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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, Tomaino M, Parente E, Comune A, Giacopelli D, Napoli P, Gargaro A, Brignole M. Temporal relationship between haemodynamic changes and activation of closed-loop stimulation during a tilt-induced vasovagal syncope. Europace 2024; 26:euae045. [PMID: 38340330 PMCID: PMC10886438 DOI: 10.1093/europace/euae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/06/2024] [Indexed: 02/12/2024] Open
Abstract
AIMS A dual-chamber pacemaker with closed-loop stimulation (CLS) mode is effective in reducing syncopal recurrences in patients with asystolic vasovagal syncope (VVS). In this study, we explored the haemodynamic and temporal relationship of CLS during a tilt-induced vasovagal reflex. METHODS AND RESULTS Twenty patients underwent a tilt test under video recording 3.9 years after CLS pacemaker implantation. Three patients were excluded from the analysis because of no VVS induced by the tilt test (n = 1) and protocol violation (n = 2). In 14 of the remaining 17 patients, CLS pacing emerged during the pre-syncopal phase of circulatory instability when the mean intrinsic heart rate (HR) was 88 ± 12 b.p.m. and systolic blood pressure (SBP) was 108 ± 19 mmHg. The CLS pacing rate thereafter rapidly increased to 105 ± 14 b.p.m. within a median of 0.1 min [inter-quartile range (IQR), 0.1-0.7 min] when the SBP was 99 ± 21 mmHg. At the time of maximum vasovagal effect (syncope or pre-syncope), SBP was 63 ± 17 mmHg and the CLS rate was 95 ± 13 b.p.m. The onset of CLS pacing was 1.7 min (IQR, 1.5-3.4) before syncope or lowest SBP. The total duration of CLS pacing was 5.0 min (IQR, 3.3-8.3). Closed-loop stimulation pacing was not observed in three patients who had a similar SBP decrease from 142 ± 22 mmHg at baseline to 69 ± 4 mmHg at the time of maximum vasovagal effect, but there was no significant increase in HR (59 ± 1 b.p.m.). CONCLUSION The reproducibility of a vasovagal reflex was high. High-rate CLS pacing was observed early during the pre-syncopal phase in most patients and persisted, although attenuated, at the time of maximum vasovagal effect. REGISTRATION ClinicalTrials.gov identifier: NCT06038708.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, 80126 Naples, Italy
| | - Marco Tomaino
- Department of Cardiology, Ospedale Generale Regionale, Bolzano, Italy
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, 80126 Naples, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, 80126 Naples, Italy
| | | | - Paola Napoli
- Research Clinical Unit, Biotronik Italy, Milan, Italy
| | | | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milan, Italy
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Benditt DG, Goldstein M. Aging and Susceptibility to Cardioinhibitory Response in Vasovagal Syncope: A Physiological or Methodological Issue? JACC Clin Electrophysiol 2024:S2405-500X(24)00014-8. [PMID: 38385915 DOI: 10.1016/j.jacep.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/01/2024] [Indexed: 02/23/2024]
Affiliation(s)
- David G Benditt
- Cardiac Arrhythmia Center, University of Minnesota, Minneapolis, Minnesota, USA.
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van Zanten S, de Jong JSY, Scheffer MG, Kaal ECA, de Groot JR, de Lange FJ. A cross-sectional nationwide survey of guideline based syncope units in the Netherlands: the SU-19 score-a novel validation for best practices. Europace 2023; 26:euae002. [PMID: 38190741 PMCID: PMC10793571 DOI: 10.1093/europace/euae002] [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: 10/27/2023] [Revised: 12/06/2023] [Accepted: 01/03/2024] [Indexed: 01/10/2024] Open
Abstract
AIMS We aimed to identify all syncope units (SUs) in the Netherlands and assess the extent to which these SUs fulfil the essential requirements outlined by the consensus statements of the European Heart Rhythm Association and the European Society of Cardiology syncope guidelines. For this, we developed the SU-19 score, a novel guideline based validation tool for best practice. METHODS AND RESULTS All outpatient clinics of cardiology, neurology, and internal medicine in the Netherlands were screened for presence of any form of structured specialized syncope care. If present, these were included as SUs and requested to complete a questionnaire regarding syncope care. We assessed all SUs using the SU-19 score regarding structure (3 points), available tests (12 points), and initial evaluation (4 points). Twenty SUs were identified in the Netherlands, both academic (5/20) and non-academic hospitals (15/20), 17/20 reported multidisciplinary involvement during initial evaluation. In 19/20, neurology, cardiology, or both were responsible for the syncope management. Non-physicians were involved performing the head-up tilt test (44%) and initial evaluation (40%). The mean SU-19 score was 18.0 ± 1.1, 45% achieved the maximum score of 19 points. Variations were observed in protocols for active standing test, carotid sinus massage, and head-up tilt test. CONCLUSION There is a network of 20 SUs in the Netherlands. Forty-five per cent fully met the SU-19 score (mean 18.0 ± 1.1). Slight variety existed in protocols for autonomic function tests. Neurology and cardiology were mostly involved in syncope management. Non-physicians play an important role in syncope care.
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Affiliation(s)
- Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD Delft, The Netherlands
| | - Jelle S Y de Jong
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Heart Centre, Amsterdam, The Netherlands
| | - Mike G Scheffer
- Department of Cardiology, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD Delft, The Netherlands
| | - Evert C A Kaal
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Joris R de Groot
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Heart Centre, Amsterdam, The Netherlands
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Heart Centre, Amsterdam, The Netherlands
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Brignole M, Groppelli A, Russo V, Fedorowski A, van Dijk G, Alboni P. The Rate of Asystolic Reflex Syncope Is Not Influenced by Age. JACC Clin Electrophysiol 2023:S2405-500X(23)00901-5. [PMID: 38243997 DOI: 10.1016/j.jacep.2023.11.021] [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: 09/26/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND The head-up tilt test (HUT) and other evidence suggest that the vagal effect on the heart decreases with age. OBJECTIVES The main aim of the study was to assess whether this age effect also affects the rate of asystole in spontaneous reflex syncope (RS). METHOD We performed an analysis of pooled individual data from 4 studies that recruited patients ≥40 years of age affected by certain or suspected RS who received an implantable loop recorder (ILR) and reported follow-up data on syncope recurrence. We assessed the presence of asystolic syncope of >3 seconds or nonsyncopal asystole of >6 seconds recorded by ILR and compared the findings to tilt test results on the same patients. RESULTS A total of 1,046 patients received ILR because of unexplained syncope. Of these, 201 (19.2%) had a documentation of an asystolic event of 10-second (Q1-Q3: 6- to 15-second) duration. They were subdivided in 3 age tertiles: ≤60 years (n = 64), 61 to 72 years (n = 72), and ≥73 years (n = 65). The rate of asystolic events was similar in the 3 subgroups (50.1%, 50.1%, and 49.2%, respectively; P = 0.99). Conversely, the rate of asystolic syncope induced during HUT (performed in 169 of 201) was greatly age dependent (31.0%, 12.1%, and 11.1% in increasing age tertiles, respectively; P = 0.009). CONCLUSIONS The rate of the spontaneous asystolic form of RS documented by ILR is constant at any age >40 years. Conversely, the rate of asystolic syncope induced by HUT is higher in younger patients and decreases with age. The contrasting results between spontaneous and tilt-induced events cast doubt on the concept that asystole in RS is less common in older patients.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milan, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milan, Italy.
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Monaldi Hospital, Naples, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Solna, Sweden; Department of Medicine, Karolinska Institute, Solna, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Paolo Alboni
- Section of Cardiology, Ospedale Privato Quisisana, Ferrara, Italy
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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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Johansson M, Fedorowski A. Situational vs vasovagal syncope: one but different? Heart 2023; 110:3-4. [PMID: 37591689 DOI: 10.1136/heartjnl-2023-323180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Affiliation(s)
- Madeleine Johansson
- Department of Clinical Sciences, Lund University, Faculty of Medicine, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Faculty of Medicine, Malmö, Sweden
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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van Rossum IA, de Lange FJ, Benditt DG, van Zwet EW, van Houwelingen M, Thijs RD, van Dijk JG. Variability of cardioinhibition in vasovagal syncope: differences between subgroups during cardioinhibition and beyond. Clin Auton Res 2023; 33:749-755. [PMID: 37874434 PMCID: PMC10751252 DOI: 10.1007/s10286-023-00991-5] [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: 07/04/2023] [Accepted: 09/30/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE We compared hemodynamic parameters between subjects with marked, intermediate and minimal cardioinhibition during vasovagal syncope. METHODS The study included subjects with a decrease in heart rate while experiencing a complete vasovagal syncope during tilt-table testing. The subjects were classified as having marked, intermediate or minimal cardioinhibition, based on tertile values of the decrease in heart rate. Hemodynamic parameters between these groups were compared before tilt in the supine position, shortly after tilt and during cardioinhibition. RESULTS A total of 149 subjects with a median age of 43 (interquartile range 24-60) years were included in the study. Among the three groups with different levels of cardioinhibition, the highest heart rate was observed in subjects with marked cardioinhibition both before and shortly after tilt and at the start of cardioinhibition. The heart rate decrease in these subjects was both larger and faster compared to subjects with minimal and intermediate cardioinhibition. CONCLUSION Subjects with marked cardioinhibition have both a larger and faster decrease in heart rate compared to subjects with intermediate and minimal cardioinhibition, as early as from the start of cardioinhibition. Marked cardioinhibition is related to differences in hemodynamic profiles already present well before the start of cardioinhibition.
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Affiliation(s)
- Ineke A van Rossum
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300, Leiden, The Netherlands.
| | - Frederik J de Lange
- Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marc van Houwelingen
- Department of Experimental Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300, Leiden, The Netherlands
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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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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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Torabi P, Hamrefors V, Sutton R, Brignole M, Fedorowski A. Definitive aetiology of unexplained syncope after cardiovascular autonomic tests in a tertiary syncope unit. Europace 2023; 25:euad247. [PMID: 37589189 PMCID: PMC10505743 DOI: 10.1093/europace/euad247] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/24/2023] [Accepted: 08/13/2023] [Indexed: 08/18/2023] Open
Abstract
AIMS Syncope is a common condition with many possible causes, ranging from benign to life-threatening aetiologies. Establishing a diagnosis can be difficult, and specialized syncope units, using cardiovascular autonomic tests (CATs), including a head-up tilt test, can increase the diagnostic yield. However, up to one-fifth of examined patients have inconclusive CAT results. The aim of the present study was to investigate the predictive value of history, and clinical findings for unexplained syncope after CAT and characterize the group with negative results. METHODS AND RESULTS Consecutive syncope patients [n = 2663, 61% women, median age 52 (32-69) years] were evaluated and CAT explained aetiology of syncope in 79% of cases, whereas 21% remained unexplained. Predictors of negative CAT were older age at first syncope (+8% higher odds per 10-year increment, P = 0.042), higher supine heart rate (HR; +12% per 10 b.p.m.; P = 0.003), absence of prodromes (+48%; P < 0.001), hypertension (+45%; P = 0.003), diabetes (+82%; P < 0.001), heart failure (+98%; P = 0.014), and coronary artery disease (+51%; P = 0.027). Compared with vasovagal syncope, patients with negative CAT were older, reported more often the absence of prodromes, and had a higher burden of cardiovascular comorbidities. CONCLUSION A cardiovascular autonomic test established the cause of syncope in 79% of patients evaluated in a syncope unit. Syncope without prodromes and cardiovascular comorbidities were significant predictors of failure to reveal an aetiology from assessment by CAT. These are known risk factors for cardiac syncope and patients with inconclusive CAT warrant further investigation.
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Affiliation(s)
- Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Clinical Physiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milano, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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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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Corvino AR, Russo V, Monaco MGL, Garzillo EM, Guida D, Comune A, Parente E, Lamberti M, Miraglia N. Vasovagal Syncope at Work: A Narrative Review for an Occupational Management Proposal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5460. [PMID: 37107742 PMCID: PMC10138125 DOI: 10.3390/ijerph20085460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/29/2023] [Accepted: 04/07/2023] [Indexed: 05/11/2023]
Abstract
Syncope is a complex clinical manifestation that presents considerable diagnostic difficulties and, consequently, numerous critical issues regarding fitness for work, especially for high-risk tasks. To date, it is impossible to quantify the exact impact of syncope on work and public safety since it is highly improbable to identify loss of consciousness as the fundamental cause of work or driving-related accidents, especially fatal injuries. Working at high-risk jobs such as public transport operators, in high elevations, or with exposure to moving parts, construction equipment, fireworks, or explosives demand attention and total awareness. Currently, no validated criteria or indicators are available for occupational risk stratification of a patient with reflex syncope to return to work. By drawing inspiration from the updated literature, this narrative review intends to summarise the leading knowledge required regarding the return to work for subjects affected by syncope. According to the available data, the authors highlighted some key findings, summarised in macro-items, such as defined risk stratification for vasovagal accidents, return to work after a critical event, and a focus on pacemaker (PM) implementation. Lastly, the authors proposed a flowchart for occupational physicians to help them manage the cases of workers affected by syncope and exposed to levels of risk that could represent a danger to the workers' health.
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Affiliation(s)
- Anna Rita Corvino
- Experimental Medicine Department-Hygiene, Occupational, and Forensic Medicine Division-Occupational Forensic Area, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (A.R.C.); (D.G.); (M.L.); (N.M.)
| | - Vincenzo Russo
- Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80131 Naples, Italy; (V.R.); (A.C.); (E.P.)
| | | | | | - Daniele Guida
- Experimental Medicine Department-Hygiene, Occupational, and Forensic Medicine Division-Occupational Forensic Area, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (A.R.C.); (D.G.); (M.L.); (N.M.)
| | - Angelo Comune
- Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80131 Naples, Italy; (V.R.); (A.C.); (E.P.)
| | - Erika Parente
- Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”—Monaldi Hospital, 80131 Naples, Italy; (V.R.); (A.C.); (E.P.)
| | - Monica Lamberti
- Experimental Medicine Department-Hygiene, Occupational, and Forensic Medicine Division-Occupational Forensic Area, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (A.R.C.); (D.G.); (M.L.); (N.M.)
| | - Nadia Miraglia
- Experimental Medicine Department-Hygiene, Occupational, and Forensic Medicine Division-Occupational Forensic Area, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (A.R.C.); (D.G.); (M.L.); (N.M.)
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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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Brignole M, Rivasi G, Fedorowski A, Ståhlberg M, Groppelli A, Ungar A. Tests for the identification of reflex syncope mechanism. Expert Rev Med Devices 2023; 20:109-119. [PMID: 36814102 DOI: 10.1080/17434440.2023.2174428] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Treatment efficacy of reflex syncope is mainly related to the mechanism underlying syncope rather than its etiology or clinical presentation. The predominant mechanism underlying reflex syncope can be assigned to hypotensive or to bradycardic phenotypes. AREAS COVERED Methodology and diagnostic criteria of the most useful tests for the identification of hypotensive and bradycardic phenotypes are discussed. Diagnostic tests for the hypotensive phenotype include office blood pressure measurement with active standing test, home, and wearable blood pressure monitoring, 24-h ambulatory blood pressure monitoring and tilt table test. Diagnostic tests for the bradycardic phenotype include carotid sinus massage, tilt table test and prolonged ECG monitoring. EXPERT OPINION In reflex syncope, the documentation of bradycardia/asystole during a syncopal episode does not rule out the possibility that a preceding or parallel hypotensive reflex plays an important role. Similarly, even when a hypotensive mechanism is established, the possibility of an associated cardioinhibitory reflex should be investigated. Investigating the mechanism of reflex syncope is mandatory in patients with severe recurrent episodes, with the final aim to develop a personalized treatment strategy. Recent trials have demonstrated the benefits of personalized mechanism-based therapy, thus highlighting the importance of a comprehensive assessment of the mechanisms underlying syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Marcus Ståhlberg
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Antonella Groppelli
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Sun R, Kang Y, Zhang M, Wang H, Shi L, Li X. Development of a nomogram model to predict malignant vasovagal syncope in Chinese children. Front Pediatr 2023; 11:1158537. [PMID: 37077332 PMCID: PMC10109463 DOI: 10.3389/fped.2023.1158537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/17/2023] [Indexed: 04/21/2023] Open
Abstract
Objective Vasovagal syncope (VVS) is the commonest form of syncope, and malignant VVS draws substantial attention due to its life-threatening cardiac asystolic risk. This study aimed to explore the predictive role of a wide panel of clinical indicators for malignant VVS in children, and further to develop a nomogram model. Methods This is a retrospective case-control study. VVS is diagnosed based on head-up tilt test (HUTT). STATA software (version 14.0) was used for statistical analysis, and effect sizes are expressed as odds ratio (OR) and 95% confidence interval (CI). Results Total 370 children with VVS were analyzed, and of them 16 children had malignant VVS. Sixteen malignant VVS and 64 non-malignant VVS were matched on age and sex by a 1:4 propensity scores matching method. Mean corpuscular hemoglobin (MCH) and standard deviation of average RR intervals milliseconds (SDANN) were significantly and independently associated with malignant VVS after adjusting for confounders, with OR reaching 1.437 (95% CI: 1.044 to 1.979; P = 0.026) and 1.035 (95% CI: 1.003 to 1.068; P = 0.029), respectively. Calibration and discrimination analyses revealed that the addition of MCH and SDANN can enhance model performance. Then, a nomogram to predict malignant VVS was developed using general characteristics and two above significant factors, and higher values in medical history, number of syncope, MCH and SDANN were associated with a greater risk of malignant VVS. Conclusion MCH and SDANN were two promising factors for the development of malignant VVS, and modeling of significant factors in a nomogram can provide strong reference to aid clinical decision-making.
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Affiliation(s)
- Rui Sun
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
- Department of Cardiology, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, China
| | - Yingying Kang
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
- Graduate School of Peking Union Medical College, Capital Institute of Pediatrics, Beijing, China
| | - Mingming Zhang
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Hongmao Wang
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Lin Shi
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Xiaohui Li
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
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