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Sotiriadou M, Antoniadis AP, Fragakis N, Vassilikos V. Is the Adenosine Test Obsolete in the Clinical Assessment of Syncope of Unknown Origin? Arrhythm Electrophysiol Rev 2021; 10:230-234. [PMID: 35106173 PMCID: PMC8785082 DOI: 10.15420/aer.2021.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/01/2021] [Indexed: 01/10/2023] Open
Abstract
Syncope is a common clinical condition affecting 50% of the general population; however, its exact pathophysiology and underlying mechanisms remain elusive. The adenosine test (ADT) has been proposed as a complementary diagnostic test in the work-up of syncope of unknown origin aiming to further elucidate the underlying pathogenetic mechanism of spontaneous syncope. Although ADT has not been endorsed by the recent European Society of Cardiology guidelines on syncope management, the use of a quick, safe and non-invasive test which can contribute to an accurate diagnosis and rationalised therapy, may deserve further consideration. This review summarises the evidence on the role of ADT in the investigation and management of syncope of unknown origin and highlights future perspectives in this area. The authors also analyse the current challenges and research targets on adenosine plasma levels and its receptors due to the involvement of the adenosine pathway in the ADT response.
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Affiliation(s)
- Melani Sotiriadou
- Third Cardiology Department, Hippokration General Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Antonios P Antoniadis
- Third Cardiology Department, Hippokration General Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Nikolaos Fragakis
- Third Cardiology Department, Hippokration General Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Vassilios Vassilikos
- Third Cardiology Department, Hippokration General Hospital, Aristotle University Medical School, Thessaloniki, Greece
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van Dijk JG, van Rossum IA, Thijs RD. The pathophysiology of vasovagal syncope: Novel insights. Auton Neurosci 2021; 236:102899. [PMID: 34688189 DOI: 10.1016/j.autneu.2021.102899] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 12/16/2022]
Abstract
The pathophysiology of vasovagal syncope (VVS) is reviewed, focusing on hemodynamic aspects. Much more is known about orthostatic than about emotional VVS, probably because the former can be studied using a tilt table test (TTT). Recent advances made it possible to quantify the relative contributions of the three factors that control blood pressure: heart rate (HR), stroke volume (SV) and total peripheral resistance (TPR). Orthostatic VVS starts with venous pooling, reflected in a decrease of SV. This is followed by cardioinhibition (CI), which is a decrease of HR that accelerates the ongoing decrease of BP, making the start of CI a literal as well as fundamental turning point. The role of hormonal and other humoral factors, respiration and of psychological influences is reviewed in short, leading to the conclusion that a multidisciplinary approach to the study of the pathophysiology of VVS may yield new insights.
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Affiliation(s)
- J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Ineke A van Rossum
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands
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Komatsu S, Sumiyoshi M, Miura S, Kimura Y, Shiozawa T, Hirano K, Odagiri F, Tabuchi H, Hayashi H, Sekita G, Tokano T, Nakazato Y, Daida H. A proposal of clinical ECG index "vagal score" for determining the mechanism of paroxysmal atrioventricular block. J Arrhythm 2016; 33:208-213. [PMID: 28607616 PMCID: PMC5459424 DOI: 10.1016/j.joa.2016.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/12/2016] [Accepted: 10/06/2016] [Indexed: 11/07/2022] Open
Abstract
Background Paroxysmal atrioventricular block (P-AVB) is a well-known cause of syncope; however, its underlying mechanism is difficult to determine. This study aimed to evaluate a new ECG index, the “vagal score (VS),” to determine the mechanism of P-AVB. Methods We evaluated the VS in 20 patients with P-AVB (13 men, 7 women; aged 25–78 years [mean, 59.3 years]). The VS was developed by assigning 1 point each for the following: (1) no AVB or intraventricular conduction disturbance on the baseline ECG, (2) PR prolongation immediately before P-AVB, (3) sinus slowing immediately before P-AVB, (4) initiation of P-AVB by PP prolongation, (5) sinus slowing during ventricular asystole, and (6) resumption of AV conduction with PP shortening, and by assigning –1 point each for (7) the initiation of P-AVB by a premature beat, and (8) resumption of AV conduction by an escape beat. Based on the clinical situations and electrophysiologic findings, we considered the mechanism of P-AVB as vagally mediated or intrinsic conduction disease (ICD). Results The VS ranged from 5 to –2 points for each patient. Five patients with a definite vagally mediated P-AVB had high VSs (3–5 points). We observed characteristic ECG findings of ICD consisting of changes in AV conduction by an extrasystole and/or escape beat in only 5 of the 6 patients (83%) with a low VS (1 to –2). Conclusions The VS is simple and potentially useful for determining the mechanism of P-AVB. P-AVB with a VS ≥3 strongly suggested a vagally mediated mechanism.
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Affiliation(s)
- Sayaka Komatsu
- Department of Cardiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Masataka Sumiyoshi
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Seiji Miura
- Department of Cardiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Yuki Kimura
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Tomoyuki Shiozawa
- Department of Cardiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Keiko Hirano
- Department of Cardiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Fuminori Odagiri
- Department of Cardiology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Haruna Tabuchi
- Department of Cardiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Hidemori Hayashi
- Department of Cardiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Gaku Sekita
- Department of Cardiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Takashi Tokano
- Department of Cardiology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Yuji Nakazato
- Department of Cardiology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Hiroyuki Daida
- Department of Cardiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
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Fragakis N, Antoniadis AP, Saviano M, Vassilikos V, Pappone C. The use of adenosine and adenosine triphosphate testing in the diagnosis, risk stratification and management of patients with syncope: current evidence and future perspectives. Int J Cardiol 2015; 183:267-73. [PMID: 25725201 DOI: 10.1016/j.ijcard.2015.01.089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 12/08/2014] [Accepted: 01/03/2015] [Indexed: 10/24/2022]
Abstract
Syncope is a significant source of cardiovascular-related morbidity yet the etiology is frequently obscure and the identification of patients at highest risk is challenging. Adenosine (AD) and adenosine triphosphate (ATP) administrations have been suggested as potentially useful non-invasive tools in the diagnostic workup of patients with neurally-mediated or bradycardia-related syncope. It has been postulated that both compounds by modulating the autonomic innervation in the heart and exerting negative chronotropic and dromotropic effects in the conduction system, may unmask the mechanism of syncope. However, the clinical implications derived from the efficacy of both tests in the investigation of syncope remain unclear mainly due to inconclusive and occasionally contradictory results of published studies. This review article summarizes recent and past information in the use of ATP and AD in the investigation of syncope with emphasis on clinical trials. We present the current level of evidence for the use of these agents in clinical practice, identify areas where further research is warranted and highlight the future perspectives of these agents as complements to an accurate risk-stratification of patients with syncope.
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Affiliation(s)
- Nikolaos Fragakis
- 3rd Cardiology Department, Hippokration Hospital, Aristotle University Medical School, Thessaloniki, Greece.
| | - Antonios P Antoniadis
- 3rd Cardiology Department, Hippokration Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Massimo Saviano
- Department of Arrhythmology, Maria Cecilia Hospital, Cotignola, Italy
| | - Vassilios Vassilikos
- 3rd Cardiology Department, Hippokration Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Carlo Pappone
- Department of Arrhythmology, Maria Cecilia Hospital, Cotignola, Italy
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