Head-up Tilt Table Research Articles

Improvement of nutritional status enhances cognitive and physical functions in older adults with orthostatic hypotension

ObjectivesMalnutrition may be an important risk factor for orthostatic hypotension (OH). The aim of this study was to investigate the relationship between malnutrition and OH, and the effect of nutritional improvement on cognitive functions and gait-balance parameters in patients with OH. MethodsA total of 692 patients were included in the study. The Head-up Tilt Table Test and Mini Nutritional Assessment (MNA) were implemented for participants. Patients underwent a comprehensive geriatric assessment, including a neurocognitive evaluation and physical performance. After 6 mo, the participants who had OH were reevaluated. ResultsWomen comprised 64.8% of the patients and the mean age was 74.98 ± 7.68 y. The frequencies of OH, malnutrition, and risk of malnutrition were 31.9%, 7.4%, and 13.3%, respectively. The rates of dementia, hypertension, sarcopenia, frailty, and a history of falls in the past year were higher in the OH-positive group. OH was associated with malnutrition (odds ratio: 2.48; confidence interval, 1.35‒4.54; P = 0.003) and risk of malnutrition (odds ratio: 1.64; CI, 1.03‒2.62; P = 0.035) in contrast with normal nutritional status. A higher MNA score during the follow-up period resulted in improved cognitive and gait-balance scores when confounding factors were adjusted (P < 0.05). Patients with OH whose MNA score improved during the follow up also had a significant decrease in the number of falls (P = 0.034). ConclusionsOptimization of nutritional status may improve global cognition and gait-balance functions, and prevent falls in older people with OH.

Do indices of baroreflex failure and peripheral noradrenergic deficiency predict the magnitude of orthostatic hypotension in Lewy body diseases?

Patients with neurogenic orthostatic hypotension in the setting of Lewy body diseases (LBnOH) typically have baroreflex failure and peripheral noradrenergic deficiency. Either or both of these abnormalities might determine the magnitude of OH in individual patients. We retrospectively correlated the orthostatic fall in systolic blood pressure (∆BPs) during active standing or 5min of head-up tilt at 90° from horizontal as a function of several baroreflex and sympathetic noradrenergic indices. Physiological, neurochemical, and sympathetic neuroimaging data from the Valsalva maneuver, head-up tilt table testing, and thoracic 18F-dopamine positron emission tomographic scanning (18F-DA PET) were analyzed from 72 patients with LBnOH [44 with Parkinson disease (PD) and nOH, 28 with pure autonomic failure]. Comparison subjects had PD without OH (N = 44) or PD risk factors without parkinsonism or OH (N = 28) or were healthy volunteers (N = 8). Indices of baroreflex function included the Valsalva maneuver-associated baroreflex areas in Phase II (BRA-II) and IV (BRA-IV), the pressure recovery time (PRT), and baroreflex-cardiovagal and adrenergic sensitivities (BRS-V and BRS-A). The fractional orthostatic increment in plasma norepinephrine (Fx∆NE) provided a neurochemical index of baroreflex-sympathoneural function. As expected, the LBnOH group had baroreflex-sympathoneural and baroreflex-cardiovagal impairment and low cardiac 18F-DA-derived radioactivity. Among patients, values for ∆BPs correlated with BRA-II, BRA-IV, BRS-V, and Fx∆NE but not with values for PRT, BRS-A, supine plasma NE, or 18F-DA-derived radioactivity. Across individual patients with LBnOH, quantitative indices of baroreflex dysfunctions and peripheral noradrenergic deficiency are inconsistently associated with the magnitude of OH, even under controlled laboratory conditions.

Orthostatic Hypotension in Elderly Patients with Essential Tremor

PurposeEssential tremor (ET) is the most common movement disorder in which dysautonomia symptoms can be present. We aimed to evaluate the presence of orthostatic hypotension (OH) and its relationship with the clinical features.Patients and MethodsForty-four elderly patients with ET and 118 healthy elderly controls were included. OH was assessed via the head-up tilt table test and defined, according to the change in position, as a drop of at least 20 mmHg in systolic blood pressure and/or 10 mmHg in diastolic blood pressure. Tremor severity was evaluated using the Fahn-Tolosa-Marin Tremor Rating (FTMTR) Scale. All patients underwent geriatric comprehensive assessment.ResultsThere were no differences between the controls and patients with ET regarding age and gender. The mean age was 72.8±6.1, the mean disease duration 19.1±13.5 years and the mean FTMTR score was 30.9±17.1 in patients with ET. The frequency of OH at the 1st minute in patients with ET was higher than in controls (31.8% vs 17.8%, p=0.046). Furthermore, the frequency of jaw tremor in patients with OH was higher than in those without OH (35.7% vs 6.7%, p=0.025). About 28.6% of ET patients with OH had orthostatic symptoms.ConclusionWe demonstrated that ET patients, particularly those with jaw tremors, had OH and that most of them were asymptomatic. Therefore, in order to protect patients from complications related to OH, it would be appropriate to evaluate OH in the follow-up and treatment of elderly patients with ET.

Usefulness of Squatting Combined with the Blood Pressure Measurement for Orthostatic Intolerance in Dizziness Clinic

Background Orthostatic intolerance (OI) is a common clinical symptom in dizziness clinic. The head-up tilt table test (HUT) is one of the primary clinical examination for evaluating OI. There is no consensus on the optimum method for diagnosis of orthostatic hypotension (OH). Herein, we performed the additional squat combined with blood pressure (BP) monitoring for OI patients with normal HUT. Methods The study included 32 consecutive patients with orthostatic intolerance for 3 months since April, 2018 (Period I) and 27 patients with orthostatic intolerance for 3 months since April, 2019 (Period II) in dizziness clinic of Chungnam National University Hospital. During Period II, the additional squat combined with BP test was performed for normal HUT results in patients with OI. In squat combined orthostatic BP measurement, the first BP measurement was taken following 3 minutes of rest at the squat position; afterwards the patients were raised upright and the measurement was monitored for 2 minutes, using a continuous beat-to-beat BP monitoring. Results In this study, there was significant difference in OH diagnosis (p<0.001); 40.6% (13/32) by conventional HUT (Period I) vs. 92.5% (25/33) by conventional HUT and additional squat test for normal HUT (Period II). In patients with normal HUT, the positive OH was 86.7% (13/15) by the additional squat combined BP measurement (Period II). Conclusions In addition to HUT, squat test combined with BP measurement might be more informative for understanding and diagnosing the OH, particularly in patients with OI and normal HUT in dizziness clinic. Keywords: Orthostatic intolerance, Tilt table test

"Complex" Vasovagal Syncope: A Zebra Among Horses.

Background: Vasovagal syncope (VVS) occurs due to cerebral hypoperfusion from a fall in blood pressure, with accompanying bradycardia in most cases. Seizure and/or asystole may accompany VVS, though their prediction within the VVS cohort remains elusive.Objective: To further characterize VVS and to find predictive features of “complex” VVS (defined as VVS associated with seizures and/or asystole).Methods: We reviewed medical records of all patients who were referred for orthostatic intolerance and had a definite VVS during the head-up tilt table testing (HUTT). The following variables were recorded: cardiovascular indices during HUTT, autonomic testing results, and semiology of asystole and/or seizure when present. Simple frequency and correlation analysis were performed using the ANOVA.Results: A total of 78 independent VVS were recorded in 60 patients of which 24% were not preceded by presyncope. Vasodepressor (45%) and mixed (38%) VVS were the most prevalent types. Eighteen (23%) were complex VVS; five had an associated seizure (SySz), nine were accompanied by asystole (SyAs), and four had both (SySzAs). Males were significantly more likely to have complex VVS. Mean asystole duration was somewhat longer in the SyAsSz group. The severity of bradycardia significantly correlated with complex VVS and was a predictor of SySz. Autonomic abnormalities were frequent but did not distinguish the two VVS subgroups. Seizures had multiple distinguishing features from those typically associated with epileptic seizures.Conclusions: The underlying pathophysiologic mechanisms of complex VVS remain unclear, but the severity of cerebral hypoperfusion due to bradycardia likely plays a key role in seizure generation.

Postural orthostatic tachycardia syndrome in patients of orthostatic intolerance symptoms: an ambispective study.

BackgroundA Postural orthostatic tachycardia syndrome (POTS) is infrequently diagnosed in routine practice because of the variable range of symptoms that could be seen in cardiac rhythm disorders, vertigo, chronic fatigue syndrome and anxiety panic disorder. POTS is a chronic debilitating condition that affects day to day efficient working of an individual. We have planned a study to look for POTS in patients who are having orthostatic intolerance symptoms and underwent a head-up tilt table test (HUTT).AimTo study the prevalence of POTS in patients of orthostatic intolerance (OI) symptoms and to analyze symptomatology, its association with neurocardiogenic syncope (NCS), and its outcome.MethodsWe reviewed the medical records of 246 patients presented with symptoms of OI seen at our centre from January 2010 till March 2019. Out of them, 40 patients included, those qualifying the criteria for POTS on HUTT.ResultsThe mean age of the cohort was 25.90 ± 10.33 years with a range of 15 to 55 years, and males comprised 52.5% (21/40) of total patients. The most frequent presenting orthostatic symptoms of POTS patients are loss of consciousness (77.5%), lightheadedness (75%), and palpitation (67.5%). A total of 18 patients (45%) had coexisting neurocardiogenic syncope.ConclusionPOTS is a prevalent condition and have a significant impact on the quality of life, and the majority of patients may not present with OI symptoms during HUTT. We have to keep this possibility in young patients of transient loss of consciousness because it may coexist with NCS.

Early-onset and recurrent reflex syncope is associated with left ventricular diastolic filling and left atrial function properties

Abstract Background/Introduction The effects of the left atrial and ventricular function in the pathophysiology of reflex syncope remain elusive. Head-up tilt table test (HUTT) is frequently used in the diagnostic workup of patients with syncope, but the outcomes of HUTT have not been attributed to any anatomical or functional cardiac characteristics. Purpose We sought to assess the effects of anatomical and functional echocardiographic features of the left atrium and the left ventricle at rest in the clinical presentation of syncope and the outcomes of HUTT. Methods We investigated patients with a history of syncope and symptoms suggestive of reflex syncope who underwent HUTT. Specific echocardiographic indices of left cardiac morphology and function were assessed at rest. The patients were divided into two groups, those who presented with syncopal episodes at age &amp;lt;35 years (group A) and those who presented with syncopal episodes at age &amp;gt;35 years (group B). Results In 119 patients (age 46.75±21.17 years, 69 women), patients in group A exhibited a higher chance for numerous (&amp;gt;3) syncopal episodes (odds ratio [OR] 3.4, 95% Confidence Interval [CI] 1.41 to 7.93, p&amp;lt;0.05). Group A showed also a trend for positive HUTT (OR 1.99, 95% CI 0.97 to 4.23, p=0.08). In patients with positive HUTT, Group A had higher E-wave velocity (0.83 vs 0.65 m/sec, p&amp;lt;0.05), lower A-wave velocity (0.60 vs 0.75 m/sec, p&amp;lt;0.05), higher E/A ratio (1.54 vs 1.00, p&amp;lt;0.05), higher e' wave velocity (0.16 vs 0.10 m/sec, p&amp;lt;0.05) and lower E/e' (5.64 vs 7.85, p&amp;lt;0.05). Also, patients in group A exhibited lower left atrial volumes (min 9.88 vs 16.21 ml, p&amp;lt;0.05, max 30.42 vs 44.89 ml, p&amp;lt;0.05), higher left atrial strain reservoir (40.56 vs 32.42%, p&amp;lt;0.05) and higher left atrial strain booster (25.94 vs 18.06%, p&amp;lt;0.05). Conclusion(s) Patients with a younger age of onset and recurrent syncopal episodes manifest smaller dimensions of the left atrium with distinct patterns of diastolic performance and better reservoir and booster function. These findings may indicate a more pronounced susceptibility of this group of patients to preload reduction, thereby triggering the mechanism of reflex syncope. Funding Acknowledgement Type of funding source: None

Regional analysis of cerebral hemodynamic changes during the head-up tilt test in Parkinson's disease patients with orthostatic intolerance.

.Significance: Cerebral oxygenation changes in the superior, middle, and medial gyri were used to elucidate spatial impairments of autonomic hemodynamic recovery during the head-up tilt table test (HUTT) in Parkinson’s disease (PD) patients with orthostatic intolerance (OI) symptoms.Aim: To analyze dynamic oxygenation changes during the HUTT and classify PD patients with OI symptoms using clinical and oxygenation features.Approach: Thirty-nine PD patients with OI symptoms [10: orthostatic hypotension (PD-OH); 29: normal HUTT results (PD-NOR)] and seven healthy controls (HCs) were recruited. Prefrontal oxyhemoglobin (HbO) changes during the HUTT were reconstructed with diffuse optical tomography and segmented using the automated anatomical labeling system. Decision trees were used for classification.Results: HCs and PD-NOR patients with positive rates of HbO change (PD-POS) showed the greatest HbO recovery in the superior frontal gyrus (SFG) during tilt. PD-OH and PD-NOR patients with negative rates of HbO change (PD-NEG) showed asymmetric reoxygenation. The classification accuracy was 89.4% for PD-POS versus PD-NEG, 71% for PD-NOR versus PD-OH, and 55.8% for PD-POS versus PD-NEG versus PD-OH. The oxygenation features were more discriminative than the clinical features.Conclusions: PD-OH showed decreased right SFG function, which may be associated with impaired compensatory autonomic responses to orthostatic stress.

Left Ventricular end Diastolic Diameter in Patients of Mild and Severe Postural Orthostatic Tachycardia Syndrome

Introduction Postural orthostatic tachycardia syndrome (POTS) is a form of dysautonomia presenting with palpitations, lightheadedness, brain fog, headaches, nausea and fainting¹. Several tests are used in POTS workup. Most important is the Tilt Table Test. POTS is diagnosed as change of 30 beats per minute(bpm) or more in adults and 40 bpm in people less than 18 or heart rate greater than 120 bpm within 10 minutes of head-up tilt table test. Left ventricular end diastolic diameter(LVEDD) shows the amount of blood in the left ventricle at the end of the diastole². If this diameter is less than normal then it may be the one reason contributing to the large increase in heart rate in severe POTS patients.The aim of the study is to indicate the role of LVEDD in increase of heart rate in patients of severe POTS as compared to mild POTS. Methods We analysed the POTS patients retrospectively. Inclusion Criteria POTS patients who underwent tilt table test during their workup, were analysed. Experimental Group Those having a change of 50 bpm or greater in heart rate during tilt table test were included in this group and termed as severe POTS patients. Total 132 patients meet this criteria. Control Group It comprises 144 patients having heart rate changes between 30 to 50 during tilt table test and termed as patients with mild POTS. LVEDD of these patients were measured through their echocardiograms. Females having LVEDD < 3.8 cm and Males having LVEDD < 4.2 cm were considered abnormally low diameter. Results Out of 132 patients of the experimental group (severe POTS), 32 patients (24%) had below normal LVEDD i.e. below 3.8 cm in females and below 4.2 cm in males. While in the control group, 36 patients (25%) out of 144 had abnormal LVEDD. Remaining patients have their LVEDD within the normal range. Postural orthostatic tachycardia syndrome (POTS) is a form of dysautonomia presenting with palpitations, lightheadedness, brain fog, headaches, nausea and fainting¹. Several tests are used in POTS workup. Most important is the Tilt Table Test. POTS is diagnosed as change of 30 beats per minute(bpm) or more in adults and 40 bpm in people less than 18 or heart rate greater than 120 bpm within 10 minutes of head-up tilt table test. Left ventricular end diastolic diameter(LVEDD) shows the amount of blood in the left ventricle at the end of the diastole². If this diameter is less than normal then it may be the one reason contributing to the large increase in heart rate in severe POTS patients.The aim of the study is to indicate the role of LVEDD in increase of heart rate in patients of severe POTS as compared to mild POTS. We analysed the POTS patients retrospectively. POTS patients who underwent tilt table test during their workup, were analysed. Those having a change of 50 bpm or greater in heart rate during tilt table test were included in this group and termed as severe POTS patients. Total 132 patients meet this criteria. It comprises 144 patients having heart rate changes between 30 to 50 during tilt table test and termed as patients with mild POTS. LVEDD of these patients were measured through their echocardiograms. Females having LVEDD < 3.8 cm and Males having LVEDD < 4.2 cm were considered abnormally low diameter. Out of 132 patients of the experimental group (severe POTS), 32 patients (24%) had below normal LVEDD i.e. below 3.8 cm in females and below 4.2 cm in males. While in the control group, 36 patients (25%) out of 144 had abnormal LVEDD. Remaining patients have their LVEDD within the normal range.

Functional Capacity in Patients of Severe and Mild Postural Orthostatic Tachycardia Syndrome

Introduction Postural orthostatic tachycardia syndrome (POTS) is a form of dysautonomia presenting with palpitations, lightheadedness, brain fog, headaches, and fainting¹. Several tests are used in POTS workup. Most important is the Tilt Table Test. POTS is diagnosed as change of 30 beats per minute(bpm) or more in adults and 40 bpm in people less than 18 or heart rate greater than 120 bpm within 10 minutes of head-up tilt table test. Metabolic stress test is done in patients of POTS to measure the performance of heart and lungs during physical stress². Functional capacity (FC) in this test indicates the ability of heart to cope with stress.The aim of this study is to measure functional capacity in mild and severe POTS patients and compare both groups Methods We analysed the POTS patients retrospectively. Inclusion Criteria POTS patients who underwent tilt table test during their workup, were included. Experimental Group Those having a change of 50 bpm or greater in heart rate during tilt table test were included in this group and termed as severe POTS patients, consisted of 124 patients. Control Group It comprises 136 patients having heart rate changes between 30 to 50 during tilt table test and termed as mild POTS patients. Functional capacity (FC) of these patients was taken from metabolic stress test. FC above 80% was considered normal, between 60% to 80% mildly reduced and below 60% as severely reduced. RESULTS Out of 124 patients in the experimental group (severe POTS), 61(46%) patients have severely reduced FC and 43(35%) patients have mildly reduced FC. While out of 136 patients in the control group, 46(34%) patients have severely reduced FC and 56(41%) have mildly reduced FC. p-value between the two groups is 0.0317

Prolongation of Electrocardiographic T Wave Parameters Recorded during the Head-Up Tilt Table Test as Independent Markers of Syncope Severity in Children.

The head-up tilt table test (HUTT) with the upright phase is used to help determine an imbalance of the sympathetic nervous system that is related to abnormal electrocardiographic repolarization in children with vasovagal syncope (VVS) and also in patients with the long QT syndrome (LQTS). The study attempted to evaluate T wave morphology and QT and TpTe (Tpeak–Tend) intervals recorded in ECG during the HUTT for a more accurate diagnosis of children with VVS. The group investigated 70 children with a negative HUTT result: 40 patients with VVS and 30 healthy volunteers without syncope. The RR interval as well as TpTe, and QTc intervals were measured in lead V5 of electrocardiogram (ECG) on admission to the hospital and during three phases of the HUTT. In syncopal children, which included 23 children with bifid or flat T waves and 17 patients with normal T waves in the upright phase, the QTc and TpTe were longer (p < 0.001) compared to the other test phases and longer (p < 0.001) than in the control group, respectively, with the risk of arrhythmias. Only in the control group, the TpTe was shorter (p < 0.001) in the upright phase than in the other tilt phases. The TpTe in the upright phase (>70 ms) was a good discriminator, and was better than the QTc (>427 ms). Prolongation of electrocardiographic TpTe and QT intervals, in addition to the (abnormal T wave morphology recorded during the HUTT, are helpful for identifying VVS children more predisposed to ventricular arrhythmias with a latent risk of LQTS. Further studies are required to assess the value of these repolarization parameters in clinical practice.

Relationship between sarcopenia and orthostatic hypotension.

The relationship between sarcopenia and orthostatic hypotension (OH) is unclear. The aim of the present study was to investigate associations between sarcopenia/sarcopenia severity and OH. A total of 511 patients attending a geriatric outpatient clinic were included. OH was defined as a decrease in systolic and/or diastolic blood pressure of ≥ 20mmHg and/or ≥ 10mmHg, respectively, when one transitions from the supine to an upright position. OH was measured by the Head-up Tilt Table test at 1, 3 and 5min (OH1, OH3 and OH5, respectively). Sarcopenia and its severity were defined according to the revised European consensus on definition and diagnosis. The mean age of the sample was 75.40 ± 7.35years, and 69.9% were female. The prevalence of probable sarcopenia, sarcopenia and severe sarcopenia was 42.2%, 6.06% and 11.1%, respectively. After adjustment for all covariates, systolic OH1, OH1 and systolic OH5 were statistically significantly different between severe sarcopenia and the robust group (odds ratio [OR]: 3.26, confidence interval [CI] 0.98-10.84; P = 0.05 for systolic OH1; OR 4.31, CI 1.31-14.15; P = 0.016 for OH1; OR 4.09, CI 1.01-16.55; P = 0.048 for systolic OH5). Only systolic OH1 was statistically different between the sarcopenia and severe sarcopenia groups (OR 2.64, CI 1.87-8.73; P = 0.012). OH1 and OH5 were statistically significant different between severe sarcopenia and probable sarcopenia groups (P < 0.05); there was no relationship between the robust group and probable sarcopenia (P > 0.05). There is a close relationship between sarcopenia and severe sarcopenia and OH in older adults. Therefore, when a healthcare practitioner is evaluating an older patient with sarcopenia, OH should also be evaluated, and vice versa.

The Role and Importance of the Tilt Table Test in Pediatrics

Introduction: The head-up tilt table test is noninvasive diagnostic procedure, which is used in the diagnosis of syncope. Syncope presents a benign short-term disorder of cerebral circulation with the sudden loss of consciousness and muscle tone. Aim: The aim is to present not only the role and importance of orthostatic tests in the daily clinical practice of pediatric cardiology, neuropediatrics but also pediatrics in general. Patients and Methods: This study has retrospective descriptive character and included the period from April 1997 to June 2020, during which the registration and analysis of orthostatic stability tests (head-up/tilt table test, tilt table test) was performed. Medical documentation of outpatient and hospitalized patients on the Paediatric Clinic of Clinical Center University of Sarajevo (Register of Tilt Table Test) was used. Results: During this period, 1029 tests were registered and analyzed. Modification test (head-up) was performed in 132 (12.8%) patients, and since 2008, classic tilt table test was performed in 897 (87.1%) patients. Patients were 6.5–19 years old, with a predominance of female patients 611 (59.4%). There were 519 (50.4%) patients who were 15–19 years old and 510 (49.6%) patients who were under 15 years of age. Indications were syncope or suspected syncope in 671 (65.2%) patients, cardiovascular etiology (arrhythmias, chest pain, congenital heart defects [CHDs], surgically corrected CHDs, hypotension, and hypertension) in 195 (19%) patients, neuropediatric pathology (epilepsia, suspected epilepsia, headache, vertigo) in 101 (9.8%) patients, and other indications in 62 (6.03%) patients. From the total number of tests, 862 were first tests (83.4%) and 167 were control tests (16.3%). The positive test was found in 538 (52.3%) patients, most often vasovagal syncope (473 patients or 87.9%). Conclusion: Tilt table test is a reliable diagnostic tool in examining the etiology of syncope, primarily vasovagal, and is an extremely important method primarily in cardiopediatric and neuropediatric daily diagnostics.

The Differences in the Diagnostic Profile in Children with Vasovagal Syncope between the Result of Head-Up Tilt Table Test.

(1) Background: The features characterizing vasovagal syncope (VVS) are an important factor in the correct evaluation of diagnostic risk stratification in children and adolescents. The aim of the study was to determine the value of identifying the clinical characteristics in children with VVS. (2) Methods: We made a retrospective analysis of the medical records of 109 children with diagnosed VVS. We investigated the specific characteristics of syncope in children with VVS including the positive VVS (+) and negative VVS (−) result of the Head-Up Tilt Table Test (HUTT). (3) Results: We did not observe significant differences in the prodromal symptoms of VVS with HUTT response. In addition to typical prodromal symptoms, no difference in statistically reported palpitations (35/109 or 32.1%) and chest discomfort (27/109 or 27.7%) were recorded. Fear–pain–stress emotions as circumstances of syncope were more often reported by children with a negative HUTT (p = 0.02). Cramps–contractures (p = 0.016) and speech disorders (p = 0.038) were significantly higher in the group with negative HUTT. (4) Conclusions: There is a close relationship in the diagnostic profile between the negative and positive results of head-up tilt table test in children with vasovagal syncope.

P1101Is there any link between vitamin D deficiency and vasovagal syncope?

Abstract Background This study aimed to investigate serum 25[OH]D levels between patients with vasovagal syncope(VVS) diagnosed by head-up tilt table test (HUTT) and patients who do not develop syncope during the test. Methods Sixty-eight consecutive patients [mean age 33.2 ± 14.5 years, 49 females (72.1%)] were categorized based on their HUTT results (positive vs. negative, n = 40 vs. 28).25[OH]D levels were measured by chemiluminescent microparticle immunoassay method in all patients. Results There was no difference between the two groups in terms of blood tests, Body Mass Index, gender, echocardiographic findings(p &amp;gt; 0.05).Mean 25[OH]D level was lower in HUTT positive patients when compared to the HUTT negative group(p &amp;lt; 0.05).25[OH]D levels were significantly lower between patients over the age 25 in two groups (mean level 17.9 ± 7.3 vs 26.3 ± 8.5, respectively,p &amp;lt; 0.005).(Table 1) Conclusion We found that patients diagnosed VVS by HUTT test had lower 25[OH]D levels.Measurement of vitamin D level may be an important factor in VVS patients. Table 1 Head-up Tilt Testing positive (n = 40) negative (n = 28) p value Age (years) 33.2 ± 13.7 33.3 ± 15.9 0.973 Female gender (%) 31 (77.5) 18(64.3) 0.232 BMI (kg/m2) 23.4 ± 3.1 23.0 ± 2.6 0,596 EF (%) 59.2 ± 1.6 59.1 ± 1.3 0.357 LA (mm) 34 ± 2.4 33 ± 2.7 0.715 RA (mm) 32 ± 2.5 31 ± 2.7 0.141 Vitamin D (ng/mL) 16.5 ± 6.6 23.9 ± 9.5 0.001 Vitamin B12 (pg/mL) 355.1 ± 124.6 378 ± 87.0 0.367 TSH (mIU/L) 1.8 ± 0.8 1.7 ± 0.9 0.367 Glucose (mg/dL) 87.0 ± 7.4 90.5 ± 8.1 0.076 Creatinine (mg/dL) 0.6 ± 0.1 0.7 ± 0.1 0..55 Sodium (mmol/L) 139.8 ± 2.0 139.7 ± 2.5 0.931 Potassium (mmol/L) 4.1 ± 0.3 4.1 ± 0.2 0.674 Calcium (mg/dL) 8.9 ± 0.9 8.9 ± 1.1 0.476 Wbc (x103/uL) 7.3 ± 1.6 6.9 ± 1.6 0.339 Hb (g/dL) 13.3 ± 1.3 13.5 ± 1.8 0.664 Age (years) Vitamin D level Vitamin D level 0.132 ≤ 25 (n = 31) 14.8 ± 5.5 21.2 ± 10.2 0.057 &amp;gt; 25 (n = 37) 17.9 ± 7.3 26.3 ± 8.5 0.005 Patients characteristics of Head-up Tilt Testing positive and negative group

Safety and efficacy of leadless pacemaker for cardioinhibitory vasovagal syncope

Single-chamber leadless pacemakers (LPs) have been shown to be an effective alternative to conventional transvenous pacemakers (CTPs), but their benefit in the context of cardioinhibitory vasovagal syncope (CI-VVS) is unknown. The purpose of this study was to evaluate the safety and efficacy of LP compared with dual-chamber CTP for CI-VVS. We conducted a multicenter, retrospective study comparing patients who received LP or dual-chamber CTP for drug-refractory CI-VVS. CI-VVS was diagnosed clinically and supported by cardiac monitoring and head-up tilt table testing. The primary efficacy endpoint was freedom from syncope during follow-up. Secondary endpoints included device efficacy and safety estimated by device-related major and minor adverse events (AEs). Seventy-two patients (24 LP, 48 CTP; age 32 ± 5.5 years; 90% female; syncope frequency 7.6 ± 3.4 per year) were included. At 1 year, 91% of patients (22/24) in the LP group and 94% of patients (43/48) in the CTP group met the primary efficacy endpoint (P = .7). Device efficacy endpoint was met in 92% of the LP group and 98% of the CTP group (P = .2). Early major AEs occurred in 2 of 24 in the LP group and 3 of 48 in the CTP group (P = .4). Late major AEs occurred in 0 of 24 in the LP group and 2 of 48 in the CTP group (P = 1). In patients with CI-VVS, single-chamber LP demonstrated equivalent efficacy in reducing syncopal events compared to dual-chamber CTP, with a similar safety profile.

Neurohormones in the Pathophysiology of Vasovagal Syncope in Adults.

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.

Zipf's Law of Vasovagal Heart Rate Variability Sequences.

Cardiovascular self-organized criticality (SOC) has recently been demonstrated by studying vasovagal sequences. These sequences combine bradycardia and a decrease in blood pressure. Observing enough of these sparse events is a barrier that prevents a better understanding of cardiovascular SOC. Our primary aim was to verify whether SOC could be studied by solely observing bradycardias and by showing their distribution according to Zipf’s law. We studied patients with vasovagal syncope. Twenty-four of them had a positive outcome to the head-up tilt table test, while matched patients had a negative outcome. Bradycardias were distributed according to Zipf’s law in all of the patients. The slope of the distribution of vasovagal sequences and bradycardia are slightly but significantly correlated, but only in cases of bradycardias shorter than five beats, highlighting the link between the two methods (r = 0.32; p < 0.05). These two slopes did not differ in patients with positive and negative outcomes, whereas the distribution slopes of bradycardias longer than five beats were different between these two groups (−0.187 ± 0.004 and −0.213 ± 0.006, respectively; p < 0.01). Bradycardias are distributed according to Zipf’s law, providing clear insight into cardiovascular SOC. Bradycardia distribution could provide an interesting diagnosis tool for some cardiovascular diseases.

Is there any link between vitamin D deficiency and vasovagal syncope?

BackgroundThis study aimed to investigate serum 25[OH]D levels between patients with vasovagal syncope (VVS) diagnosed with head‐up tilt table test (HUTT) and age‐matched healthy people.MethodsThe study included 75 consecutive patients (32.3 ± 10.7 years), who presented with syncope and underwent HUTT and 52 healthy controls (32.9 ± 14.1 years). HUTT patients were divided into two groups according to whether there was syncope response to the test. Patients underwent cardiac, psychiatric, and neurological investigation. Serum 25[OH]D levels were measured by chemiluminescent microparticle immunoassay method.ResultsThere was no difference between the two groups in terms of age, gender, body mass index (BMI), echocardiographic findings (P > .05). Mean serum 25[OH]D (24.5 ± 6.3 vs 20.1 ± 8.8 ng/mL, P = .003) and vitamin B12 levels (436.4 ± 199.2 vs 363.1 ± 107.6 pg/mL, P = .009) was lower in syncope patients when compared to the control group. In correlation analyses, syncope was shown as correlated with the vitamin D (r = −264, P = .003) and vitamin B12 levels (r = −233, P = .009). But, multivariate regression analyses showed that only vitamin D increased risk of syncope [OR: 0.946, 95% CI (0.901‐0.994)]. There was no difference in terms of age, gender, BMI, echocardiographic findings between the in HUTT positive (n = 45) and negative groups (n = 29). Only vitamin D level was significantly lower in HUTT positive group (17.5 ± 7.7 vs 24.4 ± 9.1 ng/mL, P = .002). There was no difference among in the vasovagal subgroups in terms of vitamin D level and other features.ConclusionVitamin D and B12 levels were reasonably low in syncope patients, but especially low Vitamin D levels were associated with VVS diagnosed in HUTT.

73 Is There A Real Relationship Between Body Mass Index and Vasovagal Syncope or is it Just Anecdote?

Abstract Introduction Syncope is characterised by global cerebral hypoperfusion rapidly causing a transient loss of consciousness with loss of voluntary muscle tone and a subsequent spontaneous, prompt and complete recovery. It is often caused by Neurally mediated reflex syncope syndromes of which Vasovagal syncope (VVS) is the commonest form. The prodromal symptoms of VVS are explained by circulatory alterations (vasodilatation and bradycardia) and autonomic activation. Whilst many triggers and risk factors for such alterations are recognised, they are incompletely understood. Anecdotally, being “young and thin” is a risk factor but there is little published data evaluating the relationship between body weight and VVS. Whilst VVS can often be diagnosed on clinical history alone, further evaluation is warranted in some patients. The validated test to assess susceptibility to VVS is the head-up-tilt table (HUT) test. We set out to evaluate the relationship between Body Mass Index (BMI) and the outcome of HUT testing. Methods We reviewed the outcomes of 1193 patients attending for HUT testing at the University Hospitals of Leicester between December 2014 and October 2017. The protocol used was a 40 minute passive HUT (70 degree) followed by sublingual nitroglyserin. The parameters of height, weight, gender and test outcome were recorded prospectively and interrogated retrospectively. Results Of the 1193 patients, the passive HUT test was positive for VVS in 293 patients. These patients were then sub-grouped by BMI as set out in the table. The chances of VVS, as diagnosed by HUT testing are almost doubled in those with a (clinically underweight) BMI range 16-20. (p value 0.002-0.001) Discussion The presented data supports the anecdotal experience of many clinicians: that low BMI may be associated with an increased tendency to VVS. The physiological basis for this (if it is real) is not understood and requires further evaluation since it may have implications for future management strategies. Larger studies are required to further analyse this relationship to determine if BMI is an independent predictor or risk factor for VVS.