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Pacing and Clinical Electrophysiology :... Dec 2021Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of... (Review)
Review
Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of recurrent syncope can result in physical injury as well as psychological distress. This article provides a brief overview of current management strategies and a detailed overview of therapeutic modalities such as closed loop stimulation (CLS) and cardioneuroablation (CNA).
Topics: Ablation Techniques; Algorithms; Cardiac Pacing, Artificial; Diagnosis, Differential; Humans; Quality of Life; Syncope, Vasovagal
PubMed: 34748224
DOI: 10.1111/pace.14402 -
Heart Rhythm Jun 2018In part I of this study, we found that the classical studies on vasovagal syncope, conducted in fit young subjects, overstated vasodilatation as the dominant hypotensive... (Review)
Review
In part I of this study, we found that the classical studies on vasovagal syncope, conducted in fit young subjects, overstated vasodilatation as the dominant hypotensive mechanism. Since 1980, blood pressure and cardiac output have been measured continuously using noninvasive methods during tilt, mainly in patients with recurrent syncope, including women and the elderly. This has allowed us to analyze in more detail the complex sequence of hemodynamic changes leading up to syncope in the laboratory. All tilt-sensitive patients appear to progress through 4 phases: (1) early stabilization, (2) circulatory instability, (3) terminal hypotension, and (4) recovery. The physiology responsible for each phase is discussed. Although the order of phases is consistent, the time spent in each phase may vary. In teenagers and young adults, progressive hypotension during phases 2 and 3 can be driven by vasodilatation or falling cardiac output. The fall in cardiac output is secondary to a progressive decrease in stroke volume because blood is pooled in the splanchnic veins. In adults a fall in cardiac output is the dominant hypotensive mechanism because systemic vascular resistance always remains above baseline levels.
Topics: Electrocardiography; Hemodynamics; Humans; Syncope, Vasovagal; Tilt-Table Test
PubMed: 29246828
DOI: 10.1016/j.hrthm.2017.12.013 -
JAMA Internal Medicine Jun 2021
Topics: Humans; Syncope, Vasovagal
PubMed: 33587095
DOI: 10.1001/jamainternmed.2020.9151 -
Journal of Cardiovascular... Oct 2022Catheter-based cardioneuroablation is increasingly being utilized to improve outcomes in patients with vasovagal syncope and atrioventricular block due to vagal... (Review)
Review
Catheter-based cardioneuroablation is increasingly being utilized to improve outcomes in patients with vasovagal syncope and atrioventricular block due to vagal hyperactivity. There is now increasing convergence among enthusiasts on its various aspects, including patient selection, technical steps, and procedural end-points. This pragmatic review aims to take the reader through a step-by-step approach to cardioneuroablation: we begin with a brief overview of the anatomy of intrinsic cardiac autonomic nervous system, before focusing on the indications, preprocedure and postprocedure management, necessary equipment, and its potential limitations.
Topics: Atrioventricular Block; Catheter Ablation; Heart; Humans; Syncope, Vasovagal; Vagus Nerve
PubMed: 35362165
DOI: 10.1111/jce.15480 -
Heart Rhythm Jun 2015
2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope.
Topics: Child; Female; Humans; Male; Middle Aged; Postural Orthostatic Tachycardia Syndrome; Societies, Medical; Syncope, Vasovagal; Tachycardia, Sinus
PubMed: 25980576
DOI: 10.1016/j.hrthm.2015.03.029 -
European Journal of Internal Medicine Jun 2023Syncope is a short-term transient loss of consciousness, characterized by rapid onset and complete spontaneous recovery. According to the 2018 European Society of... (Review)
Review
Syncope is a short-term transient loss of consciousness, characterized by rapid onset and complete spontaneous recovery. According to the 2018 European Society of Cardiology guidelines, three different types of syncope have been identified. However, all forms of syncope share a common final pathophysiological event, global cerebral hypoperfusion, which results from the inability of the circulatory system to maintain blood pressure at the level required to efficiently supply blood to the brain. The vasovagal syncope (VVS) is the most common form of syncope. Although, VVS is generally harmless, its frequent occurrence can negatively affect quality of life and increase the risk of adverse events. The pathophysiological mechanisms underlying VVS remain obscure. The multifaceted nature of VVS presents a veritable challenge to understanding this condition and developing preventative strategies. Thus, the aim of this review was to discuss the factors contributing to the pathogenesis of VVS and provide guidance for future research.
Topics: Humans; Syncope, Vasovagal; Quality of Life; Syncope; Blood Pressure; Cardiology; Tilt-Table Test
PubMed: 37030995
DOI: 10.1016/j.ejim.2023.03.025 -
Practical Neurology Nov 2023Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving...
Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving sublingual nitroglycerine after 15 min, while monitoring beat-to-beat blood pressure (BP) and recording on video. Tilt testing is time-consuming but it is clinically useful and can guide therapy. Complications are rare. Syncope types include vasovagal syncope where BP falls after >3 min of tilt-up and later the heart rate falls; classic orthostatic hypotension where there is an immediate, progressive BP fall with minimal heart rate change; delayed orthostatic hypotension with a late BP fall after a stable phase but little or no heart rate rise; psychogenic pseudosyncope with apparent loss of consciousness, but no BP fall and a moderate heart rate rise; and postural orthostatic tachycardia syndrome where there is a significant heart rate rise but no BP fall.
Topics: Humans; Hypotension, Orthostatic; Tilt-Table Test; Syncope; Syncope, Vasovagal; Heart Rate; Blood Pressure
PubMed: 37726165
DOI: 10.1136/pn-2023-003749 -
Heart Rhythm Nov 2022Cardioneuroablation (CNA) has emerged as promising therapy for patients with refractory vasovagal syncope (VVS). (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cardioneuroablation (CNA) has emerged as promising therapy for patients with refractory vasovagal syncope (VVS).
OBJECTIVE
The purpose of this study was to provide a freedom from syncope estimate for CNA, including subgroup analysis by method and target of ablation.
METHODS
A systematic search was performed in MEDLINE and EMBASE according to the PRISMA guidelines until February 14, 2022. Observational studies and clinical trials reporting freedom from syncope were included. Meta-analysis was performed with a random-effects model.
RESULTS
A total of 465 patients were included across 14 studies (mean age 39.8 ± 4.0 year; 53.5% female). Different techniques were used to guide CNA: 50 patients (10.8%) by mapping fractionated electrograms, 73 (15.7%) with the spectral method, 210 (45.2%) with high-frequency stimulation, 73 (15.7%) with a purely anatomically guided method, and 59 (12.6%) with a combination. The target was biatrial in 168 patients (36.1%), left atrium only in 259 (55.7%), and right atrium only in 38 (8.2%). The freedom from syncope was 91.9% (95% confidence interval [CI] 88.1%-94.6%; I = 6.9%; P = .376). CNA limited to right atrial ablation was associated with a significant lower freedom from syncope (81.5%; 95% CI 51.9%-94.7%; P <.0001) vs left atrial ablation only (94.0%; 95% CI 88.6%--6.9%) and biatrial ablation (92.7%; 95% CI 86.8%-96.1%). Subgroup analysis according to the technique used to identify ganglionated plexi did not show any significant difference in freedom from syncope (P = .206).
CONCLUSION
This meta-analysis suggests a high freedom from syncope after CNA in VVS. Well-designed, double-blind, multicenter, sham-controlled randomized clinical trials are needed to provide evidence for future guidelines.
Topics: Humans; Female; Adult; Male; Syncope, Vasovagal; Atrial Fibrillation; Heart Atria; Atrial Appendage; Catheter Ablation; Randomized Controlled Trials as Topic; Multicenter Studies as Topic
PubMed: 35716859
DOI: 10.1016/j.hrthm.2022.06.017 -
Autonomic Neuroscience : Basic &... Dec 2021Vasovagal syncope (VVS) is a very common form of fainting. Treatment begins with patient education about the mechanism of fainting, and the non-lethal nature of... (Review)
Review
Vasovagal syncope (VVS) is a very common form of fainting. Treatment begins with patient education about the mechanism of fainting, and the non-lethal nature of vasovagal syncope. In this article, we review several non-pharmacological approaches that form the foundation of our current treatments. These include increases in dietary salt and water intake, the use of compression garments, physical counter-maneuvers and tilt-training. When these approaches are inadequate, medications can sometimes be effective. While the evidence base for the pharmacological treatment of VVS is modest, recent trial data have found drugs to be useful in placebo-controlled randomized trials. For select patients, and those patients more refractory to medications, procedural treatments may be an option. In this review, we discuss the current state of evidence for the non-pharmacological and pharmacological treatments for VVS, as well as some novel, emerging therapies for VVS.
Topics: Humans; Syncope, Vasovagal; Tilt-Table Test
PubMed: 34763249
DOI: 10.1016/j.autneu.2021.102904 -
JAMA Internal Medicine Jun 2021
Topics: Humans; Syncope, Vasovagal
PubMed: 33587099
DOI: 10.1001/jamainternmed.2020.9148