Recurrence Of Syncope Research Articles

Two-year morbidity and mortality in elderly patients with syncope

syncope is a common cause of hospitalisation in the elderly. However, morbidity and mortality in elderly patients with syncope is not well established. two-hundred and forty-two patients older than 65 years consecutively referred to the participating centres for evaluation of transient loss of consciousness were enrolled in a multicentre 2-year longitudinal observational study. Mortality and syncope recurrences were recorded and multidimensionally evaluated at 6, 12, 18 and 24 months. at 24 months, total mortality was 17.2% and syncope recurrence was 32.5%. Cardiac syncope was more frequent in deceased than in survivor patients (21.7 versus 12.3%; P = 0.03), whereas neuro-mediated (62.1 versus 66.2%; P = 0.357) and unexplained syncope (10.8 versus 11.8%; P = 0.397) did not differ between the two groups. Drug-induced and/or multifactorial syncope was less frequent in patients with syncope recurrence (5.7 versus 10.7%; P = 0.02). Kaplan-Meyer curves indicated that mortality and syncope recurrence increased significantly with age (P = 0.006 and P = 0.008, respectively). At multivariate analysis, mortality was significantly predicted by age and comorbidity (hazard ratios: 1.17 and 1.39, and 95% confidence interval 1.01-1.37 and 1.01-1.93, respectively), and syncope recurrence by age and disability (hazard ratio: 1.13 and 1.04, 95% confidence interval 1.01-1.25 and 1.04-2.25, respectively). Depression increased from baseline to the end of follow-up (from 28.3 to 41.4%; P = 0.001). in our patients, mortality was related to increasing age and comorbidity, whereas recurrence was related to increasing age and disability. Cardiac syncope was more frequent in deceased than in survivor patients, and syncope recurrence was high despite a low incidence of unexplained syncope.

What Can We Expect from the ISSUE 3 Trial?

The ISSUE 3 Trial is designed to demonstrate which patients with vasovagal syncope over the age of 40 years will benefit from pacing dual chamber with the rate drop response. The trial has completed its recruitment of 521 patients and 78 have now been randomized in Phase 2, which is the Pacing ON versus Pacing OFF comparison. During this Phase the end-points are recurrence of syncope or two years of follow-up without recurrence. It has been calculated that 27 early end-points will be sufficient to determine a significant difference between the groups. The background, details and design of the trial are explained. Some early findings are presented. Definitive results are expected by the end of 2011.

Effectiveness of Midodrine treatment in patients with recurrent vasovagal syncope not responding to non-pharmacological treatment (STAND-trial)

Initial treatment of vasovagal syncope (VVS) consists of advising adequate fluid and salt intake, regular exercise, and physical counterpressure manoeuvres. Despite this treatment, up to 30% of patients continue to experience regular episodes of VVS. We investigated whether additional Midodrine treatment is effective in these patients. In our study, patients with at least three syncopal and/or severe pre-syncopal recurrences during non-pharmacological treatment were eligible to receive double-blind cross-over treatment starting either with Midodrine or placebo. Treatment periods lasted for 3 months with a wash-out period of 1 week in-between. At baseline and after each treatment period, we collected data about the recurrence of syncope and pre-syncope, side effects, and quality of life (QoL). Twenty-three patients (17% male, mean age 32) included in the cross-over trial received both Midodrine and placebo treatment. The proportion of patients who experienced syncopal and pre-syncopal recurrences did not differ significantly between Midodrine and placebo treatment (syncope: 48 vs. 65%, P= 0.22; pre-syncope: 74 vs. 78%, P> 0.99). The median number of syncopes and pre-syncopes per 3 months were also not significantly different during Midodrine and placebo treatment (0 vs. 1; P= 0.57; and 6 vs. 8; P= 0.90). The occurrence of side effects was similar during Midodrine and placebo treatment (48 vs. 57%; P= 0.75). Also, QoL did not differ significantly. Our findings indicate that additional Midodrine treatment is less effective in patients with VVS not responding to non-pharmacological treatment than reported as first-line treatment.

Single coronary artery giving rise to an intraseptal left coronary artery in a patient presenting with neurocardiogenic syncope

Syncope occurs frequently in adolescents, and is often benign. Potential worrisome syncopal events include those occurring with exertion, concurrent chest pain, dyspnoea or palpitations, and those with focal or diffuse neurologic changes. A 16-year-old female was referred to our institution for a history of exercise-induced spells. She was diagnosed since the age of 2 years with neurocardiogenic syncope and postural orthostatic tachycardia syndrome. She had been evaluated at multiple institutions, and was followed by pediatric neurology for a diagnosis of migraines. Owing to recurrent worsening symptoms and a syncopal episode requiring resuscitation, an echocardiogram was performed. The right coronary was normal, but the left coronary artery ostium could not be identified well. Doppler patterns were suspicious of an abnormal left coronary artery, and computed tomography angiography was performed. This revealed a single coronary artery arising from the right aortic sinus, with the left coronary artery arising from the proximal coronary trunk and coursing through the infundibular septum. This was surgically treated utilising a left internal mammary artery bypass graft to the left anterior descending coronary artery. A year later, she has not experienced any recurrence of syncope, and has returned to athletic activity. This case highlights the index of suspicion that must be present when evaluating any patient with syncope, both clinically and via echocardiography. A computed tomography angiogram is indicated for better evaluation of coronary artery anatomy when an anomalous coronary cannot be ruled out by echocardiography.

Syncope Due to Idiopathic Paroxysmal Atrioventricular Block: Long-Term Follow-Up of a Distinct Form of Atrioventricular Block

We present data on patients with syncope due to paroxysmal atrioventricular (AV) block unexplainable in terms of currently known mechanisms. Paroxysmal AV block is known to be due to intrinsic AV conduction disease or to heightened vagal tone. We evaluated 18 patients presenting with unexplained syncope who had: 1) normal baseline standard electrocardiogram (ECG); 2) absence of structural heart disease; and 3) documentation, by means of prolonged ECG monitoring at the time of syncopal relapse, of paroxysmal third-degree AV block with abrupt onset and absence of other rhythm disturbances before or during the block. The study group consisted of 9 men and 9 women, mean age 55 ± 19 years, who had recurrent unexplained syncope for 8 ± 7 years and were subsequently followed up for as long as 14 years (4 ± 4 years on average). The patients had no structural heart disease, standard ECG was normal, and electrophysiological study was negative. In all patients, prolonged ECG monitoring documented paroxysmal complete AV block with 1 or multiple consecutive pauses (mean longest pause: 9 ± 7 s at the time of syncope); AV block occurred without P-P cycle lengthening or PR interval prolongation. During the observation time, no patient had permanent AV block; on permanent cardiac pacing, no patient had further syncopal recurrences. Common clinical and electrophysiological features define a distinct form of syncope due to idiopathic paroxysmal AV block characterized by a long history of recurrent syncope, absence of progression to persistent forms of AV block, and efficacy of cardiac pacing therapy.

Association between psychological complaints and recurrence of vasovagal syncope

Vasovagal syncope (VVS), the most common cause of transient loss of consciousness (T-LOC), is often accompanied by higher levels of psychological distress. We investigated to what extent psychological complaints interact with the effects of non-pharmacological treatment in patients with frequently recurring VVS. Patients with ≥3 episodes of VVS in the 2years prior to the start of the study openly received non-pharmacological treatment. Before treatment initiation, we determined the level of general psychological complaints by the Symptom Checklist 90-R (SCL-90-R) questionnaire. We regularly evaluated syncopal recurrence during follow-up. We compared the SCL-90-R scores of VVS patients in our study with the corresponding scores of healthy Dutch subjects (reference population). We examined whether patients with more recurrences during follow-up had higher SCL-90-R scores at baseline and whether this association changed when adjusting for other factors associated with recurrence using logistic regression. Total SCL-90-R scores were higher in our cohort of patients with frequent episodes of VVS than in the reference population (142 vs. 118; p<0.001). During the first 6months of treatment, 42% of patients experienced syncopal recurrence(s). The SCL-90-R scores of these patients were significantly higher compared with patients without syncopal recurrence in this period (160 vs. 130; p=0.01). After adjusting for other predictors of recurrence, especially the number of episodes before inclusion, the association between SCL-90-R scores and recurrence remained intact. Levels of general psychological complaints are higher in patients with syncopal recurrence during non-pharmacological treatment of VVS, even after adjusting for previous syncopal episodes.

The natural history of carotid sinus syncope and the effect of cardiac pacing

Therefore, a question arises as to what the real usefulness of pacing therapy is and which patients need this therapy. Lopes et al. 11 performed a retrospective analysis of 138 patients who were followed-up for � 5 years, thus adding an important contribution to the effect of cardiac pacing in CSS patients. Taking into account this study, in this article we tried to summarize the current knowledge about pacing therapy of this old syndrome. We performed a MedLine search among peer-review journals in the English language for articles dealing with the natural and unnatural history of CSS; we excluded case reports. We found 12 studies 6,7,11 – 20 which reported sufficient follow-up data for analysis. In total, we were able to analyse the natural history of 305 patients and the effect of cardiac pacing in another 601 patients affected by severe recurrent syncope. The results are shown in Figure 1. The studies were largely heterogeneous in regard to the selection of patients, duration, and position (supine or standing) of the carotid sinus massage, criteria for identification of mixed forms, and different mode of pacing (single- vs. dual-chamber). Despite these limitations, the figure suggests that syncopal recurrence rates during follow-up with pacing ranged between 0 and 20%, whereas the recurrence of syncope was always higher in untreated patients, with the rates between 20 and 60%. The specificity of carotid sinus massage increases if reproduction of spontaneous syncope during carotid massage is a requisite for positivity of the test. The so-called ‘Method of Symptoms’ requires a longer duration of the massage, in general for 10 s. The recent ESC guidelines on syncope 2 recommend that CSS be diagnosed if spontaneous symptoms are reproduced together with the documentation of an abnormal reflex. Figure 2 shows the results of metanalysis of three controlled studies 6,7,15 in which carotid sinus massage was performed according to the ‘Method of Symptoms’. The studies were sufficiently homogeneous (Mantel– Haenszel heterogeneity test: P ¼ 0.39). The mean length of the pause induced by the carotid sinus massage ranged from 5.2 to 7.3 s. During a mean observation period of up to 3.3 years, syncope recurred in 9% of patients treated with a pacemaker and in 38% of control untreated patients. The cumulative odds ratio was 0.15 (95% CI 0.06–0.36). Finally, in a registry of 169 consecutive patients treated with permanent pacemaker in our departments from 1988 to 1994, 19 the actuarial estimate of syncopal recurrence was 7% at 1 year, 16% at 3 years, and 20% at 5 years. Cardiac pacing seems less effective in preventing pre-syncope than syncope. Indeed, pre-syncope and minor symptoms have been reported in 25, 6 27, 7 and 43% 20 patients after pacemaker implant. Moreover, two randomized trials 6,7 failed to show the superiority of cardiac pacing compared with no pacing in reducing the rate of pre-syncope. It seems that pacing transforms syncope to pre-syncope probably because it is effective in counteracting the asystolic reflex that causes syncope but it is less effective against the vasodepressor component of the reflex which is frequently associated even with the so-called dominant cardioinhibitory forms. Lopes et al. 11 reported a lower 6% rate of

Long-Term Outcome of Intensive Education as Treatment of Vasovagal Syncope: Median 3 Year Follow-Up

Background: Treatment of vasovagal syncope has been not well established. We assessed the hypothesis that intensive education is effective. Methods: A total of 367 subjects who were diagnosed with vasovagal syncope by head-up tilt test from May 2006 to Dec. 2008 were investigated retrospectively. Group 1 (n=210) were treated with only intensive education. Group 2 (n=157) received conventional treatment of mediation plus simple explanation; beta-blocker (n=131), other (n=22). 312 subjects were interviewed with telephone during median 3 year follow-up and 53 visited regularly at outpatient clinic. The frequency of syncope episodes were divided into grade 0 (0 episode), grade 1 (1∼2), and grade 3 (3<). Results: Gender, diabetes history, the frequency of syncope were not different between group (p<0.05). Group 2 was older, had more hypertension, coronary disease than group 1. After a follow-up of 31±10 months, the frequency of syncope episodes after treatment reduced from grade 1.3±0.5 to grade 0.1±0.3 but 36 of 330 (11%) had syncope recurrence (grade 1.06±0.23). In multivariate regression analysis, young age (OR0.97, p=0.024) was an independent predictor of syncope recurrence and intensive education was not associated with increased risk of syncope. After propensity score analysis, intensive education was not associated with syncope recurrence. Conclusions: The efficacy of intensive education as treatment of vasovagal syncope was not different from that of conventional treatment.

What Can We Expect from the ISSUE 3 Trial?

The ISSUE 3 Trial is designed to demonstrate which patients with vasovagal syncope over the age of 40 years will benefit from pacing dual chamber with the rate drop response. The trial has completed its recruitment of 521 patients and 78 have now been randomized in Phase 2, which is the Pacing ON versus Pacing OFF comparison. During this Phase the end-points are recurrence of syncope or two years of follow-up without recurrence. It has been calculated that 27 early end-points will be sufficient to determine a significant difference between the groups. The background, details and design of the trial are explained. Some early findings are presented. Definitive results are expected by the end of 2011.

Recent History of Vasovagal Syncope in a Young, Referral‐Based Population Is a Stronger Predictor of Recurrent Syncope Than Lifetime Syncope Burden

accurate selection of patients for vasovagal syncope studies requires strong risk stratification and knowledge of the natural history of syncope. We aimed to test the hypothesis that recent history of vasovagal syncope compared to distant history better predicts subsequent recurrence of syncope. in all, 208 subjects with a positive tilt test and ≥ 3 lifetime syncope spells were followed for 1 year. Syncope episodes in the preceding year and total historical spells were compared for their ability to predict a syncope recurrence using the criteria of optimal statistical significance, best linear separation of risk populations, and impact on power calculations. The number of vasovagal syncope spells in the preceding year better predicted syncope recurrence when compared to total number of historical spells (likelihood ratio statistic 28.4, P < 0.0001; versus 20.4, P = 0.001), and showed a substantial effect as the number of syncope events increased. For example, syncope recurred in 22% of those with <2 spells in the previous year compared to 69% in those with >6 spells. A history of no syncope compared to any syncope in the preceding year was associated with a 1-year probability of 7% versus 46% for syncope recurrence. A study designed to detect a 50% decrease in syncope recurrence at P = 0.05 with 80% power would require 159 patients with at least 3 lifetime spells, and only 108 patients with at least 3 spells in the previous year. the number of syncope events in the year preceding clinical evaluation is the best predictor of syncope recurrence.

Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry

AimsTo collect information on the use of the Reveal implantable loop recorder (ILR) in the patient care pathway and to investigate its effectiveness in the diagnosis of unexplained recurrent syncope in everyday clinical practice.Methods and resultsProspective, multicentre, observational study conducted in 2006–2009 in 10 European countries and Israel. Eligible patients had recurrent unexplained syncope or pre-syncope. Subjects received a Reveal Plus, DX or XT. Follow up was until the first recurrence of a syncopal event leading to a diagnosis or for ≥1 year. In the course of the study, patients were evaluated by an average of three different specialists for management of their syncope and underwent a median of 13 tests (range 9–20). Significant physical trauma had been experienced in association with a syncopal episode by 36% of patients. Average follow-up time after ILR implant was 10 ± 6 months. Follow-up visit data were available for 570 subjects. The percentages of patients with recurrence of syncope were 19, 26, and 36% after 3, 6, and 12 months, respectively. Of 218 events within the study, ILR-guided diagnosis was obtained in 170 cases (78%), of which 128 (75%) were cardiac.ConclusionA large number of diagnostic tests were undertaken in patients with unexplained syncope without providing conclusive data. In contrast, the ILR revealed or contributed to establishing the mechanism of syncope in the vast majority of patients. The findings support the recommendation in current guidelines that an ILR should be implanted early rather than late in the evaluation of unexplained syncope.

Independent role of reduced arterial baroreflex sensitivity during head-up tilt testing in predicting vasovagal syncope recurrence

The involvement of arterial baroreflex function in the pathophysiology of vasovagal syncope (VVS) is controversial, and there are no published data supporting its clinical usefulness. The aim of this study was to evaluate the role of arterial baroreflex sensitivity (BRS) at baseline and during head-up tilt testing (HUT) in predicting the recurrence of VVS. The study involved otherwise healthy patients with a history of unexplained syncope who underwent diagnostic HUT by being tilted to 70 degrees after 10 min supine rest; the test was potentiated by the administration of 300 microg of nitroglycerine (NTG) after 20 min. Beat-to-beat heart rate and systolic blood pressure were continuously recorded, and the sequence method was used to measure arterial baroreflex control of heart rate. The 190 enrolled patients were followed up for 18 +/- 6 months, during which 34 experienced a total of 90 episodes of syncope recurrence. In a stepwise multivariate analysis, female gender [hazard ratio (HR): 2.74; P = 0.008], the presence of >or=3 syncope events before HUT (HR: 3.36; P = 0.004), and BRS below median value after the start of HUT or after the administration of NTG (HR: 3.79; P = 0.006) were significantly and independently associated with the recurrence of syncope. Moreover, when a BRS value of less than the median was added to the other independent factors in a stepwise model, a significant increase in discrimination (C-index: 0.77) and model fitting (P = 0.001) was observed. Reduced BRS during HUT has independent and incremental value in predicting the recurrence of syncope, thus supporting its potential usefulness in the clinical management of patients.

Long‐Term Follow‐Up of Patients with Syncope Evaluated by Head‐Up Tilt Test

Clinicians may be tempted to consider a positive head-up tilt test (HUTT) an unfavorable prognostic indicator. We investigated whether results of routine HUTT predict long-term recurrence of syncope. We analyzed syncope recurrence at long-term among 107 patients (mean age 51 +/- 20 years) receiving HUTT for diagnostic evaluation of unexplained/suspected neurocardiogenic syncope in our Institute. HUTT was positive in 76 patients (vasodepressive response, n = 58; cardioinhibitory, n = 5; mixed, n = 13). During a median follow-up of 113 months (range, 7-161), 34 (32%) patients experienced recurrence (24 [32%] with positive HUTT during 110 months (7-159); 10 [32%] with negative HUTT during 120 [22-161] months). Actuarial freedom from recurrence at 10 years did not significantly differ for patients with positive/negative test results (after passive/active phases) or with different positive response patterns (vasodepressive, cardioinhibitory, mixed). By contrast, history of >4 syncopes in the 12 months preceding HUTT stratified risk of recurrence, irrespective of HUTT positivity/negativity. At Cox proportional hazards analysis, history of >4 syncopes in the 12 months preceding HUTT was the single independent risk factor for recurrence both in the overall study population (HR, 1.7; 95% CI, 1.07-2.69) and within the subset of patients who tested positive (HR, 1.83; 95% CI, 1.07-3.17). This long-term follow-up study reinforces the concept that a positive HUTT should not be considered an unfavorable prognostic indicator; frequency of recent occurrences may be a more valid predictor.

Early and late outcome of treated patients referred for syncope to emergency department: the EGSYS 2 follow-up study

We evaluated the early (1 month) and late (2 years) death rate and syncopal relapses of patients referred for syncope to 11 general hospitals emergency departments. Patients were enrolled in the Evaluation of Guidelines in SYncope Study 2 (EGSYS 2) study. The guidelines of the European Society of Cardiology were strictly followed in the management of patients. Out of the 465 patients enrolled in the EGSYS 2 study, 398 (86%) underwent a complete follow-up. We excluded 18 patients with non-syncopal attacks. Among the remaining 380 patients, death of any cause occurred in 35 (9.2%). The mean follow-up was 614 +/- 73 days. Six deaths (17% of total) occurred during the first month of follow-up. Patients who died were older, had a higher incidence of structural heart disease and/or abnormal ECG, had injuries related to syncope and higher EGSYS score. Syncope recurred in 63 (16.5%) patients. Syncopal relapses occurred in only one patient during the first month of follow-up. The incidence of syncopal recurrences was unrelated to the mechanism of syncope. No clinical differences were found between patients with or without syncopal recurrence and in patients with EGSYS score < or >or=3. A peak of cardiovascular mortality but not of syncopal recurrences was observed in patients attending to the emergency department for syncope within the first month. Late unfavourable outcomes were caused by associated cardiovascular diseases rather than by the mechanism of syncope. The causes of syncope did not determine the recurrence rate.

Lack of association between genetic polymorphisms affecting sympathetic activity and tilt-induced vasovagal syncope

Although the pathophysiology of vasovagal syncope is not completely understood, the involvement of sympathetic nervous system alterations has been suggested. Since predisposition to fainting during orthostatic challenge may be associated with genetic variations, we sought to explore the role of genetic polymorphisms affecting sympathetic nervous system function in the susceptibility to tilt-induced vasovagal syncope. We genotyped 129 subjects with recurrent unexplained syncope who underwent tilt testing, and investigated the recurrence of syncope. The analysed polymorphisms were Arg492Cys ( ADRA1A gene), Ser49Gly and Arg389Gly ( ADRB1), Arg16Gly and Gln27Glu ( ADRB2), 825C/T ( GNB3), –1021C/T ( DBH) and S/L ( SLC6A4). No association of the aforementioned genetic variants with both tilt test outcomes and new syncopal episodes during follow-up was found. None of the considered polymorphisms influencing sympathetic activity is a major risk factor for vasovagal syncope in Italian patients.

Prospective evaluation of non-pharmacological treatment in vasovagal syncope

Initial treatment of vasovagal syncope (VVS) consists of assuring an adequate fluid and salt intake, regular exercise and application of physical counterpressure manoeuvres. We examined the effects of this non-pharmacological treatment in patients with frequent recurrences. One hundred patients with > or =3 episodes of VVS in the 2 years prior to the start of the study openly received non-pharmacological treatment. We evaluated this treatment both with respect to syncopal recurrences, factors associated with recurrence, and quality of life (QoL). The median number of syncopal recurrences was lower in the first year of non-pharmacological treatment compared with the last year before treatment (median 0 vs. 3; P < 0.001), but 49% of patients experienced at least one recurrence. In multivariable analysis, a higher syncope burden prior to inclusion was significantly associated with syncopal recurrence. Disease-specific QoL improved over time, with larger improvements for patients with more reduction in syncope burden. In patients with frequent recurrences of VVS, non-pharmacological treatment has a beneficial effect on both syncopal recurrence and QoL, but nearly half of these patients still experience episodes of syncope.

Preliminary observations on the use of closed-loop cardiac pacing in patients with refractory neurocardiogenic syncope

In many patients with recurrent neurocardiogenic syncope (NCS), a significant fall in blood pressure precedes any appreciable decline in heart rate. Closed-loop pacing (CLS) employs a sensing system that measures myocardial contractility, thereby providing a potential way to detect the onset of NCS at a much earlier point in time than that provided by standard pacing systems. Patients were included in the study if they suffered from recurrent NCS and met all of the following criteria: (1) They had suffered at least two syncopal episodes in the preceding 6 months. (2) Patients were refractory to (or intolerant of) all conventional, non-pharmacological, or pharmacological treatments. (3) They had evidence of asystole (>10 s) or severe bradycardia (heart rate <30 bpm) on implantable loop recorder or during head-up tilt test (HUTT). Thirty five patients meeting the above criterion received 44 devices. Twelve patients received a standard unit (with rate drop or rate hysterisis response) and 32 patients received a CLS unit (Cylos, Biotronik). The pacemaker implantation was termed successful if there was no recurrence of syncope, if the syncope burden decreased by > or =50%, if only presyncope occurred, or if the syncope occurred but with significant warning symptoms. Thirty-five patients, 29 females and six males, age 41 +/- 11, with refractory NCS underwent pacemaker implantation. Mean follow-up was 9 +/- 3 months. Out of 32 patients who received CLS, nine had a conventional pacemaker implanted in the past. Recurrence (59% vs 83%), reduction in syncope burden and pacemaker success (84% vs 25%, P = 0.002), and occurrence prodrome/warning signs (40% vs 16%) were much better in the closed-loop group. These preliminary observations suggest that dual-chamber CLS pacing may be promising therapy for refractory NCS. Further randomized trials will be needed to better determine the role of this therapy in refractory NCS.

Coronary arterial spasm in single right coronary artery

We presented a case of anomalous single-coronary artery detected incidentally during routine coronary angiography. A 32-year-old male Chinese patient presented with recurrent pre-syncope and six episodes of syncope. Coronary angiography and coronary-computed tomography (CT)-angiography performed by a dual-source computed tomography (DSCT) revealed that the patient had a single large right coronary artery. A moderately large branch originated from the proximal part of the single right coronary artery and extended to the left, passing the anterior to the pulmonary artery, and divided into the anterior descending artery branch and circumflex branch at the base of the left auricular appendage. The episodes of the syncope were suspected to be caused by coronary arterial spasm, so this patient was on a regimen of 30 mg of diltiazem every 6 h and had no recurrence of syncope during follow-up.

Highlights in clinical autonomic neurosciences

Syncope occurring while driving has obvious implications for personal and public safety. In this report, the authors aimed to define the clinical characteristics, causes, and prognosis of syncope while driving. Using a case-control design, they studied consecutive patients evaluated for syncope from 1996 through 1998 at the Mayo Clinic in Rochester, Minnesota. Of 3877 patients identified, 381 (9.8%) had syncope while driving (driving group). Compared with the 3496 patients (90.2%) who did not have syncope while driving, the driving group was younger (P<0.01) and had higher percentages of male patients (P<0.001) and patients with a history of any cardiovascular disease (P<0.01) and stroke (P<0.02). Syncope while driving was commonly caused by neurally mediated syncope (37.3%) and cardiac arrhythmias (11.8%). Long-term survival in the driving group was comparable to that of an age- and sex-matched cohort from the Minnesota population. Among the driving group, syncope recurred in 72 patients, 35 of whom (48.6%) had recurrence >6 months after the initial evaluation. Recurrences during driving happened in 10 patients in the driving group, 7 of which (70%) were >12 months after the initial evaluation. Overall, neurally mediated syncope was the most common type of syncope while driving. Their findings about the late recurrences of syncope (often >6 months of follow-up) and the overall low incidence of recurrent syncope while driving, may inform future recommendations on driving for these patients.

Syncope While Driving

The risk of syncope occurring while driving has obvious implications for personal and public safety. We aimed to define the clinical characteristics, causes, and prognosis of syncope while driving. In this case-control study of consecutive patients evaluated for syncope from 1996 through 1998 at an academic medical center, we documented causes, clinical characteristics, and recurrence of syncope while driving. Of 3877 patients identified, 381 (9.8%) had syncope while driving (driving group). Compared with the 3496 patients (90.2%) who did not have syncope while driving, the driving group was younger (P=0.01) and had higher percentages of male patients (P<0.001) and patients with a history of any cardiovascular disease (P=0.01) and stroke (P=0.02). Syncope while driving was commonly caused by neurally mediated syncope (37.3%) and cardiac arrhythmias (11.8%). Long-term survival in the driving group was comparable to that of an age- and sex-matched cohort from the Minnesota population (P=0.15). Among the driving group, syncope recurred in 72 patients, 35 of whom (48.6%) had recurrence >6 months after the initial evaluation. Recurrences during driving happened in 10 patients in the driving group, 7 of which (70%) were >12 months after the initial evaluation. In our study, neurally mediated syncope was the most common type of syncope while driving. The causes of syncope, the late recurrences of syncope (during > or =6 months of follow-up), and the overall low incidence of recurrent syncope while driving provide useful information to supplement current recommendations on driving for these patients.