Follow-up of asystolic episodes in patients with cardioinhibitory, neurally mediated syncope and VVI pacemaker

doi:10.1016/0002-9149(93)90985-L

The American Journal of Cardiology

Volume 72, Issue 15, 15 November 1993, Pages 1152-1155

https://doi.org/10.1016/0002-9149(93)90985-L Get rights and content

Abstract

The occurrence rate of spontaneous asystolic episodes during long-term follow-up in patients with abnormal asystolic responses induced by means of vasovagal maneuvers was evaluated. The heart rate of 23 patients (mean age 64 ± 12 years; 6 women and 17 men) affected by neurally mediated syncope (mean 4.3 ± 4.9 episodes) was continuously monitored by a specially designed implanted pacemaker able to detect and store in its memory all asystolic episodes lasting 3 to 6 or >6 seconds. Asystolic, neurally mediated syncope was diagnosed when a reflex asystole of >3 seconds was induced during carotid sinus massage (n = 22), eyeball compression test (n = 3) or headup tilt test (n = 2). During a total of 357 months (mean 15 ± 7) of monitoring, asystolic episodes occurred in 17 patients (74%): 1,765 episodes of 3- to 6-second (median 3) duration occurred in 14 patients, and 47 episodes of >6-second (median 2) duration occurred in 11. The actuarial estimates of occurrence of asystolic episodes of >3 and >6 seconds were 82 and 53%, respectively, after 2 years of follow-up. Only 12 episodes of 3 to 6 seconds (0.7%), and 20 episodes of >6 seconds (43%) resulted in presyncopal or syncopal symptoms. Thus, an asystolic response to vasovagal maneuvers predicts the occurrence of spontaneous asystolic episodes during follow-up. With few exceptions, spontaneous episodes are asymptomatic and their incidence is low.

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Cited by (79)

Systemic and cerebral circulatory adjustment within the first 60 s after active standing: An integrative physiological view
2021, Autonomic Neuroscience: Basic and Clinical
Citation Excerpt :
No data are available comparing the anoxia reserve time in young adults with those in older subjects, but the following observations suggest that the anoxia reserve time in older adults is quite similar to that measured in young adults. First, records of spontaneous episodes of presyncope and syncope in older patients during very prolonged ECG monitoring showed that spontaneous episodes of asystole lasting >6 s elicited symptoms of presyncope or syncope in up to 40% of 23 older patients with recurrent syncope (Menozzi et al., 1993). With shorter asystolic episodes lasting 3–6 s patients were symptomatic in only 0.7%.
Transient cardiovascular and cerebrovascular responses within the first minute of active standing provide the means to assess autonomic, cardiovascular and cerebrovascular regulation using a real-world everyday stimulus. Traditionally, these responses have been used to detect autonomic dysfunction, and to identify the hemodynamic correlates of patient symptoms and attributable causes of (pre)syncope and falls.
This review addresses the physiology of systemic and cerebrovascular adjustment within the first 60 s after active standing. Mechanical factors induced by standing up cause a temporal mismatch between cardiac output and vascular conductance which leads to an initial blood pressure drops with a nadir around 10 s. The arterial baroreflex counteracts these initial blood pressure drops, but needs 2–3 s to be initiated with a maximal effect occurring at 10 s after standing while, in parallel, cerebral autoregulation buffers these changes within 10 s to maintain adequate cerebral perfusion. Interestingly, both the magnitude of the initial drop and these compensatory mechanisms are thought to be quite well-preserved in healthy aging.
It is hoped that the present review serves as a reference for future pathophysiological investigations and epidemiological studies. Further experimental research is needed to unravel the causal mechanisms underlying the emergence of symptoms and relationship with aging and adverse outcomes in variants of orthostatic hypotension.
Usefulness of Tilt Testing and Carotid Sinus Massage for Evaluating Reflex Syncope
2018, American Journal of Cardiology
Citation Excerpt :
The 3-seconds cutoff for asystole is too sensitive, with a high percentage of positive responses reported in subjects without history of syncope.31 In addition, clinical data suggest that asystole inferior to 6 seconds is frequently asymptomatic32,33 and mean asystole duration during spontaneous syncope lasts 9 seconds,34 so a new 6-seconds cutoff has been proposed.27 Referring to BP, until the 1980s it was measured with a brachial sphygmomanometer and the delay in different measurements led to the concept of cardioinhibition without decrease in BP.
Thirty years ago Tilt Testing (TT) was described as a tool in the diagnostic work-up of vasovagal syncope; after its initial success, some flaws have become evident. The concept of hypotensive susceptibility has provided the test a new relevance, shifting from diagnosis only, to therapeutic management. Carotid Sinus Massage (CSM) was introduced at the beginning of the XX century; the technique has evolved over years, whereas the concept of carotid sinus syndrome (CSS) has remained unchanged and uncontested for more than half a century. Nowadays, CSS is a matter of debate, with new classifications and criteria coming on the scene. Recently, a common central etiological mechanism has been hypothesized for reflex syncope, manifesting as CSS, vasovagal syncope or both. In this context, TT and CSM acquire an important role in clinical practice, being essential for a complete diagnosis and treatment. Recalling their historical background, the present paper illustrates an actual interpretation of TT and CSM.
Pacing in Reflex (Neurally-Mediated) Syncopes
2016, Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy
Syncope: Diagnosis and management
2015, Current Problems in Cardiology
Citation Excerpt :
In patients who have a predominately cardioinhibitory response, pacing has been shown to be effective. Indeed, patients with carotid sinus syndrome have a high prevalence of asystole during prolonged monitoring75,76 and fewer recurrences after pacing when compared with patients without pacing therapy.77,78 Accordingly, in the most recent guidelines, it is stated that permanent pacing is indicated for recurrent syncope caused by spontaneously occurring carotid sinus stimulation that induces >3 seconds of asystole (Class I) and is reasonable for syncope without provocative events in patients who have a hypersensitive cardioinhibitory response of 3 seconds or longer (Class IIa).
Syncope is defined as transient loss of consciousness due to global cerebral hypoperfusion. It is characterized by having a relatively rapid onset, brief duration with spontaneous and full recovery. The major challenge in the evaluation of patients with syncope is that most patients are asymptomatic at the time of their presentation. A thorough history and physical examination including orthostatic assessment are crucial for making the diagnosis. After initial evaluation, short-term risk assessment should be performed to determine the need for admission. If the short-term risk is high, inpatient evaluation is needed. If the short-term risk is low, outpatient evaluation is recommended. In patients with suspected cardiac syncope, monitoring is indicated until a diagnosis is made. In patients with suspected reflex syncope or orthostatic hypotension, outpatient evaluation with tilt-table testing is appropriate. Syncope units have been shown to improve the rate of diagnosis while reducing cost and thus are highly recommended.
2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy
2014, Revista Espanola de Cardiologia
Pacing in Neurally Mediated Syncope Syndromes
2011, Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy

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Follow-up of asystolic episodes in patients with cardioinhibitory, neurally mediated syncope and VVI pacemaker

Abstract

Am Heart J

J Electrocardiol

Am J Cardiol

Am J Cardiol

The clinical and prognostic significance of the asystolic response during the head-up tilt test

Eur J Cardiac Pacing & Electrophysiol

Tilting towards a diagnosis in recurrent unexplained syncope

Lancet

Spontaneous occurrence of the induced cardioinhibitory vasovagal reflex

PACE

Validation of a new method for the choice of the pacing mode in carotid sinus syndrome with or without sinus bradycardia

PACE

A prospective evaluation and follow-up of patients with syncope

N Engl J Med