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Clinical Autonomic Research : Official... Dec 2023Vasovagal syncope is a common clinical condition that lacks effective medical therapies despite being associated with significant morbidity. Current guidelines suggest... (Meta-Analysis)
Meta-Analysis
PURPOSE
Vasovagal syncope is a common clinical condition that lacks effective medical therapies despite being associated with significant morbidity. Current guidelines suggest that serotonin-specific reuptake inhibitors might suppress vasovagal syncope but supporting studies have been small and heterogenous. The purpose of this study was to evaluate the efficacy of serotonin-specific reuptake inhibitors to prevent syncope in patients with recurrent vasovagal syncope by conducting a systematic review and meta-analysis of published studies.
METHODS
Relevant randomized controlled trials were identified from the MEDLINE and Embase databases without language restriction from inception to August 2022, and ClinicalTrials.gov. All studies were conducted in clinical syncope populations and compared the benefit of serotonin versus placebo. Weighted relative risks were estimated using random effects meta-analysis techniques.
RESULTS
Three studies (n = 204) met inclusion criteria. Patients were 42 ± 13 years of age and 51% female. Serotonin-specific reuptake inhibitors were found to substantially reduce the likelihood of a patient having at least one recurrence of vasovagal syncope [relative risk (RR) 0.34 (0.20-0.60), p < 0.01] with minimal between-study heterogeneity (I = 0%, p = 0.67). Serotonin-specific reuptake inhibitors in two reports provided significant protection against clinical presyncope [RR 0.43 (0.24-0.77), p < 0.01], with minimal between-study heterogeneity (I = 0%, p = 0.80).
CONCLUSIONS
Serotonin-specific reuptake inhibitors may be effective in preventing syncope induced by head-up tilt testing and in syncope in the community in randomized, double-blinded clinical trials.
Topics: Humans; Female; Male; Syncope, Vasovagal; Serotonin; Syncope; Selective Serotonin Reuptake Inhibitors; Tilt-Table Test
PubMed: 37971641
DOI: 10.1007/s10286-023-01000-5 -
Journal of Electrocardiology 2023A16-year-old female underwent tilt table testing, which resulted positive for reflex vasodepressive syncope. 12‑lead ECG during syncope showed T-wave inversion in...
A16-year-old female underwent tilt table testing, which resulted positive for reflex vasodepressive syncope. 12‑lead ECG during syncope showed T-wave inversion in infero-lateral leads, along with QTc interval increase >100 msec compared to baseline. These abnormalities rapidly disappeared in supine position with resumption of consciousness. Complete cardiac evaluation excluded heart disease. T-wave changes and moderate QTc prolongation are relatively common in young (mainly female) patients undergoing tilt table testing and they appear benign in nature. However, in a minority of cases, on the basis of the clinical context and after an accurate ECG analysis, further examinations may be warranted.
Topics: Adolescent; Female; Humans; Electrocardiography; Heart; Syncope; Syncope, Vasovagal; Tilt-Table Test
PubMed: 37947362
DOI: 10.1016/j.jelectrocard.2023.10.005 -
Annals of Case Reports 2023Nontraumatic exertional syncope can be an ominous event reflecting profound arterial hypotension, cerebral hypoperfusion, and transient loss-of consciousness that occurs...
Nontraumatic exertional syncope can be an ominous event reflecting profound arterial hypotension, cerebral hypoperfusion, and transient loss-of consciousness that occurs most commonly in patients with underlying cardiovascular disease. In contradistinction, transient loss-of-consciousness in "healthy adults" is typically vasovagal syncope related to exaggerated orthostatic cardiovascular responses attributed to a hyper-reactive autonomic nervous system. In the present report, a 34 yo male presents to the hospital emergency department (ED) for a sudden loss of consciousness and fall ultimately related to cardiac syncope ascribed to chronic recreational marijuana use complicated by coronary vasospasm.
PubMed: 37946711
DOI: 10.29011/2574-7754.101468 -
European Journal of Pediatrics Jan 2024Serum uric acid (UA) level has been proven to be related to several cardiovascular and metabolic diseases. In the present study, we examined if baseline serum UA level...
Serum uric acid (UA) level has been proven to be related to several cardiovascular and metabolic diseases. In the present study, we examined if baseline serum UA level could predict the therapeutic efficacy of midodrine hydrochloride on vasovagal syncope (VVS) in children. The pediatric VVS patients who received midodrine hydrochloride from November 2008 to October 2022 were enrolled. After a median treatment duration of 3 months, the therapeutic effect was evaluated. According to the patients' responses to midodrine hydrochloride, which was determined by the recurrence of syncope, they were divided into effective and ineffective groups. The baseline variables were explored using univariable and multivariate logistic analysis. The predictive efficacy was assessed by receiver operating characteristic curve (ROC), precision-recall curve (PR), Hosmer-Lemeshow test, calibration curve, and decision curve analysis (DCA). Totally, 53 participants were included in the study. Among the 51 patients who were successfully followed up, 29 (56.9%) responded to midodrine hydrochloride (effective group), and the other 22 (43.1%) failed to respond to midodrine hydrochloride (ineffective group). The participants in effective group had lower baseline serum UA level than those in ineffective group (276.5 ± 73 μmol/L vs. 332.7 ± 56 μmol/L, p = 0.004). Multivariable logistic analysis showed that serum UA was associated with the therapeutic response (odds ratio (OR): 0.985, 95% confidence interval (CI): 0.974-0.997, p = 0.01). ROC analysis indicated that using baseline serum UA < 299 μmol/L as a threshold value yielded a sensitivity of 77.3% and a specificity of 79.3% in predicting the treatment response to midodrine hydrochloride. The area under the PR curve was 0.833. Hosmer-Lemeshow test yielded a p value of 0.58, and calibration plot indicated that the model was well-fitted. DCA demonstrated that treatment decision depending on the baseline serum UA level resulted in a favorable net benefit. Conclusion: This pilot study suggested that the baseline serum UA level could be taken as a predictor of therapeutic effect of midodrine hydrochloride on VVS in children. What is Known: • Empirical and unselected use of midodrine hydrochloride has an unfavorable therapeutic effect on VVS in children. Serum uric acid (UA) is closely linked to cardiovascular events. What is New: • A low baseline serum UA level successfully predicts the therapeutic effectiveness of midodrine hydrochloride on VVS in children.
Topics: Humans; Child; Midodrine; Uric Acid; Pilot Projects; Syncope, Vasovagal; ROC Curve
PubMed: 37904034
DOI: 10.1007/s00431-023-05297-2 -
Clinical Autonomic Research : Official... Dec 2023We compared hemodynamic parameters between subjects with marked, intermediate and minimal cardioinhibition during vasovagal syncope.
PURPOSE
We compared hemodynamic parameters between subjects with marked, intermediate and minimal cardioinhibition during vasovagal syncope.
METHODS
The study included subjects with a decrease in heart rate while experiencing a complete vasovagal syncope during tilt-table testing. The subjects were classified as having marked, intermediate or minimal cardioinhibition, based on tertile values of the decrease in heart rate. Hemodynamic parameters between these groups were compared before tilt in the supine position, shortly after tilt and during cardioinhibition.
RESULTS
A total of 149 subjects with a median age of 43 (interquartile range 24-60) years were included in the study. Among the three groups with different levels of cardioinhibition, the highest heart rate was observed in subjects with marked cardioinhibition both before and shortly after tilt and at the start of cardioinhibition. The heart rate decrease in these subjects was both larger and faster compared to subjects with minimal and intermediate cardioinhibition.
CONCLUSION
Subjects with marked cardioinhibition have both a larger and faster decrease in heart rate compared to subjects with intermediate and minimal cardioinhibition, as early as from the start of cardioinhibition. Marked cardioinhibition is related to differences in hemodynamic profiles already present well before the start of cardioinhibition.
Topics: Humans; Young Adult; Adult; Middle Aged; Syncope, Vasovagal; Tilt-Table Test; Hemodynamics; Heart Rate; Triazoles
PubMed: 37874434
DOI: 10.1007/s10286-023-00991-5 -
European Journal of Pediatrics Jan 2024Vasovagal syncope (VVS) is a clinically common neurally mediated syncope. The relationship between different hemodynamic types of VVS and clinical syncopal symptoms has...
UNLABELLED
Vasovagal syncope (VVS) is a clinically common neurally mediated syncope. The relationship between different hemodynamic types of VVS and clinical syncopal symptoms has not been reported. The purpose of this research is to explore relationship between hemodynamic types and syncopal symptoms in pediatric VVS. Two thousand five hundred thirteen patients diagnosed with VVS at the age of 3-18 years, average age was 11.76 ± 2.83 years, including 1124 males and 1389 females, due to unexplained syncope and pre-syncope from single-center of January 2001 to December 2021 were retrospectively analyzed. Subjects were divided into two groups according to the presence or absence of syncopal symptoms: syncope group (1262 cases) and pre-syncope group (1251 cases). (1) Baseline characteristics: age, height, weight, systolic blood pressure (SBP), and diastolic blood pressure (DBP) increased in the syncope group compared with the pre-syncope group; the composition ratio of females was more than that of males in the syncope group; and the composition ratio of VVS-cardioinhibited (VVS-CI) and VVS-mixed (VVS-M) was more in the syncope group than that of the pre-syncope group (all P < 0.05). (2) Univariate analysis: age, height, weight, SBP, DBP, female, VVS-CI, and VVS-M were potential risk factors for the presence of syncopal symptoms (all P < 0.05). (3) Multivariate analysis: VVS-CI and VVS-M were independent risk factors for the presence of syncopal symptoms, with an increased probability of 203% and 175%, respectively, compared to VVS-vasoinhibited (VVS-VI) (all P < 0.01).
CONCLUSION
The hemodynamic type of pediatric VVS is closely related to the syncopal symptoms.
WHAT IS KNOWN
• There are varying probabilities of syncopal episodes in different hemodynamic types of VVS, and there is a lack of research to assess the comparative risk of syncope in children with different hemodynamic types of VVS.
WHAT IS NEW
• The probability in presence of syncopal symptoms varies greatly between different hemodynamic types of VVS. • VVS-CI and VVS-M had a 203% and 175% increased risk in presence of syncopal symptoms compared with VVS-VI, respectively.
Topics: Male; Humans; Female; Child; Adolescent; Child, Preschool; Syncope, Vasovagal; Retrospective Studies; Tilt-Table Test; Syncope; Hemodynamics
PubMed: 37855929
DOI: 10.1007/s00431-023-05278-5 -
European Journal of Cardiovascular... Oct 2023Implantation of an implantable cardiac monitor (ICM) is a simple procedure, but adds significant and increasing workload to the arrhythmia service. In 2020, we...
AIMS
Implantation of an implantable cardiac monitor (ICM) is a simple procedure, but adds significant and increasing workload to the arrhythmia service. In 2020, we established a nurse-led ICM implantation service. We aimed to analyze patient satisfaction, adverse events during implant and ICM re-interventions with nurse-led ICM implantation (N-Implant) compared to physician-led ICM implantation (P-Implant).
METHOD AND RESULTS
From January 2020 to December 2021 we included all consecutive patients implanted with an ICM in a prospective registry. We collected data on patient characteristics, implant procedure and follow-up. Patients were interviewed by phone four weeks after ICM implantation.Of 321 patients implanted with an ICM (median age 67 years; 33% women), 189 (59%) were N-Implants. More N-Implants were performed in the outpatient clinic compared to P-Implants (95% vs. 8%; p<0.001). Two N-Implant patients experienced vaso-vagal reaction during implantation (1%), whereas no adverse events occurred during P-Implant (p=0.51). 297 patients (93%) completed the questionnaire. Duration of pain was shorter and wound closure after 2 weeks better following N-Implant (p=0.019 and p=0.018). A minor bruise or swelling at the implant site was reported more frequently after N-Implant (p=0.003 and p=0.041). Patient satisfaction was excellent with both N-Implant and P-Implant (99% and 97%; p=0.16). After a median follow-up of 242 days (range 7-725 days), five ICMs (2%) were explanted prematurely, without differences among groups. Reasons for premature explants were local discomfort (n=2), infection, MRI and ICM malfunction.
CONCLUSION
Nurse-led ICM implantation has excellent patient satisfaction without compromising safety. N-Implant both expands nursing competencies and reduces physician workload.
PubMed: 37851866
DOI: 10.1093/eurjcn/zvad103 -
Clinical Physiology and Functional... Mar 2024Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes... (Review)
Review
Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value.
Topics: Humans; Reproducibility of Results; Tilt-Table Test; Syncope; Syncope, Vasovagal; Hypotension, Orthostatic; Heart Rate
PubMed: 37839043
DOI: 10.1111/cpf.12859 -
Vnitrni Lekarstvi 2023Orthostatic intolerance (OI) is defined as a group of diseases which symptoms are typically manifested in a standing position. These symptoms result from cerebral...
Orthostatic intolerance (OI) is defined as a group of diseases which symptoms are typically manifested in a standing position. These symptoms result from cerebral hypoperfusion and disappear in the supine position. We include postural orthostatic intolerance syndrome (POTS), orthostatic hypotension (OH) and vasovagal orthostatic syncope in this group of diseases. Each of them have similar clinical presentation (blurred vision, weakness, dizziness, nausea, headaches, fatigue). However, they vary from each other in biochemical, autonomic and hemodynamic characteristics. The aim of the work is to provide an overview of humoral and non-human markers that are involved in the etiopathogenesis of orthostatic intolerance.
Topics: Humans; Orthostatic Intolerance; Postural Orthostatic Tachycardia Syndrome; Syncope; Syncope, Vasovagal; Biomarkers
PubMed: 37827818
DOI: 10.36290/vnl.2023.066 -
BMJ Case Reports Oct 2023The current evidence for vasovagal syncope management is that cardiac pacing is only indicated in a highly select group of patients where symptoms can be linked to...
The current evidence for vasovagal syncope management is that cardiac pacing is only indicated in a highly select group of patients where symptoms can be linked to bradycardic episodes. High spinal cord injury can lead to autonomic dysfunction and sympathetic nervous system hypoactivity. A high spinal cord injury can theoretically precipitate profound bradycardia leading to haemodynamic instability and syncope. A patient in his 50s with a history of C2 spinal injury was admitted to our tertiary centre for management of what was initially thought to be septic shock causing hypotension and syncope. With evidence to suggest this patient's presentation may be profound reflex syncope in the context of unopposed parasympathetic signalling, consensus was reached to implant a permanent pacemaker. Remarkably, the patient's haemodynamics stabilised and there were no further episodes of syncope.
Topics: Humans; Bradycardia; Cardiac Pacing, Artificial; Pacemaker, Artificial; Spinal Cord Injuries; Syncope; Syncope, Vasovagal; Male; Middle Aged
PubMed: 37816572
DOI: 10.1136/bcr-2023-255020