Usefulness of Transdermal Scopolamine for Vasovagal Syncope (original) (raw)
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Efficacy of Different Treatment Strategies for Neurocardiogenic Syncope
Pace-pacing and Clinical Electrophysiology, 1995
Objectives: The purpose of this study was to evaluate the efficacy of different therapeutic approaches for patients with a history of syncope and positive head-up tilt testing. Background: Head-up tilt testing has gained broad acceptance as a reliable diagnostic method for the assessment of patients with recurrent unexplained syncope. However, once the diagnosis is established, there is no consensus on the most appropriate treatment. In this respect, efficacy of drug therapy in preventing recurrence of symptoms in such patients is not entirely clear, and controversies exist regarding the need to confirm the effects of pharmacological interventions. Methods: Clinical follow-up was obtained in 303 patients with a history of syncope and positive head-up tilt testing. After the diagnostic head-up tilt, patients were assigned to different therapeutic approaches according to their preference or logistic impediments. Of 303 patients, 44 received empiric therapy, 210 were treated with medications proven effective during repeated head-up tilt testing, and 49 refused or discontinued medical therapy. The three groups were similar with regard to age, sex, and clinical presentation. The mean follow-up was 2.8 ±1.8 years. Among the patients treated according to head-up tilt guided therapy, 130 were on beta blockers, 35 on theophylline, 10 on ephedrine, 31 on disopyramide, and 4 on miscellaneous regimens. Empiric treatment consisted of beta blockers in 37 of 44 patients and other drugs in the remaining patients. Results: During the follow-up, recurrence of symptoms was experienced in 12 (6%) of the 210 patients receiving the head-up tilt guided therapy, 16 (36%) of 44 in the empiric therapy group, and 33 (67%) of 49 in the no therapy group. Recurrence of symptoms in patients on empiric or no therapy was significantly more frequent as compared to the head-up tilt guided therapy group (P<0.01). Conclusions: In patients with unexplained syncope and positive upright tilt testing, therapeutic strategies identified on the basis of response during head-up tilt have a more positive impact on the recurrence of symptoms during follow-up.
Mechanism of Syncope in Patients With Isolated Syncope and in Patients With Tilt-Positive Syncope
Circulation, 2001
Background Because of its episodic behavior, the correlation of spontaneous syncope with an abnormal finding can be considered a reference standard. Methods and Results We inserted an implantable loop recorder in 111 patients with syncope, absence of significant structural heart disease, and a normal ECG; tilt-testing was negative in 82 (isolated syncope) and positive in 29 (tilt-positive). The patients had had ≥3 episodes of syncope in the previous 2 years and were followed up for 3 to 15 months. Results were similar in the isolated syncope group and the tilt-positive group: syncope recurred in 28 (34%) and 10 patients (34%), respectively, and electrocardiographic correlation was found in 24 (23%) and 8 (28%) patients, respectively. The most frequent finding, which was recorded in 46% and 62% of patients, respectively, was one or more prolonged asystolic pauses, mainly due to sinus arrest, preceded for a few minutes by progressive bradycardia or progressive tachycardia-bradycardia....
Journal of Cardiovascular Electrophysiology, 1996
Sympathetic Activation in Neurocardiogenic Syncope. Introduction: Tilt table testing is widely used in the management of palients with neurocardiogenic syncope. However, the exact pathophysiologic mechanism of this disorder is still under debate. Likewise, therapy of these patients continues to represent a challenge in many cases. Therefore, the present study aimed to gain further insight into the pathophysiology of this syndrome and to examine easily accessihie clinical parameters that can improve therapy selection. Methods and Results: In 16 patients with neurocardiogenic syncope, changes in endogenous catecholaniine concentrations were determined during repeated tilt table testing before and during treatment with metoprolol. Tachycardia preceded .syncope in 8 of l() responders compared to only 1 of 6 nonresponders (P < 0.05). In responders, the relative increase in epinephrine levels averaged 197% ± 51% during drug-free tilting and 75% ± 33% during repeated testing while on /9-hlocker therapy (P < 0.05). In nonresponders, there was a smaller relative increase in epinephrine averaging 137% ± 35% at baseline tilt. During repeated tilt testing, a similar increase was observed in these patients with recurrent syncope (156% ± 104%; P = NS compared to haseline). Conclusion: In patients with neurocardiogenic syncope who show both an increase in epinephrine concentration during tilt test and sinus tachycardia prior to the onset of symptoms,-blocker treatment is very effective. These findings confirm the major role of sympathetic activation as a trigger of syncope. Particularly, heart rate changes at the onset of syncope may allow early identification of patients responding to antiadrenergic therapy.
The American Journal of Cardiology, 1995
This study was undertaken to assess the value of sublingual nitroglycerin administration during u as a simple practical test for the diagnosis o P right tilt vasovagal syncope. To this purpose, 235 patients with syncope of unknown origin and no evidence of organic heart disease (110 men, mean age 52 f 20 years) and 35 asymptomatic control subjects underwent head-up tilt testing with nitroglycerin challenge. Patients and subjects were tilted at 60" for 45 + 20 minutes; the initial 45 minutes were without medication and the final 20 minutes after 300 pg of sublingual nitroglycerin. During the drug-free phase of the test, 59 patients (25%) and no controls had a positive response. After drug administration, a positive response (syncope in associa-I n recent years head-up tilt testing has gained great popularity as a means of diagnosing vasovagal syn-c0pe.l The reported sensitivity and specificity of headup tilt without pharmacologic provocation range from 32% to 74% (mean 47%) and from 90% to 100% (mean 95%), respectively.2-g The addition of isoproterenol to head-up tilt increases the test sensitivity up to 87%,'O but decreases its specificity to values between 55% and 100% (mean 76%).6,1o-" This has prompted the use of other drugs as provocative agents during upright tilt.14-16 In a previous study,16 we reported on the usefulness of nitroglycerin infusion in conjunction with head-up tilt; the test proved to be more sensitive and feasible than the isoproterenol test, and equally specific, but the protocol used was quite complicated and time-consuming.16 The aim of the present study was to assess the diagnostic value of a new simplified, more rapid and practical protocol for the nitroglycerin test, consisting of sublingual administration of the drug after an initial period of conventional unmedicated head-up tilt.
Europace, 2013
The aim of this European Heart Rhythm Association (EHRA) survey was to provide an insight into the current practice of work-up and management of patients with syncope among members of the EHRA electrophysiology research network. Responses were received from 43 centres. The majority of respondents (74%) had no specific syncope unit and only 42% used a standardized assessment protocol or algorithm. Hospitalization rates varied from 10% to 25% (56% of the centres) to .50% (21% of the centres). The leading reasons for hospitalization were features suggesting arrhythmogenic syncope (85% of respondents), injury (80%), structural heart disease (73%), significant comorbidities (54%), and older age (41%). Most widely applied tests were electrocardiogram (ECG), echocardiography, and Holter monitoring followed by carotid sinus massage and neurological evaluation. An exercise test, tilt table test, electrophysiological study, and implantation of a loop recorder were performed only if there was a specific indication. The use of a tilt table test varied widely: 44% of respondents almost always performed it when neurally mediated syncope was suspected, whereas 37% did not perform it when there was a strong evidence for neurally mediated syncope. Physical manoeuvres were the most widely (93%) applied standard treatment for this syncope form. The results of this survey suggest that there are significant differences in the management of patients with syncope across Europe, specifically with respect to hospitalization rates and indications for tilt table testing in neurally mediated syncope. The majority of centres reported using ECG, echocardiography, and Holter monitoring as their main diagnostic tools in patients with syncope, whereas a smaller proportion of centres applied specific assessment algorithms. Physical manoeuvres were almost uniformely reported as the standard treatment for neurally mediated syncope.
Cardioinhibitory syncope: from pathophysiology to treatment—should we think on cardioneuroablation?
Journal of Interventional Cardiac Electrophysiology, 2020
Vasovagal syncope (VVS) is the most common type of syncope; the lone cardioinhibitory syncope represents only a small group of patients; however, the "cardioinhibitory component" is highly prevalent in reflex syncope and can be severe enough to produce asystole, lasting for a few seconds followed by a recovery to sinus beats. The environment in which syncope occurs can compromise life, and in-depth knowledge of the disease can prevent deaths and guide the appropriate management. The therapeutic cornerstone is general measures (increase water and salt) followed by pharmacologic therapy; for cardioinhibitory syncope, both treatments fail most of the time, and the next therapeutic option is pacemaker implantation. However, although the pacemaker causes a reduction in syncope, recurrence is high, and a one-time, effective, and safe intervention would be ideal. Cardioneuroablation (CNA) therapy has been proposed as a pacemaker alternative with these characteristics. CNA has shown a high reduction or even complete syncope elimination during 3 years of follow-up in some studies. Patients also reported prolonged prodromal periods, which allowed them enough time to abort the syncope. Invasive therapies like CNA require further extensive cohort studies, randomized clinical trials, and more substantial follow-up to evaluate adverse side effects. This review highlights syncope pathophysiology, dividing it into a central theory and a peripheral theory, the diagnosis explaining the head-up tilt test protocols, and treatments like CAN, representing it with figures for a simplified understanding.
Reproducibility of head-up tilt test in patients with syncope
Clinical Cardiology, 1996
As the head-up tilt test (HUT) is employed to verify the efficacy of undertaking a treatment, we prospectively evaluated the reproducibility of positive and negative results, as well as that of the response type in 64 consecutive patients (mean age 34.6 ± 22.9 years) with syncope of unknown cause. Two HUTs (60 min, 75° ), separated by an interval of 9.77 ± 8.21 days, were performed on each patient. Positive responses were reproduced in the second HUT in 54.5% of the patients. A greater reproducibility (84.3%) was observed for negative responses. Of the 31 patients with a negative first test, 5 had a positive response during the second HUT. Using a multivariate analysis, no clinical variable correlated with the reproducibility of positive or negative results. Likewise, neither arterial pressure nor heart rate observed during the test were correlated with reproducibility. Of 18 patients who reproduced positive responses, 12 (66.6%) did so with the same response modality. In three patients with documented monomorphic sustained ventricular tachycardia, which was hemodynamically well tolerated, and in one patient with temporal spike wave activity in the electroencephalogram, HUT was also positive. It was concluded that the low reproducibility of HUT limits its usefulness as a tool for evaluating treatment efficacy. The variability of the type of response suggests a common mechanism leading to cardioinhibitory and vasodepressor reactions. A positive result in only the second study shows the rationale of performing two tests when the first one is negative.