Recurrence Of Syncope Research Articles

Efficacy and feasibility of isometric arm counter-pressure manoeuvres to abort impending vasovagal syncope during real life.

Isometric arm exercises are able to increase blood pressure during the phase of impending vasovagal syncope. We evaluated their efficacy and feasibility during daily life in a group of 29 consecutive patients affected by vasovagal syncopes. The patients were trained to use arm tensing and/or handgrip in case of occurrence of symptoms of impending syncope. During 14+/-6 months of follow-up, 260 episodes of impending syncope were reported by 19 patients; the manoeuvres were self-administered by these patients in 98% of cases and were able to abort syncope in 99.6% of cases. Overall, 5 episodes of syncope occurred in 5 patients (17%), in 4 cases without and in 1 with activation of the manoeuvres. Syncope recurred in 4 (40%) of 10 patients aged >65 years versus only 1 (5%) of 19 patients aged < or =65 years, p=0.03. The non-responders had more episodes of impending syncope than responders (37+/-32 vs 3+/-4, p=0.001). Among 19 clinical variables, age in years was the only significant predictor of syncopal recurrence. No patients had injury or other adverse morbidity related to the relapses. Isometric arm counter-pressure manoeuvres are able to abort impending vasovagal syncope in most patients aged < or =65 years. Arm counter-pressure manoeuvres are feasible, safe and well accepted by the patients in the daily life.

Incidence, diagnostic yield and safety of the implantable loop-recorder to detect the mechanism of syncope in patients with and without structural heart disease.

To evaluate the incidence, diagnostic yield and safety of implantable loop recorders (ILRs) in patients with or without structural heart disease (SHD). Two-hospitals, observational, prospective study in consecutive patients with unexplained syncope who underwent an ILR implantation. Between November 1997 and December 2002, a total of 2052 patients with syncope were evaluated (referral population of 590000 inhabitants). The diagnosis remained unexplained in 371 (18%). Of these, 103 patients (5% of total, 28% of unexplained syncope) received an ILR. SHD was present in 38 (37%), and absent in 65 (63%). During a median follow-up of 13 months, syncope was recorded in 52 patients. While patients with and without SHD had similar incidence of syncope recurrence, its mechanism was different. Patients with SHD more frequently had paroxysmal AV block and tachyarrhythmias and patients without SHD more frequently had sinus bradycardia/sinus arrest or no arrhythmia. More patients with SHD finally received an ILR-guided therapy. Sudden death occurred in one patient with SHD. Five syncope-related injuries were noted in 3 patients. The mechanism of syncope is different in patients with and without SHD; diagnostic yield and safety are similar in both groups. About 28% of patients with unexplained syncope have an indication to ILR implantation. The need for ILR implantation in the general population is 34 implants/million inhabitants/year.

Atrioventricular block during upright tilt table test.

Patients with a cardioinhibitory response (asystole or atrioventricular block [AVB]) during upright tilt table test (UTT) constitute a therapeutic challenge. Our present knowledge is partial and in those who experience AVB is absent. Furthermore, we ignore if there is any difference between both groups, particularly pacemaker indication. We aimed to study patients with a cardioinhibitory response during UTT and incidence of AVB during UTT, compared to asystole; plus the outcome during prolonged follow-up. Of 867 patients who underwent UTT, 172 were positive for a neurally mediated response, all with normal neurocardiovascular evaluation. Of the 172 patients, 6 (3.4%) developed AV block (group A), and 26 (15.1%) experienced asystole (group B). Group A included 6 women (100%), mean age 21 +/- 12 years. All patients in group A had sinus rate deceleration during AVB. Group B included 10 women (38%), mean age 28 +/- 17 years, and a mean pause of 15 +/- 9 seconds. We contacted 30 of 32 patients, mean follow-up of 45 +/- 38 months. Seven patients in group B had syncopal recurrences; five had 2 or more episodes. One patient from group B received a DDD pacemaker. In group A, one had one recurrence. No deaths were observed. AVB during UTT is rare, occurs in young women, and is always associated with sinus rate deceleration. Medium- to long-term prognosis is good, and equivalent to patients with asystole. There is no evidence that patients with AVB during UTT require a pacemaker implant.

Tilt Training for Recurrent Neurocardiogenic Syncope: Effectiveness, Patient Compliance, and Scheduling the Frequency of Training Sessions

Unsatisfactory results obtained with medical therapy and dual-chamber pacing for prevention of recurrent neurocardiogenic syncope necessitated the development of new treatment modalities. Tilt-training, a novel treatment for recurrent neurocardiogenic syncope based on exercise sessions with prolonged upright posture (either on a tilt-table or standing on foot against a wall), was shown to be effective in preventing the recurrence of neurocardiogenic syncope. The purpose of this study was to demonstrate the long-term beneficial effects of a transient tilt training program lasting 2 months. Thirty-two patients with recurrent neurocardiogenic syncope (mean number of syncope episodes in the last 6 months was 3.4 +/- 2.3) constituted the study group. All of the patients were tilt test positive. The patients were taught a tilt training program with 2 phases (in-hospital training with repeated tilt procedures until 3 consecutive negative results were obtained and home exercises with standing against a wall) and home exercises lasted a maximum of 2 months. After this training program, the patients received no treatment and were followed for the recurrence of syncope. At the end of the follow-up period (376 +/- 45 days), 81% of the patients were free of recurrent syncope. This study revealed that similar successful results can also be obtained with a transient tilt training program as a first line treatment strategy. Less interference with the daily activities of the patients is the major advantage of this strategy. The ease of performance and high effectiveness rate will most likely result in more frequent utilization of this treatment modality.

P-343 Syncopal recurrence following ICD implantation for spontaneous syncopal ventricular tachycardia

P-343 Syncopal recurrence following ICD implantation for spontaneous syncopal ventricular tachycardia

P-343 Syncopal recurrence following ICD implantation for spontaneous syncopal ventricular tachycardia

P-343 Syncopal recurrence following ICD implantation for spontaneous syncopal ventricular tachycardia

Ablation of Nonsustained or Hemodynamically Unstable Ventricular Arrhythmia Originating From the Right Ventricular Outflow Tract Guided by Noncontact Mapping

Conventional activation or pacemapping is effective in guiding ablation of ventricular tachyarrhythmia originating from right ventricular outflow tract (RVOT). However, in selected patients with hemodynamically unstable or nonsustained tachycardia, noncontact mapping may be an effective alternative method to guide ablation in RVOT. Five patients with symptomatic hypotension during ventricular tachycardia (VT) or nonsustained tachyarrhythmia originating from the RVOT had radiofrequency ablation guided by noncontact mapping. All patients had a history of syncope and the tachyarrhythmias were refractory to antiarrhythmic therapy. Four patients had spontaneous sustained VT of a cycle length from 250 to 300 ms and one had symptomatic ventricular ectopic beats. Two patients were diagnosed to have arrhythmogenic right ventricular cardiomyopathy (ARVC). Sustained VT with hypotension was induced in two patients and nonsustained VT in three patients. Isopotential color maps were used to locate the earliest activation site of the tachyarrhythmia in RVOT. Three patients had tachyarrhythmia exit sites at the septal region and two at lateral region of RVOT. Low voltage area and diastolic activity were detected in the two patients with ARVC. Radiofrequency ablation guided by noncontact mapping was performed during sinus rhythm in all patients. The number of ablation attempts ranged from 1 to 14. After follow-up for 12 +/- 5.8 months, there was no recurrence of tachyarrhythmia and syncope in all five patients. Noncontact mapping is a safe and effective alternative method to guide ablation of hemodynamically unstable or nonsustained ventricular arrhythmia originating from RVOT.

International Study on Syncope of Uncertain Etiology 2: the management of patients with suspected or certain neurally mediated syncope after the initial evaluation rationale and study design.

Multi-centre, prospective observational study. Main objective is to verify the value of implantable loop recorder (ILR) in assessing the mechanism of syncope and the efficacy of the ILR-guided therapy after syncope recurrence. Patients who met the following criteria are included: suspected or definite neurally mediated syncope based on initial evaluation; >/=3 syncope episodes in the last 2 years; severe clinical presentation of syncope requiring treatment initiation in the judgement of the investigator and age >30 years. Patients with one or more of the following are excluded: carotid sinus syndrome; suspected or definite heart disease and high likelihood of cardiac syncope; symptomatic orthostatic hypotension diagnosed by standing blood pressure measurement; loss of consciousness different from syncope (e.g. epilepsy, psychiatric, metabolic, drop-attack, TIA, intoxication, cataplexy) and subclavian steal syndrome. END-POINTS: The primary end-points are the ECG-documented syncopal events and the syncope recurrences after application of ILR-guided therapy. SAMPLE SIZE AND DURATION: A minimum of 400 patients will be enrolled during an anticipated period of 3 years.

The Second Vasovagal Pacemaker Study (VPSII)

The Second Vasovagal Pacemaker Study (VPSII): A double‐blind randomized controlled trial of pacemaker therapy for the prevention of syncope in patients with recurrent severe vasovagal syncope. Three previous small randomized trials have reported that pacemaker therapy is very beneficial for patients with severe recurrent vasovagal syncope. However these trials were not double blind and were thus at risk of bias in assessment of outcomes and of a ‘placebo‐effect’ of surgery. To determine if pacing therapy reduces the risk of syncope in patients with vasovagal syncope. A double‐blind randomized trial of pacemaker therapy was performed. After implantation of a dual chamber pacemaker, 100 patients from 15 centres were randomized, double blind, to receive dual chamber pacing (DDD) with rate drop response or to have only sensing with no pacing (ODO). Patients were followed for up to 6 months and the primary outcome of the study was time to first recurrence of syncope. Results: Patients were well matched as to baseline characteristics. In the year prior to randomization patients had had a median of 4 episodes of syncope. No patients were lost to follow up. Of the patients randomized to ODO, 22 of 52 (42%) had recurrent syncope within 6 months, compared to 16 of 48 (33%) of the patients in the DDD group. The cumulative risk of syncope at 6 months was 40% (95% confidence interval 25%, 52%) for the ODO group and was 31% (95% confidence interval 17%, 43%) for the DDD group. The relative risk reduction in time to syncope with DDD pacing was 30% (95% confidence interval −33%, 63%, p = 0.14 one‐sided). Lead dislodgement or repositioning occurred in 7 patients, one patient had vein thrombosis and another had pericardial tamponade leading to removal of the pacemaker system. One patient had infection involving the pacemaker generator. Conclusions: This double blind randomized trial does not confirm the results of earlier smaller unblinded randomized trials. Because of the weak evidence of efficacy of pacemaker therapy and the risk of complications, pacemaker therapy should not be recommended as first line therapy for patients with recurrent vasovagal syncope.

P1521 Time to first recurrence of syncope in patients with syncope

P1521 Time to first recurrence of syncope in patients with syncope

P1515 Correlation of cardio-inhibitory responses in head-up tilt tests and ATP tests with spontaneous syncope recurrence documented by implantable loop recorders

P1515 Correlation of cardio-inhibitory responses in head-up tilt tests and ATP tests with spontaneous syncope recurrence documented by implantable loop recorders

Outcome of Patients With Dual-Chamber Pacemakers Implanted for the Prevention of Neurally Mediated Syncope

Dual-chamber pacemaker insertion (PI) has been found to reduce the recurrence of neurally mediated syncope (NMS) in 3 randomized trials. However, the long-term benefits of PI are unknown. To assess the natural history of NMS, we followed a cohort of 40 patients who underwent PI for frequent NMS for 46 to 75 months. We assessed the reduction in syncope frequency after PI and the time to first recurrence of syncope. Sixty months after PI, 32.5% of patients remained free of NMS. The frequency of syncope decreased from 0.46 to 0.06 spells/month (before to after PI, p = 0.04). Two groups of patients were identified, with responders to PI defined as having a 75% decrease in the frequency of NMS. Responders (n = 22) experienced a significant decrease in the frequency of NMS (0.31 to 0.01 spells/month, p <0.0001), whereas nonresponders did not experience a similar reduction (p = 0.8). Responders could not be identified by either baseline or tilt-test parameters. Patients without an early recurrence of syncope after PI (within 6 months) experienced a significant reduction in the frequency of NMS (0.24 to 0.02 spells/month, p = 0.0002), although the reduction was not significant (p = 0.3) in patients with an early recurrence of syncope. Some, but not all, patients respond to permanent PI for NMS. The long-term benefit of permanent PI can be predicted by timing of the first recurrence of syncope, but not by preimplantation factors.

Mechanism of syncope in patients with positive adenosine triphosphate tests

ObjectivesWe prospectively evaluated the mechanism of syncope in patients with positive adenosine triphosphate (ATP) tests (defined as the induction of atrioventricular [AV] block with a ventricular pause ≥6 s after an intravenous bolus of 20 mg ATP). BackgroundPatients with unexplained syncope tend to have more positive ATP tests results than those without syncope. MethodsAn implantable loop recorder (ILR) was inserted in 36 ATP-positive patients (69 ± 10 years; 22 women; median of 6 syncopal episodes); 15 of them also had a positive response to tilt testing. ResultsDuring the follow-up of 18 ± 9 months, 18 patients (50%) had syncopal recurrence and 16 (44%) had an electrocardiographically documented episode: AV block (n = 3: paroxysmal in 2 and permanent in 1), AV block followed by sinus arrest (n = 1), sinus arrest (n = 5), sinus bradycardia <40 beats/min (n = 2), normal sinus rhythm (n = 2), sinus tachycardia (n = 1), rapid atrial fibrillation (n = 1), and ectopic atrial tachycardia (n = 1). Bradycardia was documented in a total of 11 cases (69%), and a long ventricular pause (4 to 29 s) was present in eight cases (50%). All three patients with ILR-documented AV block had previously had a negative tilt test, whereas seven of eight with ILR-documented sinus bradycardia or sinus arrest had previously had a positive tilt test. ConclusionsIn patients with adenosine-sensitive syncope, the mechanism of syncope is heterogeneous, although bradycardia is the most frequent finding. Adenosine triphosphate–induced AV block predicts AV block as the mechanism of spontaneous syncope in only a few tilt-negative patients.

Long-term follow-up results of tilt training therapy in patients with recurrent neurocardiogenic syncope.

Tilt twining therapy is considered as a first choice treatment for neurocardiogenic syncope in the Department of Cardiology, University of Leuven. However, long-term compliance to therapy may be difficult when patients become asymptomatic. In a single center uncontrolled study, the long-term clinical outcome of 38 patients was studied after a follow-up period of 43 +/- 7.8 months. At the time of assessment 29 patients had abandoned tilt twining therapy, while 9 still continued on a regular basis. In this series, 31 (82%) of 38 patients were free from syncope and 25 (66%) of 38 were completely asymptomatic. During follow-up, seven patients reported the recurrence of at least one syncope. Of these seven patients, six had discontinued tilt training therapy. The number of syncopes after discontinuation was significantly lower as compared with the period before initiation of tilt twining. In only one patient syncope recurrence was observed during rather irregular tilt training therapy. Moreover, in 19 patients who abandoned tilt training after about 1 year, no syncope recurrence was reported during daily life, which suggests that the disturbed autonomic reflex activity in these patients may have been restored.

Nonarrhythmic syncope documented by an implantable loop recorder (an ISSUE substudy)

Owing to the episodic behavior of syncope, the correlation of spontaneous syncopal episodes with an abnormal finding can be regarded as a reference standard. In the International Study on Syncope of Uncertain Etiology (ISSUE),1,2 the most frequent finding observed during syncopal recurrences was severe bradycardia or an asystolic pause, thus establishing the mechanism of syncope. In the other cases, normal sinus rhythm was frequently recorded at the time of syncope. Although not diagnostic, this finding allows us to definitely exclude an arrhythmia as the cause of syncope. In this substudy from ISSUE, we analyzed in detail the characteristics of patients who had an electrocardiographically documented nonarrhythmic syncope.

Vasovagal syncope: a prospective, randomized, crossover evaluation of the effect of propranolol, nadolol and placebo on syncope recurrence and patients’ well-being

ObjectivesWe sought to assess the relative therapeutic efficacy of propranolol, nadolol and placebo in recurrent vasovagal syncope (VVS). BackgroundCentral and peripheral mechanisms have been implicated in the pathogenesis of VVS. Propranolol, nadolol and placebo have different sites of action on central and/or peripheral mechanisms. It has not yet been clarified whether one of the aforementioned treatments is more efficient than the others in reducing clinical episodes and exerting a beneficial effect on patients’ well-being. MethodsWe studied 30 consecutive patients with recurrent VVS and a positive head-up tilt test. All were serially and randomly assigned to propranolol, nadolol or placebo. Therapy with each drug lasted three months. On the day of drug crossover, patients reported the total number of syncopal and presyncopal attacks during the previous period. They also gave a general assessment of their quality of life, taking into account: 1) symptom recurrence; 2) drug side effects; and 3) their personal well-being during therapy (scale 0 to 4: 0 = very bad/discontinuation; 1 = bad; 2 = good; 3 = very good; 4 = excellent). At the end of the nine-month follow-up period, they reported whether they preferred a specific treatment over the others. ResultsSpontaneous syncopal and presyncopal episode recurrence during each three-month follow-up period was reduced by all drugs tested (analysis of variance [ANOVA]: chi-square = 67.4, p < 0.0001 for syncopal attacks; chi-square = 60.1, p < 0.0001 for presyncopal attacks) No differences were observed in the recurrence of syncope and presyncope among the three drugs. All drugs improved the patients’ well-being (ANOVA: chi-square = 61.9, p < 0.0001). ConclusionsPropranolol, nadolol and placebo are equally effective treatments in VVS, as demonstrated by a reduction in the recurrence of syncope and presyncope, as well as an improvement in the patients’ well-being.

Exercise-related syncope in young competitive athletes without evidence of structural heart disease. Clinical presentation and long-term outcome.

Exercise-related syncopal spells in athletes receive great attention and are a source of anxiety in the sporting world. The aim of the present study is to describe the clinical presentation, the yield of the initial diagnostic work-up and the long-term outcome of a series of consecutive competitive athletes with recurrent exercise-related syncopal spells. The study cohort included 33 athletes (20 females, mean age 21.4+/-3.2 years) referred for recurrent unexplained episodes of exercise-related syncope (mean number of spells before evaluation 4.66+/-1.97). All athletes underwent an extensive evaluation, including echocardiography, 24-h electrocardiographic monitoring, exercise testing, cardiac electrophysiological study and head-up tilt testing. The echocardiographic examination revealed the presence of a mitral valve prolapse in two cases (6.0%). During maximal exercise testing, four athletes (12.1%) developed hypotension associated with pre-syncope. Twenty-two subjects (66.6%) showed a positive response to head-up tilt testing. During follow-up (33.5+/-17.2 months) 11/33 athletes (33.3%) showed at least one recurrence of exercise-related syncope (mean time to first recurrence 20.4+/-14.5 months). No other adverse event of any kind was noted during follow-up. The Kaplan-Meier estimates of first recurrence of exercise-related syncope after 12, 36 and 60 months were 9.1%, 24.4% and 42.9%. The number and frequency of exercise-related syncopal spells before evaluation were found to be univariate predictors of syncope recurrence (P<0.001). However, in the multivariate analysis, the number of exercise-related syncopal spells before evaluation was found to be the only independent predictor of syncope recurrence (P<0.05). These findings support the idea that recurrent exercise related-syncope is not associated with an adverse outcome in athletes without cardiac disease.

Low recurrence of syncope in patients with inducible sustained ventricular tachyarrhythmias treated with an implantable cardioverter-defibrillator.

To determine the effectiveness of the implantable cardioverter defibrillator (ICD) in preventing recurrence of syncope in patients with structural heart disease, previously unexplained syncope and inducible ventricular arrhythmias. Thirty-eight patients with syncope, structural heart disease and inducible arrhythmias had an ICD implanted. All ICDs delivered antitachycardia pacing and shocks of adjusted energy. Detection and therapy were programmed according to uniform criteria. The mean age of the patients was 63+/-11 years and most of them were male (36/38). After a mean follow-up of 28+/-15 (4-61) months, six patients died and one underwent heart transplantation. Syncope recurred in three patients, but in none of them was it caused by an arrhythmic event. In 18 patients, 113 episodes of ventricular tachycardia/ventricular fibrillation were detected and appropriately treated by the ICD. The mean time from implant until first appropriate therapy was 18+/-14 months. The actuarial probability of receiving appropriate therapy was 20% and 42% at 12 and 24 months, respectively. In patients with unexplained syncope, structural heart disease and inducible arrhythmias, ICD prevents syncope associated with arrhythmic events. Frequent effective use of antitachycardia pacing and shocks of adjusted energy seem essential to this aim.

Long-term outcome of patients with asystole induced by head-up tilt test.

To analyse the long-term outcome of the largest reported cohort of patients presenting asystole during head-up tilt test. Since 1990, 1322 patients with syncope of unknown origin have undergone tilt-table testing. Of those, 330 patients (24 X 9%) presented an abnormal response (syncope or pre-syncope). Furthermore, 58 of those patients (17 X 5%) suffered a period of asystole (> or = 3000 ms) during the test. Asystole (median (interquartile range)) lasted 10 (4, 19 X 2) s (range 3-90). Two different protocols (angles) of tilting (Westminster (60 degrees) n=1124; isoproterenol (80 degrees) n=198)) influenced the time to the syncopal episode (13 (6 X 5, 20 X 5) vs 2 (1, 6 X 5) min, P=0,0005) but not the duration of the asystole. During this period, therapy for asystole featured three different stages: first patients were treated with pacemakers; later drug therapy (metoprolol and/or etilefrine) was recommended; lastly (from 1995), no specific treatment was given. In a cohort age- and gender-matched study, those patients without were compared to those with asystole in a 2:1 basis. During 40 X 7 months of follow-up (17 X 7, 66 X 8), 12 patients (20 X 6%) with asystole had syncopal recurrences. Furthermore, 34 patients (28 X 8%) without asystole presented syncopal episodes during a follow-up of 51 X 6 months (29 X 3, 73 X 1) (P=ns). The Kaplan-Meier analysis in patients with and without asystole showed a mean time free of recurrence of 92 X 6 +/- 6 months vs 82 X 6 +/- 4 X 7 months (P=ns). The previous number of syncopes had a significant relationship with recurrences (P=0 X 002), but not therapy. There were no cardiac related deaths. (1) Asystole during head-up tilt test does not imply a malignant outcome and syncope recurrence is low; (2) pacemaker or drug therapy do not significantly influence outcome which correlates to the previous number of syncopal episodes but not to gender, age, asystole occurrence, asystole duration and timing to asystole during head-up tilt test; (3) tilting protocol (angle) might influence time to and incidence of asystole during head-up tilt test.

Prevalence and prognostic significance of psychiatric disorders in patients evaluated for recurrent unexplained syncope

We aimed to assess the psychiatric profile and prognostic value of psychiatric disorders (PDs) in patients presenting with unexplained syncope. Forty patients with recurrent unexplained syncope referred for head-up tilt testing were compared with age- and sex-matched patients free of known chronic PDs referred for arrhythmia. All patients underwent a semistandardized psychiatry questionnaire (Mini-International Neuropsychiatric Interview) to assess their profile. Additional stress coping was performed to study adaptational processes to stressful situations. After tilt testing and psychiatric evaluation, a drug-free follow-up was performed in patients with syncope. Of the 80 patients who referred to the psychiatric interview, 40 had evidence of at least 1 psychiatric disorder. They were 26 patients (65%) in the syncope group and 14 patients (35%) in the control group (p = 0.01). Detailed analysis revealed a more frequent subprofile of anxiety and panic disorders in patients with syncope than in controls (30% vs 12% and 20% vs 10%, respectively), whereas the subprofile of depression was similar in both groups. Moreover, those with syncope were more likely to have a high anxiety index (25 ± 5 vs 22 ± 4, p = 0.004), and were more prone to avoidance-oriented coping strategies when experiencing undesirable life events than controls. Considering syncope patients, no difference could be found between the 25 with a positive tilt test and the 15 with a negative tilt test with respect to the number of syncopal episodes and psychiatric profile. After a 3-year drug-free follow-up, 15 patients (37.5%) had at least 1 recurrent syncope. The recurrence rate was similar in patients with positive and negative head-up tilt test results (9 of 25 vs 6 of 15, respectively). In contrast, the syncopal recurrence rate was higher in patients who fulfilled criteria for affective disorders (13 of 26 vs 2 of 14, 95% confidence interval 1.09 to 2.55, relative risk 1.7, p = 0.04). Thus, patients with recurrent unexplained syncope are more anxious and are more prone to panic disorders and avoidance-oriented coping strategies than control patients with arrhythmia. The presence of a psychiatric disorder is associated with an increased risk of recurrence. The outcome of such patients may be improved with recognition and treatment of PDs.