Advertisement

Vasovagal Syncope with Asystolic Pause: Drugs, Pacemaker, or Both?

  • A. Moya
  • G. Permanyer-Miralda
  • J. Sagristá-Sauleda
Conference paper

Abstract

One of the problems in the assessment of syncope is that most clinical episodes are not witnessed. Therefore, features such as asystole during the attack must be assumed on the basis of indirect evidence such as its induction with provocative maneuvers. Head up tilt test (HUT) is the most widely used of such maneuvers, and most discussions on the management or significance of asystole during syncope are based on the development of asystole during HUT. Therefore, before addressing the particular issue of asystole in vasovagal syncope (VVS), a critical review of the reliability of HUT to draw conclusions about such a topic is justified.

Keywords

Tilt Test Cardiac Pace Vasovagal Syncope Unexplained Syncope Dual Chamber Pace 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Kenny RA, Ingram A, Bayliss J, Sutton R (1986) Head-up tilt: a useful test for investigating unexplained syncope. Lancet 1:1352–1354PubMedCrossRefGoogle Scholar
  2. 2.
    Almquist A, Goldenberg IF, Milstein S et al (1989) Provocation of bradycardia and hypotension by isoproterenol and upright tilt test in patients with unexplained syncope. N Engl J Med 320: 346–351PubMedCrossRefGoogle Scholar
  3. 3.
    Milstein S, Reyes WJ, Benditt DG (1989) Upright body tilt for evaluation of patients with recurrent, unexplained syncope. PACE 12: 117–124PubMedGoogle Scholar
  4. 4.
    Strasberg B, Rechavia E, Sagie A et al (1989) The head-up tilt test in patients with syncope of unknown origin. Am Heart J 118: 923–927PubMedCrossRefGoogle Scholar
  5. 5.
    Fitzpatrick AP, Theodorakis G, Vardas P, Sutton R (1991) Methodology of head-up tilt testing in patients with unexplained syncope. J Am Coll Cardiol 17: 125–30PubMedCrossRefGoogle Scholar
  6. 6.
    Sheldon R, Killam S (1992) Methodology of isoproterenol-tilt table testing in patients with syncope. J Am Coll Cardiol 19: 773–779PubMedCrossRefGoogle Scholar
  7. 7.
    Shalev Y, Gal R, Tchou P et al (1991) Echocardiographic demonstration of decreased left ventricular dimensions and vigorous myocardial contraction during syncope induced by head-up tilt test. J Am Coll Cardiol 1991; 18: 746–751CrossRefGoogle Scholar
  8. 8.
    Grubb BP, Gerard G, Temesy-Armos P, Roush K, Hanhn H, Elliot L (1991) Cerebral vasoconstriction during upright tilt induced syncope. PACE 1991; 14: 662 (abstr)Google Scholar
  9. 9.
    Fitzpatrick A, Williams T, Ahmed R, Lightman S, Bloom SR, Sutton R (1992) Echocardiographic and endocrine changes during vasovagal syncope induced by prolonged head-up tilt. Eur J Cardiac Pacing Electrophysiol 2: 121–128Google Scholar
  10. 10.
    Moya A, Permanyer-Miralda G, Sagrista J, Mont L, Rius T, Soler-Soler J (1993) Analisis de las respuestas a la prueba en tabla basculante en función de las características clínicas de los episodios sincopales en pacientes sin cardiopatia aparente. Rev Esp Cardiol 46: 214–219Google Scholar
  11. 11.
    Sutton R, Petersen M, Brignole M, Raviele A, Menozzi C, Giani P (1992) Proposed classification for tilt induced vaso-vagal syncope. Eur J Cardiac Pacing Electrophysiol 2: 12.180–183Google Scholar
  12. 12.
    Milstein S, Buetikofer J, Dunnigan A, Benditt DG, Gornik C, Reyes WJ (1990) Usefulness of disopyramide for prevention of upright tilt-induced hypotension-bradycardia. Am J Cardiol 65: 1339–13344PubMedCrossRefGoogle Scholar
  13. 13.
    Raviele A, Gasparini G, Di Pede F, Delise P, Bonso A, Piccolo E (1990) Usefulness of head-up tilt-test in evaluating patients with syncope of unknown origin and negative electrophysiologic study. Am J Cardiol 65:1322–1327PubMedCrossRefGoogle Scholar
  14. 14.
    Grubb BP, Wolfe DA, Samoil D, Temesy-Armos P, Hahn H, Elliott L (1993) Usefulness of fluoxetine for prevention of resistant upright tilt induced syncope. PACE 16: 458–464PubMedCrossRefGoogle Scholar
  15. 15.
    Sra JS, Murthy VS, Jayazery M et al (1992) Use of intravenous esmolol to predict efficacy of oral beta-adrenergic blocker therapy in patients with neurocardiogenic syncope. J Am Coll Cardiol 402–408Google Scholar
  16. 16.
    Grubb BP, Temesy-Armos P, Hann H, Elliot L (1991) Utility of upright tilt-table testing in the evaluation and management of syncope of unknown origin. Am J Med 90: 6–10PubMedCrossRefGoogle Scholar
  17. 17.
    Morillo CA, Leitch JW, Yee R, Klein GJ (1993) A placebo controlled trial of intravenous and oral disopyramide for prevention of neurally mediated syncope induced by head-up tilt. J Am Coll Cardiol 22: 1843–1848PubMedCrossRefGoogle Scholar
  18. 18.
    Wolfe DA, Grubb BP, Temesy-Armos PN, Samoil D, Kosinski DJ, Brewster PS (1993) Usefulness of verapamil in preventing upright tilt induced (vasovagal-mediated) hypotension and bradycardia. J Am Coll Cardiol 21: 172A (abstr)Google Scholar
  19. 19.
    Natale A, Sra J, Dhala A et al (1993) Clinical follow-up in 327 patients with positive head-up tilt: how should appropriate therapy be chosen? Circulation 88: I-398 (abstr)Google Scholar
  20. 20.
    Fitzpatrick AP, Ahmed R, Williams S, Sutton R (1991) A randomised trial of medical therapy in “malignant vasovagal syndrome” or neurally-mediated bradycardia/hypotension syndrome“. Eur J Cardiac Pacing Electrophysiol 2: 99–102Google Scholar
  21. 21.
    Fitzpatrick AP, Travill CM, Vardas PE et al (1990) Recurrent symptoms after ventricular pacing in unexplained syncope. PACE 13: 619–624PubMedCrossRefGoogle Scholar
  22. 22.
    Fitzpatrick A, Theodorakis G, Ahmed R, Williams T, Sutton R (1991) Dual chamber pacing aborts vasovagal syncope induced by head-up 600 tilt. PACE 13: 13–19CrossRefGoogle Scholar
  23. 23.
    Grubb BP, Temesy-Armos P, Moore J, Wolfe D, Hahn H, Elliot L (1992) Head-upright tilt-table testing in evaluation and management of the malignant vasovagal syndrome. Am J Cardiol 69: 904–908PubMedCrossRefGoogle Scholar
  24. 24.
    Sra JS, Jayazery MR, Avitalli B et al (1993) Comparison of cardiac pacing with drug therapy in the treatment of neurocardiogenic (vasovagal) syncope with bradycardia or asystole. N Engl J Med 328: 1085–1090PubMedCrossRefGoogle Scholar
  25. 25.
    Samoil D, Grubb BP, Brewster P, Moore J, Temesy-Armos P (1993) Comparison of single and dual chamber pacing techniques in prevention of upright tilt induced vasovagal syncope. Eur J Cardiac Pacing Electrophysiol 3: 36–41Google Scholar
  26. 26.
    Moya A, Permanyer-Miralda G, Sagristà J, Mont L, Rius T, Soler-Soler J (1993) Response to dual chamber pacing in patients with syncope and positive tilt test with cardioinhibitory response. PACE 16: 936 (abstr)Google Scholar
  27. 27.
    Benditt DG, Petersen M, Lurie KG, Giubb BP, Sutton R (1995) Cardiac pacing for prevention of recurrent vasovagal syncope. Ann Intern Med 122: 204–209PubMedGoogle Scholar
  28. 28.
    Kramer MS (1988) Diagnostic tests. In: Kramer MS (ed) Clinical epidemiology and biostatistics. Springer, Berlin Heidelberg New York, pp 201–219CrossRefGoogle Scholar
  29. 29.
    Brignole M, Menozzi C, Gianfranchi L, Oddine D, Lollis G, Berttulla A (1991) Neurally mediated syncope detected by carotid sinus massage and head-up tilt test in sick sinus syndrome. Am J Cardiol 68: 1032–1036PubMedCrossRefGoogle Scholar
  30. 30.
    Kapoor WN, Brant N (1992) Evaluation of syncope by upright tilt testing with isoproterenol. A nonspecific test. Ann Intern Med 116: 356–363Google Scholar
  31. 31.
    Ambrosi P, Djiane P, Durand JM et al (1992) Intérêt et limites du test d’inclinaison dans le diagnostic étiologique des malaises brefs. Arch Mal Coeur 85: 345–350PubMedGoogle Scholar
  32. 32.
    Raviele A, Gasparini G, Di Pede F et al (1994) Nitroglycerin infusion during upright tilt: a new test for the diagnosis of vaso-vagal syncope. Am Heart J 127: 103–111PubMedCrossRefGoogle Scholar
  33. 33.
    Kapoor WN (1990) Evaluation and outcome of patients with syncope. Medicine 69: 160–175PubMedCrossRefGoogle Scholar
  34. 34.
    Kapoor WN, Smith MA, Miller NL (1994) Upright tilt testing in evaluating syncope. A comprehensive literature review. Am J Med 97: 78–88PubMedCrossRefGoogle Scholar
  35. 35.
    Glick G, Yu PN (1963) Hemodynamic changes during spontaneous vasovagal reaction. Am J Med 34: 42–51PubMedCrossRefGoogle Scholar
  36. 36.
    Abboud FM (1989) Ventricular syncope: is the heart a sensory organ? N Engl J Med 320: 390–392PubMedCrossRefGoogle Scholar
  37. 37.
    Thames MD, Kopfenstein HS, Abboud FM, Marck AL, Walker JL (1978) Preferential distribution of inhibitory cardiac receptors with vagal afferents to the inferoposterior wall of left ventricle during coronary occlusion in the dog. Cire Res 43: 521–529Google Scholar
  38. 38.
    García Civera R, Ruíz Grandi R, Cosín Aguilar J, López Merino V (1989) Sfncope vasovagal. In: García Civera R, Sanjuan Maïíez R, Cosín Aguilar J, López Merino V (eds). Sfncope. MCR, Barcelona, pp 177–198Google Scholar
  39. 39.
    Moya A, Permanyer-Miralda G, Sagrista-Sauleda J et al (1995) Limitations of head-up tilt test for evaluating the efficacy of therapeutic interventions in patients with vasovagal syncope: results of a controlled study of etilefrine versus placebo. J Am Coll Cardiol 25: 65–69PubMedCrossRefGoogle Scholar
  40. 40.
    Sra JS, Murthy VS, Jayazery MR et al (1992) Use of intravenous esmolol to predict efficacy of oral beta-adrenergic blocker therapy in patients with neurocardiogenic syncope. J Am Coll Cardiol. 19: 402–408CrossRefGoogle Scholar
  41. 41.
    Fitzpatrick AP, Travill CM, Vardas PE et al (1991) A randomised trial of medical therapy in “malignant vasovagal syndrome” or neurally-mediated bradycardia/hypotension syndrome“. Eur J Cardiac Pacing Electrophysiol 2:99–102Google Scholar
  42. 42.
    Blanc JJ, Corber C, Mansourati J, Genet L (1991) Evaluation du traitment betabloquant dans les syncopes vasovagals reproduits par le test d’inclinaison. Arch Mal Coeur 84: 1453–1457PubMedGoogle Scholar
  43. 43.
    Brignole M, Menozzi C, Gianfranchi L, Lolli G, Bottoni N, Oddone D (1992) A controlled trial of acute and long-term medical therapy in tilt-induced neurally mediated syncope. Am J Cardiol 70: 339–342PubMedCrossRefGoogle Scholar
  44. 44.
    Milstein S, Buetikofer J, Dunningan A, Benditt DG, Gornick C, Reyes WJ (1990) Usefulness of disopyramide for prevention of upright tilt-induced hypotension-bradycardia. Am J Cardiol 65: 1339–1344PubMedCrossRefGoogle Scholar
  45. 45.
    López Candel J, Picó Aracil F, Sanchez Munoz JJ et al (1993) Sincope vasovagal maligno. Diagnostico’y ensayo terapéutico basado en el test del ortostatismo (test del tilt). Rev Esp Cardiol 46: 28–33Google Scholar
  46. 46.
    Grubb BP, Wolfe DA, Samoil D, Temesy-Armos P, Hahn H, Elliot L (1991) Usefulness of fluoxetine for prevention of resistant upright tilt induced syncope. PACE 90: 6–10Google Scholar
  47. 47.
    Brignole M, Menozzi C, Gianfranchi L, Bottoni N, Lolli G (1992) The clinical and prognosis significance of asystolie response during the head-up tilt test. Eur J Cardiac Pacing Electrophysiol 2: 109–113Google Scholar
  48. 48.
    Moya A, Permanyer-Miralda G, Sagrista J, Rius T, Mont L, Soler-Soler J (1993) Influencia del use del isoproterenol en la respuesta al exploración en tabla basculante en pacientes con sincope de causa desconocida. Rev Esp Cardiol 46 [Suppl 1]: 11 (abstr)Google Scholar
  49. 49.
    de Buitleir M, Grogan EW, Picone MF, Casteen JA (1993) Immediate reproducibility of the tilt table test in adults with unexplained syncope. Am J Cardiol 71: 304–307PubMedCrossRefGoogle Scholar
  50. 50.
    Chen XC, Chen MY, Remole S et al (1992) Reproducibility of head up tilt-table testing for eliciting susceptibility to neurally mediated syncope in patients without structural heart disease. Am J Cardiol 69: 755–760PubMedCrossRefGoogle Scholar
  51. 51.
    Brooks R, Ruskin JN, Powell AC, Newell J, Garan H, McGovern BA (1993) Prospective evaluation of day-to-day reproducibility of upright tilt-table testing in unexplained syncope. Am J Cardiol 71: 1289–1292PubMedCrossRefGoogle Scholar
  52. 52.
    Grubb BP, Wolfe D, Temesy-Armos P, Hahn H, Elliot L (1992) Reproducibility of head-up tilt table test results in patients with syncope. PACE 15: 1477–1481PubMedCrossRefGoogle Scholar
  53. 53.
    Sheldon R, Splawinski J, Killiam S (1992) Reproducibility of isoproterenol tilt-table tests in patients with syncope. Am J Cardiol 69: 1300–1305PubMedCrossRefGoogle Scholar
  54. 54.
    Fish FA, Strasburger JF, Benson DW (1992) Reproducibility of a symptomatic response to upright tilt in young patients with unexplained syncope. Am J Cardiol 70: 605–609PubMedCrossRefGoogle Scholar
  55. 55.
    Milstein S, Buetikofer J, Lesser J et al (1991) Cardiac asystole: a manifestation of neurally mediated hypotension-bradycardia. J Am Coll Cardiol 14: 1622–1632Google Scholar
  56. 56.
    Rius T, Moya A, Sagristâ J, Permanyer-Miralda G, Mont L, Soler-Soler J (1993) Valor de la prueba en tabla basculante en pacientes portadores de marcapasos VVI con sfncopes recidi-vantes. Rev Esp Cardiol 46 [Suppl I]: 11 (abastract)Google Scholar
  57. 57.
    Dangovian MI, Jarandilla R, Frumin H (1992) Prolonged asystole during head-up tilt table testing after beta-blockade. PACE 15: 14–16PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia, Milano 1996

Authors and Affiliations

  • A. Moya
    • 1
  • G. Permanyer-Miralda
    • 1
  • J. Sagristá-Sauleda
    • 1
  1. 1.Servei de CardiologiaHospital General Universitari Vall d’HebronBarcelonaSpain

Personalised recommendations