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European Heart Journal 2002 23(6):483-489; doi:10.1053/euhj.2001.2900
Copyright © 2002 by the European Society of Cardiology.
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Long-term outcome of patients with asystole induced by head-up tilt test

G Barón-Esquiviasa,f1, A Pedrotea, A Cayuelab, J.I Vallea, J.M Fernándeza, E Aranaa, M Fernándeza, F Moralesc, J Burgosa and A Martínez-Rubiod

a Cardiology Department, Hospital Universitario Virgen del Rocío, Sevilla, Spain
b Supportive Unit for Research, Hospital Universitario Virgen del Rocío, Sevilla, Spain
c Cardiology Section, Hospital de Puerto Real, Cadiz, Spain
d Cardiology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

revised May 1, 2001; accepted June 2, 2001

Abstract

Aims To analyse the long-term outcome of the largest reported cohort of patients presenting asystole during head-up tilt test.

Methods and Results Since 1990, 1322 patients with syncope of unknown origin have undergone tilt-table testing. Of those, 330 patients (24·9%) presented an abnormal response (syncope or pre-syncope). Furthermore, 58 of those patients (17·5%) suffered a period of asystole (≥3000ms) during the test. Asystole (median (interquartile range)) lasted 10 (4, 19·2)s (range 3–90). Two different protocols (angles) of tilting (Westminster (60°) n=1124; isoproterenol (80°) n=198)) influenced the time to the syncopal episode (13 (6·5, 20·5) vs 2 (1, 6·5)min,P =0,0005) but not the duration of the asystole. During this period, therapy for asystole featured three different stages: first patients were treated with pacemakers; later drug therapy (metoprolol and/or etilefrine) was recommended; lastly (from 1995), no specific treatment was given. In a cohort age- and gender-matched study, those patients without were compared to those with asystole in a 2:1 basis. During 40·7 months of follow-up (17·7, 66·8), 12 patients (20·6%) with asystole had syncopal recurrences. Furthermore, 34 patients (28·8%) without asystole presented syncopal episodes during a follow-up of 51·6 months (29·3, 73·1) (P=ns). The Kaplan–Meier analysis in patients with and without asystole showed a mean time free of recurrence of 92·6±6 months vs 82·6±4·7 months (P=ns). The previous number of syncopes had a significant relationship with recurrences (P=0·002), but not therapy. There were no cardiac related deaths.

Conclusions (1) Asystole during head-up tilt test does not imply a malignant outcome and syncope recurrence is low; (2) pacemaker or drug therapy do not significantly influence outcome which correlates to the previous number of syncopal episodes but not to gender, age, asystole occurrence, asystole duration and timing to asystole during head-up tilt test; (3) tilting protocol (angle) might influence time to and incidence of asystole during head-up tilt test.

Key Words: Asystole, treatment, syncope, tilt-test

f1 Correspondence: Gonzalo Barón-Esquivias, MD, Avda de Portugal, 19. 3° izda, 41004 Sevilla, Spain. e-mail:gbaron@jet.es

References

  1. Kenny RA, Ingram A, Bayliss J, Sutton R. Head-up tilt a useful test for investigating unexplained syncope. Lancet. 1986;1:1325–1354[Web of Science][Medline]
  2. Fitzpatrick A, Theodorakis G, Vardas P. The incidence of malignant vasovagal syndrome in patients with recurrent syncope. Eur Heart J. 1991;12:389–394[Abstract/Free Full Text]
  3. Sutton R, Petersen M, Brignole M, Raviele A, Menozzi C, Giani P. Proposed classification for tilt induced vasovagal syncope. Eur J Card Pacing Electrophysiol. 1992;3:180–183
  4. Benditt DG. Neurally mediated syncopal syndromes: Pathophysiological concepts and clinical evaluation. PACE. 1997;20:572–584
  5. Milstein S, Buetinofer J, Lesser J. Cardiac asystole: a manifestation of neurally mediated hypotension-bradycardia. J Am Coll Cardiol. 1989;14:1.626–1.632[Abstract]
  6. Maloney J, Jaeger F, Fouad-Tarazi F, Morris H. Malignant vasovagal syndrome: prolonged asystole provoked by head up tilt. Cleve Clin J Med. 1988;55:542–548[Web of Science][Medline]
  7. Pedrote A, Errazquin J, Quero J, Sobrino M, Hernández MC. Prolonged cardiac asystole that requires resuscitation manoeuvers during a Head-up tilt table test. Rev Esp Cardiol. 1993;46:313–315[Medline]
  8. Barón-Esquivias G, Pedrote-Martínez A, Errázquin-Saez de Tejada F. Anomalous result and worsening of vasovagal syncope after a therapeutic regime with metoprolol guided by head-up tilt test. Eur J Card Pacing Electrophysiol. 1996;6:60–61
  9. Dhala A, Natale A, Sra J. Relevance of asystole during Head-up tilt testing. Am J Cardiol. 1995;75:251–254[CrossRef][Web of Science][Medline]
  10. Folino AF, Buja GF, Martini B, Miorelli M, Nava A. Prolonged cardiac arrest and complete AV block during upright tilt test in young patients with syncope of unknown origin-prognostic and therapeutic implications. Eur Heart J. 1992;13:1416–1421[Abstract/Free Full Text]
  11. Barón G, Pedrote A, Cardenal R, Pérez Cano B, L-Haldón J, Errazquin F. Estudio y tratamiento de la asistolia desarrollada durante el test de la tabla basculante (Abstr). Rev Esp Cardiol. 1998;51:65
  12. Menozzi C, Brignole M, Lolli G. Follow-up of asystolic episodes in patients with cardioinhibitory, neurally mediated syncope and VVI pacemaker. Am J Cardiol. 1995;72:1152–1155
  13. Fitzpatrick AP, Theodorakis G, Vardas P, Sutton R. Methodology of head-up tilt testing in patients with unexplained syncope. J Am Coll Cardiol. 1991;17:125–130[Abstract]
  14. Almquist A, Goldberg IF, Milstein S, Chen MY, Chen XC, Hansen R. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med. 1989;320:346–351[Abstract]
  15. Gregoratos G, Ceitlin MD, Conill A. ACC/AHA Guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: Executive summary. Circulation. 1998;97:1325–1335[Free Full Text]
  16. Fitzpatrick A, Sutton R. Tilting towards a diagnosis in unexplained recurrent syncope. Lancet. 1989;1:658–660[Web of Science][Medline]
  17. Petersen ME, Chamberlain-Webber R, Fitzpatrick AP, Ingram A, Williams T, Sutton R. Permanent pacing for cardioinhibitory malignant vasovagal syndrome. Br Heart J. 1994;71:274–281[Abstract/Free Full Text]
  18. Sra JB, Jazayeri MR, Avitall B. Comparison of cardiac pacing with drug therapy in the treatment of neurocardiogenic (vasovagal) syncope with bradycardia or asystole. N Engl J Med. 1993;328:1085–1090[Abstract/Free Full Text]
  19. Grubb BP, Temesy-Armos P, Moore J, Wolfe D, Hahn H, Elliot L. Head-upright tilt-table testing in evaluation and management of the malignant vasovagal syndrome. Am J Cardiol. 1992;69:904–908[CrossRef][Web of Science][Medline]
  20. Brignole M, Menozzi C, Gianfranchi L, Bottoni N, Lolli G. The clinical and prognostic significance of the asystolic response during the head-up tilt test. Eur J Cardiovasc Pacing Electrophysiol. 1992;2:109–113
  21. Deal BJ, Strieper M, Scagliotti D. The medical therapy of cardioinhibitory syncope in pediatric patients. PACE. 1997;20:1759–1761
  22. Pérez-Paredes M, Picó F, Sánchez JG. Prognosis and long-term follow-up in patients with syncope of unknown origin and cardiac asystole induced by head-up tilt test. Rev Esp Cardiol. 1997;50:314–319[Web of Science][Medline]
  23. Barón-Esquivias G, Pedrote A, Cayuela A. Age and gender differences in basal and isoprenaline protocols for head-up tilt table testing. Europace. 2001;3:136–140[Abstract/Free Full Text]
  24. Benditt DG, Ferguson DW, Grubb BP. Tilt table testing for assessing syncope. American College of cardiology. J Am Coll Cardiol. 1996;28:263–275[CrossRef][Web of Science][Medline]
  25. Petersen ME, Price D, Williams T, Jensen N, Rift K, Sutton R. Short AV interval VDD pacing does not prevent tilt induced vasovagal syncope in patients with cardioinhibitory vasovagal syndrome. PACE. 1994;17:882–891
  26. el-Bedawi JCM, Wahbha MA, Hainsworth R. Cardiac pacing does not improve orthostatic tolerance in patients with vasovagal syncope. Clin Auton Res. 1994;4:233–237[CrossRef][Medline]
  27. Benditt DG. Cardiac pacing for prevention of vasovagal syncope. J Am Coll Cardiol. 1999;33:21–23[Free Full Text]
  28. Benditt DG, Petersen M, Lurie KG, Grubb BP, Sutton R. Cardiac pacing for prevention of recurrent vasovagal syncope. Ann Intern Med. 1995;122:204–209[Abstract/Free Full Text]
  29. Sheldon R. Pacing to prevent vasovagal syncope. Cardiol Clin. 2000;18:81–93[CrossRef][Medline]
  30. Sra JS, Jazayeri MR, Dhala A, Deshpande S, Blanck Z, Akhtar M. Neurocardiogenic syncope, diagnosis, mechanisms, and treatment. Cardiol Clin. 1993;11:183–191[Medline]
  31. Fitzpatrick A, Theodorakis G, Ahmed R, Williams T, Sutton R. Dual chamber pacing aborts vasovagal syncope induced by head-up 60: tilt. PACE. 1991;14:13–19
  32. Moya A, Permanyer G, Sagrista J, Mont L, Rius T, Soler J. Response to dual chamber pacing patients with syncope and positive tilt test with cardioinhibitory response (Abstr). PACE. 1993;16:936
  33. Samoil D, Grubb BP, Brewster P. Comparison of single and dual chamber pacing techniques in prevention of upright tilt induced vasovagal syncope. Eur J Cardiovasc Pacing Electrophysiol. 1993;1:36–41
  34. Maloney JD, Jaeger FJ, Rizo-Patron C, Zhu DW. The role of pacing for the management of neurally mediated syncope: Carotid sinus syndrome and vasovagal syncope. Am Heart J. 1994;127:1030–1037[CrossRef][Web of Science][Medline]
  35. Kosinski D, Grubb BP, Elliot L, Dubois B. Treatment of malignant neurocardiogenic syncope with dual chamber cardiac pacing and fluoxetine hydrochloride. PACE. 1995;18:1455–1457
  36. Lacroix D, Koukam C, Plug D. Asystolic cardiac arrest during head-up tilt test: incidence and therapeutic Implications. PACE. 1997;20:2746–2754
  37. Benditt DG, Sutton R, Gamage M. Clinical experience with Thera-DR rate drop response pacing algorithm in carotid sinus syndrome and vasovagal syncope. PACE. 1997;20:832–839
  38. Grubb BP. Permanent cardiac pacing: New and emerging indications other than cardiomyopathies. Barold S, Mugica J. Recent advances in cardiac pacing: Goals for the 21st Century. Armonk: Futura Publishing Co; 1998. p. 89–99
  39. Sheldon R, Koshman ML, Wilson W, Kieser T, Rose S. Effect of dual-chamber pacing with automatic rate-drop sensing on recurrent neurally mediated syncope. Am J Cardiol. 1998;81:158–162[CrossRef][Web of Science][Medline]
  40. Abe H, Iwami Y, Nagatomo T, Miura Y, Nakashima Y. Treatment of malignant neurocardiogenic vasovagal syncope with a rate drop algorithm in dual chamber cardiac pacing. PACE. 1998;21:1473–1475
  41. McLeod KA, Wilson N, Hewitt J, Norrie J, Stephenson JBP. Cardiac pacing for severe childhood neurally mediated syncope with reflex anoxic seizures. Heart. 1999;82:721–725[Abstract/Free Full Text]
  42. Shah CP, Thakur RJ, Xie B, Pathak P. Dual chamber pacing for neurally mediated syncope with a prominent cardioinhibitory component. PACE. 1999;22:999–1003
  43. Mitton CR, Rose MS, Koshman ML, Sheldon RS. Cost-utility analysis of pacemakers for the treatment of vasovagal syncope. Am J Cardiol. 1999;84:1356–1359[CrossRef][Web of Science][Medline]
  44. Di Girolamo E, Di-Torio C, Leonzio L. Usefulness of a tilt training program for the prevention of refractory neurocardiogenic syncope in adolescents: a controlled study. Circulation. 1999;100:1798–1801[Abstract/Free Full Text]
  45. Raviele A, Brignole M, Sutton R. Effect of etilefrine in preventing syncopal recurrence in patients with vasovagal syncope. A double-blind randomized placebo-controlled trial. Circulation. 1999;99:1452–1457[Abstract/Free Full Text]
  46. Madrid AH, Ortega J, Rebollo JG. Lack of efficacy of atenolol for the prevention of neurally mediated syncope, in a highly symptomatic population. A prospective, double blind, randomized and placebo controlled study. J Am Coll Cardiol. 2001;37:554–559[Abstract/Free Full Text]
  47. Connolly SJ, Sheldon R, Roberts RS, Gent M. The North American Vasovagal pacemaker study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope. J Am Coll Cardiol. 1999;33:16–20[Abstract/Free Full Text]
  48. Sutton R, Brignole M, Menozzi C. Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope. Pacemaker versus no therapy: a multicenter randomized study. Circulation. 2000;102:294–299[Abstract/Free Full Text]

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