the absence of significant heart disease, investigations need to be tailored to diagnose neurally mediated causes for syncope and detection of intermittent bradycardia. The improved understanding of syncope has arisen from studies using improved investigational tools for syncope, in particular loop recorders, which are able to monitor cardiac rhythm over long periods. In those without structural heart disease and undifferentiated syncope, neurally mediated causes should be pursed initially. Tilt testing and loop recorders are employed most often in this cohort. Electrophysiological studies have largely been supplanted by implantable cardioverter defibrillator use in structural heart disease, with a low yield in patients with preserved heart function.
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Affiliation(s)
- Paul A Gould
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada
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Paisey JR, Yue AM, Treacher K, Roberts PR, Morgan JM. Implantable loop recorders detect tachyarrhythmias in symptomatic patients with negative electrophysiological studies. Int J Cardiol 2005; 98:35-8. [PMID: 15676163 DOI: 10.1016/j.ijcard.2003.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2003] [Revised: 06/20/2003] [Accepted: 06/21/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Implantable loop recorders (ILR) are a valuable tool in the investigation of syncope and compare favourably with non-invasive and intracardiac electrophysiological assessment of bradycardia. They are known to detect tachyarrhythmias but have not been shown to add to the diagnostic yield of electrophysiological testing in symptomatic patients. METHODS We prospectively studied the first 41 patients (aged 48+/-19 years) in whom ILR were used at our institution after negative electrophysiological studies (EPS). All patients were symptomatic with palpitations (11), syncope (22) or both (8). Nine patients had known structural heart disease (two ischaemic, four cardiomyopathy, two valvular and one congenital). Patients were assessed according to demographic factors, symptoms and investigations. Loop recordings were analysed and assessed according to conventional criteria. RESULTS Among 41 patients in whom electrophysiological studies had failed to demonstrate arrhythmias, six were found to have clinically significant tachyarrhythmias (four ventricular and two supraventricular). CONCLUSION ILR diagnose prognostically significant tachyarrhythmias in symptomatic patients with negative electrophysiological studies.
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Affiliation(s)
- John R Paisey
- Wessex Cardiothoracic Centre, Southampton University Hospitals, Southampton SO16 6YD, UK.
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Rugg-Gunn FJ, Simister RJ, Squirrell M, Holdright DR, Duncan JS. Cardiac arrhythmias in focal epilepsy: a prospective long-term study. Lancet 2004; 364:2212-9. [PMID: 15610808 DOI: 10.1016/s0140-6736(04)17594-6] [Citation(s) in RCA: 238] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with epilepsy are at risk of sudden unexpected death. Neurogenic cardiac arrhythmias have been postulated as a cause. Electrocardiograms (ECG) can be monitored by use of an implantable loop recorder for up to 18 months. We aimed to determine the frequency of cardiac arrhythmias in patients with refractory focal seizures over an extended period. METHODS 20 patients received an implantable loop recorder at one hospital in the UK. Devices were programmed to record automatically if bradycardia (<40 beats per min) or tachycardia (>140 beats per min) were detected. Additionally, in the event of a seizure, patients and relatives could initiate ECG recording with an external activator device. Data were analysed at regular intervals and correlated with seizure diaries. FINDINGS More than 220000 patient-hours were monitored over 24 months, during which ECGs were captured on implantable loop recorders in 377 seizures. One patient withdrew from the study. In 16 patients, median heart rate during habitual seizures exceeded 100 beats per min. Ictal bradycardia (<40 beats per min) was rare, occurring in eight (2.1%) recorded events, in seven patients. Four patients (21%) had bradycardia or periods of asystole with subsequent permanent pacemaker insertion. Three of these four (16% of total) had potentially fatal asystole. INTERPRETATION Clinical characteristics of patients with peri-ictal cardiac abnormalities are closely similar to those at greatest risk of sudden unexpected death in epilepsy. Asystole might underlie many of these deaths, which would have important implications for the investigation of similar patients and affect present cardiac-pacing policies.
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Affiliation(s)
- Fergus J Rugg-Gunn
- National Society for Epilepsy and Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, UK
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Krahn AD, Klein GJ, Yee R, Skanes AC. The use of monitoring strategies in patients with unexplained syncope. Clin Auton Res 2004; 14 Suppl 1:55-61. [PMID: 15480931 DOI: 10.1007/s10286-004-1008-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Syncope is a complex clinical syndrome with multiple etiologies that can be very difficult to diagnose. The major obstacles to diagnosis are the periodic and unpredictable nature of events and the high spontaneous remission rate. Short-term electrocardiographic monitoring is often unproductive in patients when initial non-invasive testing is negative, particularly when a paroxysmal arrhythmia is suspected. The external and implantable loop recorders extend the ability to monitor cardiac patients, enhancing the diagnostic yield to as high as 85% in difficult to diagnose syncope. Several recent studies suggest that prolonged monitoring with an implantable loop recorder has a role in patients with syncope and conduction disturbances, negative tilt testing, unexplained seizures and may be superior to conventional testing with tilt and electrophysiologic studies in selected patients.
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Affiliation(s)
- Andrew D Krahn
- Division of Cardiology, University of Western Ontario, London (ON), Canada,
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Krahn AD, Klein GJ, Skanes AC, Yee R. Insertable loop recorder use for detection of intermittent arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:657-64. [PMID: 15125724 DOI: 10.1111/j.1540-8159.2004.00502.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The advent of prolonged monitoring with the implanted loop recorders has revolutionized the quest for detection of elusive infrequent arrhythmias in patients with unexplained syncope. The capability of prolonged monitoring has permitted us to obtain symptom rhythm correlation in the majority of patients suspected to have underlying infrequent arrhythmia. The implanted loop recorder is easily implanted in the left pectoral region with a minimally invasive procedure, providing at least 14 months of continuous monitoring that is both patient and automatically activated. Several recent studies suggest that it plays a major role in patients with infrequent symptoms and suspected arrhythmia, including patients with syncope and conduction disturbances, mild to moderate underlying heart disease, and atypical epilepsy. In a randomized trial, the device was found to be cost-effective and improved diagnostic yield compared to conventional tilt and electrophysiological testing. Wider application of prolonged monitoring is ongoing, including assessment of ventricular arrhythmias, atrial fibrillation, and conduction disturbances. The implantable loop recorder is most useful in patients with infrequent unexplained syncope when noninvasive testing is negative.
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Affiliation(s)
- Andrew D Krahn
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
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Krahn AD, Klein GJ, Skanes AC, Yee R. Use of the implantable loop recorder in evaluation of patients with unexplained syncope. J Cardiovasc Electrophysiol 2003; 14:S70-3. [PMID: 12950523 DOI: 10.1046/j.1540-8167.14.s9.19.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Syncope is a complex symptom with multiple potential etiologies that can be difficult to establish. The major obstacles to diagnosis are the periodic and unpredictable nature of events and the high spontaneous remission rate. Short-term ECG monitoring often is unproductive when initial noninvasive testing is negative due to the low probability of recurrence during the brief monitoring period. Implantable loop recorders extend the ability to monitor cardiac patients, enhancing the diagnostic yield to as high as 85% in difficult to diagnose syncope. Several recent studies suggest that prolonged monitoring with an implantable loop recorder has a role in patients with syncope and conduction disturbances, negative tilt testing, and unexplained seizures, and may be superior to conventional testing with tilt and electrophysiologic studies.
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Affiliation(s)
- Andrew D Krahn
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
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Abstract
Monitoring devices are an important adjunct to the clinical assessment of patients who experience falls. The use of these devices should be guided by the clinical history, a physical assessment, and routine investigations. Quantitative measures of postural sway should be used in conjunction with clinical measures to provide a more accurate assessment of gait and balance. Assessment of blood pressure changes during the investigation of neurocardiovascular causes of syncope and falls in older adults should be performed with noninvasive digital photoplethysmographic devices, so long as their appropriate use and limitations are applied and understood. Only minimal information can be gained from short-term heart rate and rhythm monitoring in patients with infrequent symptoms. The usefulness of long-term ECG monitoring (with both external and implantable recorders) is well established for the diagnosis of unexplained syncope but requires further assessment in older individuals who experience falls. Twenty-four-hour measurements of ambulatory blood pressure generally are not diagnostically helpful in patients who experience falls or syncope but do have a role in the monitoring of therapeutic interventions.
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Affiliation(s)
- Colette M Seifer
- Cardiovascular Investigation Unit, Institute for the Health of the Elderly, University of Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, United Kingdom
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Futterman LG, Lemberg L. Ambulatory electrocardiographic monitoring: use of the implantable loop recorder in the evaluation of syncope. J Cardiovasc Nurs 2002; 16:24-33. [PMID: 11958441 DOI: 10.1097/00005082-200204000-00004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Syncope may be related to a large spectrum of medical and psychologic disorders, yet the precise etiology is often difficult to determine. Although the evaluation of syncope involves extensive testing, nearly 50% of these individuals remain without definitive diagnosis. Because of the infrequent and unpredictable nature of syncope, many ambulatory screening techniques are not suited to diagnose syncope. The use of an implantable loop recording device provides continuous monitoring of heart rate and rhythm during syncopal events and may help clinicians arrive at a more precise diagnosis in a more timely manner. The Reveal Plus implantable loop recorder (ILR) (Medtronic USA, Minneapolis, Minn) has demonstrated its clinical utility in evaluating syncope and drug-refractory seizure disorders.
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Affiliation(s)
- Laurie G Futterman
- University of Miami School of Medicine, Jackson Memorial Medical Center, Florida, USA
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Abstract
Neurocardiogenic syncope is the most common cause of syncope presenting in the outpatient setting. It is usually encountered among individuals without an underlying heart disease, but not uncommonly participates in the syncope mechanism of patients with an obstructive or an arrhythmic cardiac cause for syncope as well. The vasovagal event is caused by a transient profound hypotensive reaction most commonly associated with inappropriate bradycardia resulting from activation of a complex autonomic reflex. The pathophysiology of neurocardiogenic syncope has been elucidated by tilt table testing, a noninvasive and well-tolerated method for reproducing the event in susceptible individuals. Although the majority of people with vasovagal fainting need no specific treatment, treatment is required for those presenting with problematic features such as frequent events accompanied by trauma or accidents, and occasionally by a severe cardioinhibitory pattern response. A number of different drugs have been proposed to favourably act on different aspects of the neurocardiogenic reflex but only a few randomised, placebo-controlled, drug-specific trials are currently available. Alternatively, cardiac pacing has also been introduced for patients who have symptoms that are drug-refractory or for those with a severe cardioinhibitory hypotensive response. The selection of the appropriate treatment plan should be individualised after consideration of patient history, clinical characteristics and preference, results of the baseline tilting study, and the existing evidence from the few randomised, controlled studies performed so far.
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Affiliation(s)
- K A Gatzoulis
- University Department of Cardiology, Hippokration General Hospital, Athens, Greece
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