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European Heart Journal Advance Access published online on June 25, 2009
European Heart Journal, doi:10.1093/eurheartj/ehp255
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org

Recurrent vasovagal syncope: comparison between clomipramine and nitroglycerin as drug challenges during head-up tilt testing

Panayota Flevari1,2,*, Dionyssios Leftheriotis1,2, Christophoros Komborozos1,2, Katerina Fountoulaki1,2, Nikolaos Dagres1,2, George Theodorakis1,2 and Dimitrios Kremastinos1,2

1 2nd Department of Cardiology, Attikon University Hospital, Athens, Greece
2 2nd Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece

Received 1 November 2008; revised 8 April 2009; accepted 4 May 2009 * Corresponding author. Tel: +30 694 494 2630, Fax: +30 210 583 2351, Email: pflevari{at}yahoo.com

Aims: To compare the responses between clomipramine, a centrally acting substance, and nitroglycerin, with mainly peripheral action, when each drug is used during tilt test for the induction of vasovagal syncope (VVS).

Methods and results: Hundred patients with recurrent episodes of classical VVS underwent two tilt tests in a randomized sequence. One test included 20 min of tilt at 60° with intravenous administration of 5 mg clomipramine (clomipramine tilt), whereas the other test included an initial 30 min period of passive 60° tilt, followed by sublingual spray administration of 400 µg nitroglycerin (nitroglycerin tilt). Fifty asymptomatic subjects served as controls. Following clomipramine tilt, a positive response occurred in 73 patients (73%), a negative response in 23 (23%), and drug intolerance in 4 (4%). With nitroglycerin tilt, these percentages were 52, 48, and 0%, respectively. Significant differences were observed regarding positive responses (clomipramine vs. nitroglycerin: 73/100 vs. 52/100, P < 0.05), as well as negative responses (23/100 vs. 48/100, respectively, P < 0.05). A high concordance rate was observed in positive responses.

Conclusion: In the evaluation of patients with recurrent classical VVS, clomipramine tilt is associated with an increased positive yield relative to nitroglycerin tilt. This suggests that central mechanisms may be more important than peripheral ones in VVS pathogenesis.

Key Words: Tilt testing • Vasovagal syncope • Clomipramine • Nitroglycerin


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