Valsalva Maneuver in Pulmonary Arterial Hypertension: Susceptibility to Syncope and Autonomic Dysfunction.
Mar Philip L,Nwazue Victor,Black Bonnie K,Biaggioni Italo,Diedrich André,Paranjape Sachin Y,Loyd James E,Hemnes Anna R,Robbins Ivan M,Robertson David,Raj Satish R,Austin Eric D
BACKGROUND:Patients with pulmonary arterial hypertension (PAH) are routinely instructed to avoid performing the Valsalva maneuver for fear of syncope or sudden cardiac death. The mechanism of this action has not been elucidated. We conducted a case-control trial of nine patients with PAH and 15 healthy control subjects to determine if systemic hemodynamic changes during the Valsalva maneuver in these patients invoke greater susceptibility to syncope than healthy control subjects. Metrics commonly employed in autonomic testing were used to assess the degree of autonomic failure. METHODS:Common Valsalva parameters, including adrenergic baroreflex sensitivity, pressure recovery time, systolic BP (SBP) recovery, diastolic BP (DBP) recovery, mean arterial pressure recovery, and the Valsalva ratio, were calculated. Mann-Whitney U tests were used to compare continuous variables. The primary end point was adrenergic baroreflex sensitivity. RESULTS:Patients with PAH had lower adrenergic baroreflex sensitivity (9.7 ± 4.6 mm Hg/s vs 18.8 ± 9.2 mm Hg/s; P = .005), longer pressure recovery time (3.6 ± 2.5 s vs 1.7 ± 0.8 s; P = .008), similar SBP recovery (-13 ± 11 mm Hg vs -12 ± 23 mm Hg; P = .640), less DBP recovery (-1 ± 12 mm Hg vs 13 ± 14 mmHg; P = .025), less mean arterial pressure recovery (-5 ± 11 mm Hg vs 5 ± 17 mm Hg; P = .048), and a decreased Valsalva ratio (1.25 ± 0.11 vs 1.60 ± 0.22; P < .001) compared with healthy control subjects. CONCLUSIONS:Compared with healthy control subjects, patients with PAH are more susceptible to syncope during the Valsalva maneuver because of autonomic dysfunction causing cerebral hypoperfusion. These study patients with PAH exhibited a degree of susceptibility to syncope similar to a spectrum of patients with intermediate autonomic failure who typically experience a SBP drop of 10 to 30 mm Hg with standing.
Atrial Fibrillation in Older Patients with Syncope and Dementia: Insights from the Syncope and Dementia Registry.
Journal of the American Medical Directors Association
OBJECTIVES:To evaluate the clinical characteristics and the long-term outcome of atrial fibrillation (AF) patients with dementia and history of syncope or falls. DESIGN:Observational: analysis of a prospective registry. SETTING AND PARTICIPANTS:Between 2012 and 2016, the Syncope and Dementia Registry enrolled patients in 12 geriatric departments. Follow-up evaluation was at 12 months. MEASURES:Clinical, functional, and cognitive assessment. RESULTS:Of the 522 patients (women, 62.1%; Mini-Mental State Examination 17 ± 6), 26.4% have or presented an AF history. Patients with AF were older (85 ± 6 vs 83 ± 6 years, P = .012), with higher heart rate (78 ± 17 vs. 73 ± 14 bpm, P < .001), prescribed drugs (6.9 ± 2.9 vs 5.9 ± 2.7, P < .001), and an increased number (3.9 ± 2.0 vs 3.0 ± 1.8, P < .001) and severity of comorbidities. Oral anticoagulant therapy was underprescribed (39.9%). Cardiac syncope was more frequently diagnosed (18.8 vs 4.9%, P < .001). At multivariate analysis, AF patients were characterized by advanced age, a higher severity of comorbidities, a greater number of prescribed drugs, an increased heart rate, and a more frequent presence of cardiac symptoms. One-year mortality differed little between patients with and without AF (27.7 vs 22.1%, P = .229). In the arrhythmia group, multivariate predictors of prognosis were disability (number of lost BADLs; P = .020) and a higher heart rate (P = .006). CONCLUSIONS AND IMPLICATIONS:AF and postural stability-related issues often co-exist in persons with dementia. This complex of conditions is associated with an intricate clinical picture, underprescription of oral anticoagulants, and high long-term mortality. Future studies are needed to evaluate the effects of therapy optimization in this population.
Diagnostic yield of neuroimaging in syncope patients without high-risk symptoms indicating neurological syncope.
İdil Hasan,Kılıc Turgay Yılmaz
The American journal of emergency medicine
OBJECTIVES:Diagnostic tests are widely used for patients with syncope in the emergency department (ED). This study aimed to determine the diagnostic yield of neuroimaging in patients with syncope without high-risk symptoms. METHODS:Adult patients who presented to the ED with syncope in 2016 were screened retrospectively. Patients who suffered from mild head trauma due to syncope were also included. Patients with neurological examination findings (confusion, amnesia, focal neurological deficit, severe headache, dizziness, nausea and vomiting), patients on anticoagulants, patients with known intracranial malignancies and those whose loss of consciousness was attributed to reasons other than syncope were excluded from the study. RESULTS:A total of 1114 patients were included in the study. The median age was 48 years (IQR = 34-66 years) and 576 (51.7%) of the patients were male. The neuroimaging tests performed were cranial computerized tomography (CT) in 694 (62.3%) cases and magnetic resonance imaging (MRI) in 114 (10.2%) cases. Mild head trauma due to syncope was observed in 116 (10.4%) patients. None of the neuroimaging studies revealed any clinically significant findings. CONCLUSION:Neuroimaging is not beneficial in patients whose medical history and physical examination do not indicate neurogenic syncope, even if the patient has mild head trauma.
Comorbidity of Neurally Mediated Syncope and Allergic Disease in Children.
Wang Yaru,Du Junbao,Jin Hongfang,Liao Ying
Frontiers in immunology
Neurally mediated syncope (NMS) is the most common underlying disease of pediatric syncope, which generally includes vasovagal syncope (VVS), postural tachycardia syndrome (POTS), and situational syncope. Allergic diseases involving the respiratory system, digestive system, skin, and other systems are prevalent in children. In recent years, increasing attention has been paid to children with the comorbidity of NMS and allergic diseases. This article reviews the featured clinical manifestations and pathogenesis of the comorbidity according to the progress of related studies. Clinical studies have shown that the comorbidity rate of pediatric VVS and/or POTS with allergic diseases amounts to ~30-40%, referring to the whole population of children with VVS and/or POTS. Additionally, children with the comorbidity present some relatively special clinical characteristics. A series of mechanisms or regulatory factors relating to allergies, such as the imbalance of vasoactive elements, dysfunction of the autonomic nervous system (ANS), and autoimmunity may play a role in the development of the comorbidity. Moreover, 90% of children with cough syncope, a type of situational syncope, have a history of asthma, indicating a potential relationship between asthma and NMS. Further studies exploring the clinical characteristics and pathogenesis of the comorbidity are still needed to aid in the diagnosis and treatment of children with NMS.
Low-blood pressure phenotype underpins the tendency to reflex syncope.
Brignole Michele,Rivasi Giulia,Sutton Richard,Kenny Rose Anne,Morillo Carlos A,Sheldon Robert,Raj Satish R,Ungar Andrea,Furlan Raffaello,van Dijk Gert,Hamdan Mohamed,Hamrefors Viktor,Engström Gunnar,Park Chloe,Soranna Davide,Zambon Antonella,Parati Gianfranco,Fedorowski Artur
Journal of hypertension
BACKGROUND:We hypothesized that cardiovascular physiology differs in reflex syncope patients compared with the general population, predisposing such individuals to vasovagal reflex. METHODS:In this multicohort cross-sectional study, we compared aggregate data of resting SBP, DBP, pulse pressure (PP) and heart rate (HR), collected from six community-based cohort studies (64 968 observations) with those from six databases of reflex syncope patients (6516 observations), subdivided by age decades and sex. RESULTS:Overall, in male individuals with reflex syncope, SBP (-3.4 mmHg) and PP (-9.2 mmHg) were lower and DBP (+2.8 mmHg) and HR (+5.1 bpm) were higher than in the general population; the difference in SBP was higher at ages above 60 years. In female individuals, PP (-6.0 mmHg) was lower and DBP (+4.7 mmHg) and HR (+4.5 bpm) were higher than in the general population; differences in SBP were less pronounced, becoming evident only above 60 years. Compared with male individuals, SBP in female individuals exhibited slower increase until age 40 years, and then demonstrated steeper increase that continued throughout remaining life. CONCLUSION:The patients prone to reflex syncope demonstrate a different resting cardiovascular haemodynamic profile as compared with a general population, characterized by lower SBP and PP, reflecting reduced venous return and lower stroke volume, and a higher HR and DBP, suggesting the activation of compensatory mechanisms. Our data contribute to a better understanding why some individuals with similar demographic characteristics develop reflex syncope and others do not. VIDEO ABSTRACT:http://links.lww.com/HJH/B580.
Sex Differences in Vasovagal Syncope: A Post Hoc Analysis of the Prevention of Syncope Trials (POST) I and II.
Deveau Adam P,Sheldon Robert,Maxey Connor,Ritchie Deborah,Doucette Steve,Parkash Ratika
The Canadian journal of cardiology
BACKGROUND:Vasovagal syncope (VVS) occurs in > 40% of individuals at least once in their lifetime. Sex-dependent differences in presentation and outcomes are not understood. We sought to determine differences in clinical presentation, treatment modalities, and outcomes of VVS between men and women. METHODS:Data were collected as part of the Prevention of Syncope Trials (POST) I and II, 2 multicenter, placebo-controlled, randomized trials testing the effectiveness of metoprolol and fludrocortisone, respectively. Data regarding clinical presentation, outcomes, and time to first syncope event after randomization were compared. RESULTS:Of the 418 patients (280 women and 138 men), women were younger at the time of first syncope event (21 vs 26 years P = 0.002) and had a lower baseline systolic blood pressure (117 vs 124 mm Hg, P < 0.001). Response to heat as a trigger for syncope was more common in women (68% vs 48%, P = 0.011). Clinical presentation in women consisted more commonly of feeling warm, having seizures, and experiencing more postsyncope fatigue (68% vs 54%, P = 0.048; 10% vs 2.7%, P = 0.045; 75% vs 59%, P = 0.017, respectively). Women were more likely to experience recurrent syncope after adjustment for prerandomization syncope burden and randomization assignment (hazard ratio, 1.56; 95% confidence interval, 1.10-2.22; P = 0.012). CONCLUSION:Clinical presentation and provocative factors of VVS differ between men and women, as do recurrent events. Recognition of these differences may help target therapy specifically in men and women.
The Diagnostic Value of Cardiac Deceleration Capacity in Vasovagal Syncope.
Zheng Lihui,Sun Wei,Liu Shangyu,Liang Erpeng,Du Zhongpeng,Guo Jingrui,Wu Lingmin,Asirvatham Samuel J,Yao Yan
Circulation. Arrhythmia and electrophysiology
BACKGROUND:Increased parasympathetic activity is thought to play important roles in syncope events of patients with vasovagal syncope (VVS). However, direct measurements of the vagal control are difficult. The novel deceleration capacity (DC) of heart rate measure has been used to characterize the vagal modulation. This study aimed to assess vagal control in patients with VVS and evaluate the diagnostic value of the DC in VVS. METHODS:Altogether, 161 consecutive patients with VVS (43±15 years; 62 males) were enrolled. Tilt table test was positive in 101 and negative in 60 patients. Sixty-five healthy subjects were enrolled as controls. DC and heart rate variability in 24-hour ECG, echocardiogram, and biochemical examinations were compared between the syncope and control groups. RESULTS:DC was significantly higher in the syncope group than in the control group (9.6±3.3 versus 6.5±2.0 ms, <0.001). DC was similarly increased in patients with VVS with a positive and negative tilt table test (9.7±3.5 and 9.4±2.9 ms, =0.614). In multivariable logistic regression analyses, DC was independently associated with syncope (odds ratio=1.518 [95% CI, 1.301-1.770]; =0.0001). For the prediction of syncope, the area under curve analysis showed similar values when comparing single DC and combined DC with other risk factors (=0.1147). From the receiver operator characteristic curves for syncope discrimination, the optimal cutoff value for the DC was 7.12 ms. CONCLUSIONS:DC>7.5 ms may serve as a good tool to monitor cardiac vagal activity and discriminate VVS, particularly in those with negative tilt table test.
Timing of Circulatory and Neurological Events in Syncope.
van Dijk J Gert,van Rossum Ineke A,Thijs Roland D
Frontiers in cardiovascular medicine
Syncope usually lasts less than a minute, in which short time arterial blood pressure temporarily falls enough to decrease brain perfusion so much that loss of consciousness ensues. Blood pressure decreases quickest when the heart suddenly stops pumping, which happens in arrhythmia and in severe cardioinhibitory reflex syncope. Loss of consciousness starts about 8 s after the last heart beat and circulatory standstill occurs after 10-15 s. A much slower blood pressure decrease can occur in syncope due to orthostatic hypotension Standing blood pressure can then stabilize at low values often causing more subtle signs (i.e., inability to act) but often not low enough to cause loss of consciousness. Cerebral autoregulation attempts to keep cerebral blood flow constant when blood pressure decreases. In reflex syncope both the quick blood pressure decrease and its low absolute value mean that cerebral autoregulation cannot prevent syncope. It has more protective value in orthostatic hypotension. Neurological signs are related to the severity and timing of cerebral hypoperfusion. Several unanswered pathophysiological questions with possible clinical implications are identified.
The Search for the Genes of Vasovagal Syncope.
Sheldon Robert S,Sandhu Roopinder K
Frontiers in cardiovascular medicine
Only humans faint, and not all do so. Syncope tends to recur, and the predisposition to syncope can persist over many decades. Observations such as these have suggested that there may be a genetic predisposition to vasovagal syncope. It seems to have a high prevalence in some families; having a parent who faints increases the likelihood of an offspring fainting, and this is increased even further if both biological parents faint. Numerous studies have correlated a number of genotypes with positive tilt tests. However, the control subjects are usually those who faint, but have negative tilt tests, making the conclusions about association with the clinical phenotype less certain. Twin studies, highly focused genome-wide association studies, and gene duplicate studies all suggest there are sites in the genome that associate with vasovagal syncope, although the specific genes, pathways, and proteins are unknown. A recent large, candidate gene study of kindreds with high, multigenerational prevalence of the vasovagal syncope identified 3 genes that associate with vasovagal syncope. Our understanding of the genetic correlates of vasovagal syncope is in its infancy, with much to be understood.
Early standardized clinical judgement for syncope diagnosis in the emergency department.
du Fay de Lavallaz J,Badertscher P,Zimmermann T,Nestelberger T,Walter J,Strebel I,Coelho C,Miró Ò,Salgado E,Christ M,Geigy N,Cullen L,Than M,Javier Martin-Sanchez F,Di Somma S,Frank Peacock W,Morawiec B,Wussler D,Keller D I,Gualandro D,Michou E,Kühne M,Lohrmann J,Reichlin T,Mueller C,
Journal of internal medicine
BACKGROUND:The diagnosis of cardiac syncope remains a challenge in the emergency department (ED). OBJECTIVE:Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score. METHODS:In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ. RESULTS:Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy. CONCLUSION:ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.
Cardioneuroablation for cardioinhibitory vasovagal syncope.
John Leah A,Mullis Andin,Payne Joshua,Tung Roderick,Aksu Tolga,Winterfield Jeffrey R
Journal of cardiovascular electrophysiology
BACKGROUND:Cardioneuroablation (CNA) is an emerging technique being used to treat patients with cardioinhibitory vasovagal syncope (VVS). We describe a case of CNA in targeting atrial ganglionated plexi (GP) based upon anatomical landmarks and fractionated electrogram (EGM) localization in a patient with cardioinhibitory syncope. CASE PRESENTATION:A 20-year-old healthy female presented with malignant VVS and symptomatic sinus pauses, with the longest detected at 10 s. She underwent acutely successful CNA with demonstration of vagal response (VR) noted after ablation of left sided GP, and tachycardia noted with right sided GP ablation. All GP sites were defined by anatomical landmarks and EGM analysis. By using the fractionation mapping software of Ensite Precision mapping system with high density mapping, fragmented EGMs were successfully detected in each GP site. One month after vagal denervation, there were no recurrent syncopal episodes or sinus pauses. Longer term follow-up with implantable loop recorder is planned. CONCLUSION:We performed CNA in a patient with VVS by utilizing a novel approach of combined use of high density mapping and fractionation mapping software. With this approach, we were able to detect fractionation in all GP sites and demonstrate acute VR. This workflow may allow for a new, standardized technique suitable for widespread use.
The Syncope-Falls Index: a tool for predicting risk of syncope and complex falls in the older adult based on cumulative health deficits.
QJM : monthly journal of the Association of Physicians
BACKGROUND:Syncope is aetiologically diverse and associated with adverse outcomes; in older people, there is clinical overlap with complex falls presentations (i.e. recurrent, unexplained and/or injurious). AIM:To formulate an index to predict future risk of syncope and falls in the Irish longitudinal study on ageing (TILDA). DESIGN/METHODS:Using the frailty index methodology, we selected, from TILDA Wave 1 (2010), 40 deficits that might increase risk of syncope and falls. This syncope-falls index (SYFI) was applied to TILDA Wave 1 participants aged 65 and over, who were divided into three risk groups (low, intermediate and high) based on SYFI tertiles. Multivariate logistic regression models were used to investigate, controlling for age and sex, how SYFI groups predicted incident syncope, complex falls and simple falls occurring up to Wave 4 of the study (2016). RESULTS:At Wave 1, there were 3499 participants (mean age 73, 53% women). By Wave 4, of the remaining 2907 participants, 185 (6.4%) had reported new syncope, 1077 (37.0%) complex falls and 218 (7.5%) simple falls. The risk of both syncope and complex falls increased along the SYFI groups (high risk group: odds ratio 1.88 [1.26-2.80], P = 0.002 for syncope; 2.22 [1.82-2.72], P < 0.001 for complex falls). No significant relationship was identified between SYFI and simple falls. CONCLUSION:The 6-year incidences of falls and syncope were high in this cohort. SYFI could help identify older adults at risk of syncope and complex falls, and thus facilitate early referral to specialist clinics to improve outcomes.
Brugada syndrome and syncope: A systematic review.
Mascia Giuseppe,Della Bona Roberta,Ameri Pietro,Canepa Marco,Porto Italo,Brignole Michele
Journal of cardiovascular electrophysiology
INTRODUCTION:Distinguishing syncope due to malignant arrhythmias from an incidental benign form in Brugada syndrome (BrS) is often difficult. Through systematic literature review, we evaluated the role of syncope in predicting subsequent malignant arrhythmias in BrS. METHODS:A comprehensive literature search was performed on PubMed (MeSH search terms "Brugada syndrome" and "syncope"). Overall, 9 studies for a total of 1347 patients were included. Patients were stratified as affected by suspected arrhythmic syncope (SAS), undefined syncope (US) or neurally-mediated syncope (NMS). RESULTS:Overall, 15.7% of the 279 patients with SAS had malignant arrhythmic events during a mean follow-up of 67 months, corresponding to 2.8 events per 100/person year. At the same time, 7% of the 527 patients affected by US had malignant arrhythmias during a mean follow-up of 39 months, corresponding 2.2 events per 100/person year. Conversely, 0.7% of 541 patients with NMS had malignant arrhythmic events at follow-up, corresponding to 0.13 events per 100/person year (p = .0001 NMS versus SAS and US pooled). CONCLUSION:In BrS population, the risk of arrhythmic events in the follow-up may be stratified according to the clinical evaluation. The "relatively" low predictive value of the clinical diagnosis of SAS warrants for a more accurate multi-parametric assessment, to restrict the number of candidates for implantable cardioverter-defibrillator therapy.
Recurrent Cardiogenic Syncope From Extrinsic Organ Anomaly.
Tan Jose Mariano T,Park Hanna S,Cohle Stephen D,Spurlock David J,McNamara Michael W,Franey Laura M,Abdallah Wissam M
CASE PRESENTATION:A 40-year-old woman presented with recurrent syncope. She reported multiple (>20) episodes of non-prodromal loss of consciousness, periodically provoked by physical exertion. One episode resulted in a nasal fracture due to the abrupt nature of her syncope. The characterization of each episode was inconsistent with a neurogenic seizure. Other causes of syncope (vasovagal, situational, carotid hypersensitivity, and orthostasis) were also deemed unlikely. On physical examination, a low-pitched, brief adventitious sound was appreciated after each S2 sound in the right lower sternal border. The remainder of the physical examination was unremarkable. Initial workup, including complete blood count, comprehensive metabolic panel, cardiac enzymes, and ECG yielded normal results. The chest radiograph did not show any gross cardiac or pulmonary parenchymal pathologic condition (Fig 1). Telemetry did not demonstrate any malignant arrhythmias, and video-guided EEG did not document any seizure activity.
Syncope and Palpitations: A Review.
von Alvensleben Johannes C
Pediatric clinics of North America
Syncope and palpitations are common complaints for patients presenting to their primary care provider. They represent symptoms that most often have a benign etiology but rarely can be the first warning sign of a serious condition, such as arrhythmias, structural heart disease, or noncardiac disease. The history, physical examination, and noninvasive testing can, in most cases, distinguish benign from pathologic causes. This article introduces syncope and palpitations, with emphasis on the differential diagnoses, initial presentation, diagnostic strategy, and various management strategies.
Incidence, characteristics, determinants, and prognostic impact of recurrent syncope.
Zimmermann Tobias,du Fay de Lavallaz Jeanne,Nestelberger Thomas,Gualandro Danielle M,Strebel Ivo,Badertscher Patrick,Lopez-Ayala Pedro,Widmer Velina,Freese Michael,Miró Òscar,Christ Michael,Cullen Louise,Than Martin,Martin-Sanchez F Javier,Di Somma Salvatore,Peacock W Frank,Keller Dagmar I,Boeddinghaus Jasper,Twerenbold Raphael,Wussler Desiree,Koechlin Luca,Walter Joan E,Bürgler Franz,Geigy Nicolas,Kühne Michael,Reichlin Tobias,Lohrmann Jens,Mueller Christian
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology
AIMS:The aim of this study is to characterize recurrent syncope, including sex-specific aspects, and its impact on death and major adverse cardiovascular events (MACE). METHODS AND RESULTS:We characterized recurrent syncope in a large international multicentre study, enrolling patients ≥40 years presenting to the emergency department (ED) with a syncopal event within the last 12 h. Syncope aetiology was centrally adjudicated by two independent cardiologists using all information becoming available during syncope work-up and long-term follow-up. Overall, 1790 patients were eligible for this analysis. Incidence of recurrent syncope was 20% [95% confidence interval (CI) 18-22%] within the first 24 months. Patients with an adjudicated final diagnosis of cardiac syncope (hazard ratio (HR) 1.50, 95% CI 1.11-2.01) or syncope with an unknown aetiology even after central adjudication (HR 2.11, 95% CI 1.54-2.89) had an increased risk for syncope recurrence. Least Absolute Shrinkage and Selection Operator regression fit on all patient information available early in the ED identified >3 previous episodes of syncope as the only independent predictor for recurrent syncope (HR 2.13, 95% CI 1.64-2.75). Recurrent syncope carried an increased risk for death (HR 1.87, 95% CI 1.26-2.77) and MACE (HR 2.69, 95% CI 2.02-3.59) over 24 months of follow-up, however, with a time-dependent effect. These findings were confirmed in a sensitivity analysis excluding patients with syncope recurrence or MACE before or during ED evaluation. CONCLUSION:Recurrence rates of syncope are substantial and vary depending on syncope aetiology. Importantly, recurrent syncope carries a time-dependent increased risk for death and MACE. TRIAL REGISTRATION:BAsel Syncope EvaLuation (BASEL IX, ClinicalTrials.gov registry number NCT01548352).
Age Is a Predictor for the Syncope Recurrence in Elderly Vasovagal Syncope Patients With a Positive Head-Up Tilt Test.
Guo Yongjuan,Chen Xiaomin,Zeng Tianze,Wang Lin,Cen Lvwei
Frontiers in cardiovascular medicine
Valid predictors of the syncope recurrence in vasovagal syncope (VVS) patients with a positive head-up tilt test (HUTT) are currently lacking. The goal of this study was to identify the predictive performance of age for the recurrence of syncope in VVS patients with a positive HUTT. In total, 175 VVS patients with a positive HUTT were observed for 6-32 months, and the recurrence of ≥1 syncope or typical pre-syncope prodromal episodes during follow-up was considered syncope recurrence. The population was divided into 2 groups, namely, a syncope recurrence group (44 patients) and a no syncope recurrence group (131 patients). The baseline clinical data, haemodynamic parameters, and classification of VVS on the HUTT were analyzed. Logistic regression was used to analyse the effect size and confidence interval for age. A receiver operating characteristic (ROC) curve analysis was used to assess the predictive performance and investigate the predictive value of age by the area under the curve (AUC). The median age of the syncope recurrence group was older than that of the no syncope recurrence group [60.0 (47.8, 66.0) years>53.0 (43.0, 62.0) years], and there was a significant difference between the two groups ( < 0.05). The trend for syncope recurrence changed with advancing age, and the logistic regression model adjusted by sex showed that older patients had an increased risk of syncope recurrence in VVS with a positive HUTT [OR value: 1.03, 95% confidence interval (CI): 1.008-1.061, < 0.05]. Age was a valid predictor for the recurrence of syncope in elderly VVS patients with a positive HUTT (AUC: 0.688; 95% CI: 0.598-0.777, < 0.05). The cut-off value was 53.5 years, and the sensitivity and specificity were 72.7 and 52.7%, respectively. Age may be a valid predictor for syncope recurrence in elderly VVS patients with a positive HUTT. The rate of syncope recurrence increased with advancing age, especially in females.
Different Types of Syncope Presenting to Clinic: Do We Miss Cardiac Syncope?
Al-Busaidi Ibrahim S,Jardine David L
Heart, lung & circulation
BACKGROUND:In the outpatient setting, differentiation of cardiac syncope (CS) from other more common forms of syncope is difficult, particularly in the elderly. We examined the frequency of the different types of syncope in a clinic population and estimated missed CS cases. METHODS:We retrospectively examined the relevant data for patients assessed in our Christchurch Hospital syncope clinic over a 5-year study period (1 January 2011-31 December 2015). Patients who were later found to have cardiac syncope (and were not initially diagnosed in our clinic) were counted as "missed" cases. RESULTS:Eight hundred thirty-nine (839) patients (median age 57, interquartile range: 35-73 years, 56% female) were assessed during the study period. Vasovagal syncope (VVS) was the most frequent diagnosis (42.8%) followed by drug-related postural hypotension (DRPH) (26.6%). Cardiac syncope was initially diagnosed in only 3.1%. Of 30 CS patients initially assessed in syncope clinic who later required pacing, 18 (2.1%) were missed CS. In this group, 12-lead electrocardiograph (ECG) was normal in 50% and the majority (n=10) were tilt-positive. The 2.5-year mortality was 5.7% (n=48) including three sudden unexpected cardiac deaths. CONCLUSION:Vasovagal syncope and DRPH were by far the most frequent diagnoses. Cardiac syncope was less frequent because patients were selected mainly from an outpatient population, not the emergency department. In a small number of patients, CS was missed for the following reasons: (1) coexistence of cardiac conduction system disease with VVS and DRPH in the elderly, and (2) insensitivity of 12-lead ECG, in-hospital telemetry and out-of-hospital Holter monitoring for detecting conduction system disease early in its development.
Genetic markers of vasovagal syncope.
Sheldon Robert S,Gerull Brenda
Autonomic neuroscience : basic & clinical
Vasovagal syncope may have a genetic predisposition. It has a high prevalence in some families, and children of a fainting parent are more likely to faint than those without a parent who faints. Having two fainting parents or a fainting twin increases the likelihood even further. Several genotypes appear to associate with the phenotype of positive tilt tests, but the control subjects are usually those who faint and have negative tilt tests. Twin studies, highly focused genome-wide association studies, and copy number variation studies all suggest there are loci in the genome that associate with vasovagal syncope, although the specific genes, pathways, and proteins are unknown. A recent multigenerational kindred candidate gene study identified 3 genes that associate with vasovagal syncope. The best evidence to date is for central signaling genes involving serotonin and dopamine. Genome-wide association studies to date have not yet been helpful. Our understanding of the genetic correlates of vasovagal syncope leaves ample opportunity for future work.
ACR Appropriateness Criteria® Syncope.
,Kligerman Seth J,Bykowski Julie,Hurwitz Koweek Lynne M,Policeni Bruno,Ghoshhajra Brian B,Brown Michael D,Davis Andrew M,Dibble Elizabeth H,Johnson Thomas V,Khosa Faisal,Ledbetter Luke N,Leung Steve W,Liebeskind David S,Litmanovich Diana,Maroules Christopher D,Pannell Jeffrey S,Powers William J,Villines Todd C,Wang Lily L,Wann Samuel,Corey Amanda S,Abbara Suhny
Journal of the American College of Radiology : JACR
Syncope and presyncope lead to well over one million emergency room visits in the United States each year. Elucidating the cause of syncope or presyncope, which are grouped together given similar etiologies and outcomes, can be exceedingly difficult given the diverse etiologies. This becomes more challenging as some causes, such as vasovagal syncope, are relatively innocuous while others, such as cardiac-related syncope, carry a significant increased risk of death. While the mainstay of syncope and presyncope assessment is a detailed history and physical examination, imaging can play a role in certain situations. In patients where a cardiovascular etiology is suspected based on the appropriate history, physical examination, and ECG findings, resting transthoracic echocardiography is usually considered appropriate for the initial imaging. While no imaging studies are considered usually appropriate when there is a low probability of cardiac or neurologic pathology, chest radiography may be appropriate in certain clinical situations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Frequency of injuries associated with syncope in the prevention of syncope trials.
Jorge Juliana G,Pournazari Payam,Raj Satish R,Maxey Connor,Sheldon Robert S
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology
AIMS:Syncope can lead to injuries. We determined the frequency, severity, and predictors of injuries due to syncope in cohorts of syncope patients. METHODS AND RESULTS:Participants were enrolled in the POST2 (fludrocortisone) and POST4 (midodrine) vasovagal syncope (VVS) randomized trials, and POST3 enrolled patients with bifascicular block and syncope. Injury was defined as minor (bruising, abrasions), moderate (lacerations), and severe (fractures, burns, joint pain), and recorded up to 1 year after enrolment. A total of 459 patients (median 39 years) were analysed. There were 710 faints occurred in 186 patients during a 1-year follow-up. Fully 56/186 (30%) of patients were injured with syncope (12% of overall group). There were 102 injuries associated with the 710 faints (14%), of which 19% were moderate or severe injuries. Neither patient age, sex, nor the presence of prodromal symptoms associated with injury-free survival. Patients with bifascicular block were more prone to injury (relative risk 1.98, P = 0.018). Patients with ≥4 faints in the prior year had more injuries than those with fewer faints (relative risk 2.97, P < 0.0001), but this was due to more frequent syncope, and not more injuries per faint. In VVS patients, pharmacological therapy significantly reduced the likelihood of an injury due to a syncopal spell (relative risk 0.64, P = 0.015). Injury severity did not associate with age, sex, or prior-year syncope frequency. CONCLUSION:Injuries are frequent in syncope patients, but only 4% of injuries were severe. None of age, sex, and prodromal symptoms associate with injury.
Syncope and electrocardiogram.
Suspected transient loss of consciousness and syncope are common causes of hospitalization in older patients. Arrhythmias are the most common cardiac causes of syncope. Although a number of instrumental diagnostic procedures are usually routinely performed in patients with suspected syncope, a 12-lead electrocardiogram (ECG) is the only instrumental test recommended for the initial evaluation of these patients. In this paper current literature on this topic will be reviewed, including ECG diagnostic criteria and findings suggestive of cardiac syncope. The ECG may disclose an arrhythmia associated with a high likelihood of syncope, avoiding further evaluations and permitting institution of specific treatment in 7% of patients referred to emergency department. When the cause of syncope remains uncertain after initial evaluation the next step is to assess the risk of major cardiovascular events or sudden cardiac death. An abnormal ECG selected patients with high probability of cardiac syncope. ECG diagnostic criteria and ECG findings suggesting arrhythmic syncope are presented. Indications and potential clinical implications of ECG monitoring will be discussed too. A careful, well-conducted medical history focused on the suspected syncopal event is crucial for the diagnosis. In this setting, the ECG is a mandatory diagnostic tool which, although normal in the majority of patients of syncope, has the potential to identify patients with high likelihood of cardiac syncope due to arrhythmic or cardiopulmonary disorder.
Risk Factors for Syncope Associated With Multigenerational Relatives With a History of Syncope.
Fedorowski Artur,Pirouzifard Mirnabi,Sundquist Jan,Sundquist Kristina,Sutton Richard,Zöller Bengt
JAMA network open
Importance:Reflex syncope is the major cause of transient loss of consciousness, which affects one-third of the population, but effective treatment for individuals with severe syncope is lacking. Better understanding of reflex syncope predisposition may offer new therapeutic solutions. Objectives:To determine the familial risk of syncope in first-, second-, and third-degree relatives of affected individuals and to explore the role of genes and family environment in reflex syncope. Design, Setting, and Participants:In this national population-based family cohort study, the Swedish multigeneration register was linked to 3 Swedish nationwide registers: hospital discharge, outpatient care, and primary care registers for the period from 1997 to 2015. Sibling pairs born to Swedish parents between 1948 and 2005 were included. Linkage was also made to half-siblings and cousins. Data analysis was performed from June to October 2020. Exposures:Register-based syncope diagnosis among relatives: pairs of twins, siblings, half-siblings, and cousins. Main Outcomes and Measures:Odds ratios for syncope were calculated for relatives (twins, siblings, half-siblings, and cousins) of individuals who had syncope compared with relatives of individuals without syncope for reference. Sensitivity analysis excluding families with definite nonreflex syncope diagnosis was performed. Results:Among the study population of 2 694 442 participants, 1 381 453 (51.3%) were male, and the median (interquartile range) age was 32 (22-43) years. The study population consisted of 24 020 twins, 1 546 108 siblings, 264 244 half-siblings, and 1 044 546 cousins. In total, 61 861 (2.30%) unique individuals were diagnosed with syncope. Sixty-two percent (38 226) of the syncope-positive individuals were female. The odds ratio (OR) for syncope was 2.39 (95% CI, 1.61-3.53) for twins, 1.81 (95% CI, 1.71-1.91) for siblings, 1.28 (95% CI, 1.20-1.37) for half-siblings, and 1.13 (95% CI, 1.10-1.17) for cousins of individuals with syncope. The OR was highest among male twins at 5.03 (95% CI, 2.57-9.85). The proportion of syncope-positive individuals was consistently higher in women vs men, regardless of degree of relationship (twins: 346 [2.88%] vs 193 [1.61%]; siblings: 22 111 [2.92%] vs 13 419 [1.70%], half-siblings: 4148 [3.44%] vs 2425 [1.93%], cousins: 14 498 [2.87%] vs 9246 [1.72%]). Exclusion of nonreflex syncope diagnoses did not change syncope risk in affected families. Conclusions and Relevance:In this Swedish national population-based study, the risk of syncope among relatives of affected individuals was associated with the relationship degree and was strongest in twins and siblings, which suggests that there are genetic components of reflex syncope. Women were more likely to experience syncope independently of family relationship. A better understanding of genetic predisposition to reflex syncope may offer new therapeutic options in severely affected individuals.