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Guo Y, Lin T, Lin N, Lin H. Effectiveness analysis of deceleration capacity and traditional heart rate variability in diagnosing vasovagal syncope. Front Cardiovasc Med 2024; 11:1333684. [PMID: 39290211 PMCID: PMC11405235 DOI: 10.3389/fcvm.2024.1333684] [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: 11/05/2023] [Accepted: 08/13/2024] [Indexed: 09/19/2024] Open
Abstract
Background Vasovagal syncope (VVS) is a prevalent medical condition with a lack of efficient methods for its detection. Aim This study aimed to explore an objective clinical indicator in diagnosing VVS. Methods The retrospective analysis involved clinical data of 243 syncope patients from 1 June 2020 to 31 July 2023. Among them, 108 patients had a negative result in the tilt test (TTT), while the remaining 135 patients had a positive result in the TTT. Relevant statistical methods were utilized to examine the correlation between VVS and different indicators of heart rate variability. Results After screening, 354 patients being considered for VVS were evaluated, resulting in a final sample size of 243. Sex, age, deceleration capacity (DC), and standard deviation of all normal-to-normal intervals (SDNNs) were the variables that showed statistical significance between the TTT(-) group and the TTT(+) group. Independent risk factors identified by multivariate logistic regression were DC [odds ratio (OR) 1.710, 95% confidence interval (CI) 1.388-2.106, P < 0.001] and SDNN (OR 1.033, 95% CI 1.018-1.049, P < 0.001). Comparing the groups, receiver operating characteristic analysis revealed a notable distinction in both DC and SDNN [the respective areas under the curve were 0.789 (95% CI 0.730-0.848) and 0.702 (95% CI 0.637-0.767); the cutoff values were 7.15 and 131.42; P < 0.001, respectively]. Conclusion In summary, DC can function as an impartial and easily accessible clinical marker for differentiating VVS. A value exceeding 7.15 ms might suggest a higher likelihood of syncope.
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Affiliation(s)
- Yongzhe Guo
- Department of Cardiology, Fujian Heart Medical Center, Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, China
| | - Tao Lin
- Department of Epidemiology, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Nanyu Lin
- Department of Cardiology, Fujian Heart Medical Center, Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, China
| | - Huizhong Lin
- Department of Cardiology, Fujian Heart Medical Center, Fujian Institute of Coronary Heart Disease, Fujian Medical University Union Hospital, Fuzhou, China
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Goh CH, Ferdowsi M, Gan MH, Kwan BH, Lim WY, Tee YK, Rosli R, Tan MP. Assessing the efficacy of machine learning algorithms for syncope classification: A systematic review. MethodsX 2024; 12:102508. [PMID: 38162148 PMCID: PMC10755776 DOI: 10.1016/j.mex.2023.102508] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Syncope is a transient loss of consciousness with rapid onset. The aims of the study were to systematically evaluate available machine learning (ML) algorithm for supporting syncope diagnosis to determine their performance compared to existing point scoring protocols. We systematically searched IEEE Xplore, Web of Science, and Elsevier for English articles (Jan 2011 - Sep 2021) on individuals aged five and above, employing ML algorithms in syncope detection with Head-up titl table test (HUTT)-monitored hemodynamic parameters and reported metrics. Extracted data encompassed subject count, age range, syncope protocols, ML type, hemodynamic parameters, and performance metrics. Of the 6301 studies initially identified, 10 studies, involving 1205 participants aged 5 to 82 years, met the inclusion criteria, and formed the basis for it. Selected studies must use ML algorithms in syncope detection with hemodynamic parameters recorded throughout HUTT. The overall ML algorithm performance achieved a sensitivity of 88.8% (95% CI: 79.4-96.1%), specificity of 81.5% (95% CI: 69.8-92.8%) and accuracy of 85.8% (95% CI: 78.6-92.8%). Machine learning improves syncope diagnosis compared to traditional scoring, requiring fewer parameters. Future enhancements with larger databases are anticipated. Integrating ML can curb needless admissions, refine diagnostics, and enhance the quality of life for syncope patients.
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Affiliation(s)
- Choon-Hian Goh
- Department of Mechatronics and BioMedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
- Centre for Healthcare Science and Technology, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
| | - Mahbuba Ferdowsi
- Department of Mechatronics and BioMedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
- Centre for Healthcare Science and Technology, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
| | - Ming Hong Gan
- Department of Mechatronics and BioMedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
| | - Ban-Hoe Kwan
- Department of Mechatronics and BioMedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
- Centre for Healthcare Science and Technology, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
| | - Wei Yin Lim
- Electrical and Computer Systems Engineering, School of Engineering and Advanced Engineering Platform, Monash University Malaysia, Bandar Sunway 47500, Selangor, Malaysia
| | - Yee Kai Tee
- Department of Mechatronics and BioMedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
- Centre for Healthcare Science and Technology, Universiti Tunku Abdul Rahman, 43000 Kajang, Selangor, Malaysia
| | - Roshaslina Rosli
- ACT4Health Services and Consultancy, 47300 Petaling Jaya, Malaysia
| | - Maw Pin Tan
- Ageing and Age-Associated Disorders Research Group, Department of Medicine, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
- Department Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, 47500 Bandar Sunway, Malaysia
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Martone AM, Parrini I, Ciciarello F, Galluzzo V, Cacciatore S, Massaro C, Giordano R, Giani T, Landi G, Gulizia MM, Colivicchi F, Gabrielli D, Oliva F, Zuccalà G. Recent Advances and Future Directions in Syncope Management: A Comprehensive Narrative Review. J Clin Med 2024; 13:727. [PMID: 38337421 PMCID: PMC10856004 DOI: 10.3390/jcm13030727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Syncope is a highly prevalent clinical condition characterized by a rapid, complete, and brief loss of consciousness, followed by full recovery caused by cerebral hypoperfusion. This symptom carries significance, as its potential underlying causes may involve the heart, blood pressure, or brain, leading to a spectrum of consequences, from sudden death to compromised quality of life. Various factors contribute to syncope, and adhering to a precise diagnostic pathway can enhance diagnostic accuracy and treatment effectiveness. A standardized initial assessment, risk stratification, and appropriate test identification facilitate determining the underlying cause in the majority of cases. New technologies, including artificial intelligence and smart devices, may have the potential to reshape syncope management into a proactive, personalized, and data-centric model, ultimately enhancing patient outcomes and quality of life. This review addresses key aspects of syncope management, including pathogenesis, current diagnostic testing options, treatments, and considerations in the geriatric population.
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Affiliation(s)
- Anna Maria Martone
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Iris Parrini
- Department of Cardiology, Mauriziano Hospital, Largo Filippo Turati, 62, 10128 Turin, Italy
| | - Francesca Ciciarello
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | - Vincenzo Galluzzo
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | - Stefano Cacciatore
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Claudia Massaro
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Rossella Giordano
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Tommaso Giani
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Giovanni Landi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | | | - Furio Colivicchi
- Division of Cardiology, San Filippo Neri Hospital-ASL Roma 1, Via Giovanni Martinotti, 20, 00135 Rome, Italy;
| | - Domenico Gabrielli
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy;
| | - Fabrizio Oliva
- “A. De Gasperis” Cardiovascular Department, Division of Cardiology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, 3, 20162 Milan, Italy;
| | - Giuseppe Zuccalà
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
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Brignole M, Groppelli A, Russo V, Fedorowski A, van Dijk G, Alboni P. The Rate of Asystolic Reflex Syncope Is Not Influenced by Age. JACC Clin Electrophysiol 2023:S2405-500X(23)00901-5. [PMID: 38243997 DOI: 10.1016/j.jacep.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND The head-up tilt test (HUT) and other evidence suggest that the vagal effect on the heart decreases with age. OBJECTIVES The main aim of the study was to assess whether this age effect also affects the rate of asystole in spontaneous reflex syncope (RS). METHOD We performed an analysis of pooled individual data from 4 studies that recruited patients ≥40 years of age affected by certain or suspected RS who received an implantable loop recorder (ILR) and reported follow-up data on syncope recurrence. We assessed the presence of asystolic syncope of >3 seconds or nonsyncopal asystole of >6 seconds recorded by ILR and compared the findings to tilt test results on the same patients. RESULTS A total of 1,046 patients received ILR because of unexplained syncope. Of these, 201 (19.2%) had a documentation of an asystolic event of 10-second (Q1-Q3: 6- to 15-second) duration. They were subdivided in 3 age tertiles: ≤60 years (n = 64), 61 to 72 years (n = 72), and ≥73 years (n = 65). The rate of asystolic events was similar in the 3 subgroups (50.1%, 50.1%, and 49.2%, respectively; P = 0.99). Conversely, the rate of asystolic syncope induced during HUT (performed in 169 of 201) was greatly age dependent (31.0%, 12.1%, and 11.1% in increasing age tertiles, respectively; P = 0.009). CONCLUSIONS The rate of the spontaneous asystolic form of RS documented by ILR is constant at any age >40 years. Conversely, the rate of asystolic syncope induced by HUT is higher in younger patients and decreases with age. The contrasting results between spontaneous and tilt-induced events cast doubt on the concept that asystole in RS is less common in older patients.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milan, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Ospedale San Luca, Milan, Italy.
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Monaldi Hospital, Naples, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Solna, Sweden; Department of Medicine, Karolinska Institute, Solna, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Paolo Alboni
- Section of Cardiology, Ospedale Privato Quisisana, Ferrara, Italy
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Russo V, Parente E, Comune A, Laezza N, Rago A, Golino P, Nigro G, Brignole M. The clinical presentation of syncope influences the head-up tilt test responses. Eur J Intern Med 2023; 110:41-47. [PMID: 36639324 DOI: 10.1016/j.ejim.2023.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/08/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Little is still known about the positivity rate of nitroglycerin (NTG) potentiated head-up tilt test (HUTT) according to the history-based clinical features of syncope. The study aimed to compare the HUTT positivity rate and type of responses in patients with classical and non-classical vasovagal syncope (VVS). MATERIALS AND METHODS We retrospectively evaluated all consecutive patients who underwent NTG-potentiated HUTT for VVS. The study population was dichotomized into classical and non-classical VVS. RESULTS A total of 1285 VVS patients (45± 19.1 years; 49.6% male) were enrolled: 627 (48.8%) had a history of classical VVS and 658 (51.2%) of non-classical VVS. HUTT was positive in 866 (67.4%) patients. The positivity rate was significantly higher in patients with classical compared to those with non-classical VVS (81.5% vs 54%; P< 0.0001). Cardioinhibitory response showed similar total positivity rate (27.6% vs 31%; P= 0.17), but higher relative prevalence among positive tests (57.7% vs 33.9%, P< 0.0001) in patients with non-classical VVS. At multivariable analysis, classical reflex syncope, male sex, history of traumatic syncope and use of diuretics were independent predictors of HUTT positivity. CONCLUSION The clinical presentation of syncope influences the overall HUTT positivity rate and the type of responses. Cardioinhibitory response and traumatic syncope are more likely in patients with non-classical VVS.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy.
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Nunzia Laezza
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Paolo Golino
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
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Russo V, Parente E, Groppelli A, Rivasi G, Tomaino M, Gargaro A, Giacopelli D, Ungar A, Parati G, Fedorowski A, Sutton R, van Dijk JG, Brignole M. Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology. Europace 2023; 25:263-269. [PMID: 36796797 PMCID: PMC10103574 DOI: 10.1093/europace/euac154] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
This review addresses tilt-testing methodology by searching the literature which reports timing of asystole and loss of consciousness (LOC). Despite the Italian protocol being the most widely adopted, its stipulations are not always followed to the letter of the European Society of Cardiology guidelines. The discrepancies permit reassessment of the incidence of asystole when tilt-down is early, impending syncope, compared with late, established LOC. Asystole is uncommon with early tilt down and diminishes with increasing age. However, if LOC is established as test-end, asystole is more common, and it is age-independent. Thus, the implications are that asystole is commonly under-diagnosed by early tilt-down. The prevalence of asystolic responses observed using the Italian protocol with a rigorous tilt down time is numerically close to that observed during spontaneous attacks by electrocardiogram loop recorder. Recently, tilt-testing has been questioned as to its validity but, in selection of pacemaker therapy in older highly symptomatic vasovagal syncope patients, the occurrence of asystole has been shown to be an effective guide for treatment. The use of head-up tilt test as an indication for cardiac pacing therapy requires pursuing the test until complete LOC. This review offers explanations for the findings and their applicability to practice. A novel interpretation is offered to explain why pacing induced earlier may combat vasodepression by raising the heart rate when sufficient blood remains in the heart.
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Affiliation(s)
- Vincenzo Russo
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Erika Parente
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Marco Tomaino
- Ospedale Generale Regionale, Via Lorenz Böhler, 5, 39100 Bolzano, Italy
| | - Alessio Gargaro
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Daniele Giacopelli
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
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Sun R, Kang Y, Zhang M, Wang H, Shi L, Li X. Development of a nomogram model to predict malignant vasovagal syncope in Chinese children. Front Pediatr 2023; 11:1158537. [PMID: 37077332 PMCID: PMC10109463 DOI: 10.3389/fped.2023.1158537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/17/2023] [Indexed: 04/21/2023] Open
Abstract
Objective Vasovagal syncope (VVS) is the commonest form of syncope, and malignant VVS draws substantial attention due to its life-threatening cardiac asystolic risk. This study aimed to explore the predictive role of a wide panel of clinical indicators for malignant VVS in children, and further to develop a nomogram model. Methods This is a retrospective case-control study. VVS is diagnosed based on head-up tilt test (HUTT). STATA software (version 14.0) was used for statistical analysis, and effect sizes are expressed as odds ratio (OR) and 95% confidence interval (CI). Results Total 370 children with VVS were analyzed, and of them 16 children had malignant VVS. Sixteen malignant VVS and 64 non-malignant VVS were matched on age and sex by a 1:4 propensity scores matching method. Mean corpuscular hemoglobin (MCH) and standard deviation of average RR intervals milliseconds (SDANN) were significantly and independently associated with malignant VVS after adjusting for confounders, with OR reaching 1.437 (95% CI: 1.044 to 1.979; P = 0.026) and 1.035 (95% CI: 1.003 to 1.068; P = 0.029), respectively. Calibration and discrimination analyses revealed that the addition of MCH and SDANN can enhance model performance. Then, a nomogram to predict malignant VVS was developed using general characteristics and two above significant factors, and higher values in medical history, number of syncope, MCH and SDANN were associated with a greater risk of malignant VVS. Conclusion MCH and SDANN were two promising factors for the development of malignant VVS, and modeling of significant factors in a nomogram can provide strong reference to aid clinical decision-making.
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Affiliation(s)
- Rui Sun
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
- Department of Cardiology, Capital Institute of Pediatrics-Peking University Teaching Hospital, Beijing, China
| | - Yingying Kang
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
- Graduate School of Peking Union Medical College, Capital Institute of Pediatrics, Beijing, China
| | - Mingming Zhang
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Hongmao Wang
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Lin Shi
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Xiaohui Li
- Department of Cardiology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
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Abstract
INTRODUCTION Cardioneuroablation is increasingly being utilized to improve outcomes in patients with vagally mediated bradyarrhythmias. However, there are still controversial issues in the field including patient selection, safety and efficacy, and procedural end-points. AREAS COVERED In this review, the current role of cardioneuroablation is summarized, and controversial issues related to the modality are discussed. EXPERT OPINION According to small open-label cohort studies, overall freedom from syncope recurrence was higher than 90% after cardioneuroablation in patients with vasovagal syncope (VVS). Use of the electrogram-based strategy or high-frequency stimulation demonstrate similar success rate except in procedures limited to the right atrium. Based on a recently published randomized controlled trial and metanalysis, it may be possible now to make a strong recommendation for cardioneuroablation in patients <40 years of age, and those with the cardioinhibitory or mixed type of VVS who continue to experience frequent and/or burdensome syncope recurrences. Considering patients with VVS are prone to significant placebo/expectation effect, sham-controlled trials may help to quantify the placebo effect. In well-selected patients with functional atrioventricular block and sinus bradycardia, may result in encouraging medium-term outcomes. However, functional bradycardia is identified in a minority of patients presenting with high-grade atrioventricular block or sinus node dysfunction.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Asad Khan
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Henry Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
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9
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Bennett AJ, Levine BD. The argument against tilt table testing in the geriatric population. J Am Geriatr Soc 2022; 70:3293-3295. [PMID: 36254345 DOI: 10.1111/jgs.18053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/30/2021] [Accepted: 01/01/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Ari J Bennett
- Cardiology Division, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Cardiology Division, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Benjamin D Levine
- Cardiology Division, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Exercise Physiology, Institute for Exercise and Environmental Medicine, Dallas, Texas, USA
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10
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Morillo CA, Brignole M. Pacing for vasovagal syncope: Tips for use in practice. Auton Neurosci 2022; 241:102998. [DOI: 10.1016/j.autneu.2022.102998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 05/17/2022] [Accepted: 05/30/2022] [Indexed: 11/27/2022]
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Russo V, Parente E, Rago A, Comune A, Laezza N, Papa AA, Chamberland C, Huynh T, Golino P, Brignole M, Nigro G. Cardioinhibitory syncope with asystole during nitroglycerin potentiated head up tilt test: prevalence and clinical predictors. Clin Auton Res 2022; 32:167-173. [PMID: 35524080 PMCID: PMC9236999 DOI: 10.1007/s10286-022-00864-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/04/2022] [Indexed: 11/21/2022]
Abstract
AIMS The aim of our study was to evaluate the prevalence and clinical predictors of cardioinhibitory (CI) responses with asystole at the nitroglycerin (NTG)-potentiated head-up tilt test (HUTT) in patients with a history of syncope admitted to a tertiary referral syncope unit. METHODS We retrospectively evaluated all consecutive patients who underwent NTG-potentiated HUTT for suspected reflex syncope at our institution from March 1 2017 to May 1 2020. The prevalence of HUTT-induced CI syncope was assessed. Univariate and multivariate analyses were performed to test the association of asystolic response to HUTT with a set of clinical covariates. RESULTS We enrolled 1285 patients (45 ± 19.1 years; 49.6% male); 368 (28.6%) showed HUTT-induced CI response with asystole. A multivariate analysis revealed that the following factors were independently associated with HUTT-induced CI syncope: male sex (OR 1.48; ConInt 1.14-1.92; P = 0.003), smoking (OR 2.22; ConInt 1.56-3.115; P < 0.001), traumatic syncope (OR: 2.81; ConInt 1.79-4.42; P < 0.001), situational syncope (OR 0.45; ConInt 0.27-0.73; P = 0.002), and the use of diuretics (OR 9.94; ConInt 3.83-25.76; P < 0.001). CONCLUSIONS The cardioinhibitory syncope with asystole induced by NTG-potentiated HUTT is more frequent than previously reported. The male gender, smoking habit, history of traumatic syncope, and use of diuretics were independent predictors of HUTT-induced CI responses. Conversely, the history of situational syncope seems to reduce this probability.
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Affiliation(s)
- Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy.
| | - Erika Parente
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Nunzia Laezza
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Andrea Antonio Papa
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | | | - Thao Huynh
- Division of Cardiology, McGill Health University, McGill University, Montreal, Canada
| | - Paolo Golino
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Michele Brignole
- Faint & Fall programme, Department of Cardiology, IRCCS Istituto Auxologico Italiano - San Luca Hospital, Milan, Italy
| | - Gerardo Nigro
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
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12
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Jorge JG, Raj SR, Teixeira PS, Teixeira JAC, Sheldon RS. Likelihood of injury due to vasovagal syncope: a systematic review and meta-analysis. Europace 2021; 23:1092-1099. [PMID: 33693816 DOI: 10.1093/europace/euab041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Vasovagal syncope (VVS) is the most common type of syncope and is usually considered a benign disorder. The potential for injury is worrisome but the likelihood is unknown. We aimed to determine the proportion of patients injured due to VVS. METHODS AND RESULTS A systematic search of studies published until August 2020 was performed in multiple medical and nursing databases. Included studies had data on the proportion of patients with injury due to VVS prior to study enrolment. Random effects methods were used. Twenty-three studies having 3593 patients met inclusion criteria. Patients were diagnosed clinically with VVS, and 82% had >2 syncopal episodes before enrolment. Tilt test was positive in 60% and 14 studies reported comorbidities (32.6% hypertensive). The weighted mean injury rate was 33.5% [95% confidence interval (CI): 27.3-40.5%]. The likelihood of injury correlated with population age (r = 0.4, P = 0.05), but not with sex, positive tilt test, or hypertension. The injury rates were 25.7% (95% CI: 19.1-32.8%) in studies with younger patients (mean age ≤50 years, n = 1803) and 43.4% (95% CI: 34.9-52.3%) in studies with older patients (P = 0.002). Nine studies reported major injuries; with a weighted mean rate of major injuries of 13.9% (95% CI: 9.5-19.8%). CONCLUSION Injuries due to syncope are frequent, occurring in 33% of patients with VVS. The risk of major injuries is substantial. Older patients are at higher risk. Clinicians should be aware of the risk of injuries when providing care and advice to patients with VVS.
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Affiliation(s)
- Juliana G Jorge
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Pedro S Teixeira
- Clinica Fit Labor Centro de Performance Humana, Niteroi, Rio de Janeiro, Brazil
| | - Jose A C Teixeira
- Clinica Fit Labor Centro de Performance Humana, Niteroi, Rio de Janeiro, Brazil
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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13
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Brignole M, Kessisoglu F, Croci F, Solano A, Donateo P, Maggi R, Solari D, Bertolone C, Fontana D, Oddone D, Rivasi G, Rafanelli M, Casini N, Ungar A. Complementary effectiveness of carotid sinus massage and tilt testing for the diagnosis of reflex syncope in patients older than 40 years: a cohort study. Europace 2021; 22:1737-1741. [PMID: 33078193 DOI: 10.1093/europace/euaa204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/23/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Indications, methodology, and diagnostic criteria for carotid sinus massage (CSM) and tilt testing (TT) have been standardized by the 2018 Guidelines on Syncope of the European Society of Cardiology. Aim of this study was to assess their effectiveness in a large cohort which reflects the performance under 'real-world' conditions. METHODS AND RESULTS We analysed all patients who had undergone CSM and TT in the years 2003-2019 for suspected reflex syncope. Carotid sinus massage was performed according to the 'Method of Symptoms'. Tilt testing was performed according to the 'Italian protocol' which consists of a passive phase followed by a sublingual nitroglycerine phase. For both tests, positive test was defined as reproduction of spontaneous symptoms in the presence of bradycardia and/or hypotension. Among 3293 patients (mean age 73 ± 12 years, 48% males), 2019 (61%) had at least one test positive. A bradycardic phenotype was found in 420 patients (13%); of these, 60% were identified by CSM, 37% by TT, and 3% had both test positive. A hypotensive phenotype was found in 1733 patients (53%); of these, 98% were identified by TT and 2% had both TT and CSM positive. CONCLUSION The overall diagnostic yield of the tests in patients >40-year-old with suspected reflex syncope was 61%. Both CSM and TT are useful for identifying those patients with a bradycardic phenotype, whereas CSM has a limited value for identifying the hypotensive phenotype. Since the overlap of responses between tests is minimal, both CSM and TT should be performed in every patient over 40 years receiving investigation for unexplained but possible reflex syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Ospedale San Luca, Milano, Italy
| | | | - Francesco Croci
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Alberto Solano
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Paolo Donateo
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Roberto Maggi
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Diana Solari
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Cristina Bertolone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Daniele Fontana
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Daniele Oddone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Giulia Rivasi
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Martina Rafanelli
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Niccolò Casini
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Andrea Ungar
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
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14
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Diagnosis and prevention of the vasodepressor type of neurally mediated syncope in Japanese patients. PLoS One 2021; 16:e0251450. [PMID: 34170907 PMCID: PMC8232444 DOI: 10.1371/journal.pone.0251450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/27/2021] [Indexed: 01/04/2023] Open
Abstract
We investigated circulatory dynamics in patients with vasodepressor type neurally mediated syncope (VT-NMS) by performing high-resolution Holter electrocardiography and a correlation analysis of changes in adenylate cyclase activity, blood pressure, and pulse during the head-up tilt test. Holter electrocardiography was performed for 30 patients. Adenylate cyclase activity was evaluated in lymphocytes from blood samples taken at rest and during the head-up tilt test. There was no change in autonomic nerve fluctuation during electrocardiography in VT-NMS patients, but our results showed a significant difference in blood pressure and adenylate cyclase activity between VT-NMS patients and healthy volunteers; the systolic blood pressure of VT-NMS patients decreased after 5 min, while at 10 min, the adenylate cyclase activity was the highest (0.53%) and the systolic blood pressure was the lowest (111.8 mm Hg). Pulse rates increased after 10 min. VT-NMS patients showed higher blood pressure, pulse rate, and adenylate cyclase activity during the tilt test than did healthy volunteers. In patients with syncope, standing for longer than 10 minutes may increase the risk of VT-NMS. From our results, we consider it likely that high systolic blood pressure and adenylate cyclase activity at rest cause fainting in VT-NMS patients. Our findings may be helpful for identifying individuals with a high risk of developing NMS in the healthy population.
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15
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Moloney D, Romero-Ortuno R, Kenny RA. Vasovagal Syncope. JAMA Intern Med 2021; 181:880. [PMID: 33587095 DOI: 10.1001/jamainternmed.2020.9151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- David Moloney
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Roman Romero-Ortuno
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Rose Anne Kenny
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
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16
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Linde C, Crijns HJGM. Pacing for repeated vagal reflex-mediated syncope: an old problem with a solution. Eur Heart J 2021; 42:517-519. [PMID: 33332532 DOI: 10.1093/eurheartj/ehaa975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cecilia Linde
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden.,Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | - Harry J G M Crijns
- Maastricht University Medical Center, Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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17
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Brignole M, Rivasi G. New insights in diagnostics and therapies in syncope: a novel approach to non-cardiac syncope. Heart 2021; 107:864-873. [PMID: 33462120 DOI: 10.1136/heartjnl-2020-318261] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022] Open
Abstract
This article aims to give advice on how to identify and manage patients with syncope who are at risk of severe outcomes, that is, at risk of trauma, potentially life-threatening episodes or frequent recurrences reducing quality of life. The first step of syncope diagnostic assessment is to identify patients with cardiac syncope, and once established, these patients must receive the adequate mechanism-specific treatment. If cardiac syncope is unlikely, reflex (neurally mediated) syncope and orthostatic hypotension are the most frequent causes of transient loss of consciousness. For these presentations, efficacy of therapy is largely determined by the mechanism of syncope rather than its aetiology or clinical features. The identified mechanism of syncope should be carefully assessed and assigned either to hypotensive or bradycardic phenotype, which will determine the choice of therapy (counteracting hypotension or counteracting bradycardia). The results of recent trials indicate that 'mechanism-specific therapy' is highly effective in preventing recurrences. Established mechanism-specific treatment strategies include withdrawal of hypotensive drugs, applying fludrocortisone and midodrine for the hypotensive phenotype and cardiac pacing in the bradycardic phenotype.
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Affiliation(s)
- Michele Brignole
- Department of Cardiovascular, Neural and Metabolic Sciences, Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence, Firenze, Italy
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18
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Zheng L, Sun W, Liu S, Liang E, Du Z, Guo J, Wu L, Asirvatham SJ, Yao Y. The Diagnostic Value of Cardiac Deceleration Capacity in Vasovagal Syncope. Circ Arrhythm Electrophysiol 2020; 13:e008659. [PMID: 33197331 DOI: 10.1161/circep.120.008659] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increased parasympathetic activity is thought to play important roles in syncope events of patients with vasovagal syncope (VVS). However, direct measurements of the vagal control are difficult. The novel deceleration capacity (DC) of heart rate measure has been used to characterize the vagal modulation. This study aimed to assess vagal control in patients with VVS and evaluate the diagnostic value of the DC in VVS. METHODS Altogether, 161 consecutive patients with VVS (43±15 years; 62 males) were enrolled. Tilt table test was positive in 101 and negative in 60 patients. Sixty-five healthy subjects were enrolled as controls. DC and heart rate variability in 24-hour ECG, echocardiogram, and biochemical examinations were compared between the syncope and control groups. RESULTS DC was significantly higher in the syncope group than in the control group (9.6±3.3 versus 6.5±2.0 ms, P<0.001). DC was similarly increased in patients with VVS with a positive and negative tilt table test (9.7±3.5 and 9.4±2.9 ms, P=0.614). In multivariable logistic regression analyses, DC was independently associated with syncope (odds ratio=1.518 [95% CI, 1.301-1.770]; P=0.0001). For the prediction of syncope, the area under curve analysis showed similar values when comparing single DC and combined DC with other risk factors (P=0.1147). From the receiver operator characteristic curves for syncope discrimination, the optimal cutoff value for the DC was 7.12 ms. CONCLUSIONS DC>7.5 ms may serve as a good tool to monitor cardiac vagal activity and discriminate VVS, particularly in those with negative tilt table test.
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Affiliation(s)
- Lihui Zheng
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College (L.Z., S.L., E.L., Z.D., J.G., L.W., Y.Y.)
| | - Wei Sun
- Department of cardiology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, China (W.S.)
| | - Shangyu Liu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College (L.Z., S.L., E.L., Z.D., J.G., L.W., Y.Y.)
| | - Erpeng Liang
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College (L.Z., S.L., E.L., Z.D., J.G., L.W., Y.Y.)
| | - Zhongpeng Du
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College (L.Z., S.L., E.L., Z.D., J.G., L.W., Y.Y.)
| | - Jingrui Guo
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College (L.Z., S.L., E.L., Z.D., J.G., L.W., Y.Y.)
| | - Lingmin Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College (L.Z., S.L., E.L., Z.D., J.G., L.W., Y.Y.)
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic & Mayo Foundation, Rochester, MN (S.J.A.)
| | - Yan Yao
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College (L.Z., S.L., E.L., Z.D., J.G., L.W., Y.Y.)
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19
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Kajdič N, Zupan Mežnar A, Šinkovec M, Žižek D. Diagnostic yield of implantable loop recorders in patients with unexplained syncope: single-center experience. Minerva Cardiol Angiol 2020; 69:419-425. [PMID: 32989968 DOI: 10.23736/s2724-5683.20.05247-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A significant proportion of patients have syncope of uncertain etiology. While implantable loop recorder (ILR) has become an important diagnostic tool in diagnosing syncope, its contemporary role in accordance with the recently updated syncope guidelines is not well established. The purpose of this single-center retrospective study was to determine the diagnostic yield of ILR in patients with unexplained syncope following initial diagnostic work-up as recommended by the guidelines. METHODS Medical records of 100 consecutive patients with syncope or presyncope who received ILR following the recently updated recommended diagnostic work-up were retrospectively evaluated. RESULTS Seven patients were lost to follow-up (7%). During a median follow-up of 12 months (IQR 6.5-27.5), syncope or presyncope recurred in 61 patients (65.6%). In 37 (37/61, 60.7%), correlation between abnormal heart rhythm and symptoms was confirmed by ILR. Syncope was predominantly caused by bradyarrhythmia (33/37, 89.2%). Of the remaining four patients, three (8.1%) had ventricular tachycardia and one had atrial fibrillation with rapid ventricular response. Arrhythmogenic cause of syncope or presyncope was excluded in 24 patients (24/61, 39.3%) as no arrhythmia was recorded at the time of reported symptoms. Median time to establishing diagnosis was 354 days (171-783). CONCLUSIONS The diagnostic yield of ILR after initial inconclusive recommended diagnostic work-up in accordance with the relevant guidelines was high. The findings affirm ILR as an important diagnostic tool in contemporary management of syncope.
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Affiliation(s)
- Nina Kajdič
- Department of Cardiology, University Medical Center of Ljubljana, Ljubljana, Slovenia
| | - Anja Zupan Mežnar
- Department of Cardiology, University Medical Center of Ljubljana, Ljubljana, Slovenia
| | - Matjaž Šinkovec
- Department of Cardiology, University Medical Center of Ljubljana, Ljubljana, Slovenia
| | - David Žižek
- Department of Cardiology, University Medical Center of Ljubljana, Ljubljana, Slovenia -
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20
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Aksu T, Guler TE, Bozyel S, Yalin K, Gopinathannair R. Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation. Europace 2020; 22:1320-1327. [DOI: 10.1093/europace/euaa230] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
Aims
Previous reports have suggested that cardioneuroablation (CNA) can be effective in reducing syncopal recurrences in patients with vasovagal syncope (VVS). This study assessed the efficacy of CNA in preventing a positive response to head-up tilt testing (HUT).
Methods and results
This is a single-centre retrospective study reviewing prospectively collected data. Fifty-one consecutive patients with VVS were included in the study. After confirmation of >3 s asystole on HUT, all patients underwent CNA. Head-up tilt testing was repeated 1 month after CNA. The main outcome measures were recurrence of syncope episode and positive response on HUT. During a median follow-up period of 11 months (interquartile range 3–27 months), all but 3 (5.8%) of 51 patients were free of syncope. Repeated HUTs were negative in 44 (86.2%) patients. When patients with recurrent syncope were excluded, vasodepressor response was seen in three cases and cardioinhibitory response in one case, respectively. Cardioneuroablation caused significant and durable shortening of RR interval in all cases. This effect was significantly higher in patients without positive HUT responses.
Conclusion
This pilot study shows that CNA can effectively prevent recurrent syncopal episodes in patients with refractory VVS. Head-up tilt testing seems as a valuable diagnostic tool not only to select suitable candidates and but also to evaluate success of CNA.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Tumer Erdem Guler
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Serdar Bozyel
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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21
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de Jong JS, Jardine DL, Lenders JW, Wieling W. Pacing in vasovagal syncope: A physiological paradox? Heart Rhythm 2020; 17:813-820. [DOI: 10.1016/j.hrthm.2019.09.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Indexed: 10/26/2022]
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22
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Bautista-Vargas WF. Asystole in an older patient with recurrent falls. Case report. CASE REPORTS 2020. [DOI: 10.15446/cr.v6n1.82558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Recurrent falls are a usual problema in older patients. It is therefore important to learn how to differentiate a pathological or syncopal episode from a simple stumbling fall, especially in patients who have limitations for communicating clearly and are poorly understood, in general terms, during the medical consultation. Implantable loop recorders (ILR) have been used as an investigation tool in selected cases of recurrent falls in older patients. Consequently, this case report aims to describe its usefulness in this type of patients.Case presentation: An 87-year-old female patient, hypertensive, with a history of recent stroke and frequent falls —referred to as stumbling—, received an implantable loop recorder due to atrial fibrillation. During one follow-up appointment, a 36-second pause related to a fall was documented, so a bicameral pacemaker was implanted.Conclusions: Evaluating repeated falls in older patients is complex; it must be done in detail to rule out syncopal episodes. Implantable devices to diagnose arrhythmic causes are useful and allow achieving accurate diagnoses and establish specific behaviors aimed at improving the quality of life of patients.
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23
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Sediva H, Hnat T, Bonaventura J, Slesarenko J, Veselka J. Head-Up Tilt Test in Risk Stratification of Patients with Hypertrophic Cardiomyopathy. Int J Angiol 2019; 28:245-248. [PMID: 31787823 DOI: 10.1055/s-0039-1688983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Conflicting results have been published considering the role of head-up tilt test (HUTT) positivity as a prognostic factor in patients with hypertrophic cardiomyopathy (HCM). The relationship between HCM patients' genotype and their HUTT results has not been previously reported. The aim of this study was to evaluate patients with HCM and their HUTT results in regard to its value for outcome prediction and to investigate the relation of patients' genotype and their HUTT results. Seventy-four (51 ± 15 years; 42% women; median follow-up 72 months) HCM patients were divided into two groups based on their HUTT results and were retrospectively analyzed. In 67 (90.5%) subjects included in the analysis, next-generation sequencing-based genomic testing was performed. A composite end point of unexplained syncope, heart failure hospitalization, and death was defined. A total of 14 patients (18.9%) had positive HUTT (HUTT+), whereas 60 (81.1%) had negative HUTT (HUTT-). Except for the New York Heart Association functional class ( p = 0.01), both groups had similar characteristics. Positive genotype was evenly distributed between the two groups. Composite end point occurred in 5 patients (35.7%) in HUTT+ group versus 14 (23.3%) patients in HUTT- group ( p = 0.33). We did not find a relationship between HUTT results and long-term outcome. We found no association between HUTT results and genotype.
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Affiliation(s)
- Hana Sediva
- Department of Cardiology, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - T Hnat
- Department of Cardiology, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - J Bonaventura
- Department of Cardiology, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - J Slesarenko
- Department of Cardiology, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - J Veselka
- Department of Cardiology, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
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Komiyama T, Nagata E, Hashida T, Sakama S, Ayabe K, Kamiguchi H, Sasaki A, Yoshioka K, Kobayashi H. Neurally mediated syncope diagnosis based on adenylate cyclase activity in Japanese patients. PLoS One 2019; 14:e0214733. [PMID: 30998713 PMCID: PMC6472876 DOI: 10.1371/journal.pone.0214733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/19/2019] [Indexed: 12/11/2022] Open
Abstract
The study aims to clarify the mechanism in patients with neurally mediated syncope (NMS), focusing on the adenylate cyclase (AC) activity level in lymphocytes. This study included 40 subjects: 22 healthy volunteers and 18 NMS patients. We investigated the changes in AC activity that occur during of syncope at rest and during the head-up tilt (HUT) test. We obtained 8 mL of blood at rest time and four times during the HUT test. Then, we measured the AC activity and the test reagent was added to the lymphocytes (10,000) and reacted for 30 min at room temperature. We were able to determine the standard value of AC activity when adrenaline (AD) and isoproterenol (IP) were added to lymphocytes. The results of our study showed one of the causes of NMS has a difference in AC activity level and classification of the patients into two different types of NMS was possible: either the vasodepressor type (VT) or mixed type (MT). At rest time, VT patients showed significantly higher AC activity (AD; 100 μM: p = 0.005, IP; 50 μM: p = 0.02) and MT patients showed significantly lower AC activity (AD; 10 μM: p = 0.02, IP; 50 μM: p = 0.004) than the average AC activity in healthy volunteers. Moreover, VT patients had significantly higher AC activity than healthy volunteers at the four points of the HUT test. MT patients had significantly lower AC activity (AD: p = 0.04 and IP: p = 0.04) than healthy volunteers at the rest time of HUT. Our study showed a significant difference in AC activities between NMS patients and healthy volunteers at rest. Therefore, a detailed NMS diagnosis can be made by examining AC activity levels in blood taken at rest time.
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Affiliation(s)
- Tomoyoshi Komiyama
- Department of Clinical Pharmacology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Eiichiro Nagata
- Department of Neurology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Tadashi Hashida
- Department of Cardiovascular Internal Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Susumu Sakama
- Department of Cardiovascular Internal Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Kengo Ayabe
- Department of Cardiovascular Internal Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Hiroshi Kamiguchi
- Support Center for Medical Research and Education, Tokai University, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Ayumi Sasaki
- Support Center for Medical Research and Education, Tokai University, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Koichiro Yoshioka
- Department of Cardiovascular Internal Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
| | - Hiroyuki Kobayashi
- Department of Clinical Pharmacology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan
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Kohno R, Nantsupawat T, Benditt DG. Trends in Subcutaneous Cardiac Monitoring Technology. J Innov Card Rhythm Manag 2018; 9:3247-3255. [PMID: 32494499 PMCID: PMC7252872 DOI: 10.19102/icrm.2018.090703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/02/2018] [Indexed: 02/07/2023] Open
Abstract
Ambulatory cardiac monitoring is a rapidly expanding field and one that is likely to progress beyond electrocardiographic (ECG) and blood pressure recordings. To date, the primary cardiac monitoring focus has been ambulatory ECG (AECG) monitoring. In this setting, AECG monitoring has become a diagnostic tool used daily by physicians of many specialties. In this regard, both wearable and subcutaneous ECG monitoring technologies are now widely available, with the appropriate choice for a given patient being best determined by the frequency with which the patient’s symptom recurrences are expected. In other words, the less frequent the symptomatic events, then the longer the monitoring duration requirement should be. However, multiple factors other than the technology used impact success. For example, wearable AECG systems are only capable of monitoring patients for a period of a few days to several weeks due to limited battery longevity, patient intolerance to cutaneous ECG electrodes, the cumbersome nature of the device, or a combination of these factors. Current-generation insertable cardiac monitors (ICMs), on the other hand, offer three years of monitoring and infrequent skin irritation. Additionally, automatic remote download, a valuable feature in many cases, is only offered by certain wearable technologies, but is an option in all currently available ICMs. This report focuses on the current status of subcutaneous ICMs and their indications and limitations. The goal is to highlight the variety of utility of current ICM technologies and to provide insight into potential future subcutaneous ICM applications.
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Affiliation(s)
- Ritsuko Kohno
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Teerapat Nantsupawat
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 993] [Impact Index Per Article: 165.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Walsh KE, Baneck T, Page RL, Brignole M, Hamdan MH. Psychogenic pseudosyncope: Not always a diagnosis of exclusion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:480-486. [PMID: 29478246 DOI: 10.1111/pace.13316] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/18/2018] [Accepted: 01/31/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Psychogenic pseudosyncope (PPS) frequently mimics syncope. The aim of this study was to assess the prevalence and clinical features of PPS and its relationship to vasovagal syncope (VVS). METHODS We examined retrospectively the medical records of 1,401 consecutive patients referred to a syncope unit. We identified patients who had the final diagnosis of PPS. In these patients, we retrieved the initial diagnosis made during their first visit and the subsequent tests performed leading to the final diagnosis. RESULTS Fourteen (1.0%) patients (mean age 35 ± 14; 11 females) were diagnosed as having PPS: seven had a diagnosis of PPS alone and seven had both VVS and PPS. High frequency of attacks (53 ± 35 attacks during the previous year), prolonged loss of consciousness (minutes to > 1 hour), and a history of psychiatric disorders characterized PPS patients. Tilt test reproduced a PPS attack in the presence of normal blood pressure and heart rate in seven patients (50%), and induced VVS in another three patients who had the final diagnosis of both PPS and VVS. In two patients, one or more events occurred during the clinic visits and were directly witnessed by the clinic personnel. CONCLUSIONS We have shown that 1% of referrals to a syncope unit have the final diagnosis of PPS and that up to 50% of cases presented with a different initial diagnosis, namely VVS. Our findings suggest that causality between syncope and psychiatric disorders is likely bidirectional. The presence of a multidisciplinary team is important to address this often unrecognized relationship.
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Affiliation(s)
- Kathleen E Walsh
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Trisha Baneck
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Richard L Page
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michele Brignole
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Genoa, Italy
| | - Mohamed H Hamdan
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Olshansky B. Vasovagal Syncope: To Pace or Not to Pace. J Am Coll Cardiol 2017; 70:1729-1731. [PMID: 28958329 DOI: 10.1016/j.jacc.2017.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 08/15/2017] [Accepted: 08/15/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Brian Olshansky
- Mercy Heart and Vascular Institute, Mason City, Iowa; and the University of Iowa Hospitals, Iowa City, Iowa.
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Vasovagal syncope with asystole: the role of cardiac pacing. Clin Auton Res 2017; 27:245-251. [DOI: 10.1007/s10286-017-0441-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/19/2017] [Indexed: 12/20/2022]
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Brignole M, Guieu R, Tomaino M, Iori M, Ungar A, Bertolone C, Unterhuber M, Bottoni N, Tesi F, Claude Deharo J. Mechanism of syncope without prodromes with normal heart and normal electrocardiogram. Heart Rhythm 2017; 14:234-239. [DOI: 10.1016/j.hrthm.2016.08.046] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Indexed: 12/22/2022]
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da Silva RMFL. The Current Indication for Pacemaker in Patients with Cardioinhibitory Vasovagal Syncope. Open Cardiovasc Med J 2016; 10:179-87. [PMID: 27651841 PMCID: PMC5009292 DOI: 10.2174/1874192401610010179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 05/20/2016] [Accepted: 06/06/2016] [Indexed: 11/22/2022] Open
Abstract
The most frequent cause of syncope is vasovagal reflex. It is associated with worse quality of life, depression, fatigue and physical injury. Recurrence of vasovagal syncope is an aggravating, reaching the rate of 69%. Initial step and pharmacological treatment may not work, especially in patients with recurrent syncope without prodrome. These patients can present cardioinhibitory response with asystole. Studies were designed to analyses the effectiveness of pacemaker for prevention of syncope. In this review, nonrandomized clinical trials, open-label randomized, double-blind randomized, placebo-controlled, and studies based on tilt test or Implantable Loop Recorder findings will be discussed.
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Stout N. Tilt testing: it may be safe but is it any good? Age Ageing 2016; 45:186-7. [PMID: 26941351 DOI: 10.1093/ageing/afw011] [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
Affiliation(s)
- Nigel Stout
- Sunderland Royal Hospital, Kayll Road, Sunderland, Tyne and Wear SR4 7TP, UK
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35
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Saal D, Thijs R, van Dijk J. Tilt table testing in neurology and clinical neurophysiology. Clin Neurophysiol 2016; 127:1022-1030. [DOI: 10.1016/j.clinph.2015.07.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/20/2015] [Accepted: 07/23/2015] [Indexed: 11/29/2022]
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Zyśko D, Fedorowski A, Nilsson D, Rudnicki J, Gajek J, Melander O, Sutton R. Tilt testing results are influenced by tilt protocol. Europace 2015; 18:1108-12. [DOI: 10.1093/europace/euv262] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/09/2015] [Indexed: 11/14/2022] Open
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Dovjak P. [Diagnostics and treatment of syncope]. Z Gerontol Geriatr 2014; 47:703-12; quiz 713-4. [PMID: 25398191 DOI: 10.1007/s00391-014-0824-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A transient loss of consciousness in the elderly is in most cases caused by syncope of cardiac origin. The underlying cause of syncope is of prognostic importance and should be clarified in every single case even if a definitive diagnosis can be established in only approximately two thirds of all cases. The definitive diagnosis is the key for appropriate therapeutic measures to prevent recurrences. Flowcharts can help to implement considerate and efficient stepwise diagnostic procedures. The most important diagnostic measures and treatment options according to medical evidence are presented.
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Affiliation(s)
- Peter Dovjak
- Salzkammergutklinikum Gmunden, Miller von Aichholzstraße 49, 4810, Gmunden, Österreich,
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Sutton R, Brignole M. Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis. Eur Heart J 2014; 35:2211-2212. [DOI: 10.1093/eurheartj/ehu255] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Solbiati M, Sheldon RS. Implantable rhythm devices in the management of vasovagal syncope. Auton Neurosci 2014; 184:33-9. [DOI: 10.1016/j.autneu.2014.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 05/09/2014] [Accepted: 05/19/2014] [Indexed: 11/28/2022]
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Abstract
Insertable cardiac monitors (ICMs) are leadless subcutaneous devices that continuously monitor the heart rhythm and record events over a timeframe measured in years, allowing for the diagnosis of infrequent rhythm abnormalities that can be the cause of palpitations, syncope and stroke. To date, ICMs have primarily been used in the work-up and management of syncope; however, their use in other areas of rhythm evaluation, particularly atrial fibrillation monitoring, is increasing. The Reveal LINQ™ is the smallest and most versatile ICM available and represents a dramatic leap forward in ICM technology that has the potential to transform patient care in a number of circumstances. Device miniaturization, simplified implant procedure and enhanced automation vastly increase physician and patient acceptance. The next 5 years can be expected to bring a greatly increased use of ICMs for disease diagnosis and management in a variety of clinical settings.
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Affiliation(s)
- Todd T Tomson
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 676 North St. Claire, Suite 600, Chicago, IL 60611, USA
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Sutton R, Ungar A, Sgobino P, Russo V, Massa R, Melissano D, Beiras X, Bottoni N, Ebert HH, Francese M, Jorfida M, Giuli S, Moya A, Andresen D, Brignole M. Cardiac pacing in patients with neurally mediated syncope and documented asystole: effectiveness analysis from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3) Registry. Europace 2014; 16:595-9. [PMID: 24406537 DOI: 10.1093/europace/eut323] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS The randomized, double-blind Third International Study on Syncope of Uncertain Etiology (ISSUE-3) showed that dual-chamber permanent pacing was effective in reducing the recurrence of syncope in patients ≥ 40 years with severe asystolic, probably neurally mediated syncope (NMS), documented by implantable loop recorder (ILR). Analysis in ISSUE-3 was performed according to the intention-to-treat principle. In the present study, we performed an on-treatment analysis, which included additionally those non-randomized patients followed up in the ISSUE registry to evaluate in a better manner the effectiveness of cardiac pacing therapy. METHODS AND RESULTS Initially, 504 patients received an ILR, 162 (32%) patients had a diagnosis consistent with NMS within a mean observation period of 15 ± 11 months: 99 (19%) patients had documentation of syncope with ≥ 3 s asystole or ≥ 6 s asystole without syncope. Sixty patients affected by asystolic NMS received cardiac pacing therapy and 86 (33 asystolic and 53 non-asystolic NMS) were untreated; 16 patients were lost to follow-up. Paced and unpaced groups had similar clinical characteristics. During subsequent follow-up, syncope recurred in 10 paced (17%) and in 40 non-paced (46%) patients. At 21 months, the estimated product-limit syncope recurrence rates were 27% [95% confidence interval (CI) 15-47] and 54% (95% CI 43-67), respectively (P = 0.01). With cardiac pacing, the risk of recurrence was reduced by 57% (hazard ratio = 0.43, 95% CI = 0.2-0.8). Complications of pacemaker therapy were haemothorax at implantation in one patient and lead dislodgement that required correction in two patients. CONCLUSION Permanent cardiac pacing is effective in reducing recurrence of syncope in patients ≥ 40 years with severe asystolic possible NMS with a few complications. The study shows that 61% of patients with a diagnosis of NMS made by ILR received a pacemaker but 5.1 ILRs had to be implanted to find one patient who finally had a pacemaker implanted.
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Affiliation(s)
- Richard Sutton
- Department of Cardiology, St. Mary's Hospital, Imperial College Healthcare NHS Trust, W2 1NY London, UK
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