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Fedorowski A, Rivasi G, Torabi P, Johansson M, Rafanelli M, Marozzi I, Ceccofiglio A, Casini N, Hamrefors V, Ungar A, Olshansky B, Sutton R, Brignole M, Parati G. Underlying hemodynamic differences are associated with responses to tilt testing. Sci Rep 2021; 11:17894. [PMID: 34504263 PMCID: PMC8429732 DOI: 10.1038/s41598-021-97503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022] Open
Abstract
Aim of this study was to explore whether differences in resting hemodynamic parameters may be associated with tilt test results in unexplained syncope. We analyzed age, gender, systolic (SBP), diastolic blood pressure (DBP) and heart rate (HR) by merging three large databases of patients considered likely to be of vasovagal reflex etiology, comparing patients who had tilt-induced reflex response with those who did not. Tilt-induced reflex response was defined as spontaneous symptom reproduction with characteristic hypotension and bradycardia. Relationship of demographics and baseline supine BP to tilt-test were assessed using logistic regression models. Individual records of 5236 patients (45% males; mean age: 60 ± 22 years; 32% prescribed antihypertensive therapy) were analyzed. Tilt-positive (n = 3129, 60%) vs tilt-negative patients had lower SBP (127.2 ± 17.9 vs 129.7 ± 18.0 mmHg, p < 0.001), DBP (76.2 ± 11.5 vs 77.7 ± 11.7 mmHg, p < 0.001) and HR (68.0 ± 11.5 vs 70.5 ± 12.5 bpm, p < 0.001). In multivariable analyses, tilt-test positivity was independently associated with younger age (Odds ratio (OR) per 10 years:1.04; 95% confidence interval (CI), 1.01–1.07, p = 0.014), SBP ≤ 128 mmHg (OR:1.27; 95%CI, 1.11–1.44, p < 0.001), HR ≤ 69 bpm (OR:1.32; 95%CI, 1.17–1.50, p < 0.001), and absence of hypertension (OR:1.58; 95%CI, 1.38–1.81, p < 0.001). In conclusion, among patients with suspected reflex syncope, younger age, lower blood pressure and lower heart rate are associated with positive tilt-test result.
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Affiliation(s)
- Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden. .,Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden.
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Madeleine Johansson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden
| | - Martina Rafanelli
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Irene Marozzi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Alice Ceccofiglio
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Niccolò Casini
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Brian Olshansky
- Division of Cardiology, Department of Internal Medicine, University of Iowa Hospitals, Iowa City, IA, USA
| | - Richard Sutton
- Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden.,Department of Cardiology, National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Michele Brignole
- Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Gianfranco Parati
- Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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Brignole M, Kessisoglu F, Croci F, Solano A, Donateo P, Maggi R, Solari D, Bertolone C, Fontana D, Oddone D, Rivasi G, Rafanelli M, Casini N, Ungar A. Complementary effectiveness of carotid sinus massage and tilt testing for the diagnosis of reflex syncope in patients older than 40 years: a cohort study. Europace 2021; 22:1737-1741. [PMID: 33078193 DOI: 10.1093/europace/euaa204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/23/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Indications, methodology, and diagnostic criteria for carotid sinus massage (CSM) and tilt testing (TT) have been standardized by the 2018 Guidelines on Syncope of the European Society of Cardiology. Aim of this study was to assess their effectiveness in a large cohort which reflects the performance under 'real-world' conditions. METHODS AND RESULTS We analysed all patients who had undergone CSM and TT in the years 2003-2019 for suspected reflex syncope. Carotid sinus massage was performed according to the 'Method of Symptoms'. Tilt testing was performed according to the 'Italian protocol' which consists of a passive phase followed by a sublingual nitroglycerine phase. For both tests, positive test was defined as reproduction of spontaneous symptoms in the presence of bradycardia and/or hypotension. Among 3293 patients (mean age 73 ± 12 years, 48% males), 2019 (61%) had at least one test positive. A bradycardic phenotype was found in 420 patients (13%); of these, 60% were identified by CSM, 37% by TT, and 3% had both test positive. A hypotensive phenotype was found in 1733 patients (53%); of these, 98% were identified by TT and 2% had both TT and CSM positive. CONCLUSION The overall diagnostic yield of the tests in patients >40-year-old with suspected reflex syncope was 61%. Both CSM and TT are useful for identifying those patients with a bradycardic phenotype, whereas CSM has a limited value for identifying the hypotensive phenotype. Since the overlap of responses between tests is minimal, both CSM and TT should be performed in every patient over 40 years receiving investigation for unexplained but possible reflex syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Ospedale San Luca, Milano, Italy
| | | | - Francesco Croci
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Alberto Solano
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Paolo Donateo
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Roberto Maggi
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Diana Solari
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Cristina Bertolone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Daniele Fontana
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Daniele Oddone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Giulia Rivasi
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Martina Rafanelli
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Niccolò Casini
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Andrea Ungar
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
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