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Wang J, Li H, Huang X, Hu H, Lian B, Zhang D, Wu J, Cao L. Adult vasovagal syncope with abdominal pain diagnosed by head-up tilt combined with transcranial doppler: a preliminary study. BMC Neurol 2024; 24:118. [PMID: 38600450 PMCID: PMC11005138 DOI: 10.1186/s12883-024-03623-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 04/04/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Syncope is a common condition that increases the risk of injury and reduces the quality of life. Abdominal pain as a precursor to vasovagal syncope (VVS) in adults is rarely reported and is often misdiagnosed.. METHODS We present three adult patients with VVS and presyncopal abdominal pain diagnosed by synchronous multimodal detection (transcranial Doppler [TCD] with head-up tilt [HUT]) and discuss the relevant literature. RESULTS Case 1: A 52-year-old man presented with recurrent decreased consciousness preceded by six months of abdominal pain. Physical examinations were unremarkable. Dynamic electrocardiography, echocardiography, head and neck computed tomography angiography, magnetic resonance imaging (MRI), and video electroencephalogram showed no abnormalities. Case 2: A 57-year-old woman presented with recurrent syncope for 30 + years, accompanied by abdominal pain. Physical examination, electroencephalography, and MRI showed no abnormalities. Echocardiography showed large right-to-left shunts. Case 3: A 30-year-old woman presented with recurrent syncope for 10 + years, with abdominal pain as a precursor. Physical examination, laboratory analysis, head computed tomography, electrocardiography, and echocardiography showed no abnormalities. Syncope secondary to abdominal pain was reproduced during HUT. Further, HUT revealed vasovagal syncope, and synchronous TCD showed decreased cerebral blood flow; the final diagnosis was VVS in all cases. CONCLUSIONS Abdominal pain may be a precursor of VVS in adults, and our findings enrich the clinical phenotypic spectrum of VVS. Prompt recognition of syncopal precursors is important to prevent incidents and assist in treatment decision-making. Abdominal pain in VVS may be a sign of sympathetic overdrive. Synchronous multimodal detection can help in diagnosing VVS and understanding hemodynamic mechanisms.
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Affiliation(s)
- Jingyi Wang
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macau, China
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
| | - Hua Li
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
- Affiliated Hospital of the Faculty of Chinese Medicine, Macao University of Science and Technology, Macau, China
| | - Xuming Huang
- Department of Gastroenterology, Shenzhen baoan Shiyan People's Hospital, Shenzhen, China
| | - Huoyou Hu
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Baorong Lian
- Shantou University Medical College, Shantou University, Shantou, China
| | - Daxue Zhang
- Clinical Medical College of Shenzhen Second People's Hospital, Anhui Medical University, Hefei, China
| | - Jiarui Wu
- The First School of Clinical Medicine, Guangdong Medical University, Zhanjiang, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China.
- Clinical Medical College of Shenzhen Second People's Hospital, Guangxi University of Chinese Medicine, Nanning, China.
- Hunan Provincial Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China.
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Lin J, Liu Q, Jiang R, Chen S, Yu L, Jiang C. Selective anatomical catheter ablation of left atrial ganglionated plexus for vasovagal syncope: Left superior and right anterior ganglionated plexus ablation. Pacing Clin Electrophysiol 2023; 46:1010-1018. [PMID: 37377409 DOI: 10.1111/pace.14769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Vasovagal syncope (VVS) is one of the most common causes of syncope. Traditional treatment has not achieved satisfactory results. The purpose of this study was to assess the feasibility and efficacy of selective anatomical catheter ablation of left atrial ganglionated plexus (GP) as a therapeutic strategy for the patients of symptomatic VVS. METHODS A total of 70 patients with at least once recurrent syncopal episode of VVS with a positive head-up tilt test were enrolled. They were divided into GP ablation group and control group. Patients in GP ablation group received anatomical catheter ablation of left superior ganglionated plexus (LSGP) and right anterior ganglionated plexus (RAGP). Patients in the control group were guideline-directed conventional therapy. The primary endpoint was VVS recurrences. The secondary endpoint was the recurrence of syncope and prodrome events. RESULTS There were no statistical differences in clinical characteristics between the ablation group (n = 35) and the control group (n = 35). Over a follow-up of 12 months, the ablation group had significantly lower syncope recurrence compared with the control group (5.7% vs. 25.7%, p = .02), and the ablation group had significantly lower syncope and prodrome recurrence compared with the control group (11.4% vs. 51.4%, p < .001). In GP ablation, 88.6% of the patients showed significant vagal response during LSGP ablation, and 88.6% of the patients showed significantly increased heart rate during RAGP ablation. CONCLUSIONS For patients with recurrent VVS, selective anatomical catheter ablation of LSGP and RAGP is superior to conventional therapy in reducing syncope recurrence.
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Affiliation(s)
- Jianwei Lin
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Shiquan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
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Tao C, Cui Y, Zhang C, Liu X, Zhang Q, Liu P, Wang Y, Du J, Jin H. Clinical Efficacy of Empirical Therapy in Children with Vasovagal Syncope. CHILDREN 2022; 9:children9071065. [PMID: 35884049 PMCID: PMC9315970 DOI: 10.3390/children9071065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022]
Abstract
(1) Background: This case-control study was designed to assess the efficacy of empiric treatment for vasovagal syncope in children; (2) Methods: We retrospectively enrolled 181 children with vasovagal syncope from the Department of Pediatrics of Peking University First Hospital. The participants were categorized into four groups, based on the empiric treatment received: conventional treatment, including health education and orthostatic training; conventional treatment plus oral rehydration salts; conventional treatment plus metoprolol; conventional treatment plus midodrine hydrochloride. Patients were followed up to evaluate the syncopal or presyncopal recurrence. Kaplan–Meier curves were drawn to explore the syncopal or presyncopal recurrence in children, and the differences were compared among the groups using a log-rank test; (3) Results: Among the 181 children with vasovagal syncope, 11 were lost to follow-up. The median time of follow-up was 20 (8, 42) months. The Kaplan–Meier survival curve showed no significant difference in syncopal or presyncopal recurrence in children treated with different empiric options according to a log-rank test (χ2 = 1.328, p = 0.723); (4) Conclusions: The efficacy of unselected empiric therapy of vasovagal syncope in children was limited, and the individualized therapies merit further studies.
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Affiliation(s)
- Chunyan Tao
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
- Department of Genetics and Endocrinology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Yaxi Cui
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Xueqin Liu
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Qingyou Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Ping Liu
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Yuli Wang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China; (C.T.); (Y.C.); (C.Z.); (X.L.); (Q.Z.); (P.L.); (Y.W.); (J.D.)
- Correspondence: ; Tel.: +86-10-83573165
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Yuan P, Li X, Tao C, Du X, Zhang C, Du J, Huang Y, Liao Y. Poincaré Plot Can Be a Useful Tool to Select Potential Responders to Metoprolol Therapy in Children with Vasovagal Syncope. Int J Gen Med 2022; 15:2681-2693. [PMID: 35300141 PMCID: PMC8922042 DOI: 10.2147/ijgm.s352928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Piaoliu Yuan
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xueying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Chunyan Tao
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xiaojuan Du
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Chunyu Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, People’s Republic of China
| | - Yaqian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, People’s Republic of China
- Correspondence: Ying Liao; Yaqian Huang, Department of Pediatrics, Peking University First Hospital, Xi-An Men Street No. 1, West District, Beijing, 100034, People’s Republic of China, Tel +8610-83573238; +8610-83575807, Fax +8610-66530532, Email ;
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Ali M, Pachon Maetos JC, Kichloo A, Masudi S, Grubb BP, Kanjwal K. Management strategies for vasovagal syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:2100-2108. [PMID: 34748224 DOI: 10.1111/pace.14402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/18/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of recurrent syncope can result in physical injury as well as psychological distress. This article provides a brief overview of current management strategies and a detailed overview of therapeutic modalities such as closed loop stimulation (CLS) and cardioneuroablation (CNA).
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Affiliation(s)
- Muzaffar Ali
- Sheri Kashmir Institute, Department of Cardiology, Srinagar, Jammu and Kashmir, India
| | | | - Asim Kichloo
- Central Michigan University, Internal Medicine, Saginaw, Michigan, USA.,Samaritan Medical Center, Internal Medicine, Watertown, New York, USA
| | - Sundas Masudi
- University of Liverpool School of Medicine, Liverpool, UK
| | - Blair P Grubb
- Division of cardiology, University of Toledo, Toledo, Ohio, USA
| | - Khalil Kanjwal
- Section of Cardiac electrophysiology, McLaren Greater Lansing, Lansing, Michigan, USA
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Sheldon R, Faris P, Tang A, Ayala-Paredes F, Guzman J, Marquez M, Morillo CA, Krahn AD, Kus T, Ritchie D, Safdar S, Maxey C, Raj SR. Midodrine for the Prevention of Vasovagal Syncope : A Randomized Clinical Trial. Ann Intern Med 2021; 174:1349-1356. [PMID: 34339231 DOI: 10.7326/m20-5415] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Recurrent vasovagal syncope is common, responds poorly to treatment, and causes physical trauma and poor quality of life. Midodrine prevents hypotension and syncope during tilt tests in patients with vasovagal syncope. OBJECTIVE To determine whether midodrine can prevent vasovagal syncope in usual clinical conditions. DESIGN Randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT01456481). SETTING 25 university hospitals in Canada, the United States, Mexico, and the United Kingdom. PATIENTS Patients with recurrent vasovagal syncope and no serious comorbid conditions. INTERVENTION Patients were randomly assigned 1:1 to placebo or midodrine and followed for 12 months. MEASUREMENTS The primary outcome measure was the proportion of patients with at least 1 syncope episode during follow-up. RESULTS The study included 133 patients who had had a median of 6 syncope episodes in the prior year (median age, 32 years; 73% female). Compared with patients receiving placebo, fewer patients receiving midodrine had at least 1 syncope episode (28 of 66 [42%] vs. 41 of 67 [61%]). The relative risk was 0.69 (95% CI, 0.49 to 0.97; P = 0.035). The absolute risk reduction was 19 percentage points (CI, 2 to 36 percentage points), and the number needed to treat to prevent 1 patient from having syncope was 5.3 (CI, 2.8 to 47.6). The time to first syncope was longer with midodrine (hazard ratio, 0.59 [CI, 0.37 to 0.96]; P = 0.035; log-rank P = 0.031). Adverse effects were similar in both groups. LIMITATION Small study size, young and healthy patients, relatively short observation period, and high proportion of patients from 1 center. CONCLUSION Midodrine can reduce the recurrence of syncope in healthy, younger patients with a high syncope burden. PRIMARY FUNDING SOURCE The Canadian Institutes of Health Research.
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Affiliation(s)
- Robert Sheldon
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Peter Faris
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Anthony Tang
- University of Western Ontario, London, Ontario, Canada (A.T.)
| | | | - Juan Guzman
- McMaster University, Hamilton, Ontario, Canada (J.G.)
| | - Manlio Marquez
- Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.M.)
| | - Carlos A Morillo
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Andrew D Krahn
- University of British Columbia, Vancouver, British Columbia, Canada (A.D.K.)
| | - Teresa Kus
- University of Montreal, Montreal, Quebec, Canada (T.K.)
| | - Debbie Ritchie
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Shahana Safdar
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Connor Maxey
- University of Calgary, Calgary, Alberta, Canada (R.S., P.F., C.A.M., D.R., S.S., C.M.)
| | - Satish R Raj
- University of Calgary, Calgary, Alberta, Canada, and Vanderbilt University School of Medicine, Nashville, Tennessee (S.R.R.)
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Piotrowski R, Żuk A, Baran J, Sikorska A, Kryński T, Kułakowski P. Cardioneuroablation changes the type of vasovagal response in patients with asystolic reflex syncope. Auton Neurosci 2021; 235:102838. [PMID: 34186273 DOI: 10.1016/j.autneu.2021.102838] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 05/18/2021] [Accepted: 06/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardioneuroablation (CNA) has been recently proposed as a new therapy in patients with asystolic vasovagal syncope (VVS) caused by parasympathetic overactivity. OBJECTIVE To assess the impact of CNA on the type of VV response during tilt testing (TT). METHODS The study group consisted of 20 patients (7 males, mean age 38 ± 9). All patients had a history of syncope due to asystole and confirmed asystolic VVS at baseline TT (TT1). CNA was performed in the right and left atrium. The second TT (TT2) and Holter ECG were performed three months later. All patients completed one-year follow up. RESULTS At TT1, twenty patients had cardioinhibitory syncope and 1 had mixed VVS with asystole > 3 s. During one-year follow-up no spontaneous syncopal episodes were noted. At TT2, 6 patients had no syncope whereas the remaining 13 had syncope - twelve due to vasodepressor mechanism and only one due to asystole. Mean heart rate after CNA was significantly faster and heart rate variability parameter (SDNN) lower than before the procedure (82 ± 9 vs 69 ± 11 beats/min, p = 0.0003 and 74 ± 22 vs 143 ± 40 ms, p = 000001, respectively). These changes were similar in those who fainted during TT2 and those who did not (84 ± 10 vs 81 ± 5 beats/min, p = NS and 72 ± 24 vs 72 ± 19 ms, p = NS, respectively). CONCLUSIONS CNA profoundly affects type of VV reaction causing normalization of the response to tilting or changing cardiodepression to vasodepression. Changes in heart rate and heart rate variability are consistent with attenuation of parasympathetic activity.
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Affiliation(s)
- Roman Piotrowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Anna Żuk
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Jakub Baran
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland.
| | - Agnieszka Sikorska
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Tomasz Kryński
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | - Piotr Kułakowski
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
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Hong XL, Jiang RH, Zhu JH, He JL. Ganglionated plexi ablation to treat exercise-induced vasovagal syncope: A case report. HeartRhythm Case Rep 2020; 6:854-857. [PMID: 33204622 PMCID: PMC7653476 DOI: 10.1016/j.hrcr.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Xu-Lin Hong
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Ru-Hong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Jun-Hui Zhu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Jia-Lin He
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
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9
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Y Lei L, S Chew D, K Sandhu R, S Sheldon R, R Raj S. Non-Pharmacological and Pharmacological Management of Cardiac Dysautonomia Syndromes. J Atr Fibrillation 2020; 13:2395. [PMID: 33024496 DOI: 10.4022/jafib.2395] [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: 01/02/2020] [Revised: 02/10/2020] [Accepted: 03/16/2020] [Indexed: 11/10/2022]
Abstract
Vasovagal syncope, postural orthostatic tachycardia syndrome, and inappropriate sinus tachycardia comprise a heterogenous group of common autonomic disorders that are associated with significant symptoms that impair quality of life. Clinical management of these disorders should prioritize conservative non-pharmacological therapies and consider incorporating pharmacological agents for recurrences. The selection and titration of medications may be complicated by the occurrence of potentially overlapping pathophysiological variants, differences in specific clinical presentations, and commonly associated comorbidities. However, with appropriate long-term management and specialist input, most patients note both symptomatic improvement and functional restoration over time.
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Affiliation(s)
- Lucy Y Lei
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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[Syncope]. Internist (Berl) 2020; 61:813-826. [PMID: 32542492 DOI: 10.1007/s00108-020-00821-0] [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: 10/24/2022]
Abstract
Syncope is a frequent disorder, sometimes due to life-threatening causes. The uncertainty in its diagnosis requires a standardized approach. According to the 2018 European Society of Cardiology (ESC) guidelines, new aspects in evaluation and treatment include risk stratification and decision-making strategies during the initial evaluation in the emergency department, a reconsideration of diagnostic tests, algorithms for the treatment of reflex syncope, indications for an implantable cardioverter/defibrillator in high risk patients for sudden cardiac death, and organizational aspects such as interdisciplinary syncope units. The 2018 ESC guideline and the 2019 commentaries of the German Society of Cardiology (DGK) are an excellent and comprehensive instruction for safe, effective and efficient evaluation and therapy. However, some aspects require critical appraisal. The inadequate availability and reimbursement of pivotal diagnostic tests, such as tilt table testing and the implantable loop recorder is emphasized.
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11
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Liao Y, Du J. Pathophysiology and Individualized Management of Vasovagal Syncope and Postural Tachycardia Syndrome in Children and Adolescents: An Update. Neurosci Bull 2020; 36:667-681. [PMID: 32367250 PMCID: PMC7271077 DOI: 10.1007/s12264-020-00497-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/31/2020] [Indexed: 12/12/2022] Open
Abstract
Vasovagal syncope (VVS) and postural tachycardia syndrome (POTS) are the main forms of orthostatic intolerance in pediatrics and both are underlying causes of neurally-mediated syncope. In recent years, increasing attention has been paid to the management of VVS and POTS in children and adolescents. A number of potential mechanisms are involved in their pathophysiology, but the leading cause of symptoms varies among patients. A few studies thus have focused on the individualized treatment of VVS or POTS based on selected hemodynamic parameters or biomarkers that can predict the therapeutic effect of certain therapies and improve their effectiveness. This review summarizes the latest developments in individualized treatment of VVS and POTS in children and indicates directions for further research in this field.
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Affiliation(s)
- Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China.
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12
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Cardioinhibitory syncope: from pathophysiology to treatment—should we think on cardioneuroablation? J Interv Card Electrophysiol 2020; 59:441-461. [DOI: 10.1007/s10840-020-00758-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 04/23/2020] [Indexed: 02/07/2023]
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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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Kuchinskaya EA, Pevzner AV. [Lifestyle Modification as a Method of Treatment of Vasovagal Syncope]. ACTA ACUST UNITED AC 2020; 60:93-98. [PMID: 32245359 DOI: 10.18087/cardio.2020.1.n776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/29/2019] [Indexed: 11/18/2022]
Abstract
Vasovagal syncope is the most common cause for loss of consciousness. The need for treatment of this condition is warranted by impaired quality of life and a risk of trauma due to the fall. At present, there are no medications with proven preventive effectiveness for vasovagal syncope as demonstrated by large randomized, placebo-controlled studies. At the same time, information about the pathogenesis of vasovagal reaction and provoking factors allows effective use of non-drug methods (such as patient education, physical exercise, maneuvers) in the management of patients with vasovagal syncope.
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Affiliation(s)
| | - A V Pevzner
- Russian Medical Research Center of Cardiology
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Abstract
PURPOSE OF REVIEW This article reviews the diagnosis and management of the most common disorders of orthostatic intolerance: postural tachycardia syndrome (POTS) and neurally mediated syncope. RECENT FINDINGS POTS is a heterogeneous syndrome caused by several pathophysiologic mechanisms that may coexist (limited autonomic neuropathy, hyperadrenergic state, hypovolemia, venous pooling, joint hypermobility, deconditioning). Neurally mediated syncope occurs despite intact autonomic reflexes. Management of orthostatic intolerance aims to increase functional capacity, including standing time, performance of daily activities, and exercise tolerance. Nonpharmacologic strategies (fluid and salt loading, physical countermaneuvers, compression garments, exercise training) are fundamental for patients with POTS, occasionally complemented by medications to raise blood pressure or slow heart rate. Neurally mediated syncope is best managed by recognition and avoidance of triggers. SUMMARY Significant negative effects on quality of life occur in patients with POTS and in patients with recurrent neurally mediated syncope, which can be mitigated through targeted evaluation and thoughtful management.
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Goldberger ZD, Petek BJ, Brignole M, Shen WK, Sheldon RS, Solbiati M, Deharo JC, Moya A, Hamdan MH. ACC/AHA/HRS Versus ESC Guidelines for the Diagnosis and Management of Syncope. J Am Coll Cardiol 2019; 74:2410-2423. [DOI: 10.1016/j.jacc.2019.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/26/2019] [Accepted: 09/05/2019] [Indexed: 01/07/2023]
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Sheldon RS, Lei L, Guzman JC, Kus T, Ayala-Paredes FA, Angihan J, Safdar S, Maxey C, Bennett G, Raj SR. A proof of principle study of atomoxetine for the prevention of vasovagal syncope: the Prevention of Syncope Trial VI. Europace 2019; 21:1733-1741. [DOI: 10.1093/europace/euz250] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 08/14/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
There are few effective therapies for vasovagal syncope (VVS). Pharmacological norepinephrine transporter (NET) inhibition increases sympathetic tone and decreases tilt-induced syncope in healthy subjects. Atomoxetine is a potent and highly selective NET inhibitor. We tested the hypothesis that atomoxetine prevents tilt-induced syncope.
Methods and results
Vasovagal syncope patients were given two doses of study drug [randomized to atomoxetine 40 mg (n = 27) or matched placebo (n = 29)] 12 h apart, followed by a 60-min drug-free head-up tilt table test. Beat-to-beat heart rate (HR), blood pressure (BP), and cardiac haemodynamics were recorded using non-invasive techniques and stroke volume modelling. Patients were 35 ± 14 years (73% female) with medians of 12 lifetime and 3 prior year faints. Fewer subjects fainted with atomoxetine than with placebo [10/29 vs. 19/27; P = 0.003; risk ratio 0.49 (confidence interval 0.28–0.86)], but equal numbers of patients developed presyncope or syncope (23/29 vs. 21/27). Of patients who developed only presyncope, 87% (13/15) had received atomoxetine. Patients with syncope had lower nadir mean arterial pressure than subjects with only presyncope (39 ± 18 vs. 69 ± 18 mmHg, P < 0.0001), and this was due to lower trough HRs in subjects with syncope (67 ± 30 vs. 103 ± 32 b.p.m., P = 0.006) and insignificantly lower cardiac index (2.20 ± 1.36 vs. 2.84 ± 1.05 L/min/m2, P = 0.075). There were no significant differences in stroke volume index (32 ± 6 vs. 35 ± 5 mL/m2, P = 0.29) or systemic vascular resistance index (2156 ± 602 vs. 1790 ± 793 dynes*s/cm5*m2, P = 0.72).
Conclusion
Norepinephrine transporter inhibition significantly decreased the risk of tilt-induced syncope in VVS subjects, mainly by blunting reflex bradycardia, thereby preventing final falls in cardiac index and BP.
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Affiliation(s)
- Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Lucy Lei
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Juan C Guzman
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Teresa Kus
- Department of Pharmacology and Physiology, Universite de Montreal, and Hopital du Sacre-Coeur, Montreal, Canada
| | | | - Jesse Angihan
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Shahana Safdar
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Connor Maxey
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Graham Bennett
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
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Does A Therapy for Reflex Vasovagal Syncope Really Exist? High Blood Press Cardiovasc Prev 2019; 26:273-281. [DOI: 10.1007/s40292-019-00327-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022] Open
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Ng J, Sheldon RS, Maxey C, Ritchie D, Raj V, Exner DV, Raj SR. Quality of life improves in vasovagal syncope patients after clinical trial enrollment regardless of fainting in follow-up. Auton Neurosci 2019; 219:42-48. [PMID: 31122600 DOI: 10.1016/j.autneu.2019.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/01/2019] [Accepted: 04/05/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Frequent syncope is linked to poorer health-related quality of life (HRQoL). Recurrent syncope has been observed to reduce in all groups after seeing a syncope expert and enrolling in a clinical trial. It is unknown if HRQoL improves with this reduction in syncope recurrence. OBJECTIVES We examined the change in HRQoL over time in vasovagal syncope (VVS) patients seen by a syncope expert and enrolled in a trial. We also explored whether change differed with treatment or the frequency of fainting during follow up. METHODS The Short Form Health Survey (SF36) was completed at baseline (BL), 6 m, and 12 m post-enrollment by VVS patients in the 1st and 2nd Prevention of Syncope Trials, which were multi-centered, randomized, placebo-controlled trials of metoprolol (POST) and fludrocortisone (POST2). Differences in HRQoL at BL, 6 m, and 12 m were analyzed and compared by faints in follow-up and randomization group. RESULTS Complete study data were available for 143 VVS patients (40 ± 17 years, 62% F). Over 12 months, patients reported improvement in all SF36 dimensions except for bodily pain. Post hoc analyses indicated that differences first occurred between BL and 6 m for all but general health. Fainting in follow-up or drug randomization group did not diminish the improvements. The baseline syncope burden was not different whether patients' HRQoL improved or not. CONCLUSION HRQoL of VVS patients improves over time after enrolling in a clinical trial, even with recurrent faints or randomization to placebo. Improvements may result from alternative factors, such as interaction with experts or patient adjustment.
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Affiliation(s)
- Jessica Ng
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Connor Maxey
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Debbie Ritchie
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Vidya Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Derek V Exner
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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von Scheidt W, Bosch R, Klingenheben T, Schuchert A, Stellbrink C, Stockburger M. Manual zur Diagnostik und Therapie von Synkopen. KARDIOLOGE 2019. [DOI: 10.1007/s12181-019-0319-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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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Kishihara J. Selective ablation of atrial ganglionated plexus as a therapeutic option for vasovagal syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 42:20-21. [PMID: 30426528 DOI: 10.1111/pace.13548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
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Gampa A, Upadhyay GA. Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge. J Innov Card Rhythm Manag 2018; 9:3221-3231. [PMID: 32477815 PMCID: PMC7252686 DOI: 10.19102/icrm.2018.090702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 12/11/2017] [Indexed: 11/23/2022] Open
Abstract
Neurocardiogenic syncope is the most frequent cause of syncope in the general population. Many years have been spent on determining an effective treatment for this condition. Conventional treatment usually follows a tiered approach for neurocardiogenic syncope, as follows: first, lifestyle modification, including increased fluid intake and the introduction of physical counterpressure maneuvers, is tried; then the use of targeted pharmacologic therapy, particularly agents that support blood pressure or that drive blood pressure is attempted; and, finally, pacemaker implantation in patients with a predominant cardioinhibitory component to their syncopal episodes is performed. More recently, autonomic modulation with cardiac ganglion ablation has emerged as a promising treatment modality for patients refractory to traditional approaches. In this review, we sought to summarize the existing therapies for neurocardiogenic syncope and explore the latest research on new modalities of treatment.
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Affiliation(s)
- Amulya Gampa
- Department of Internal Medicine, the University of Chicago Medicine, Chicago, IL, USA
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, the University of Chicago Medicine, Chicago, IL, USA
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24
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Ahn J, Kim HJ, Choi JI, Lee KN, Shim J, Ahn HS, Kim YH. Effectiveness of beta-blockers depending on the genotype of congenital long-QT syndrome: A meta-analysis. PLoS One 2017; 12:e0185680. [PMID: 29059199 PMCID: PMC5653191 DOI: 10.1371/journal.pone.0185680] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/17/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Beta-blockers are first-line therapy in patients with congenital long-QT syndrome (LQTS). OBJECTIVE This study sought to determine the differences in effectiveness of beta-blockers on risk reduction according to LQTS genotype. METHODS We searched MEDLINE, EMBASE, and CENTRAL databases to investigate the use of beta-blockers (atenolol, nadolol, propranolol, and metoprolol) in patients with LQTS. Hazard ratio (HR) and relative risk (RR) were extracted or calculated from studies reporting cardiac events (syncope, aborted cardiac arrest (ACA), or sudden cardiac death (SCD)). RESULTS Among 2,113 articles searched, 10 studies (7 registry-based cohort studies (Cohort) and 3 interrupted time series studies (ITS)) involving 9,727 patients were included. In a meta-analysis using a random-effect model, the use of beta-blocker was associated with significant risk reduction of all cardiac events (HR 0.49, p<0.001 in Cohort; RR 0.39, p<0.001 in ITS) and serious cardiac events (ACA or SCD) (HR 0.47, p<0.001 in Cohort). In both LQT1 and LQT2, the risk was reduced with beta-blocker therapy in Cohort (HR 0.59 in LQT1; HR 0.39 in LQT2) as well as ITS (RR 0.29 in LQT1; RR 0.48 in LQT2). Among the beta-blockers, nadolol showed a significant risk reduction in both LQT1 and LQT2 (HR 0.47 and 0.27, respectively), whereas atenolol and propranolol decreased the risk only in LQT1 (HR 0.36 and 0.46, respectively). Metoprolol showed no significant reduction in either genotype. In LQT3, beta-blocker therapy was not as effective as LQT1 or LQT2; however, it was inconclusive due to data insufficiency. CONCLUSION This meta-analysis showed that beta-blockers were effective in reducing risk of cardiac events in patients with LQTS. Among them, nadolol was effective in LQT1 and LQT2, whereas other drugs showed different effectiveness depending on LQT genotype.
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Affiliation(s)
- Jinhee Ahn
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
- Division of Cardiology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Kwang No Lee
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2017; 14:e155-e217. [PMID: 28286247 DOI: 10.1016/j.hrthm.2017.03.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 12/26/2022]
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29
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Márquez MF, Gómez-Flores JR, González-Hermosillo JA, Ruíz-Siller TDJ, Cárdenas M. [Role of the sympathetic nervous system in vasovagal syncope and rationale for beta-blockers and norepinephrine transporter inhibitors]. Medwave 2016; 16:e6824. [PMID: 28055999 DOI: 10.5867/medwave.2016.6824] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Vasovagal or neurocardiogenic syncope is a common clinical situation and, as with other entities associated with orthostatic intolerance, the underlying condition is a dysfunction of the autonomic nervous system. This article reviews various aspects of vasovagal syncope, including its relationship with orthostatic intolerance and the role of the autonomic nervous system in it. A brief history of the problem is given, as well as a description of how the names and associated concepts have evolved. The response of the sympathetic system to orthostatic stress, the physiology of the baroreflex system and the neurohumoral changes that occur with standing are analyzed. Evidence is presented of the involvement of the autonomic nervous system, including studies of heart rate variability, microneurography, cardiac innervation, and molecular genetic studies. Finally, we describe different studies on the use of beta-blockers and norepinephrine transporter inhibitors (sibutramine, reboxetine) and the rationality of their use to prevent this type of syncope.
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Affiliation(s)
- Manlio F Márquez
- Departamento de Electrofisiología, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México. Address: Juan Badiano 1, Colonia Sección XVI, Delegación Tlalpan, Distrito Federal, México.
| | - Jorge Rafael Gómez-Flores
- Departamento de Electrofisiología, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Jesús A González-Hermosillo
- Departamento de Proyectos de Innovación y Desarrollo, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | | | - Manuel Cárdenas
- Departamento de Electrofisiología, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
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Abstract
Vasovagal syncope, or the "common faint", is the most common cause of syncope. Although it is considered a benign condition, there is a significant economic burden and significant impact on quality of life in patients with recurrent syncope, particularly in older adults. Typical vasovagal syncope usually occurs in young adults, and can often be diagnosed on the basis of history, in the absence of structural heart disease. Atypical vasovagal syncope, which is more common in older adults, can be more difficult to diagnose, however. In atypical vasovagal syncope, there is often a short or absent prodrome, and amnesia for loss of consciousness is common and it can, therefore, often be misdiagnosed, for example as falls. A more standardized approach to the diagnosis and management of patients presenting with syncope or unexplained falls is required, and it is anticipated that the number of Syncope Units will increase. Treatment of vasovagal syncope is largely conservative; however, medical or device therapy may be required when syncope is severe and refractory to conservative treatment, as there is significant impact on quality of life and it can be associated with injury. The aim of this article is to provide an overview of the diagnosis and management of vasovagal syncope.
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Affiliation(s)
- R A Kenny
- From the Mercers Institute, St James's Hospital, Dublin, Ireland
| | - T McNicholas
- From the Mercers Institute, St James's Hospital, Dublin, Ireland
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Raj S, Sheldon R. Management of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia and Vasovagal Syncope. Arrhythm Electrophysiol Rev 2016; 5:122-9. [PMID: 27617091 PMCID: PMC5013178 DOI: 10.15420/aer.2016.7.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 04/26/2016] [Indexed: 01/14/2023] Open
Abstract
Postural tachycardia syndrome (POTS), inappropriate sinus tachycardia (IST) and vasovagal syncope (VVS) are relatively common clinical syndromes that are seen by physicians in several disciplines. They are often not well recognised and are poorly understood by physicians, are associated with significant morbidity and cause significant frustration for both patients and their physicians. The 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia and Vasovagal Syncope provides physicians with an introduction to these disorders and initial recommendations on their investigation and treatment. Here we summarise the consensus statement to help physicians in the management of patients with these frequently distressing problems.
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Affiliation(s)
- Satish Raj
- Libin Cardiovascular Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Robert Sheldon
- Libin Cardiovascular Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Sun W, Zheng L, Qiao Y, Shi R, Hou B, Wu L, Guo J, Zhang S, Yao Y. Catheter Ablation as a Treatment for Vasovagal Syncope: Long-Term Outcome of Endocardial Autonomic Modification of the Left Atrium. J Am Heart Assoc 2016; 5:JAHA.116.003471. [PMID: 27402231 PMCID: PMC5015383 DOI: 10.1161/jaha.116.003471] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Autonomic modification through catheter ablation of ganglionated plexi (GPs) in the left atrium has been reported previously as a treatment for vasovagal syncope. This study aimed to observe the long‐term outcome in a larger cohort. Methods and Results A total of 57 consecutive patients (aged 43.2±13.4 years; 35 women) with refractory vasovagal syncope were enrolled, and high‐frequency stimulation and anatomically guided GP ablation were performed in 10 and 47 cases, respectively. A total of 127 GP sites with positive vagal response were successfully elicited and ablated, including 52 left superior, 19 left lateral, 18 left inferior, 27 right anterior, and 11 right inferior GPs. During follow‐up of 36.4±22.2 months (range 12–102 months), 52 patients (91.2%) remained free from syncope. Prodromes recurred in 16 patients. No statistical differences were found between the high‐frequency stimulation and anatomically guided ablation groups in either freedom from syncope (100% versus 89.4%, P=0.348) or recurrent prodromes (50% versus 76.6%, P=0.167). The deceleration capacity, heart rate, and heart rate variability measurements demonstrated a reduced vagal tone lasting for at least 12 months after the procedure, with improved tolerance of repeated head‐up tilt testing. No complications were observed except for transient sinus tachycardia that occurred in 1 patient. Conclusions Left atrial GP ablation showed excellent long‐term clinical outcomes and might be considered as a therapeutic option for patients with symptomatic vasovagal syncope.
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Affiliation(s)
- Wei Sun
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Qiao
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Shi
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, China
| | - Bingbo Hou
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lingmin Wu
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinrui Guo
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Sheldon R, Raj SR, Rose MS, Morillo CA, Krahn AD, Medina E, Talajic M, Kus T, Seifer CM, Lelonek M, Klingenheben T, Parkash R, Ritchie D, McRae M, Sheldon R, Rose S, Ritchie D, McCrae M, Morillo C, Malcolm V, Krahn A, Spindler B, Medina E, Talajic M, Kus T, Langlois A, Lelonek M, Raj S, Seifer C, Gardner M, Romeo M, Poirier P, Simpson C, Abdollah H, Reynolds J, Dorian P, Birnie D, Giuffre M, Gilligan D, Benditt D, Sheldon R, Raj S, Rose M, Krahn A, Morillo C, Medina E. Fludrocortisone for the Prevention of Vasovagal Syncope. J Am Coll Cardiol 2016; 68:1-9. [DOI: 10.1016/j.jacc.2016.04.030] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/31/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
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Lee AKY, Krahn AD. Evaluation of syncope: focus on diagnosis and treatment of neurally mediated syncope. Expert Rev Cardiovasc Ther 2016; 14:725-36. [DOI: 10.1586/14779072.2016.1164034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Raj SR, Faris PD, Semeniuk L, Manns B, Krahn AD, Morillo CA, Benditt DG, Sheldon RS. Rationale for the Assessment of Metoprolol in the Prevention of Vasovagal Syncope in Aging Subjects Trial (POST5). Am Heart J 2016; 174:89-94. [PMID: 26995374 DOI: 10.1016/j.ahj.2016.01.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/20/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vasovagal syncope (VVS) is a common problem associated with a poor quality of life, which improves when syncope frequency is reduced. Effective pharmacological therapies for VVS are lacking. Metoprolol is a β-adrenergic receptor antagonist that is ineffective in younger patients, but may benefit older (≥40 years) VVS patients. Given the limited therapeutic options, a placebo-controlled clinical trial of metoprolol for the prevention of VVS in older patients is needed. STRUCTURE OF STUDY The POST5 is a multicenter, international, randomized, placebo-controlled study of metoprolol in the prevention of VVS in patients ≥40 years old. The primary endpoint is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive metoprolol 25 to 100 mg BID or matching placebo, and followed up for 1 year. Secondary end points include syncope frequency, presyncope, quality of life, and cost analysis. Primary analysis will be intention to treat, with a secondary on-treatment analysis. POWER CALCULATIONS A sample size of 222, split equally between the groups achieves 85% power to detect a hazard rate of 0.3561 when the event rates are 50% and 30% in the placebo and metoprolol arms. Allowing for 10% dropout, we propose to enroll 248 patients. IMPLICATIONS This study will be the first adequately powered trial to determine whether metoprolol is effective in preventing VVS in patients ≥40 years. If effective, metoprolol may become the first line pharmacological therapy for these patients.
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Affiliation(s)
- Satish R Raj
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada; Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, TN.
| | | | - Lisa Semeniuk
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Braden Manns
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Andrew D Krahn
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | | | - David G Benditt
- Cardiac Arrhythmia and Syncope Center, University of Minnesota, Minneapolis, MN
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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Kline RJ, Pham K, Labrie-Brown CL, Mancuso K, LeLorier P, Riopelle J, Kaye AD. Postinduction Paced Pulseless Electrical Activity in a Patient With a History of Oropharyngeal Instrumentation-Induced Reflex Circulatory Collapse. Ochsner J 2016; 16:315-320. [PMID: 27660584 PMCID: PMC5024817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Reflex hypotension and bradycardia have been reported to occur following administration of several drugs associated with administration of anesthesia and also following a variety of procedural stimuli. CASE REPORT A 54-year-old postmenopausal female with a history of asystole associated with sedated upper gastrointestinal endoscopy and post-anesthetic-induction tracheal intubation received advanced cardiac resuscitation after insertion of a temporary transvenous pacemaker failed to prevent pulseless electrical activity. The patient's condition stabilized, and she underwent successful cataract extraction, intraocular lens implantation, and pars plana vitrectomy. CONCLUSION Cardiac pacemaker insertion prior to performance of a procedure historically associated with reflex circulatory collapse can be expected to protect a patient from bradycardia but not necessarily hypotension.
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Affiliation(s)
- Ryan J. Kline
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ky Pham
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Carmen L. Labrie-Brown
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ken Mancuso
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Paul LeLorier
- Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans, LA
| | - James Riopelle
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Alan David Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA
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39
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Abstract
The diagnostic process in patients with syncope is not always easy and includes a detailed clinical history, physical examination and baseline electrocardiogram; according to the results of these initial approaches, some additional tests must be performed. Using this strategy, the cause of syncope is diagnosed in 60% to 80% of patients; in the remaining patients, risk stratification can be established to identify those patients at risk of having cardiac events or death at midterm follow-up. This article reviews the treatment of patients with syncope according to the different causes.
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Affiliation(s)
- Angel Moya
- Arrhythmia Unit, Cardiology Department, Vall d'Hebron Hospital, Autonoma University Barcelona, P. Vall d'Hebrón 119 - 129, 08035 Barcelona, Spain.
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Sheldon RS, Grubb BP, Olshansky B, Shen WK, Calkins H, Brignole M, Raj SR, Krahn AD, Morillo CA, Stewart JM, Sutton R, Sandroni P, Friday KJ, Hachul DT, Cohen MI, Lau DH, Mayuga KA, Moak JP, Sandhu RK, Kanjwal K. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm 2015; 12:e41-63. [PMID: 25980576 DOI: 10.1016/j.hrthm.2015.03.029] [Citation(s) in RCA: 564] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Indexed: 01/14/2023]
Affiliation(s)
| | | | | | | | | | | | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Alberta, Canada; Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Carlos A Morillo
- Department of Medicine, Cardiology Division, McMaster University Population Health Research Institute, Hamilton, Canada
| | | | - Richard Sutton
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Karen J Friday
- (13)Stanford University School of Medicine, Stanford, California
| | | | - Mitchell I Cohen
- Phoenix Children's Hospital, University of Arizona School of Medicine-Phoenix, Arizona Pediatric Cardiology/Mednax, Phoenix, Arizona
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide; Department of Cardiology, Royal Adelaide Hospital; and South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Jeffrey P Moak
- Children's National Medical Center, Washington, District of Columbia
| | - Roopinder K Sandhu
- University of Alberta, Department of Medicine, Division of Cardiology, Alberta, Canada
| | - Khalil Kanjwal
- Michigan Cardiovascular Institute, Central Michigan University, Saginaw, Michigan
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41
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Alagiakrishnan K. Current Pharmacological Management of Hypotensive Syndromes in the Elderly. Drugs Aging 2015; 32:337-48. [DOI: 10.1007/s40266-015-0263-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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42
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Schleifer JW, Shen W. Vasovagal syncope: an update on the latest pharmacological therapies. Expert Opin Pharmacother 2014; 16:501-13. [DOI: 10.1517/14656566.2015.996129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Syncope is defined as transient loss of consciousness due to global cerebral hypoperfusion. It is characterized by having a relatively rapid onset, brief duration with spontaneous and full recovery. The major challenge in the evaluation of patients with syncope is that most patients are asymptomatic at the time of their presentation. A thorough history and physical examination including orthostatic assessment are crucial for making the diagnosis. After initial evaluation, short-term risk assessment should be performed to determine the need for admission. If the short-term risk is high, inpatient evaluation is needed. If the short-term risk is low, outpatient evaluation is recommended. In patients with suspected cardiac syncope, monitoring is indicated until a diagnosis is made. In patients with suspected reflex syncope or orthostatic hypotension, outpatient evaluation with tilt-table testing is appropriate. Syncope units have been shown to improve the rate of diagnosis while reducing cost and thus are highly recommended.
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44
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Coffin ST, Raj SR. Non-invasive management of vasovagal syncope. Auton Neurosci 2014; 184:27-32. [PMID: 24996861 DOI: 10.1016/j.autneu.2014.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/06/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
Vasovagal syncope (VVS) is a common disorder of the autonomic nervous system. While recurrent syncope can cause very impaired quality of life, the spells are not generally life-threatening. Both non-pharmacological and pharmacological approaches can be used to treat patients. Conservative management with education, exercise and physical maneuvers, and aggressive volume repletion is adequate for controlling symptoms in most patients. Unfortunately, a minority of patients will continue to have recurrent syncope despite conservative therapy, and they may require medications. These could include vasopressor agents, beta-blockers, or neurohormonal agents. Some patients may require more aggressive device based therapy with pacemakers or radiofrequency ablation, which are emerging therapies for VVS. This paper will review non-procedure based treatments for VVS.
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Affiliation(s)
- Samuel T Coffin
- Autonomic Dysfunction Center, Vanderbilt University School of Medicine, USA; Department of Medicine, Vanderbilt University School of Medicine, USA
| | - Satish R Raj
- Autonomic Dysfunction Center, Vanderbilt University School of Medicine, USA; Department of Medicine, Vanderbilt University School of Medicine, USA; Department of Pharmacology, Vanderbilt University School of Medicine, USA.
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45
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Coffin ST, Raj SR. Ongoing clinical trials for Vasovagal Syncope: where are we in 2014? Auton Neurosci 2014; 184:77-82. [PMID: 24913692 DOI: 10.1016/j.autneu.2014.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 04/16/2014] [Accepted: 05/19/2014] [Indexed: 11/19/2022]
Abstract
Vasovagal Syncope (VVS) can lead to a markedly diminished quality of life for some patients. While there are many treatments for this condition including physical, mechanical, pharmacologic, and device-based control of heart rate, there are few that have been shown to be effective in randomized clinical trials. In our local experience, we have achieved significant improvement in symptom frequency and quality of life using algorithms based on the data available and on clinical acumen for the majority of patients with VVS. Despite this, there are still many patients who suffer from treatment refractory VVS. Fortunately, there are a number of ongoing clinical trials that are likely to add to our knowledge. Ongoing clinical trials are reviewed to examine new treatment methods for VVS that were listed on public trial registries as of April 15, 2014. Data from these trials should inform future strategies in the care of patients with VVS.
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Affiliation(s)
- Samuel T Coffin
- Autonomic Dysfunction Center, Vanderbilt University School of Medicine; Departments of Medicine, Vanderbilt University School of Medicine
| | - Satish R Raj
- Autonomic Dysfunction Center, Vanderbilt University School of Medicine; Departments of Medicine, Vanderbilt University School of Medicine; Department of Pharmacology, Vanderbilt University School of Medicine.
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46
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Almendral J, Pombo M, Martínez-Alday J, González-Rebollo JM, Rodríguez-Font E, Martínez-Ferrer J, Castellanos E, García-Fernández FJ, Ruiz-Mateas F. Update on arrhythmias and cardiac pacing 2013. ACTA ACUST UNITED AC 2014; 67:294-304. [PMID: 24774592 DOI: 10.1016/j.rec.2013.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/12/2013] [Indexed: 11/19/2022]
Abstract
This report discusses a selection of the most relevant articles on cardiac arrhythmias and pacing published in 2013. The first section discusses arrhythmias, classified as regular paroxysmal supraventricular tachyarrhythmias, atrial fibrillation, and ventricular arrhythmias, together with their treatment by means of an implantable cardioverter defibrillator. The next section reviews cardiac pacing, subdivided into resynchronization therapy, remote monitoring of implantable devices, and pacemakers. The final section discusses syncope.
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Affiliation(s)
- Jesús Almendral
- Unidad de Arritmias, Centro Integral de Enfermedades Cardiovasculares, Grupo HM Hospitales, Universidad CEU San Pablo, Madrid, Spain.
| | - Marta Pombo
- Unidad de Estimulación Cardiaca, Área de Cardiología, Hospital Costa del Sol, Marbella, Málaga, Spain
| | - Jesús Martínez-Alday
- Unidad de Arritmias, Servicio de Cardiología, Hospital de Basurto, Bilbao, Vizcaya, Spain
| | - José M González-Rebollo
- Unidad de Arritmias, Servicio de Cardiología, Complejo Asistencial Universitario de León, León, Spain
| | - Enrique Rodríguez-Font
- Unidad de Arritmias, Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Martínez-Ferrer
- Unidad de Arritmias, Servicio de Cardiología, Hospital Universitario de Araba, Vitoria, Álava, Spain
| | - Eduardo Castellanos
- Unidad de Arritmias, Centro Integral de Enfermedades Cardiovasculares, Grupo HM Hospitales, Universidad CEU San Pablo, Madrid, Spain
| | | | - Francisco Ruiz-Mateas
- Unidad de Estimulación Cardiaca, Área de Cardiología, Hospital Costa del Sol, Marbella, Málaga, Spain
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47
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Almendral J, Pombo M, Martínez-Alday J, González-Rebollo JM, Rodríguez-Font E, Martínez-Ferrer J, Castellanos E, García-Fernández FJ, Ruiz-Mateas F. Novedades en arritmias y estimulación cardiaca en 2013. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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48
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Affiliation(s)
- Pradyot Saklani
- University of Western Ontario, Arrhythmia Service, Division of Cardiology, London, Ontario, Canada
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49
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Abstract
Neurally mediated reflex syncope, more commonly known as vasovagal syncope (VVS), remains the most common cause of transient loss of consciousness and syncope in all age groups. Most evidence assessing treatment of VVS derived from randomized clinical trials is limited. Multiple modalities of both nonpharmacologic and pharmacologic strategies have been tested, with conflicting results. The treatment of VVS has been directed toward interventions that interrupt the reflex response at different levels, hypothetically preventing the onset of syncope. This article reviews the available evidence of the different nonpharmacologic and pharmacologic therapies available for the treatment of recurrent VVS.
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Affiliation(s)
- Juan C Guzman
- Department of Medicine, McMaster University, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
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50
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Klingenheben T, Ptaszynski P, Schimpf R, Schuchert A. [Syncope]. Herzschrittmacherther Elektrophysiol 2013; 24:70-71. [PMID: 23515607 DOI: 10.1007/s00399-013-0256-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- T Klingenheben
- Praxis für Kardiologie Bonn, Im Mühlenbach 2 B, Bonn, Germany.
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