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Rao BH, Gowlikar V, Vooturi S, Raj JP, Surath M. Management of patients with Reflex Vasovagal syncope with a protocol involving a yoga maneuver Tadasana. Int J Cardiol 2024; 412:132302. [PMID: 38945370 DOI: 10.1016/j.ijcard.2024.132302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND There is no universally followed protocol for managing Reflex Vasovagal syncope (VVS). METHODS VVS patients were treated with a 2 step protocol. Step I - counseling, hydration, physiotherapy, and Tadasana Yoga maneuver. Patients with ≥2 VVS recurrences were given step II care - intensification of step I, elastic stockings,and pharmacotherapy. Follow-up included assessment by periodic functional status questionnaires. RESULTS 157 patients (103 males & 54 females,mean age - 53 ± 20 years & mean LVEF - 62 ± 5%.) experienced 867 total events - 382 syncopal, and 485 near syncopal episodes over 14 ± 9 months. After step I protocol, the mean total, syncopal and near syncopal events declined from 5 ± 7 to 0.3 ± 1.2 (P < 0.0001), 3 ± 2 to 0.1 ± 0.4 (P < 0.0001) and 3 ± 6 to 0.2 ± 1.1 (P < 0.0001) respectively. Twenty (12.7%) patients had 53 event recurrences, 15- syncopal episodes in 7 and 38 near syncope events in 13. After step II, 5 patients had 14 events. At 33 ± 15 months, in 152 patients (96.8%) there were no recurrences and syncope was prevented in all (100%). The median total, syncopal and near syncopal events declined from 3 to 0,(p < 0.001) 2 to 0 (p < 0.001) and 1 to 0 (p < 0.001) respectively. There was an improvement in all the 3 quality of life parameters. CONCLUSION We demonstrate a simple and effective protocol that can be universally adopted to prevent VVS recurrences,with improvement in quality of life.
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Affiliation(s)
- B Hygriv Rao
- Department of Cardiology, KIMS Hospitals, b Arrythmia Research & Training Society (ARTS), India.
| | | | - Sudhindra Vooturi
- Department of Cardiac Rehabilitation & Physiotherapy, KIMS Hospitals, India
| | - Jeffrey Predeep Raj
- Department of Pharmacology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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Wang H, Ma W, Jin M, Li B, Sun S. Value of catecholamine levels in the differential diagnosis of vasovagal syncope and psychogenic pseudosyncope in children. Front Pediatr 2024; 12:1281196. [PMID: 38884104 PMCID: PMC11176470 DOI: 10.3389/fped.2024.1281196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 05/20/2024] [Indexed: 06/18/2024] Open
Abstract
Background and purpose Vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) can be difficult to distinguish, given their similar clinical presentations. This study was conducted to explore the clinical value of catecholamine levels in the differential diagnosis of VVS and PPS in children. Methods This retrospective case-control study was conducted with data from children with VVS and PPS who underwent head-up tilt tests (HUTTs) at the Children's Hospital of Hebei Province between March 2021 and March 2023. The data collected were baseline clinical characteristics, HUTT results, serum catecholamine levels in the supine and upright positions, and 24 h urinary catecholamine concentrations. These variables were compared between the VVS and PPS groups. Results From 328 potentially eligible cases, 54 (16.46%) cases of VVS and 24 (7.32%) cases of PPS were included in the analysis. No significant difference in age, sex, body mass index, or syncope frequency was observed between the VVS and PPS groups. The main predisposing factors for syncope were body position changes in the VSS group (83.33%) and emotional changes in the PPS group (41.67%). The episode duration was significantly shorter in the VSS group than in the PPS group (4.01 ± 1.20 vs. 24.06 ± 5.56 min, p < 0.05). The recovery time was also shorter in the VVS group than in the PPS group (1.91 ± 0.85 vs. 8.62 ± 2.55 min, p < 0.05). Relative to patients with PPS, those with VVS had significantly higher serum epinephrine (EP) levels in the upright position [199.35 (102.88, 575.00) vs. 147.40 (103.55, 227.25), p < 0.05] and lower serum epinephrine levels in the supine position [72.70 (42.92, 122.85) vs. 114.50 (66.57, 227.50), p < 0.05]. Conclusions Serum EP levels have potential value in the differential diagnosis of VVS and PPS.
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Affiliation(s)
- Hua Wang
- Department of Pediatrics, Hebei Medical University, Shijiazhuang, China
- Department of Pediatric Cardiology, Children's Hospital of Hebei Province, Shijiazhuang, China
- Hebei Provincial Key Laboratory of Pediatric Cardiovascular Disease, Shijiazhuang, China
| | - Wandong Ma
- Department of Neurosurgery, Hebei General Hospital, Shijiazhuang, China
| | - Mei Jin
- Department of Pediatric Neurology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Bo Li
- Department of Pediatric Cardiology, Children's Hospital of Hebei Province, Shijiazhuang, China
- Hebei Provincial Key Laboratory of Pediatric Cardiovascular Disease, Shijiazhuang, China
| | - Suzhen Sun
- Department of Pediatrics, Hebei Medical University, Shijiazhuang, China
- Department of Pediatric Neurology, Children's Hospital of Hebei Province, Shijiazhuang, China
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3
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Chang L, Peng L, Liu J, Wang M, Li M, Kong Q, Zhao H, Zhao C. Predictive analysis of catecholamines and electrolytes for recurrence of orthostatic intolerance in children. Front Pediatr 2023; 11:1220990. [PMID: 37705599 PMCID: PMC10495584 DOI: 10.3389/fped.2023.1220990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023] Open
Abstract
Background Orthostatic intolerance (OI) is usually mediated by the autonomic nerve and most often happens in the upright position. However, it can also occur in other positions and can be relieved by lying down while likely to have another attack after relief. In the current study, we aim to evaluate the predictive effect of catecholamines and electrolytes on the recurrence of OI in children. Materials and methods Children who were diagnosed with vasovagal syncope (VVS), postural tachycardia syndrome (POTS), and VVS combined with POTS were enrolled in this retrospective study and were followed up after 1-year physical treatment. Catecholamines in urine collected within 24 h, renin, angiotensin II, aldosterone in plasma, and electrolytes in both blood and urine collected in the morning were tested. A multivariate analysis and a receiver operating characteristic curve were used to validate the prediction effect. Results In the VVS cohort, the 24 h urine adrenaline (AD) and norepinephrine (NE) levels of the non-recurrence group were lower than the 24 h urine AD and NE levels of the recurrence group, with a significant difference of P < 0.05. A different content can also be witnessed in the POTS cohort that the urine of the non-recurrence group contained lower sodium and chlorine. As for the VVS + POTS cohort, the non-recurrence group has lower AD and NE levels and higher potassium and phosphorus levels in urine, the difference of which proved prominent as well. Conclusion The study provides further evidence that AD, NE, and electrolytes in urine are promising factors that are closely related to the recurrence of OI in children. The integrated evaluation system merging AD and NE may have better predictive ability.
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Affiliation(s)
| | | | | | | | | | | | | | - Cuifen Zhao
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
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Prakash A, Sutton R. Prospective randomized study comparing permanent pacing with rate drop response and closed loop stimulation in patients with vasovagal syncope where permanent pacing is indicated and selected as the appropriate treatment option. J Cardiovasc Electrophysiol 2023; 34:1744-1749. [PMID: 37393604 DOI: 10.1111/jce.15991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/10/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Pacing for vasovagal syncope is established. Two pacing algorithms are available. The rate-drop-response (RDR-Medtronic) is triggered by falling heart rate acting with modified rate-hysteresis. The closed loop stimulation or system (CLS-Biotronik) is triggered by impedance changes in the right ventricle reflecting falling volume and rising contractility. These are very different physiologically. Both algorithms carry favorable reports in clinical use. METHODS A randomized-controlled superiority trial is proposed to compare the two algorithms for the control of vasovagal syncope in patients for whom pacing is indicated by current guidelines in North America and Europe. Available recent evidence may be seen as supporting superiority of CLS. No comparison between the two algorithms has been made. In this trial, patients will be centrally randomized to one or other algorithm on a 1:1 basis. Two-hundred-seventy-six patients in each group will be recruited. Sample size is determined using a confidence interval of 95%, a power of 90%, and a drop-out rate of 10% to detect an 11% difference between CLS and RDR. Recurrent symptom comparison will be made by an independent committee. The Co-primary endpoints will be recurrent syncope burden compared with that in 24-months preimplant, and occurrence of syncope in 24-months follow-up. Each outcome will be compared between the two algorithms. Secondary endpoints will be program and drug therapy changes over 24-months follow-up and quality of life by questionnaire at baseline,1 and 2 years. RESULTS AND CONCLUSIONS These are anticipated to clarify the device algorithm choice and, therefore, to improve patient care.
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Affiliation(s)
- Atul Prakash
- Rutgers Medical School, Newark, New Jersey, USA
- Prime Health Care, Newark, New Jersey, USA
- St Mary's General Hospital, Passaic, New Jersey, USA
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital Campus of National Heart & Lung Institute, Imperial College, London, UK
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Longo S, Legramante JM, Rizza S, Federici M. Vasovagal syncope: An overview of pathophysiological mechanisms. Eur J Intern Med 2023; 112:6-14. [PMID: 37030995 DOI: 10.1016/j.ejim.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/09/2023] [Accepted: 03/23/2023] [Indexed: 04/10/2023]
Abstract
Syncope is a short-term transient loss of consciousness, characterized by rapid onset and complete spontaneous recovery. According to the 2018 European Society of Cardiology guidelines, three different types of syncope have been identified. However, all forms of syncope share a common final pathophysiological event, global cerebral hypoperfusion, which results from the inability of the circulatory system to maintain blood pressure at the level required to efficiently supply blood to the brain. The vasovagal syncope (VVS) is the most common form of syncope. Although, VVS is generally harmless, its frequent occurrence can negatively affect quality of life and increase the risk of adverse events. The pathophysiological mechanisms underlying VVS remain obscure. The multifaceted nature of VVS presents a veritable challenge to understanding this condition and developing preventative strategies. Thus, the aim of this review was to discuss the factors contributing to the pathogenesis of VVS and provide guidance for future research.
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Affiliation(s)
- Susanna Longo
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, Rome 00133 ITALY
| | - Jacopo M Legramante
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, Rome 00133 ITALY
| | - Stefano Rizza
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, Rome 00133 ITALY
| | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, Rome 00133 ITALY.
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Aegisdottir HM, Thorolfsdottir RB, Sveinbjornsson G, Stefansson OA, Gunnarsson B, Tragante V, Thorleifsson G, Stefansdottir L, Thorgeirsson TE, Ferkingstad E, Sulem P, Norddahl G, Rutsdottir G, Banasik K, Christensen AH, Mikkelsen C, Pedersen OB, Brunak S, Bruun MT, Erikstrup C, Jacobsen RL, Nielsen KR, Sørensen E, Frigge ML, Hjorleifsson KE, Ivarsdottir EV, Helgadottir A, Gretarsdottir S, Steinthorsdottir V, Oddsson A, Eggertsson HP, Halldorsson GH, Jones DA, Anderson JL, Knowlton KU, Nadauld LD, Haraldsson M, Thorgeirsson G, Bundgaard H, Arnar DO, Thorsteinsdottir U, Gudbjartsson DF, Ostrowski SR, Holm H, Stefansson K. Genetic variants associated with syncope implicate neural and autonomic processes. Eur Heart J 2023; 44:1070-1080. [PMID: 36747475 DOI: 10.1093/eurheartj/ehad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 11/22/2022] [Accepted: 01/05/2023] [Indexed: 02/08/2023] Open
Abstract
AIMS Syncope is a common and clinically challenging condition. In this study, the genetics of syncope were investigated to seek knowledge about its pathophysiology and prognostic implications. METHODS AND RESULTS This genome-wide association meta-analysis included 56 071 syncope cases and 890 790 controls from deCODE genetics (Iceland), UK Biobank (United Kingdom), and Copenhagen Hospital Biobank Cardiovascular Study/Danish Blood Donor Study (Denmark), with a follow-up assessment of variants in 22 412 cases and 286 003 controls from Intermountain (Utah, USA) and FinnGen (Finland). The study yielded 18 independent syncope variants, 17 of which were novel. One of the variants, p.Ser140Thr in PTPRN2, affected syncope only when maternally inherited. Another variant associated with a vasovagal reaction during blood donation and five others with heart rate and/or blood pressure regulation, with variable directions of effects. None of the 18 associations could be attributed to cardiovascular or other disorders. Annotation with regard to regulatory elements indicated that the syncope variants were preferentially located in neural-specific regulatory regions. Mendelian randomization analysis supported a causal effect of coronary artery disease on syncope. A polygenic score (PGS) for syncope captured genetic correlation with cardiovascular disorders, diabetes, depression, and shortened lifespan. However, a score based solely on the 18 syncope variants performed similarly to the PGS in detecting syncope risk but did not associate with other disorders. CONCLUSION The results demonstrate that syncope has a distinct genetic architecture that implicates neural regulatory processes and a complex relationship with heart rate and blood pressure regulation. A shared genetic background with poor cardiovascular health was observed, supporting the importance of a thorough assessment of individuals presenting with syncope.
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Affiliation(s)
- Hildur M Aegisdottir
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
| | | | | | | | | | | | | | | | | | - Egil Ferkingstad
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | - Patrick Sulem
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | | | | | - Karina Banasik
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3A, Copenhagen 2200, Denmark
| | - Alex Hoerby Christensen
- The Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls Vej 1, Herlev 2730, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
| | - Christina Mikkelsen
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Blegdamsvej 3A, Copenhagen 2200, Denmark
| | - Ole Birger Pedersen
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
- Department of Clinical Immunology, Zealand University Hospital - Køge, Lykkebækvej 1, Køge 4600, Denmark
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3A, Copenhagen 2200, Denmark
| | - Mie Topholm Bruun
- Department of Clinical Immunology, Odense University Hospital, J. B. Winsløws Vej 4, Odense 5000, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
- Department of Clinical Medicine, Aarhus University, Nordre Ringgade 1, Aarhus 8000, Denmark
| | - Rikke Louise Jacobsen
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Kaspar Rene Nielsen
- Department of Clinical Immunology, Aalborg University Hospital, Urbansgade 32, Aalborg 9000, Denmark
| | - Erik Sørensen
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Michael L Frigge
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | | | | | - Anna Helgadottir
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | | | | | - Asmundur Oddsson
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | | | | | - David A Jones
- Precision Genomics, Intermountain Healthcare, 600 S. Medical Center Drive, Saint George, UT 84790, USA
| | - Jeffrey L Anderson
- Intermountain Medical Center, Intermountain Heart Institute, 5171 S. Cottonwood Street Building 1, Salt Lake City, UT 84107, USA
- Department of Internal Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Kirk U Knowlton
- Intermountain Medical Center, Intermountain Heart Institute, 5171 S. Cottonwood Street Building 1, Salt Lake City, UT 84107, USA
- School of Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Lincoln D Nadauld
- Precision Genomics, Intermountain Healthcare, 600 S. Medical Center Drive, Saint George, UT 84790, USA
- School of Medicine, Stanford University, 291 Campus Drive, Stanford, CA 94305, USA
| | | | - Magnus Haraldsson
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
- Department of Psychiatry, Landspitali, The National University Hospital of Iceland, Hringbraut, Reykjavik 101, Iceland
| | - Gudmundur Thorgeirsson
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
- Department of Medicine, Landspitali, The National University Hospital of Iceland, Hringbraut, Reykjavik 101, Iceland
| | - Henning Bundgaard
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
- The Capital Regions Unit for Inherited Cardiac Diseases, Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - David O Arnar
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
- Department of Medicine, Landspitali, The National University Hospital of Iceland, Hringbraut, Reykjavik 101, Iceland
| | - Unnur Thorsteinsdottir
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
| | - Daniel F Gudbjartsson
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- School of Engineering and Natural Sciences, University of Iceland, Hjardarhagi 4, Reykjavik 107, Iceland
| | - Sisse R Ostrowski
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Hilma Holm
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
| | - Kari Stefansson
- deCODE genetics/Amgen, Inc., Sturlugata 8, Reykjavik 101, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmyrarvegur 16, Reykjavik 101, Iceland
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Yeom JS, Woo HO. Pediatric syncope: pearls and pitfalls in history taking. Clin Exp Pediatr 2023; 66:88-97. [PMID: 36789491 PMCID: PMC9989720 DOI: 10.3345/cep.2022.00451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/06/2022] [Indexed: 02/16/2023] Open
Abstract
Syncope is a heterogeneous syndrome with complex underlying mechanisms, hence, the spectrum of patients presenting with syncope is broad. The diagnosis of syncope begins with history taking, and an accurate diagnosis can be established through correct history taking and interpretation. Building and interpreting patient history are the main factors that cause a diagnostic yield gap between experts and nonexperts. The most frequent source of error is a clinician's misconception rather than an inaccurate account of patient symptoms. Clinicians can have several diagnostic pitfalls while evaluating patient history, which can be avoided by in-depth understanding of the link between syncope pathophysiology and clinical clues. Furthermore, clinicians need to understand the clinical features of diseases that require differentiation from syncope, such as seizures. The use of confusing terms is one of the barriers that prevents accurate diagnosis and communication between doctors and patients. In this review, we address the terms of syncope and its essential history-taking components in connection with the mechanism of syncope.
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Affiliation(s)
- Jung Sook Yeom
- Department of Pediatrics, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Gyeongsang Institute of Health Science, Jinju, Korea
| | - Hyang-Ok Woo
- Department of Pediatrics, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Gyeongsang Institute of Health Science, Jinju, Korea
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Bačkorová B, Lazúrová I. Selected biomarkers of orthostatic intolerance. VNITRNI LEKARSTVI 2023; 69:15-19. [PMID: 37827818 DOI: 10.36290/vnl.2023.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Orthostatic intolerance (OI) is defined as a group of diseases which symptoms are typically manifested in a standing position. These symptoms result from cerebral hypoperfusion and disappear in the supine position. We include postural orthostatic intolerance syndrome (POTS), orthostatic hypotension (OH) and vasovagal orthostatic syncope in this group of diseases. Each of them have similar clinical presentation (blurred vision, weakness, dizziness, nausea, headaches, fatigue). However, they vary from each other in biochemical, autonomic and hemodynamic characteristics. The aim of the work is to provide an overview of humoral and non-human markers that are involved in the etiopathogenesis of orthostatic intolerance.
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Vasovagal Syncope Is Associated with Variants in Genes Involved in Neurohumoral Signaling Pathways. Genes (Basel) 2022; 13:genes13091653. [PMID: 36140820 PMCID: PMC9498630 DOI: 10.3390/genes13091653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022] Open
Abstract
Vasovagal syncope (VVS) is the most common cause of sudden loss of consciousness. VVS results from cerebral hypoperfusion, due to abnormal autonomic control of blood circulation, leading to arterial hypotension. It is a complex disease, and its development is largely associated with genetic susceptibility. Since abnormal neurohumoral regulation plays an important role in VVS development, we analyzed the association of VVS with polymorphic variants of ADRA1A, ADRB1, HTR1A, ADORA2A, COMT, and NOS3 genes, the products of which are involved in neurohumoral signaling, in patients with a confirmed VVS diagnosis (157 subjects) and individuals without a history of syncope (161 subjects). We were able to identify the associations between VVS and alleles/genotypes ADRA1A rs1048101, ADRB1 rs1801253, ADORA2A rs5751876, and COMT rs4680, as well as NOS3 rs2070744 in biallelic combination with COMT rs4680. Thus, we are the first to observe, within a single study, the role of the genes that encode α- and β-adrenergic receptors, catechol-O-methyltransferase, adenosine receptors and nitric oxide synthase in VVS development. These findings demonstrate that the genes involved in neurohumoral signaling pathways contribute to the formation of a genetic susceptibility to VVS.
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10
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Miranda CM, da Silva RMFL, Peruhybe-Magalhães V, Brugada J. Vasoactive Biomarkers in Patients With Vasovagal Syncope During Head-Up Tilt Test: A Case-Control Study. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2022; 16:11795468221116848. [PMID: 36046183 PMCID: PMC9421056 DOI: 10.1177/11795468221116848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Abstract
Background: Vasovagal syncope (VVS) is the most common cause of syncope. Some stages of its pathophysiological mechanisms remain unclear. Vasoactive substances such as nitric oxide metabolites (NOx) and endothelin (ET) may be involved during acute orthostatic stress. Objective: To analyze plasma changes in NOx and ET and heart rate variability (HRV) in the supine positions (T1) and during the head-up tilt test (HUTT) (T2), in patients with VVS (case group) and control group. Methods: Thirty-seven patients (17 in the case group and 20 in the control group), matched for age and sex (mean aged 31.8 years) underwent HUTT with simultaneous HRV recording and venipuncture. Blood samples were collected during phases T1 and T2 and the analysis was performed without knowledge of the HUTT result. Results: In the total sample, there was an increase in NOx values (P = .014), however there was no increase in ET values from phase T1 to phase T2. Patients with VVS tended to increase plasma NOx values (P = .057) and had significantly higher plasma values compared to ET (P = .033) between phases T1 to T2. In the control group, there was no significant change in the values of these vasoactive substances. Regarding HRV, there were a decrease in the component HF (high frequency) and increased of the LF (low frequency)/HF ratio during HUTT. Conclusions: There was an increase in ET during HUTT occurred only in the case group. These patients are more likely to have an imbalance between antagonistic vasoactive biomarkers during orthostatic stress.
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Affiliation(s)
- Cláudia Madeira Miranda
- Faculty of Medicine, Federal University of Minas Gerais, Brazil.,Madre Teresa Hospital, Minas Gerais, Brazil
| | | | | | - Josep Brugada
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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11
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Dorogovtsev VN, Yankevich DS, Petrova MV, Torshin VI, Severin AE, Borisov IV, Podolskaya JA, Grechko AV. Detection of Preclinical Orthostatic Disorders in Young African and European Adults Using the Head-Up Tilt Test with a Standardized Hydrostatic Column Height: A Pilot Study. Biomedicines 2022; 10:biomedicines10092156. [PMID: 36140257 PMCID: PMC9496141 DOI: 10.3390/biomedicines10092156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/29/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Arterial hypertension (AH) remains the most common disease. One possible way to improve the effectiveness of the primary prevention of AH is to identify and control the preclinical orthostatic disturbances that precede the development of AH. The aim of the study was to determine the feasibility of a new protocol for the head-up tilt test (HUTT) with a standardized hydrostatic column height for the detection of asymptomatic orthostatic circulatory disorders and their racial differences in young African and European adults. Methods. In total, 80 young healthy adults (40 African and 40 European) aged 20–23 years performed the HUTT with a standardized hydrostatic column height of 133 cm. The hemodynamic parameters were recorded using a Task Force Monitor (3040i). The cardio-ankle vascular index (CAVI) was measured using a VaSera VS-2000 volumetric sphygmograph. Results. The baseline and orthostatic hemodynamic changes in both racial groups were within normal limits. Orthostatic circulatory disturbances were not detected in 70% of the European participants and 65% of the African participants; however, preclinical orthostatic hypertension, which precedes AH, was detected using the new HUTT protocol in 32.5% of the African participants and 20% of the European participants. The baseline CAVI was higher in the European group compared to the African group. Conclusion. The results of this study showed the feasibility of the detection of preclinical orthostatic disturbances in young adults and the detection of their racial differences using the HUTT protocol, providing the use of a standard gravity load. Further study on the evolution of preclinical orthostatic disturbances and their relation to increased vascular stiffness is necessary among large samples.
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Affiliation(s)
- Victor N. Dorogovtsev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia
- Correspondence:
| | - Dmitry S. Yankevich
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia
| | - Marina V. Petrova
- Department of Anesthesiology and Resuscitation with Medical Rehabilitation Courses, Peoples’ Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, 117198 Moscow, Russia
| | - Vladimir I. Torshin
- Department of Normal Physiology, and Department of Anesthesiology and Resuscitation with Medical Rehabilitation Courses, Peoples’ Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, 117198 Moscow, Russia
| | - Aleksander E. Severin
- Department of Normal Physiology, and Department of Anesthesiology and Resuscitation with Medical Rehabilitation Courses, Peoples’ Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, 117198 Moscow, Russia
| | - Ilya V. Borisov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia
| | - Julia A. Podolskaya
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia
| | - Andrey V. Grechko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia
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Whittle RS, Keller N, Hall EA, Vellore HS, Stapleton LM, Findlay KH, Dunbar BJ, Diaz‐Artiles A. Gravitational Dose‐Response Curves for Acute Cardiovascular Hemodynamics and Autonomic Responses in a Tilt Paradigm. J Am Heart Assoc 2022; 11:e024175. [PMID: 35861832 PMCID: PMC9707822 DOI: 10.1161/jaha.121.024175] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
The cardiovascular system is strongly dependent on the gravitational environment. Gravitational changes cause mechanical fluid shifts and, in turn, autonomic effectors influence systemic circulation and cardiac control. We implemented a tilt paradigm to (1) investigate the acute hemodynamic response across a range of directions of the gravitational vector, and (2) to generate specific dose‐response relationships of this gravitational dependency.
Methods and Results
Twelve male subjects were tilted from 45° head‐up tilt to 45° head‐down tilt in 15° increments, in both supine and prone postures. We measured the steady‐state hemodynamic response in a range of variables including heart rate, stroke volume, cardiac output, oxygen consumption, total peripheral resistance, blood pressure, and autonomic indices derived from heart rate variability analysis. There is a strong gravitational dependence in almost all variables considered, with the exception of oxygen consumption, whereas systolic blood pressure remained controlled to within ≈3% across the tilt range. Hemodynamic responses are primarily driven by differential loading on the baroreflex receptors, combined with differences in venous return to the heart. Thorax compression in the prone position leads to reduced venous return and increased sympathetic nervous activity, raising heart rate, and systemic vascular resistance while lowering cardiac output and stroke volume.
Conclusions
Gravitational dose‐response curves generated from these data provide a comprehensive baseline from which to assess the efficacy of potential spaceflight countermeasures. Results also assist clinical management of terrestrial surgery in prone posture or head‐down tilt positions.
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Affiliation(s)
- Richard S. Whittle
- Department of Aerospace Engineering Texas A&M University College Station TX
| | - Nathan Keller
- Department of Health and Kinesiology Texas A&M University College Station TX
| | - Eric A. Hall
- Department of Biomedical Engineering Texas A&M University College Station TX
| | | | | | | | - Bonnie J. Dunbar
- Department of Aerospace Engineering Texas A&M University College Station TX
| | - Ana Diaz‐Artiles
- Department of Aerospace Engineering Texas A&M University College Station TX
- Department of Health and Kinesiology Texas A&M University College Station TX
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Lisboa da Silva RMF, Oliveira PML, Tonelli HAF, Alves Meira ZM, Mota CDCC. Neurally Mediated Syncope in Children and Adolescents: An Updated Narrative Review. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2205110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Syncope presents a proportion of up to 25% among children and adolescents and accounts for 0.9% of emergency room visits. Its most frequent aetiology is neurally mediated syncope, which includes vasovagal syncope and orthostatic hypotension. Up to 70% of the paediatric population with reflex syncope is female. There are usually precipitating factors and prodromes. This mini-review will discuss the particularities of the clinical presentation, diagnosis, modified Calgary score, indications and accuracy of the head-up tilt test, classification, and pathophysiology in four sequential phases. Prognostic data and the non-pharmacological and pharmacological approaches will also be reviewed and differences regarding reflex syncope in adults will be discussed.
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Serum pyridoxine, folate, cobalamin, and homocysteine levels in children presenting with vasovagal syncope. Cardiol Young 2022; 32:762-768. [PMID: 34321136 DOI: 10.1017/s1047951121003036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recent studies confirm the role of B vitamins deficiency and hyperhomocysteinaemia in the development of dysautonomia that has been considered to be the main factor in vasovagal syncope development. The aim of the study was to investigate serum pyridoxine, folate, cobalamin, and homocysteine levels in children presenting with vasovagal syncope and to analyse the correlation between them and main clinical parameters of syncope. METHODS We studied 40 children, ages 8-17 years with a history of vasovagal syncope and 24 healthy volunteers. The serum pyridoxine, folate, cobalamin, and homocysteine levels were measured by a quantitative sandwich enzyme immunoassay technique using a commercial kit (Monobind, USA). Twenty-four-hour Holter monitoring and 24-hour ambulatory blood pressure monitoring were conducted for all participated patients. RESULTS Serum pyridoxine (9.42 ± 4.87, 16.11 ± 5.53 µg/L) and cobalamin (307.48 ± 95.50, 447.28 ± 108.85 ng/L) levels were reasonably low (p < 0.05) in patients with vasovagal syncope. Although there was no significant change in folate levels between syncope and healthy children (4.00 ± 1.34, 4.71 ± 1.73 µg/L; p = 0.20), we detected low folate-level association with longer duration of syncope (r = -0.42) and post syncope (r = -0.43) symptoms (p < 0.05). Finally, there was increased serum homocysteine level (13.55 ± 5.03, 7.81 ± 1.71 µmol/L; p < 0.05) in patients with vasovagal syncope. It was positively correlated with the average PQ interval (r = 0.35, p < 0.05) and average QTc interval (r = 0.49, p < 0.05). CONCLUSIONS The results suggested that pyridoxine, folate, cobalamin, and homocysteine may be involved in the pathogenesis of vasovagal syncope. This might provide a new approach for effective treatment of paediatric vasovagal syncope, requiring further study.
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15
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Norcliffe-Kaufmann L. Stress and the baroreflex. Auton Neurosci 2022; 238:102946. [PMID: 35086020 DOI: 10.1016/j.autneu.2022.102946] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/16/2021] [Accepted: 01/16/2022] [Indexed: 11/27/2022]
Abstract
The stress response to emotions elicits the release of glucocorticoids from the adrenal cortex, epinephrine from the adrenal medulla, and norepinephrine from the sympathetic nerves. The baroreflex adapts to buffer these responses to ensure that perfusion to the organs meets the demands while maintaining blood pressure within a within a narrow range. While stressor-evoked autonomic cardiovascular responses may be adaptive for the short-term, the recurrent exaggerated cardiovascular stress reactions can be maladaptive in the long-term. Prolonged stress or loss of the baroreflex's buffering capacity can predispose episodes of heightened sympathetic activity during stress leading to hypertension, tachycardia, and ventricular wall motion abnormalities. This review discusses 1) how the baroreflex responds to acute and chronic stressors, 2) how lesions in the neuronal pathways of the baroreflex alter the ability to respond or counteract the stress response, and 3) the techniques to assess baroreflex sensitivity and stress responses. Evidence suggests that loss of baroreflex sensitivity may predispose heightened autonomic responses to stress and at least in part explain the association between stress, mortality and cardiovascular diseases.
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van Dijk JG, van Rossum IA, Thijs RD. The pathophysiology of vasovagal syncope: Novel insights. Auton Neurosci 2021; 236:102899. [PMID: 34688189 DOI: 10.1016/j.autneu.2021.102899] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 12/16/2022]
Abstract
The pathophysiology of vasovagal syncope (VVS) is reviewed, focusing on hemodynamic aspects. Much more is known about orthostatic than about emotional VVS, probably because the former can be studied using a tilt table test (TTT). Recent advances made it possible to quantify the relative contributions of the three factors that control blood pressure: heart rate (HR), stroke volume (SV) and total peripheral resistance (TPR). Orthostatic VVS starts with venous pooling, reflected in a decrease of SV. This is followed by cardioinhibition (CI), which is a decrease of HR that accelerates the ongoing decrease of BP, making the start of CI a literal as well as fundamental turning point. The role of hormonal and other humoral factors, respiration and of psychological influences is reviewed in short, leading to the conclusion that a multidisciplinary approach to the study of the pathophysiology of VVS may yield new insights.
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Affiliation(s)
- J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Ineke A van Rossum
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands
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Abstract
Unlike noradrenaline, the sympathetic neurotransmitter which overflows to the circulation, adrenaline (ADR) is a secreted hormone, with a low plasma concentration, and plasma concentration for biological action a log order lower than that of noradrenaline. The venous drainage of the left adrenal medulla into the left renal vein does expose this vein to uniquely high plasma ADR concentrations and possible risk of thrombosis at high rates of ADR secretion. There is typically a different timeframe for adrenal medullary and sympathetic nervous system responses: ADR release is short term in contrast with sympathetic activation persisting for years in heart failure and hypertension. The historic view of Walter Cannon, subject to recent review, that the sympathoadrenal system is a unified biological system, was deconstructed further with demonstration of frequent mismatching of adrenal medullary and sympathetic nervous responses. Under gravity stimulation with standing, there is prompt sympathetic activation without ADR release. In many diseases, notably obesity, hypertension, heart failure and depressive illness, an activated sympathetic nervous system and silent adrenal medulla coexist. The therapeutic corollary of this is that ADR blockade is much less commonly needed clinically than pharmacological antagonism of the sympathetic nervous system.
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