Recurrence Of Syncope Research Articles

Syncope While Driving

As healthcare providers, our primary role is the diagnosis and management of the medical conditions of our patients. These medical conditions have an important impact on their personal lives as well as social situations. One of the most critical such interactions between a patient’s medical condition and society is syncope as it relates to driving. In our society, there is a constant conflict between the rights of the individual and the good of society. Just as limits are placed on the rights of individuals, limits are placed on the rights of society to restrict the actions of its members. Article see p 928 Syncope is an extremely common condition, accounting for 3% to 5% of the visits to emergency departments.1 There are many causes of syncope, including neurocardiogenic causes, arrhythmogenic causes, and those related to structural heart disease, among others. Although many patients never experience a recurrence, others do, and such recurrences can be extremely unpredictable. In fact, unless there is a clearly identifiable and correctable cause, when and whether a patient will have a recurrence of syncope is nearly impossible to determine. There are limited data on the causes, clinical characteristics, and predictors of syncope while driving. Nevertheless, because of the societal importance of this issue, guidelines have been written to provide recommendations to patients who have experienced syncope on the safety and timing of resumption of driving.2,3 With certain exceptions, a minimum of 6 months of abstinence from driving has been recommended after a syncopal event, with resumption of driving permitted if no further episodes have occurred. However, many of these recommendations are the consensus of experts, with very limited data on which to base the recommendations. Information on the natural history and predictors of recurrence in patients with syncope would be helpful to inform the …

α‐Adrenoceptor agonists for the treatment of vasovagal syncope: a meta‐analysis of worldwide published data

The present study was aimed at evaluating present randomized controlled trials (RCTs) regarding the effect of alpha-adrenoceptor agonists on vasovagal syncope (VVS). According to inclusion and exclusion criteria, articles were selected from medical electronic databases. RCTs were then assessed based on the Juni assessment, and meta-analysis was completed using the Review Manager 4.2 software. Indication to further evaluate effects was the recurrence of syncope during follow-up treatment or a response in the head-up tilt test (HUT) after treatment. The results were stated as odd ratio (OR), with a 95% confidence interval (CI) and a p < 0.05 significant level. In total, six RCTs were selected. Funnel plot analysis showed possible publication bias. Meta-analysis of the six RCTs, including all 165 patients in the treatment group and 164 patients in the control group, indicated that alpha-adrenoceptor agonists were more effective than placebos in treating VVS (OR = 0.21, 95% CI: 0.06-0.77, p = 0.02). The further, weighted independent t-test disclosed that the weighted mean percentage of responders for midodrine (76.3%+/- 7.7%) was significantly higher than that for etilefrine (65.5%+/- 15.4%) (t = 5.863, p < 0.001). The currently published RCTs support that alpha-adrenoceptor agonists might be effective for VVS. Midodrine can be regarded as a better choice compared with etilefrine.

Symptoms during ATP-test under pacing: Impact on syncope recurrence and prediction from the ATP-test without pacing

Syncope recurrence in patients with positive ATP-test who underwent permanent pacemaker implantation is suspected to be related to vagal vasodilatation. We studied symptoms during ATP-test in 38 temporary paced patients. Among patients with positive ATP-test who underwent permanent pacemaker implantation (N = 14), the only one patient who recurred during follow-up was symptomatic during the initial paced ATP-test. Symptoms during paced ATP-test were well predicted by a higher blood pressure (BP) drop during standard ATP-test (i.e. without pacing) (Area under ROC curves > 0.70 for all BP parameters except for relative diastolic BP drop). Moreover, BP drop during standard and paced ATP-test were significantly correlated (all p ≤ 0.03). Thus, a higher BP drop measured during ATP-test without pacing might help identify patients who would experience recurrences due to vasodilatation under permanent pacing.

Prospective evaluation of psychological distress and psychiatric morbidity in recurrent vasovagal and unexplained syncope

Syncope is experienced by a third of the population, and in the absence of cardiac pathology is most commonly of vasovagal (VVS) or unexplained origin (US). Psychiatric morbidity has been observed in up to 81% of patients with US but findings with VVS are contradictory. Little is known regarding the chronicity of their psychiatric morbidity. Objective To determine the psychological profile of patients with recurrent syncope prior to and following diagnostic head-up tilt testing (HUT), and whether it predicts syncope recurrence. Method Seventy-three women and 43 men (mean age=48±16.6) were recruited from all consenting patients referred for HUT. Psychological status (Psychiatric Symptom Index, Anxiety Sensitivity Index (ASI), Fear of Blood Injury Subscale) and presence of mood/anxiety disorders (Primary Care Evaluation of Mental Disorders) were evaluated 1 month prior to and 6 months following HUT. Follow-up data were collected for 83 patients (mean age=48±17.34). Results At baseline, clinically significant levels of distress were observed in 60% of patients. Those with US (negative HUT) had a fivefold greater risk of suffering from a depressive or anxiety disorder compared to VVS (positive HUT) after controlling for significant covariates. There was no significant change in distress level over follow-up, although psychiatric morbidity dropped from 33% to 22% ( P=.049). Syncope recurrence was predicted by elevations in baseline psychological distress (OR=1.544, P=.013) independently of lifetime number of syncopes. Conclusions Patients exhibited high levels of psychological distress and psychiatric morbidity despite reassurance and education received after HUT. Improved screening for and treatment of psychological distress in these patients is critical.

Highlights in clinical autonomic neurosciences

Billakanty, S.R., Kligman, M.D., Kanjwal, Y.M., Kosinski, D.J., Maly, G.T., Karabin, B., Grubb, B.P. (Toledo, OH, USA). 2008. New-onset orthostatic intolerance following bariatric surgery. Pacing Clin Electrophysiol 31, 884–888.

Predicting Recurrence of Vasovagal Syncope: A Simple Risk Score for the Clinical Routine

Predictors for recurrence of syncope are lacking in patients with vasovagal syncope. The aim of this study was to identify risk factors for recurrence of syncope and develop a simple prognostic risk score of clinical value. Two hundred seventy-six patients with a history of vasovagal syncope were prospectively followed for 2 years. Diagnosis of vasovagal syncope was based on clinical history and negative standard work-up. Inclusion in the study was independent from the result of the head-up tilt test, which was performed in all cases. Risk factors for syncope recurrence were evaluated by the Cox proportional hazards regression model and implemented in a risk score, which was validated with the log-rank test and an internal cross-validation. The Cox-regression analysis identified the number of previous syncopal events, history of bronchial asthma, and female gender as predictors for syncope recurrence (all P < 0.05). In contrast, head-up tilt test response had no predictive value (P = 0.881). Developing a risk score, study patients were identified as having high (recurrence rate during 2 years of follow-up: 37.2%), intermediate (24.8%), and low (6.5%) risk for syncope recurrence (receiver operating characteristic [ROC] of score 0.83, P < 0.01; Log-rank test for event-free survival, P < 0.005). In patients with vasovagal syncope, risk of recurrence can be stratified and is predictable based on a simple risk score.

Utility of implantable loop recorders for diagnosing unexplained syncope in clinical practice.

Establishing a symptom-rhythm correlation in patients with unexplained syncope is complicated because of its sporadic, infrequent, and unpredictable nature. Prolonged monitoring with an implantable loop recorder (ILR) allows the recording of electrocardiogram (ECG) data from a spontaneous syncopal event. The aim of this study was to evaluate the usefulness of the ILR for the diagnosis of syncope of unknown origin after conventional management in clinical practice. We reviewed the results with ILR implantation in patients with syncope of unknown origin after conventional management in the cardiology department at HU Marques de Valdecilla (Santander, Cantabria, Spain). One hundred and forty patients (age 64 +/- 16 y; 86 male [62%]) with syncope of unknown etiology after conventional work-up underwent prolonged monitoring with an ILR from September 1998 to February 2006; 46 patients (33%) had structural heart disease. During a mean follow-up of 346 +/- 160 d, 51 patients (36.5%) had recurrent syncope with diagnostic ECG recording. An arrhythmic cause for syncope was found in 33 of them (64.5%), with bradycardia present in 27 (53%) and tachycardia in 6 (11%). There were no sudden deaths, and 1 patient suffered a complication related to a recurrence of syncope. Long-time experience with the ILR confirmed the utility of this device in the diagnosis of unexplained syncope in clinical practice. Most of these patients had syncope of arrhythmogenic etiology that could be successfully treated. This strategy of prolonged monitoring is safe even in patients with structural heart disease.

Implantation of a permanent pacemaker in a pregnant woman under the guidance of electrophysiologic signals and transthoracic echocardiography

We describe the case of a 30-year-old pregnant woman who underwent pacemaker implantation for recurrent syncope caused by sinus arrest. In order to minimize radiation exposure, which may potentially have teratogenic effects, we decided to perform pacemaker implantation by means of a hybrid technique involving the evaluation of electrophysiologic signals and transthoracic echocardiographic imaging to guide lead positioning within the right ventricle. After the procedure, the patient was always asymptomatic and had no recurrences of syncope. Six months later, she experienced uncomplicated natural labor, and the newborn was absolutely healthy. On a 10-month follow-up examination, the lead position was still optimal, and ventricular sensing and pacing thresholds were good. Our case demonstrates that pacemaker implantation under the guidance of electrophysiologic signals and transthoracic echocardiographic imaging, with only a short view by pulsed fluoroscopy in order to verify the correct lead position, is an effective and well-tolerated procedure in pregnant women.

Reproducibility of Electrocardiographic Findings in Patients With Suspected Reflex Neurally-Mediated Syncope

The reproducibility of electrocardiographic (ECG) recordings in syncopal recurrences and the diagnostic role of nonsyncopal arrhythmias are not well known. The objective of this study was to analyse the reproducibility of the ECG findings recorded with implantable loop recorders in 41 patients with suspected neurally-mediated syncope who were included in the International Study on Syncope of Uncertain Origin-2 study and that had > or =2 events recorded by implantable loop recorders. In these patients, the electrocardiogram obtained with the first documented syncope (index syncope) was compared with other recorded events. Twenty-two patients had > or =2 syncopes, and their electrocardiograms were reproducible in 21 (95%): 15 with sinus rhythm, 5 with asystole, and 1 with ventricular tachycardia; 1 had asystole at first syncope and sinus rhythm at recurrent syncope. In 32 patients with nonsyncopal episodes, an arrhythmia was documented in 9, and all of them had the same arrhythmia during the index syncope (100% reproducibility); conversely, when sinus rhythm was documented (23 patients) during nonsyncopal episodes, an arrhythmia was still documented in 6 during the index syncope (70% reproducibility; p = 0.0004). In conclusion, the ECG findings during the first syncope are highly reproducible in subsequent syncopes. The presence of an arrhythmia during nonsyncopal episodes is also highly predictive of the mechanism of syncope, but the presence of sinus rhythm does not rule out the possibility of arrhythmia during syncope. Therefore the finding of an arrhythmia during a nonsyncopal episode allows the etiologic diagnosis of syncope, and eventually to anticipate treatment, without waiting for syncope.

Synkopendiagnostik: wann ambulant, wann stationär?

The diagnostic challenge of patients with syncope is to assess the underlying cause leading to the symptom syncope. In addition, the patient's risk for an increased mortality and for recurrent syncope has to be evaluated. Initial evaluation identifies most of these patients. Depending on the local medical health services this can be performed in an emergency department, an in- and out-hospital service or at a general practitioner. Major criteria for hospital admission are risk stratification especially for patients with a suspected rhythm-related reason for syncope and treatments to prevent syncopal recurrences. Hospital admission is not necessary for patients with a single attack or infrequent episodes who show no evidence of a cardiac cause for the syncope or of a structural heart disease. Patients who have no findings indicating the presence of life-threatening rhythm disorders can be further evaluated in a hospital or an out-clinic setting depending on the predetermined requirements of local professional bodies.

The Role of Tilt Training in Preventing Recurrent Syncope in Patients with Vasovagal Syncope: A Prospective and Randomized Study

Recurrent vasovagal syncope (VVS) can be a severely disabling disorder that may lead to an important deterioration of quality of life because of the severity and recurrence of episodes. This study sought to investigate the effectiveness of repeated orthostatic self-training in preventing syncope in patients with recurrent VVS. Eighty-two consecutive patients (mean age 41 +/- 4 years, 37 males) with recurrent VVS episodes and positive head-up tilt testing (HUT) were enrolled in this study. The patients were then randomized (1:1) to conventional therapy or conventional therapy plus additional tilt training sessions. The patients were followed for spontaneous syncope for one year. Primary end-points were the recurrence of syncope, the number of episodes, and the interval of time to the first recurrence. There were no significant differences of baseline clinical characteristics and parameters of HUT between the tilt training and control groups. The patients had 4 +/- 2/year syncopal episodes prior to the HUT. The mean follow-up after randomization was 12 +/- 2 months. Spontaneous syncope recurrence during follow-up was 56% (23 patients) versus 37% (15 patients) in the control and tilt training groups, respectively (P = 0.1). Time to first recurrence was also similar in both groups (70 +/- 20 days vs 50 +/- 15 days, P = 0.09). The frequency of recurrent syncopes was similar in all types of VVSs while the rate of episodes was significantly higher in control group in patients with vasodepressor type during follow-up period (32% vs 10%, P = 0.04). The mean number of recurrent syncope episodes was also similar in both groups (3 +/- 1 vs 2 +/- 1, P = 0.4). Tilt training was unable to influence the spontaneous syncope recurrence for recurrent VVS except for vasodepressor type.

Management of syncope: clinical and economic impact of a Syncope Unit

Aim of this observational study is to evaluate the clinical performance of a Syncope Unit, in order to assess whether the implemented organization really improves syncope management. The study enrolled patients with unexplained syncope who were consecutively referred to our Syncope Unit, either as outpatients or during hospitalization, in a 2-month period. The design of this observational study consists in three phases: a retrospective analysis of their clinical management in the 9 months prior to the first attendance at the Syncope Unit (phase one), their subsequent clinical management in the Syncope Unit (phase two) and a 9-month follow-up (phase three). The retrospective analysis of phase one showed that 25% of patients had already been hospitalized without diagnosis. After Syncope Unit evaluation, diagnosis was obtained in 82% of patients, with 15% of patients indicated to pacing. In the follow-up, 23% of patients experienced a syncopal recurrence. Our analysis indicated an 85% reduction of hospital costs in the follow-up period. The clinical and economic analysis of the three phases of our study demonstrates that a Syncope Unit allows an improved management of patients with syncope.

Syncope Predicts the Outcome of Cardiomyopathy Patients: Analysis of the SCD-HeFT Study

The outcome of congestive heart failure (CHF) patients with syncope is understood incompletely.We analyzed data from patients enrolled in the SCD-HeFT (Sudden Cardiac Death Heart Failure Trial) to determine whether syncope predicted outcomes in patients with CHF.We compared outcomes (and associated clinical characteristics) in patients with and without syncope enrolled in SCD-HeFT.In SCD-HeFT, 162 (6%) patients had syncope before randomization, 356 (14%) had syncope after randomization (similar incidence in each randomized arm), and 46 (2%) had syncope before and after randomization. A QRS duration >or=120 ms and absence of beta-blocker use predicted syncope during follow-up (hazard ratio [HR] 1.30 and 95% confidence interval [CI] 1.06 to 1.61, p = 0.014 and HR 1.25, 95% CI 1.01 to 1.56, p = 0.048, respectively). Syncope recurrence did not differ by randomization arm. However, in the implantable cardioverter-defibrillator (ICD) arm, syncope, before and after randomization, was associated with appropriate ICD discharges (HR 1.75, 95% CI 1.10 to 2.80, p = 0.019 and HR 2.91, 95% CI 1.89 to 4.47, p = 0.001, respectively). Post-randomization syncope predicted total and cardiovascular death (HR 1.41, 95% CI 1.13 to 1.76, p = 0.002 and HR 1.55, 95% CI 1.19 to 2.02, p = 0.001, respectively). The elevated relative risk of mortality for syncope versus non-syncope patients did not vary significantly across treatment arms (ICD, HR 1.54, 95% CI 1.04 to 2.27; amiodarone, HR 1.33, 95% CI 0.91 to 1.93; and placebo, HR 1.39, 95% CI 0.96 to 2.02, test for difference p = 0.86).For CHF patients with ICDs, syncope was associated with appropriate ICD activations. Syncope was associated with increased mortality risk in SCD-HeFT regardless of treatment arm (placebo, amiodarone, or ICD).

Catheter Ablation of a Polymorphic Ventricular Tachycardia Inducing Monofocal Premature Ventricular Complex

Ventricular tachycardia originating from the right ventricular outflow tract (RVOT) is considered benign, but sometimes it causes polymorphic ventricular tachycardia and ventricular fibrillation, resulting in sudden cardiac death. A 58-year-old woman without structural heart disease was admitted for evaluation of recurrent episodes of syncope. Surface ECG showed frequent repetitive premature ventricular contraction (PVC) of RVOT origin. Polymorphic ventricular tachycardia triggered by the same PVC was documented by Holter ECG during an episode of syncope. Radiofrequency catheter ablation was performed to eradicate this PVC. No polymorphic ventricular tachycardia has developed after the procedure, and the patient has had no recurrence of syncope.

Permanent cardiac pacing for neurocardiogenic syncope

Vasovagal syncope is not a benign condition in the elderly population. In patients not responsive to conservative therapy and whose abrupt faints are associated with serious injuries and seriously affected quality of life, pacemaker therapy was suggested. However, the usefulness of cardiac pacing for the prevention of recurrences of vasovagal syncope remains controversial because of the dominant role of the vasodepressor component during the episode. In the Medical Center Alkmaar, the Head-Up Tilt Test (HUTT) has been used since 1996 during the work-up of patients who present with vasovagal syncope. The HUTT showed a dominant cardioinhibitory response in 4.5% of our patients; in elderly patients with vasovagal syncope without prodromal symptoms and refractory on conservative therapy, pacemaker therapy was very effective in preventing syncope during long-term follow-up. (Neth Heart J 2008;16(Suppl1):S15-S19.).

The Effect of Orthostatic Training in the Prevention of Vasovagal Syncope and Its Influencing Factors

Recently orthostatic training has been proposed as an effective treatment for vasovagal syncope, even though some patients may relapse. This study was undertaken to assess the effect of orthostatic training on patients with vasovagal syncope and its influencing factors. The study group comprised 125 consecutive patients (51 males and 74 females), aged 40 +/- 19 years, with a history of syncope and a positive head-up tilt test. They were randomized into an orthostatic training group (64 patients) and a no treatment group (controls, 61 patients). The training programme consisted of daily 30-minute sessions of upright standing against a vertical wall 6 days a week for at least 4 weeks. After one year of follow-up, 45 (72.6%) of 62 orthostatic trained patients reported no syncopal recurrence, while only 22 of 61 controls (36.1%, P < 0.05) reported the same. Furthermore, in the training group, the patients with recurrence were older, and the number of syncopal spells in the preceding year was less than in the patients with no recurrence in the same group. Orthostatic training is an effective therapy for the prevention of vasovagal syncope. This kind of therapy was of greater benefit to patients who were younger or experienced frequent spells of syncope.

Pacing for syncope: what role? which perspective?

Cardiac pacing is the most effective therapy to prevent syncopal recurrences when syncope is due to bradycardia. Causes of bradycardia-induced syncope are intrinsic [primary dysfunction of the atrioventricular (AV) conduction system and of sinus node function] and extrinsic (vagal reflexes). Intrinsic and extrinsic mechanisms often coexist in the same patient, especially in the case of sick sinus syndrome. Although formal randomized controlled trials have not been performed, cardiac pacing is commonly considered very effective and therefore accepted as therapy of choice in all patients in whom an AV block is responsible for syncope. Cardiac pacing is also commonly indicated in patients in whom syncope is caused by sick sinus syndrome or carotid sinus syndrome. However, owing to the frequently associated vasodepressor reflex, syncope still recurs during long-term observation in ∼20% of the patients. Despite several controlled trials, the indications for cardiac pacing are still controversial in patients with vasovagal syncope (VVS). To date, cardiac pacing may be only indicated in selected older patients affected by VVS who present with severe recurrent impredictable syncopal attacks affecting quality of life. Also in these patients some rare syncopal recurrence should be expected over the long term.

Implantable loop recorder in unexplained syncope: classification, mechanism, transient loss of consciousness and role of major depressive disorder in patients with and without structural heart disease

Objective:To stratify mechanisms and predictors of unexplained syncope documented by an implantable loop recorder (ILR) in patients with and without structural heart disease (SHD).Design and setting:Prospective study in consecutive patients...

Less syncope and milder symptoms in patients treated with pacing for induced cardioinhibitory carotid sinus syndrome: a randomized study

The aim of this study was to examine the effect on symptoms in patients with induced cardioinhibitory carotid sinus syndrome (ICSS) when treated or not treated with a pacemaker. Sixty patients with a history of syncope or pre-syncope and ICSS were randomized to receive a permanent pacemaker (P group, n = 30) or no pacing (NP group, n = 30). ICSS was defined as a ventricular pause (i.e. asystole) lasting 3 s or more in response to carotid sinus stimulation. The patients were seen at 3 and 12 months and at symptoms. At 12 months, the rate of syncope in the NP group was 40% (n = 12) compared with 10% (n = 3) in the P group (P = 0.008). The majority (11 of 12) of the syncope recurrences in the NP group occurred during the first 3 months. Pre-syncope occurred in two patients (7%) in the NP group and in eight (27%) in the P group. Ten patients (33%) with recurrent syncope in the NP group later crossed-over to receive pacemaker implant. A history of syncope or pre-syncope, plus ICSS, was a strong predictor of subsequent syncope or pre-syncope. Most of the new symptoms occurred within 3 months. Pacemaker treatment effectively reduced syncope and/or resulted in milder symptoms.

New‐Onset Syncope in Older Adults: Focus on Age and Etiology

The authors explored the differences in clinical presentation, etiology, mortality, and recurrences of new-onset syncope in 502 patients across 3 age groups: middle-aged (36-60 years), older (61-75 years), and elderly (older than 75 years). Clinical features of syncopal episodes were similar except for more frequent presyncopal episodes in patients older than 75 years. Yield of diagnostic tests was similarly low except for higher incidence of positive tilt-table test (60%) in older patients. Syncope remained unexplained more frequently in the elderly (54% vs 37% in middle-aged and 43% in older adults, P=.01). Syncope recurrence was higher in the middle-aged and elderly groups. Overall mortality for the 3 age groups was similar to that recorded in the general population after adjustment for age and comorbidities. Etiology of syncope was not associated with age- and comorbidity-adjusted all-cause mortality. Cardiovascular mortality was significantly higher in patients with cardiogenic syncope (adjusted hazard ratio, 2.44; P=.044).