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Chakraborty P, Chen PS, Gollob MH, Olshansky B, Po SS. Potential consequences of cardioneuroablation for vasovagal syncope: A call for appropriately designed, sham-controlled clinical trials. Heart Rhythm 2024; 21:464-470. [PMID: 38104955 DOI: 10.1016/j.hrthm.2023.12.004] [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: 08/16/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
Cardioneuroablation (CNA) is being increasingly used to treat patients with vasovagal syncope (VVS). Bradycardia, in the cardioinhibitory subtype of VVS, results from transient parasympathetic overactivity leading to sinus bradycardia and/or atrioventricular block. By mitigating parasympathetic overactivity, CNA has been shown to improve VVS symptoms in clinical studies with relatively small sample sizes and short follow-up periods (<5 years) at selected centers. However, CNA may potentially tip the autonomic balance to a state of sympathovagal imbalance with attenuation of cardiac parasympathetic activity. A higher heart rate is associated with adverse cardiovascular events and increased mortality in healthy populations without cardiovascular diseases. Chronic sympathovagal imbalance may also affect the pathophysiology of spectra of cardiovascular disorders including atrial and ventricular arrhythmias. This review addresses potential long-term pathophysiological consequences of CNA for VVS.
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Affiliation(s)
- Praloy Chakraborty
- Heart Rhythm Institute, Section of Cardiovascular Diseases, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Peter Munk Cardiac Centre, Toronto General Hospital and University Health Network, Toronto, Ontario, Canada
| | - Peng-Sheng Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael H Gollob
- Peter Munk Cardiac Centre, Toronto General Hospital and University Health Network, Toronto, Ontario, Canada
| | - Brian Olshansky
- Department of Internal Medicine - Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Sunny S Po
- Heart Rhythm Institute, Section of Cardiovascular Diseases, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
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Dash RR, Samanta P, Das S, Jena A, Panda B, Parida BB, Mishra J. Heart Rate Variability in Unexplained Syncope Patients Versus Healthy Controls: A Comparative Study. Cureus 2023; 15:e41370. [PMID: 37546077 PMCID: PMC10399967 DOI: 10.7759/cureus.41370] [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] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Background Syncope or fainting is the sudden and transient loss of consciousness. This could lead to an increase in mortality due to sudden cardiac death or comorbidity in these patients. Heart rate variability (HRV) is a noninvasive bedside procedure for assessing the cardiovascular autonomic function. There may be an abnormal alteration in the HRV parameters in syncope patients. This can be used for looking into cardiovascular autonomic changes in syncope. This would help in early diagnosis and intervention. Objective The aim of this present study was to compare the HRV parameters between unexplained syncope patients and age-matched healthy controls and to find a correlation between HRV parameters and cardiovascular parameters like pulse and mean blood pressure. Materials and methods A five-minute continuous electrocardiogram (ECG) was recorded and HRV analysis was done by ADInstruments' PowerLab (Oxford, United Kingdom) for 25 cases and 25 controls. Results The mean standard deviation of the RR interval (SDRR) in milliseconds was found to be significantly lower in the cases (21.93 ± 3.53) as compared to controls (71.27 ± 27.40). The mean value of the low-frequency to high-frequency ratio (LF/HF) was significantly higher in cases (1.43 ± 0.40) as compared to controls (0.98 ± 1.07). However, there was no significant correlation between the pulse, blood pressure, and HRV measures. Conclusion The findings suggest a sympathetic predominance in the cases of unexplained syncope as compared to the controls.
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Affiliation(s)
- Rashmi R Dash
- Department of Physiology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Priyadarsini Samanta
- Department of Physiology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Susnato Das
- Department of Physiology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Anupam Jena
- Department of Cardiology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Bandita Panda
- Department of Research and Development, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Barsha B Parida
- Department of Physiology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Jayanti Mishra
- Department of Physiology, All India Institute of Medical Sciences., Bhubaneswar, IND
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Sardu C, Massimo Massetti M, Rambaldi P, Gatta G, Cappabianca S, Sasso FC, Santamaria M, Volpicelli M, Ducceschi V, Signoriello G, Paolisso G, Marfella R. SGLT2-inhibitors reduce the cardiac autonomic neuropathy dysfunction and vaso-vagal syncope recurrence in patients with type 2 diabetes mellitus: the SCAN study. Metabolism 2022; 137:155243. [PMID: 35732222 DOI: 10.1016/j.metabol.2022.155243] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/02/2022] [Accepted: 06/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with type 2 diabetes mellitus (T2DM) the vaso-vagal syncope (VVS) recurrence could be due to the alteration of autonomic system function, evaluated by heart rate variability (HRV), and by 123I-metaiodobenzylguanidine (123I-mIBG) myocardial scintigraphy indexes: Heart to Mediastinum ratio (H/Mlate), and Washout rate (WR). The SGLT2-I could modulate/reduce autonomic dysfunction in T2DM patients with VVS. This effect could reduce the VVS recurrence in T2DM patients. METHODS In a prospective multicenter study, after propensity score matching, we studied a population of 324 T2DM patients with VVS, divided into 161 SGLT2-I-users vs. 163 Non-SGLT2-I users. In these patients as SGLT2-I-users vs. Non-SGLT2-I users, we investigated the HRV and 123I-MIBG modifications and VVS recurrence at 12 months of follow-up. RESULTS At follow-up end, the SGLT2-I-users vs. Non-SGLT2-I users had best glucose homeostasis and lower values of inflammatory markers, and resting heart rate (p < 0.05). The SGLT2-I-users vs. Non-SGLT2-I users evidenced the lowest low frequency/high frequency ratio (LF/HFr), a significant difference for all the indexes of autonomic dysfunction via ECG Holter analysis, and higher values of H/Mlate (p < 0.05). Finally, comparing SGLT2-I-users vs. Non-SGLT2-I users, we found a higher rate of VVS recurrence events, specifically of the vasodepressor VVS recurrence at 1-year follow-up (p < 0.05). We did not find a significant difference of mixed and cardio-inhibitory VVS recurrence events at 1 year of follow-up in the study cohorts (p > 0.05). At the Cox regression analysis H/Mlate (0.710, [0.481-0.985]), and SGLT2-I therapy (0.550, [0.324-0.934]) predicted all causes of syncope recurrence at 1 year of follow-up. CONCLUSIONS Non-SGLT2-I users vs. SGLT2-I-users had alterations of the autonomic nervous system, with a higher rate of VVS recurrence at 1 year of follow-up. The indexes of cardiac denervation predicted the VVS recurrence, while the SGLT2-I reduced the risk of VVS recurrence. CLINICAL TRIAL REGISTRATION NUMBER NCT03717207.
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Affiliation(s)
- Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - M Massimo Massetti
- Cardiovascular and Arrhythmias Department "Gemelli Molise", Campobasso, Italy; Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Pietro Rambaldi
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Gianluca Gatta
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Matteo Santamaria
- Cardiovascular and Arrhythmias Department "Gemelli Molise", Campobasso, Italy.
| | - Mario Volpicelli
- Cardiovascular Diseases and Electrophysiology Unit, "S. Maria della Pietà Hospital", Naples, Italy
| | - Valentino Ducceschi
- Cardiovascular Diseases and Electrophysiology Unit, "Vecchio Pellegrini Hospital", Naples, Italy
| | - Giuseppe Signoriello
- Department of Mental Health, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; "Mediterranea Cardiocentro", Naples, Italy.
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; "Mediterranea Cardiocentro", Naples, Italy.
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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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Fish E, Barak Lanciano S, Shavit I, Palacci H, Chaiat C, Avivi I, Haber Kaptsenel E, Nussinovitch U. Venous capacitance and venous return in young adults with typical vasovagal syncope: a cross-sectional study. J Investig Med 2021; 70:402-408. [PMID: 34580160 DOI: 10.1136/jim-2021-001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 11/04/2022]
Abstract
Vasovagal syncope (VVS) has a high prevalence in the general population and is associated with potential complications. There is limited information on the possible association between venous capacitance (VC) and venous return (VR), important determinants of preload and VVS. Since the tilt test was reported to yield a high rate of false positive results, the aim of this study was to evaluate whether abnormal VC and VR at baseline could predispose individuals to VVS.To this end, 88 young, healthy volunteers were recruited and classified to 26 (29.5%) who experienced typical VVS and 62 (70.5%) who did not. VC and VR were evaluated with a commercial device and plethysmography applied to the elevated legs. Maximum venous outflow (MVO), segmental venous capacitance (SVC) and MVO/SVC ratio were calculated and averaged.No significant differences between MVO (5.0±0.5 vs 5.6±0.8, p>0.05), SVC (6.0±0.5 vs 6.3±0.8, p>0.05) or MVO/SVC ratio (0.83±0.02 vs 0.86±0.03, p>0.05) were observed for the non-VVS and VVS volunteers, respectively. There was a significant association between a higher MVO and SVC values and a larger decrease in diastolic blood pressure with standing, although correlations were weak (R2=0.0582 and 0.0681, respectively).In conclusion, at baseline, VC and VR are not impaired in healthy volunteers with a history of VVS. It remains unknown if similar results would be found in patients with cardiovascular comorbidities. Also, the sensitivity of VC and VR evaluations to identify a predisposition for VVS following physiological provocations merits further study.
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Affiliation(s)
- Ely Fish
- Department of Psychiatry, Westchester Medical Center, Valhalla, NY, USA
| | | | - Itay Shavit
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagar Palacci
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chen Chaiat
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ishay Avivi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Udi Nussinovitch
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, USA
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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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Alboni P, Messop AC, Lauri A, Furlan R. Are women really more affected by vasovagal syncope than men? J Cardiovasc Med (Hagerstown) 2021; 22:69-78. [PMID: 32925389 DOI: 10.2459/jcm.0000000000001009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It is commonly reported that vasovagal syncope (VVS) is more frequent in women. Presently, this issue has never been investigated. The purpose of this review was to evaluate, through an extensive review of the literature, whether women are really more affected by VVS than men. The gender distribution was investigated in individuals with classical and nonclassical VVS. The database PubMed was searched using the terms 'syncope', 'vasovagal syncope', 'neurally mediated syncope' and 'tilt testing'. Twelve studies dealing with classical and 75 with nonclassical VVS were eligible. In the individuals with classical (N = 1861) and nonclassical VVS (N = 9696), a trend towards a greater percentage of women emerged (P = 0.14 and 0.07, respectively). In the total population with VVS (N = 11 557), the percentage of women was significantly higher than that of men (58 versus 42%, P = 0.03). Most of the individuals were young or middle-aged. In 84% of the studies, the percentage of women was greater than that of men. A separate analysis was carried out in older VVS patients (≥60 years) and only two studies were eligible to be evaluated. Considering that almost all the studies were carried out in the western nations, where the number of men and women is almost superimposable until the age of 65 years and a bias by gender has never been reported in the management of VVS, these data strongly suggest that young and middle-aged women are more affected by VVS than their male counterparts. At present, data are too scant to draw a definitive conclusion in older VVS patients.
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Affiliation(s)
| | | | - Alessandro Lauri
- Section of Economics and Statistics, Ospedale Privato Quisisana, Ferrara
| | - Raffaello Furlan
- Internal Medicine, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, Italy
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Jang JH, Park JH, Ko KY, Baek YS, Kwon SW, Park SD, Shin SH, Woo SI, Kwan J, Kim DH. An analysis of vascular properties using pulse wave analysis in patients with vasovagal syncope. Clin Cardiol 2020; 43:781-788. [PMID: 32557670 PMCID: PMC7368349 DOI: 10.1002/clc.23380] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/08/2020] [Accepted: 04/22/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Vasovagal syncope (VVS) is a common cause of recurrent syncope. Nevertheless, the exact hemodynamic mechanism has not been elucidated. Pulse wave analysis (PWA) is widely used to evaluate vascular properties, as it reflects the condition of the entire arterial system. HYPOTHESIS Cardiovascular autonomic modulation may influence the hemodynamic mechanism and result in different vascular properties between VVS patients and healthy individuals. METHODS We enrolled consecutive patients diagnosed with VVS on head-up tilt testing from January 2014 to August 2019. Healthy subjects were enrolled as the control group. We performed PWA on all participants. Using propensity score matching, we assembled a study population with similar baseline characteristics and compared hemodynamic parameters. RESULTS A total of 111 VVS patients (43 ± 18 years, 72 females) and 475 healthy control subjects (48 ± 13 years, 192 females) were enrolled. Compared to the healthy control subjects, the VVS patients had a higher augmentation index (AIx) adjusted to a heart rate of 75 beats per minute (AIx@HR75, 20.5 ± 13.1% vs 16.7 ± 11.9%, P = .003). After 1:1 matched comparison (111 matched control), VVS patients consistently showed higher AIx@HR75 (20.5 ± 13.1% vs 16.7 ± 12.9%, P = .02) than the matched control group. According to age distribution, VVS patients showed significantly higher AIx@HR75 (10.6 ± 11.7% vs 2.5 ± 11.1%, P = .01) in a young age (15-33 years) group. CONCLUSIONS VVS patients had greater arterial stiffness than healthy subjects. This is one of the plausible mechanisms of the pathophysiology of VVS.
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Affiliation(s)
- Ji-Hun Jang
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Jin-Hee Park
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Kyu-Yong Ko
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Yong-Soo Baek
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Sung-Woo Kwon
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Sang-Don Park
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Sung-Hee Shin
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Seong-Ill Woo
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Jun Kwan
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
| | - Dae-Hyeok Kim
- Department of Cardiology, Inha University Hospital Cardiovascular Center, Incheon, Republic of Korea
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Cho KI, Lee YS, Kim BK, Kim BJ, Kim KS. Epicardial Fat Thickness is Correlated with Vagal Hyperactivity in Patients with Neurally-Mediated Syncope. J Cardiovasc Ultrasound 2017; 25:57-62. [PMID: 28770033 PMCID: PMC5526886 DOI: 10.4250/jcu.2017.25.2.57] [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: 02/25/2017] [Revised: 06/04/2017] [Accepted: 06/05/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Epicardial fat tissue has unique endocrine and paracrine functions that affect the cardiac autonomic system. The head-up tilt test (HUTT) is a simple non-invasive measurement that assesses autonomic nervous system dysfunction. We investigated the association between epicardial fat thickness (EFT) and autonomic neural tone, such as vagal tone. METHODS A total of 797 consecutive patients (mean age 46.5 years, male: 45.7%) who underwent HUTT and echocardiography between March 2006 and June 2015 were enrolled. EFT was measured during the diastolic phase of the parasternal long axis view. We excluded patients with prior percutaneous coronary intervention, old age (* 70 years old), valvular heart disease, symptomatic arrhythmias and diabetes. We divided patients into two groups based on the HUTT (positive vs. negative). RESULTS There were 329 patients (41.3%) with a negative HUTT result and 468 patients (58.7%) with a positive result. The HUTT-positive patients showed a significantly lower waist circumference, body mass index and systolic and diastolic blood pressure, although a significantly higher EFT as compared to the HUTT-negative patients (HUTT-positive, 5.69 ± 1.76 mm vs. HUTT-negative, 5.24 ± 1.60 mm; p < 0.001). EFT > 5.4 mm was associated with a positive HUTT result with 51.7% sensitivity and 63.8% specificity (p < 0.001) on receiving operator characteristic analysis. Multivariate Cox regression analysis revealed that EFT (hazard ratio: 1.02, 95% confidence interval: 1.01-1.30, p = 0.004) was an independent predictor of HUTT-positivity. CONCLSION EFT was significantly correlated with positive HUTT, which suggests an association between EFT and autonomic dysregulation.
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Affiliation(s)
- Kyoung Im Cho
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Catholic University of Daegu College of Medicine, Daegu, Korea
| | - Byong Kyu Kim
- Division of Cardiology, Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea
| | - Bong Joon Kim
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kee Sik Kim
- Division of Cardiology, Department of Internal Medicine, Catholic University of Daegu College of Medicine, Daegu, Korea
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Abstract
PURPOSE Little is known about the autonomic response to active standing in vasovagal syncope, and most works have focused on children or adolescents. The aim of this work was to study the changes in cardiac autonomic modulation in adult patients with vasovagal syncope through heart rate variability analysis with linear and short-term complexity (alpha-1) indexes during supine position and active standing, in patients with positive or negative head-up tilt test (HUTT). METHODS Twenty-five patients with vasovagal syncope were included. Heart rate variability linear and short-term complexity (alpha-1) indexes were recorded during an active standing test (15 minutes in each position) and compared among patients grouped by HUTT outcome and between positions. RESULTS During supine position, positive HUTT (+HUTT) patients had longer mean RR (1016 [850-1051] milliseconds), higher pNN50 (17.7 [9.2-26.2]), lower sympathovagal balance (1.3 [0.5-1.7]), and alpha-1 (0.9 [0.8-1.0]) than negative HUTT (-HUTT) patients (871 [776-969] milliseconds, 8.8 [2.1-14.5], 2.9 [1.3-3.9], and 1.2 [1.0-1.1], respectively). During active standing, heart rate and alpha-1 increased in both groups; in +HUTT patients, pNN50 decreased, whereas sympathovagal balance increased. The magnitude of change between positions of sympathovagal balance and alpha-1 was 6.1 and 4.8 times larger in +HUTT than -HUTT patients, respectively. CONCLUSIONS The underlying cardiac autonomic mechanism in vasovagal syncope may involve different autonomic patterns in subjects with a history of recurrent syncope and +HUTT or -HUTT.
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Abstract
Autonomic dysfunction has been associated with paroxysmal atrial fibrillation (PAF). The head-up tilt test (HUTT) is an important diagnostic tool for autonomic dysfunction. The aim of this study was to examine atrial fibrillation recurrence after RFCA by performing HUTT. A total of 488 consecutive patients with PAF who underwent RFCA were prospectively enrolled. HUTT was positive in 154 (31.6%) patients after a mean follow-up of 22.7 ± 3.5 months, and 163 (33.4%) had a recurrence. HUTT positive was significantly higher in PAF patients with recurrence compared to those without (68 (41.7%) versus 86 (26.5%), P < 0.001). Multivariate Cox regression analysis revealed that HUTT positive (HR: 1.96; 95% CI: 1.49-2.48, P < 0.001), left atrial diameter (HR: 1.77; 95%CI: 1.15-2.11, P = 0.004), AF duration (HR: 1.27; 95%CI: 0.98-1.83, P = 0.014), and sleep apnea (HR: 1.02; 95%CI: 0.81-1.53, P = 0.032) were independent predictors of clinical recurrence after RFCA. The success rate of ablation was 70.4% in patients in the HUTT negative group compared with 58.4% in patients in the HUTT positive group (log-rank P = 0.006). Patients with a positive headup tilt test were at an increased risk of AF recurrence after catheter ablation. Our results suggest that HUTT was a significant predictor for AF recurrence after catheter ablation for PAF.
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Affiliation(s)
- Jinyi Xu
- Department of Heart Function, Henan Province People's Hospital & The People's Hospital of Zhengzhou University
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Tan MP, Murray A, Hawkins T, Chadwick TJ, Kerr SRJ, Parry SW. Cardiac Iodine-123-Meta-Iodo-Benzylguanidine Uptake in Carotid Sinus Hypersensitivity. PLoS One 2015; 10:e0126241. [PMID: 26057525 PMCID: PMC4461270 DOI: 10.1371/journal.pone.0126241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 03/18/2015] [Indexed: 01/08/2023] Open
Abstract
Background Carotid sinus syndrome is the association of carotid sinus hypersensitivity with syncope, unexplained falls and drop attacks in generally older people. We evaluated cardiac sympathetic innervation in this disorder in individuals with carotid sinus syndrome, asymptomatic carotid sinus hypersensitivity and controls without carotid sinus hypersensitivity. Methods Consecutive patients diagnosed with carotid sinus syndrome at a specialist falls and syncope unit were recruited. Asymptomatic carotid sinus hypersensitivity and non-carotid sinus hypersensitivity control participants recruited from a community-dwelling cohort. Cardiac sympathetic innervation was determined using Iodine-123-metaiodobenzylguanidine (123-I-MIBG) scanning. Heart to mediastinal uptake ratio (H:M) were determined for early and late uptake on planar scintigraphy at 20 minutes and 3 hours following intravenous injection of 123-I-MIBG. Results Forty-two subjects: carotid sinus syndrome (n = 21), asymptomatic carotid sinus hypersensitivity (n = 12) and no carotid sinus hypersensitivity (n = 9) were included. Compared to the non- carotid sinus hypersensitivity control group, the carotid sinus syndrome group had significantly higher early H:M (estimated mean difference, B = 0.40; 95% confidence interval, CI = 0.13 to 0.67, p = 0.005) and late H:M (B = 0.32; 95%CI = 0.03 to 0.62, p = 0.032). There was, however, no significant difference in early H:M (p = 0.326) or late H:M (p = 0.351) between the asymptomatic carotid sinus hypersensitivity group and non- carotid sinus hypersensitivity controls. Conclusions Cardiac sympathetic neuronal activity is increased relative to age-matched controls in individuals with carotid sinus syndrome but not those with asymptomatic carotid sinus hypersensitivity. Blood pressure and heart rate measurements alone may therefore represent an over simplification in the assessment for carotid sinus syndrome and the relative increase in cardiac sympathetic innervation provides additional clues to understanding the mechanisms behind the symptomatic presentation of carotid sinus hypersensitivity.
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Affiliation(s)
- Maw Pin Tan
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Alan Murray
- Regional Medical Physics Department, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Terry Hawkins
- Regional Medical Physics Department, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Thomas J. Chadwick
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simon R. J. Kerr
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
- Falls and Syncope Service, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Steve W. Parry
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
- Falls and Syncope Service, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- * E-mail:
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Shinohara T, Ebata Y, Ayabe R, Fukui A, Okada N, Yufu K, Nakagawa M, Takahashi N. Cardiac autonomic dysfunction in patients with head-up tilt test-induced vasovagal syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:1694-701. [PMID: 25139789 DOI: 10.1111/pace.12484] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/09/2014] [Accepted: 06/11/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Vasovagal syncope (VVS) is the result of an autonomic reflex that has a final effect of reducing sympathetic drive and increasing vagal activity. However, whether syncopal symptoms are associated with pathological cardiac autonomic modulation is not fully known. We tested the hypothesis that cardiac autonomic function is impaired in patients with VVS. METHODS Eighty-four consecutive patients (59 males; 48.8 ± 20.9 years) with recurrent unexplained syncope were enrolled. The head-up tilt test (HUTT) was positive in 38 patients and negative in 46 patients. Cardiac autonomic function was assessed by baroreflex sensitivity (BRS), heart rate variability, plasma concentrations of norepinephrine, and (123) I-metaiodobenzylguanidine (MIBG) scintigraphy. RESULTS BRS indices were significantly lower in the HUTT-positive group than in the HUTT-negative group (6.1 ± 5.5 mm Hg/s vs 9.8 ± 7.6 mm Hg/s, P = 0.02). With regard to cardiac (123) I-MIBG scintigraphy, the mean heart-to-mediastinum ratio at the delayed phase tended to be lower in HUTT-positive than in HUTT-negative individuals, but this difference was not significant (2.75 ± 0.55 vs 3.02 ± 0.49, P = 0.08).The percent washout rate of (123) I-MIBG was significantly higher in the positive group compared with the negative group (40.7 ± 13.1% vs 31.5 ± 13.3%, P = 0.02). Multivariate logistic analysis revealed that the appearance of HUTT-induced VVS was predicted independently by a high percent washout rate of (123) I-MIBG (odds ratio, 0.954; 95% confidence interval, 0.903-0.998; P = 0.048). CONCLUSIONS Our results suggest that pathological autonomic cardiac modulation may play a role in the appearance of syncope in VVS patients.
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Affiliation(s)
- Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
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Gimelli A, Liga R, Giorgetti A, Genovesi D, Marzullo P. Assessment of myocardial adrenergic innervation with a solid-state dedicated cardiac cadmium-zinc-telluride camera: first clinical experience. Eur Heart J Cardiovasc Imaging 2013; 15:575-85. [DOI: 10.1093/ehjci/jet258] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Gimelli A, Liga R, Genovesi D, Giorgetti A, Kusch A, Marzullo P. Association between left ventricular regional sympathetic denervation and mechanical dyssynchrony in phase analysis: a cardiac CZT study. Eur J Nucl Med Mol Imaging 2013; 41:946-55. [DOI: 10.1007/s00259-013-2640-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 11/12/2013] [Indexed: 11/30/2022]
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Transcatheter aortic valve implantation reduces sympathetic activity and normalizes arterial spontaneous baroreflex in patients with aortic stenosis. JACC Cardiovasc Interv 2013; 6:1195-202. [PMID: 24139928 DOI: 10.1016/j.jcin.2013.06.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 06/14/2013] [Accepted: 06/20/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study sought to measure muscle sympathetic nerve activity (MSNA) in patients with aortic stenosis (AS) before and after transcatheter aortic valve implantation (TAVI) and to compare MSNA with that of control patients. BACKGROUND TAVI is an emerging therapeutic option in patients with severe AS at high risk of open heart surgery. Whether patients with AS have increased sympathetic activity remains to be established, and the effects of TAVI on the sympathetic nervous system are also unknown. METHODS We prospectively enrolled 14 patients with severe symptomatic AS treated by TAVI. Fourteen control patients matched for age, body mass index, and unscathed of AS were also included. All patients underwent MSNA and arterial baroreflex gain assessment at baseline and 1 week after TAVI for AS patients. RESULTS Patients with AS had lower blood pressure (BP) levels, a significant increase in MSNA (61.0 ± 1.7 burst/min vs. 55.4 ± 1.4 burst/min; p < 0.05), and a decrease in arterial baroreflex gain (2.13 ± 0.14% burst/mm Hg vs. 3.32 ± 0.19% burst/mm Hg; p < 0.01) compared with matched control patients. The TAVI procedures induced an increase in BP associated with a significant decrease in MSNA (from 61.0 ± 1.7 burst/min to 54.1 ± 1.0 burst/min; p < 0.01) and was associated with a significant increase in arterial baroreflex gain (from 2.13 ± 0.14% burst/mm Hg to 3.49 ± 0.33% burst/mm Hg; p < 0.01). CONCLUSIONS We report for the first time, through direct measurement of nerve activity, that patients with AS have increased sympathetic nervous system activity associated with a decrease in sympathetic baroreflex gain and that TAVI normalizes these parameters. This study provides evidence of a new beneficial effect of TAVI, namely, normalization of sympathetic nervous system hyperactivity.
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Zysko D, Melander O, Fedorowski A. Vasovagal syncope related to emotional stress predicts coronary events in later life. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:1000-6. [PMID: 23614671 DOI: 10.1111/pace.12138] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/06/2013] [Accepted: 02/25/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of the study was to assess whether history of vasovagal syncope (VVS) mediated by emotional (emotional VVS) or orthostatic stress (orthostatic VVS) is associated with an increased risk of cardiovascular (CV) events in later life. METHODS Retrospective analysis based on medical records of the consecutive 3,288 cardiologic outpatients (mean age, 61 ± 12 years; 43% men). RESULTS A total of 254 patients (7.7%) reported emotional VVS, whereas 294 (9.0%) had history of orthostatic VVS. First-ever syncopal episode was reported at a median age of 16 years (interquartile range [IQR], 12 years to 28 years), and the median total number of episodes was two (IQR, 1 to 5). There were 779 patients (23.7%) with at least one CV event, and the median age for the first CV event was 59 years (IQR, 52 years to 67 years). In the fully adjusted model, history of emotional VVS was predictive of CV event (hazard ratio [95% confidence interval]: 1.63, [1.27-2.09]; P < 0.001), myocardial infarction (1.99, [1.49-2.66]; P < 0.001), and percutaneous coronary intervention (1.84, [1.31-2.60]; P = 0.001). There was one significant interaction (P = 0.07) between history of emotional VVS and gender. Emotional VVS was predictive of CV event in men (1.89 [1.41-2.53]; P < 0.001) but not in women (1.24 [0.79-1.94]; P = 0.35). CONCLUSIONS History of emotional but not orthostatic VVS is independently associated with increased risk of coronary events in later life. The relationship between predisposition to emotional VVS in adolescence and development of cardiovascular disease requires further studies.
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Affiliation(s)
- Dorota Zysko
- Department of Emergency Medicine, Wrocław Medical University, Wrocław, Poland.
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Johansen JB, Nielsen JC. Vasovagal syncope: poorly understood, but well handled. Europace 2012; 14:1228-9. [DOI: 10.1093/europace/eus097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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