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Russo V, Pecori F, Colalillo N, Massimo N, Valentino GB, Comune A, Parente E, Nigro G. Takotsubo Syndrome Associated with Neurally Mediated Reflex Syncope: A Meta-summary of Case Reports and Literature Review. Rev Cardiovasc Med 2024; 25:264. [PMID: 39139433 PMCID: PMC11317348 DOI: 10.31083/j.rcm2507264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/18/2024] [Accepted: 05/17/2024] [Indexed: 08/15/2024] Open
Abstract
Background Neurally mediated reflex syncope (NMRS) has been recently described as a possible trigger of Takotsubo syndrome (TTS). There are few data in the literature about this association. Methods In the present meta-summary, 6 case reports describing patients who experienced TTS following an NMRS episode were included. Patient characteristics, triggers and type of syncope were collected. Results A total of 7 patients with a median age of 63.4 years (interquartile range, IQR: 47.5-76) were evaluated; 71.4% were females, mainly in the menopausal state (80%). The TTS triggers were: vasovagal syncope in 6 patients (85.7%) and situational syncope in 1 patient (14.3%). 2 patients underwent a comprehensive clinical evaluation which showed a cardioinhibitory response. Conclusions NMRS due to sudden orthostatism and emotional stress, mainly with a cardioinhibitory response, has been associated with the onset of TTS, in particular among female patients in a menopausal state.
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Affiliation(s)
- Vincenzo Russo
- Department of Translational Medical Sciences, Cardiology and Syncope Unit, University of Campania “Luigi Vanvitelli” – Monaldi Hospital, 80131 Naples, Italy
| | - Filippo Pecori
- Department of Translational Medical Sciences, Cardiology and Syncope Unit, University of Campania “Luigi Vanvitelli” – Monaldi Hospital, 80131 Naples, Italy
| | - Nicola Colalillo
- Department of Translational Medical Sciences, Cardiology and Syncope Unit, University of Campania “Luigi Vanvitelli” – Monaldi Hospital, 80131 Naples, Italy
| | - Nicola Massimo
- Department of Translational Medical Sciences, Cardiology and Syncope Unit, University of Campania “Luigi Vanvitelli” – Monaldi Hospital, 80131 Naples, Italy
| | - Giovanni Battista Valentino
- Department of Translational Medical Sciences, Cardiology and Syncope Unit, University of Campania “Luigi Vanvitelli” – Monaldi Hospital, 80131 Naples, Italy
| | - Angelo Comune
- Department of Translational Medical Sciences, Cardiology and Syncope Unit, University of Campania “Luigi Vanvitelli” – Monaldi Hospital, 80131 Naples, Italy
| | - Erika Parente
- Department of Translational Medical Sciences, Cardiology and Syncope Unit, University of Campania “Luigi Vanvitelli” – Monaldi Hospital, 80131 Naples, Italy
| | - Gerardo Nigro
- Department of Translational Medical Sciences, Cardiology and Syncope Unit, University of Campania “Luigi Vanvitelli” – Monaldi Hospital, 80131 Naples, Italy
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Willihnganz SB, Ahmed Z, Lee JJ. Delaying Suspension Syndrome Onset in Aerially Suspended Victims Through Leg Raising. Wilderness Environ Med 2024; 35:147-154. [PMID: 38465643 DOI: 10.1177/10806032241234665] [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] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Suspension syndrome (SS) develops when venous blood pools in extremities of passively suspended individuals, resulting in presyncopal symptoms and potential unconsciousness or death independent of additional injuries. We investigated use of leg raising to delay onset of SS, as it can decrease venous pooling and increase cardiac return and systemic perfusion. METHODS Participants were suspended in rock climbing harnesses at an indoor climbing wall in a legs-dangling control position or a legs-raised interventional position to compare physiological outcomes between groups. Participants were suspended for a maximum of 45 min. Onset of 2 or more symptoms of SS, such as vertigo, lightheadedness, or nausea, halted suspension immediately. We recorded each participant's heart rate, blood pressure, oxygen saturation, lower leg oxygen saturation, pain rating, and presyncope scores presuspension, midsuspension, and postsuspension, as well as total time suspended. RESULTS There were 24 participants. There was a significant difference in total time suspended between groups (43.05±6.7 min vs 33.35±9.02 min, p=0.007). There was a significant difference in heart rate between groups overall (p=0.012), and between groups, specifically at the midsuspension time interval (80±11 bpm vs 100±17 bpm, p=0.003). Pain rating was significantly different between groups (p=0.05). Differences in blood pressure, oxygen saturation, lower leg oxygen saturation, and presyncope scores were not significant. CONCLUSION Leg raising lengthened the time individuals tolerated passive suspension and delayed symptom onset.
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Affiliation(s)
| | - Zubair Ahmed
- Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, UK
| | - Justine J Lee
- Major Trauma Service, University Hospitals Birmingham, Birmingham, UK
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Wang H, Ma W, Jin M, Li B, Sun S. Value of catecholamine levels in the differential diagnosis of vasovagal syncope and psychogenic pseudosyncope in children. Front Pediatr 2024; 12:1281196. [PMID: 38884104 PMCID: PMC11176470 DOI: 10.3389/fped.2024.1281196] [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: 10/02/2023] [Accepted: 05/20/2024] [Indexed: 06/18/2024] Open
Abstract
Background and purpose Vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) can be difficult to distinguish, given their similar clinical presentations. This study was conducted to explore the clinical value of catecholamine levels in the differential diagnosis of VVS and PPS in children. Methods This retrospective case-control study was conducted with data from children with VVS and PPS who underwent head-up tilt tests (HUTTs) at the Children's Hospital of Hebei Province between March 2021 and March 2023. The data collected were baseline clinical characteristics, HUTT results, serum catecholamine levels in the supine and upright positions, and 24 h urinary catecholamine concentrations. These variables were compared between the VVS and PPS groups. Results From 328 potentially eligible cases, 54 (16.46%) cases of VVS and 24 (7.32%) cases of PPS were included in the analysis. No significant difference in age, sex, body mass index, or syncope frequency was observed between the VVS and PPS groups. The main predisposing factors for syncope were body position changes in the VSS group (83.33%) and emotional changes in the PPS group (41.67%). The episode duration was significantly shorter in the VSS group than in the PPS group (4.01 ± 1.20 vs. 24.06 ± 5.56 min, p < 0.05). The recovery time was also shorter in the VVS group than in the PPS group (1.91 ± 0.85 vs. 8.62 ± 2.55 min, p < 0.05). Relative to patients with PPS, those with VVS had significantly higher serum epinephrine (EP) levels in the upright position [199.35 (102.88, 575.00) vs. 147.40 (103.55, 227.25), p < 0.05] and lower serum epinephrine levels in the supine position [72.70 (42.92, 122.85) vs. 114.50 (66.57, 227.50), p < 0.05]. Conclusions Serum EP levels have potential value in the differential diagnosis of VVS and PPS.
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Affiliation(s)
- Hua Wang
- Department of Pediatrics, Hebei Medical University, Shijiazhuang, China
- Department of Pediatric Cardiology, Children's Hospital of Hebei Province, Shijiazhuang, China
- Hebei Provincial Key Laboratory of Pediatric Cardiovascular Disease, Shijiazhuang, China
| | - Wandong Ma
- Department of Neurosurgery, Hebei General Hospital, Shijiazhuang, China
| | - Mei Jin
- Department of Pediatric Neurology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Bo Li
- Department of Pediatric Cardiology, Children's Hospital of Hebei Province, Shijiazhuang, China
- Hebei Provincial Key Laboratory of Pediatric Cardiovascular Disease, Shijiazhuang, China
| | - Suzhen Sun
- Department of Pediatrics, Hebei Medical University, Shijiazhuang, China
- Department of Pediatric Neurology, Children's Hospital of Hebei Province, Shijiazhuang, China
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4
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Wang S, Peng Y, Wang Y, Li F, Xu Y, Zheng H, Yuan H, Hu C, Liao D, Cai H, Zhang J, Li W, Ding Y, Zhang W, Xue X, Liu X, Zhu L, Liu D, Kang M, Liu L, Chu W, Li X, Luo X, Zou R, Wang C. Relationship between syncopal symptoms and head-up tilt test modes. Cardiol Young 2024:1-6. [PMID: 38577783 DOI: 10.1017/s1047951124000726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
OBJECTIVE Head-up tilt test (HUTT) is an important tool in the diagnosis of pediatric vasovagal syncope. This research will explore the relationship between syncopal symptoms and HUTT modes in pediatric vasovagal syncope. METHODS A retrospective analysis was performed on the clinical data of 2513 children aged 3-18 years, who were diagnosed with vasovagal syncope, from Jan. 2001 to Dec. 2021 due to unexplained syncope or pre-syncope. The average age was 11.76 ± 2.83 years, including 1124 males and 1389 females. The patients were divided into the basic head-up tilt test (BHUT) group (596 patients) and the sublingual nitroglycerine head-up tilt test (SNHUT) group (1917 patients) according to the mode of positive HUTT at the time of confirmed pediatric vasovagal syncope. RESULTS (1) Baseline characteristics: Age, height, weight, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and composition ratio of syncope at baseline status were higher in the BHUT group than in the SNHUT group (all P < 0.05). (2) Univariate analysis: Age, height, weight, HR, SBP, DBP, and syncope were potential risk factors for BHUT positive (all P < 0.05). (3) Multivariate analysis: syncope was an independent risk factor for BHUT positive, with a probability increase of 121% compared to pre-syncope (P<0.001). CONCLUSION The probability of BHUT positivity was significantly higher than SNHUT in pediatric vasovagal syncope with previous syncopal episodes.
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Affiliation(s)
- Shuo Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yali Peng
- Section of Science and Education, The First People's Hospital of Changde City, Changde, China
| | - Yuwen Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fang Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi Xu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Huifen Zheng
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Shenzhen People's Hospital, Shenzhen, China
| | - Heli Yuan
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Chunyan Hu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, The Second Affiliated Hospital, University of South China, Hengyang, China
| | - Donglei Liao
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hong Cai
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Juan Zhang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wen Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yiyi Ding
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, The First People's Hospital of Changde City, Changde, China
| | - Wenhua Zhang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, The Third Hospital of Changsha, Changsha, China
| | - Xiaohong Xue
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Hunan Want Want Hospital, Changsha, China
| | - Xiaoyan Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Changsha Central Hospital, University of South China, Changsha, China
| | - Liping Zhu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Neonatology, Changsha Central Hospital, University of South China, Changsha, China
| | - Deyu Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Hunan Lixian People's Hospital, Changde, China
| | - Meihua Kang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Weijia Pediatric Hospital, Changsha, China
| | - Liping Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatric Cardiology, Hunan People's Hospital/First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Weihong Chu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Xiaoming Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics, Jieyang People's Hospital, Jieyang, China
| | - Xuemei Luo
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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Longo S, Legramante JM, Rizza S, Federici M. Vasovagal syncope: An overview of pathophysiological mechanisms. Eur J Intern Med 2023; 112:6-14. [PMID: 37030995 DOI: 10.1016/j.ejim.2023.03.025] [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: 12/13/2022] [Revised: 03/09/2023] [Accepted: 03/23/2023] [Indexed: 04/10/2023]
Abstract
Syncope is a short-term transient loss of consciousness, characterized by rapid onset and complete spontaneous recovery. According to the 2018 European Society of Cardiology guidelines, three different types of syncope have been identified. However, all forms of syncope share a common final pathophysiological event, global cerebral hypoperfusion, which results from the inability of the circulatory system to maintain blood pressure at the level required to efficiently supply blood to the brain. The vasovagal syncope (VVS) is the most common form of syncope. Although, VVS is generally harmless, its frequent occurrence can negatively affect quality of life and increase the risk of adverse events. The pathophysiological mechanisms underlying VVS remain obscure. The multifaceted nature of VVS presents a veritable challenge to understanding this condition and developing preventative strategies. Thus, the aim of this review was to discuss the factors contributing to the pathogenesis of VVS and provide guidance for future research.
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Affiliation(s)
- Susanna Longo
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, Rome 00133 ITALY
| | - Jacopo M Legramante
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, Rome 00133 ITALY
| | - Stefano Rizza
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, Rome 00133 ITALY
| | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, Rome 00133 ITALY.
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Gao Y, Jin H, Du J. Sitting intolerance: A new disease entity in children and adolescents. Pediatr Investig 2022; 6:299-301. [PMID: 36582277 PMCID: PMC9789932 DOI: 10.1002/ped4.12352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Yumeng Gao
- Department of PediatricsPeking University First HospitalBeijingChina
| | - Hongfang Jin
- Department of PediatricsPeking University First HospitalBeijingChina
| | - Junbao Du
- Department of PediatricsPeking University First HospitalBeijingChina,Key Laboratory of Molecular Cardiovascular SciencesMinistry of EducationBeijingChina
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Miranda CM, da Silva RMFL, Peruhybe-Magalhães V, Brugada J. Vasoactive Biomarkers in Patients With Vasovagal Syncope During Head-Up Tilt Test: A Case-Control Study. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2022; 16:11795468221116848. [PMID: 36046183 PMCID: PMC9421056 DOI: 10.1177/11795468221116848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Abstract
Background: Vasovagal syncope (VVS) is the most common cause of syncope. Some stages of its pathophysiological mechanisms remain unclear. Vasoactive substances such as nitric oxide metabolites (NOx) and endothelin (ET) may be involved during acute orthostatic stress. Objective: To analyze plasma changes in NOx and ET and heart rate variability (HRV) in the supine positions (T1) and during the head-up tilt test (HUTT) (T2), in patients with VVS (case group) and control group. Methods: Thirty-seven patients (17 in the case group and 20 in the control group), matched for age and sex (mean aged 31.8 years) underwent HUTT with simultaneous HRV recording and venipuncture. Blood samples were collected during phases T1 and T2 and the analysis was performed without knowledge of the HUTT result. Results: In the total sample, there was an increase in NOx values (P = .014), however there was no increase in ET values from phase T1 to phase T2. Patients with VVS tended to increase plasma NOx values (P = .057) and had significantly higher plasma values compared to ET (P = .033) between phases T1 to T2. In the control group, there was no significant change in the values of these vasoactive substances. Regarding HRV, there were a decrease in the component HF (high frequency) and increased of the LF (low frequency)/HF ratio during HUTT. Conclusions: There was an increase in ET during HUTT occurred only in the case group. These patients are more likely to have an imbalance between antagonistic vasoactive biomarkers during orthostatic stress.
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Affiliation(s)
- Cláudia Madeira Miranda
- Faculty of Medicine, Federal University of Minas Gerais, Brazil.,Madre Teresa Hospital, Minas Gerais, Brazil
| | | | | | - Josep Brugada
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Purnama MTE, Hendrawan D, Wicaksono AP, Fikri F, Purnomo A, Chhetri S. Risk factors, hematological and biochemical profile associated with colic in Delman horses in Gresik, Indonesia. F1000Res 2022; 10:950. [PMID: 35136578 PMCID: PMC8787563 DOI: 10.12688/f1000research.55312.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Horses are herd animals that have been domesticated in the last century. In several countries, an overview of risk factors and clinical evaluation in horses with colic has not been well‐described. This study aimed to evaluate risk factors and hematological profiles in horses associated with colic in Gresik, East Java, Indonesia. Methods: A cross-sectional study was performed during April - October 2019. A total of 115 horses were diagnosed based on physical examination, clinical symptoms, and rectal examination. A questionnaire was asked to the horse-owners to analyze the risk factors while the clinical examination was performed and blood samples were collected for pre-treatment and 14 days post-treatment. Hematological profile was evaluated from a whole blood sample. Serum cortisol, plasma epinephrine, and norepinephrine concentrations were also evaluated after separating the aliquots. Results: Of the 115 horses, 96 were diagnosed with colic. The horses with colic showed a significant association between cases with gender (p<0.021), breed (p<0.000), wheat bran feeding (p<0.015), concentrate feeding (p<0.003), anthelmintics administration (p<0.000), gastrointestinal parasites (p<0.000), dental diseases (p<0.024), previous exposure to colic (p<0.000), body condition score (p<0.000), and access to water per day (p<0.000). Based on whole blood and serum evaluation, there were ameliorated significantly on the hematological profile (p<0.01), serum cortisol (p<0.05), and plasma epinephrine (p<0.01) at 14 days post-treatment. Conclusion: This study has identified factors associated with colic in Delman horses. The study provides crucial information to investigate cases of colic and to contribute the development of healthcare strategies during treatment and clinical evaluation.
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Affiliation(s)
- Muhammad Thohawi Elziyad Purnama
- Division of Veterinary Anatomy, Department of Veterinary Science, Faculty of Veterinary Medicine, Universitas Airlangga, Surabaya, East Java, 60115, Indonesia
| | - Dodit Hendrawan
- Animal Health Division, Indonesian Horse Veterinarian Association, Surabaya, East Java, 60115, Indonesia
| | - Arya Pradana Wicaksono
- Animal Health Division, Indonesian Horse Veterinarian Association, Surabaya, East Java, 60115, Indonesia
| | - Faisal Fikri
- Division of Veterinary Physiology, Department of Veterinary Science, Faculty of Veterinary Medicine, Universitas Airlangga, Surabaya, East Java, 60115, Indonesia
| | - Agus Purnomo
- Department of Veterinary Surgery and Radiology, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Yogyakarta, 55281, Indonesia
| | - Shekhar Chhetri
- Department of Animal Science, College of Natural Resources, Royal University of Bhutan, Lobesa, Punakha, 13001, Bhutan
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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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10
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Fedorowski A, Rivasi G, Torabi P, Johansson M, Rafanelli M, Marozzi I, Ceccofiglio A, Casini N, Hamrefors V, Ungar A, Olshansky B, Sutton R, Brignole M, Parati G. Underlying hemodynamic differences are associated with responses to tilt testing. Sci Rep 2021; 11:17894. [PMID: 34504263 PMCID: PMC8429732 DOI: 10.1038/s41598-021-97503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022] Open
Abstract
Aim of this study was to explore whether differences in resting hemodynamic parameters may be associated with tilt test results in unexplained syncope. We analyzed age, gender, systolic (SBP), diastolic blood pressure (DBP) and heart rate (HR) by merging three large databases of patients considered likely to be of vasovagal reflex etiology, comparing patients who had tilt-induced reflex response with those who did not. Tilt-induced reflex response was defined as spontaneous symptom reproduction with characteristic hypotension and bradycardia. Relationship of demographics and baseline supine BP to tilt-test were assessed using logistic regression models. Individual records of 5236 patients (45% males; mean age: 60 ± 22 years; 32% prescribed antihypertensive therapy) were analyzed. Tilt-positive (n = 3129, 60%) vs tilt-negative patients had lower SBP (127.2 ± 17.9 vs 129.7 ± 18.0 mmHg, p < 0.001), DBP (76.2 ± 11.5 vs 77.7 ± 11.7 mmHg, p < 0.001) and HR (68.0 ± 11.5 vs 70.5 ± 12.5 bpm, p < 0.001). In multivariable analyses, tilt-test positivity was independently associated with younger age (Odds ratio (OR) per 10 years:1.04; 95% confidence interval (CI), 1.01–1.07, p = 0.014), SBP ≤ 128 mmHg (OR:1.27; 95%CI, 1.11–1.44, p < 0.001), HR ≤ 69 bpm (OR:1.32; 95%CI, 1.17–1.50, p < 0.001), and absence of hypertension (OR:1.58; 95%CI, 1.38–1.81, p < 0.001). In conclusion, among patients with suspected reflex syncope, younger age, lower blood pressure and lower heart rate are associated with positive tilt-test result.
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Affiliation(s)
- Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden. .,Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden.
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Madeleine Johansson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden
| | - Martina Rafanelli
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Irene Marozzi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Alice Ceccofiglio
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Niccolò Casini
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Brian Olshansky
- Division of Cardiology, Department of Internal Medicine, University of Iowa Hospitals, Iowa City, IA, USA
| | - Richard Sutton
- Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden.,Department of Cardiology, National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Michele Brignole
- Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Gianfranco Parati
- Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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11
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Brignole M, Rivasi G, Sutton R, Kenny RA, Morillo CA, Sheldon R, Raj SR, Ungar A, Furlan R, van Dijk G, Hamdan M, Hamrefors V, Engström G, Park C, Soranna D, Zambon A, Parati G, Fedorowski A. Low-blood pressure phenotype underpins the tendency to reflex syncope. J Hypertens 2021; 39:1319-1325. [PMID: 33560050 PMCID: PMC8183486 DOI: 10.1097/hjh.0000000000002800] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/04/2020] [Accepted: 12/30/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND We hypothesized that cardiovascular physiology differs in reflex syncope patients compared with the general population, predisposing such individuals to vasovagal reflex. METHODS In this multicohort cross-sectional study, we compared aggregate data of resting SBP, DBP, pulse pressure (PP) and heart rate (HR), collected from six community-based cohort studies (64 968 observations) with those from six databases of reflex syncope patients (6516 observations), subdivided by age decades and sex. RESULTS Overall, in male individuals with reflex syncope, SBP (-3.4 mmHg) and PP (-9.2 mmHg) were lower and DBP (+2.8 mmHg) and HR (+5.1 bpm) were higher than in the general population; the difference in SBP was higher at ages above 60 years. In female individuals, PP (-6.0 mmHg) was lower and DBP (+4.7 mmHg) and HR (+4.5 bpm) were higher than in the general population; differences in SBP were less pronounced, becoming evident only above 60 years. Compared with male individuals, SBP in female individuals exhibited slower increase until age 40 years, and then demonstrated steeper increase that continued throughout remaining life. CONCLUSION The patients prone to reflex syncope demonstrate a different resting cardiovascular haemodynamic profile as compared with a general population, characterized by lower SBP and PP, reflecting reduced venous return and lower stroke volume, and a higher HR and DBP, suggesting the activation of compensatory mechanisms. Our data contribute to a better understanding why some individuals with similar demographic characteristics develop reflex syncope and others do not. VIDEO ABSTRACT http://links.lww.com/HJH/B580.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milan
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Ducane Road, London, UK
| | - Rose Anne Kenny
- Chair Medical Gerontology, Syncope and Falls Unit, School of Medicine, St James Hospital and Trinity College, Dublin, Ireland
| | - Carlos A. Morillo
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Robert Sheldon
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Satish R. Raj
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Raffaello Furlan
- Internal Medicine, Humanitas Clinical and Research Center-IRCCS, Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mohamed Hamdan
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Chloe Park
- MRC Unit for Lifelong Health and Ageing, Institute of Cardiovascular Science, University College, London, UK
| | | | - Antonella Zambon
- IRCCS Istituto Auxologico Italiano, Biostatistics Unit
- Department of Statistics and quantitative methods, University of Milano-Bicocca
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milan
- Department of Medicine and Surgery, University of Milano Bicocca and IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milan, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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12
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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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13
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Benditt DG, van Dijk JG, Krishnappa D, Adkisson WO, Sakaguchi S. Neurohormones in the Pathophysiology of Vasovagal Syncope in Adults. Front Cardiovasc Med 2020; 7:76. [PMID: 32478097 PMCID: PMC7232538 DOI: 10.3389/fcvm.2020.00076] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/14/2020] [Indexed: 02/02/2023] Open
Abstract
Vasovagal syncope (VVS) is the most common cause of syncope across all age groups. Nonetheless, despite its clinical importance and considerable research effort over many years, the pathophysiology of VVS remains incompletely understood. In this regard, numerous studies have been undertaken in an attempt to improve insight into the evolution of VVS episodes and many of these studies have examined neurohormonal changes that occur during the progression of VVS events primarily using the head-up tilt table testing model. In this regard, the most consistent finding is a marked increase in epinephrine (Epi) spillover into the circulation beginning at an early stage as VVS evolves. Reported alterations of circulating norepinephrine (NE), on the other hand, have been more variable. Plasma concentrations of other vasoactive agents have been reported to exhibit more variable changes during a VVS event, and for the most part change somewhat later, but in some instances the changes are quite marked. The neurohormones that have drawn the most attention include arginine vasopressin [AVP], adrenomedullin, to a lesser extent brain and atrial natriuretic peptides (BNP, ANP), opioids, endothelin-1 (ET-1) and serotonin. However, whether some or all of these diverse agents contribute directly to VVS pathophysiology or are principally a compensatory response to an evolving hemodynamic crisis is as yet uncertain. The goal of this communication is to summarize key reported neurohumoral findings in VVS, and endeavor to ascertain how they may contribute to observed hemodynamic alterations during VVS.
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Affiliation(s)
- David G Benditt
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia and Syncope Center, University of Minnesota Medical School, Minneapolis, MN, United States
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Darshan Krishnappa
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia and Syncope Center, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Wayne O Adkisson
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia and Syncope Center, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Scott Sakaguchi
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia and Syncope Center, University of Minnesota Medical School, Minneapolis, MN, United States
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14
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Raj SR, Ahmed SB, Sheldon RS. Understanding vasovagal syncope: a role for sex and gender. Clin Auton Res 2020; 30:369-370. [PMID: 32300948 DOI: 10.1007/s10286-020-00689-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 01/11/2023]
Affiliation(s)
- Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, GAC70 HRIC Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada. .,Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Sofia B Ahmed
- Department of Medicine, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, GAC70 HRIC Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Medicine, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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15
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van Dijk JG, van Rossum IA, Thijs RD. Timing of Circulatory and Neurological Events in Syncope. Front Cardiovasc Med 2020; 7:36. [PMID: 32232058 PMCID: PMC7082775 DOI: 10.3389/fcvm.2020.00036] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/24/2020] [Indexed: 11/13/2022] Open
Abstract
Syncope usually lasts less than a minute, in which short time arterial blood pressure temporarily falls enough to decrease brain perfusion so much that loss of consciousness ensues. Blood pressure decreases quickest when the heart suddenly stops pumping, which happens in arrhythmia and in severe cardioinhibitory reflex syncope. Loss of consciousness starts about 8 s after the last heart beat and circulatory standstill occurs after 10-15 s. A much slower blood pressure decrease can occur in syncope due to orthostatic hypotension Standing blood pressure can then stabilize at low values often causing more subtle signs (i.e., inability to act) but often not low enough to cause loss of consciousness. Cerebral autoregulation attempts to keep cerebral blood flow constant when blood pressure decreases. In reflex syncope both the quick blood pressure decrease and its low absolute value mean that cerebral autoregulation cannot prevent syncope. It has more protective value in orthostatic hypotension. Neurological signs are related to the severity and timing of cerebral hypoperfusion. Several unanswered pathophysiological questions with possible clinical implications are identified.
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Affiliation(s)
- J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Ineke A van Rossum
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
- Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands
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16
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Barón-Esquivias G, Barón-Solís C, Ordóñez A. Pacing for Patients Suffering From Cardioinhibitory Vasovagal Syncope Using the Closed-Loop System. Front Cardiovasc Med 2020; 6:192. [PMID: 32118042 PMCID: PMC7033422 DOI: 10.3389/fcvm.2019.00192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022] Open
Abstract
One in three vasovagal syncope (VVS) patients has syncopal recurrence after diagnosis, despite the standard recommendations for the avoidance of a recurrence, and one in five patients has more than one syncopal recurrence in the medium term. Given the high prevalence of VVS, there is a large population that continues to need effective treatment. There are numerous studies that use the implantable loop recorder (ILR) to document a cardioinhibitory response during VVS, with one study, ISSUE-3, demonstrating the efficacy of pacing using the rate-drop-response algorithm to trigger pacing and prevent syncopal recurrence in this population. There are more uncertainties in the studies that have used head-up tilt test (HUT) to select the population for pacing. We have recently performed the SPAIN randomized, controlled clinical trial using HUT to select the patients for pacing. The conclusion of the study was that, with the closed-loop system to introduce pacing, there was a significant reduction in the burden of syncope and a seven-fold increase in the time to first recurrence of syncope, which was greater than in the ISSUE-3 study. Since the completion of the SPAIN trial and its inclusion in the European guidelines, in our daily clinical practice, the use of this therapy is still recommended with caution in the context of the available literature, but it has increased our confidence in so doing. One in five patients with VVS needs treatment because of a high syncopal load. If an ILR is used to select the patients for pacing, the rate-drop-response algorithm can be recommended. In patients who have asystole on HUT, pacing with the closed-loop system has higher success and must now be considered as a tenable option for VVS patients.
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Affiliation(s)
- Gonzalo Barón-Esquivias
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain.,Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain.,Centro de Investigacion en Biomedicina en Red Cardiovascular (CIBER-CV), Madrid, Spain
| | - Carmen Barón-Solís
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain
| | - Antonio Ordóñez
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain.,Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain.,Centro de Investigacion en Biomedicina en Red Cardiovascular (CIBER-CV), Madrid, Spain.,Centro Superior de Investigaciones Científicas (CSIC), Madrid, Spain
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17
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Lindenberger M, Fedorowski A, Melander O, Gallo W, Engvall J, Skoog J. Cardiovascular biomarkers and echocardiographic findings at rest and during graded hypovolemic stress in women with recurrent vasovagal syncope. J Cardiovasc Electrophysiol 2019; 30:2936-2943. [DOI: 10.1111/jce.14207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/19/2019] [Accepted: 09/26/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Marcus Lindenberger
- Department of CardiologyLinköping University HospitalLinköping Sweden
- Department of Medical and Health SciencesLinköping UniversityLinköping Sweden
| | - Arthur Fedorowski
- Department of Clinical SciencesLund UniversityMalmö Sweden
- Department of CardiologySkåne University HospitalMalmö Sweden
| | - Olle Melander
- Department of Clinical SciencesLund UniversityMalmö Sweden
| | - Widet Gallo
- Department of Clinical SciencesLund UniversityMalmö Sweden
| | - Jan Engvall
- Department of Medical and Health SciencesLinköping UniversityLinköping Sweden
| | - Johan Skoog
- Department of Medical and Health SciencesLinköping UniversityLinköping Sweden
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18
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Fedorowski A, Sutton R. Reply to the letter to the Editor of Marx et al. J Cardiovasc Electrophysiol 2019; 30:1395. [DOI: 10.1111/jce.13920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/16/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Artur Fedorowski
- Department of Clinical SciencesLund University Malmö Sweden
- Department of CardiologySkåne University Hospital Malmö Sweden
| | - Richard Sutton
- National Heart & Lung Institute, Imperial College, Hammersmith Hospital London United Kingdom
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19
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Torabi P, Ricci F, Hamrefors V, Melander O, Sutton R, Benditt DG, Fedorowski A. Impact of Cardiovascular Neurohormones on Onset of Vasovagal Syncope Induced by Head-up Tilt. J Am Heart Assoc 2019; 8:e012559. [PMID: 31208249 PMCID: PMC6645642 DOI: 10.1161/jaha.119.012559] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Vasovagal reflex is the most common form of syncope, but the pathophysiological mechanisms that initiate the reflex are not well understood. We aimed to study supine and early orthostatic levels of the neurohormones involved in control of circulatory homeostasis in relation to the onset of tilt‐induced vasovagal syncope (VVS). Methods and Results A total of 827 patients who were investigated for unexplained syncope with head‐up tilt test (HUT) and optional nitroglycerin provocation (Italian protocol) had blood samples collected while supine and after 3‐minutes of HUT. Of these, 173 (20.9%) patients developed VVS during drug‐free HUT, 161 of whom (males 44.7%; age 45±21 years) had complete data. We analyzed levels of epinephrine, norepinephrine, C‐terminal pro–arginine vasopressin, C‐terminal endothelin‐1, and midregional fragments of pro–atrial natriuretic peptide and pro‐adrenomedullin in relation to time from tilt‐up to onset of VVS. We applied a linear regression model adjusted for age and sex. The mean time to syncope was 11±7 minutes. Older age (β=0.13; SE=0.03, P<0.001), higher supine systolic blood pressure (β=0.06; SE=0.03, P=0.02), and higher supine midregional fragment of pro‐adrenomedullin predicted longer time to syncope (β=2.31; SE=0.77, P=0.003), whereas supine levels of other neurohormones were not associated with time to syncope. Among 151 patients who developed VVS later than 3 minutes of HUT, increase in epinephrine (β=−3.24; SE=0.78, P<0.001) and C‐terminal pro–arginine vasopressin (β=−2.07; SE=0.61, P=0.001) at 3 minutes of HUT were related to shorter time to syncope. Conclusions Older age, higher blood pressure, and higher level of pro‐adrenomedullin are associated with later onset of VVS during tilt testing, whereas greater increase of tilt‐induced epinephrine and vasopressin release correlate with shorter time to syncope. See Editorial Williford et al
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Affiliation(s)
- Parisa Torabi
- 1 Department of Clinical Sciences Lund University Malmö Sweden.,2 Department of Clinical Physiology Skåne University Hospital Malmö Sweden
| | - Fabrizio Ricci
- 1 Department of Clinical Sciences Lund University Malmö Sweden.,3 Department of Neuroscience, Imaging and Clinical Sciences "G. d'Annunzio" University Chieti Italy.,4 Fondazione Villa Serena per la Ricerca Città Sant'Angelo Italy
| | - Viktor Hamrefors
- 1 Department of Clinical Sciences Lund University Malmö Sweden.,5 Department of Internal Medicine Skåne University Hospital Malmö Sweden
| | - Olle Melander
- 1 Department of Clinical Sciences Lund University Malmö Sweden.,5 Department of Internal Medicine Skåne University Hospital Malmö Sweden
| | - Richard Sutton
- 6 National Heart and Lung Institute Imperial College Hammersmith Hospital Campus London United Kingdom
| | - David G Benditt
- 7 Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
| | - Artur Fedorowski
- 1 Department of Clinical Sciences Lund University Malmö Sweden.,8 Department of Cardiology Skåne University Hospital Malmö Sweden
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20
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Abstract
See Article Torabi et al
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Affiliation(s)
- Noah N Williford
- 1 University of Iowa Hospitals & Clinics the Veterans Affairs Medical Center Iowa City IA
| | - Mark W Chapleau
- 1 University of Iowa Hospitals & Clinics the Veterans Affairs Medical Center Iowa City IA
| | - Brian Olshansky
- 1 University of Iowa Hospitals & Clinics the Veterans Affairs Medical Center Iowa City IA
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21
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Kohno R, Detloff BL, Chen LY, Norby FL, Benditt DG. Epinephrine rise concept. J Cardiovasc Electrophysiol 2019; 30:1396-1397. [PMID: 30950548 DOI: 10.1111/jce.13921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Ritsuko Kohno
- Cardiovascular Division, Cardiac Arrhythmia Center, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Barry Ls Detloff
- Cardiovascular Division, Cardiac Arrhythmia Center, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Lin Yee Chen
- Cardiovascular Division, Cardiac Arrhythmia Center, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Faye L Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - David G Benditt
- Cardiovascular Division, Cardiac Arrhythmia Center, University of Minnesota Medical Center, Minneapolis, Minnesota
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