Heart Rhythm Observed During Positive Head-Up Final

8/13/2019 Heart Rhythm Observed During Positive Head-Up Final

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HEART RHYTHM OBSERVED DURING

POSITIVE HEAD-UP

TILT TESTIN VASOVAGAL SYNCOPE (VVS)

Radu Rosu, MD

ISHNE 2013, Timisoara


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BACKGROUND

Syncopeis a T-LOC due to transient globalcerebral hypoperfusion characterized by rapidonset, short duration, and spontaneous

complete recovery. Reflex syncope- cardiovascular reflexes

become intermittently inapropriate, in responseto a trigger, resulting in vasodilatation and/orbradycardia

Vasovagal syncope (VVS)- is mediated byemotion or by orthostatic stress.


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Vasovagal syncope

Vasovagal syncope is a common disorder

which accounts for 8% to 37% of syncopes.

Most patients experience infrequent faints

and seldom require more than counseling

and reassurance.

Patients with frequent and/or unpredictable

syncope, however, can be severely disabledand require therapy.


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Reflex syncope is the most frequent cause of

syncope in any setting


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Head-Up Tilt Test (HUT)


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Tilt Test indications


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Tilt testing positive responses


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OBJECTIVES:

Heart rhythm obtained during provocative

condition is often used to guide therapy in

vasovagal syncope (VVS).

The aim of this study was to analyze the

heart rhythm during positive head-up tilt test(HUT) in VVS.


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METHODS:

Retrospective observational study

32 consecutive patients presenting witha history VVS performed HUT in our

cardiology department.

December 2011 - May 2012.


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Inclusion/Exclusion Criteria

Characteristics Included

Clinical history consistent with VVS YES

Low risk patients with severe simptoms or

their occurrence in high-risk settings

YES

1 syncope YES

Age 18 years YES

Non-syncopal loss of consciousness NO

Symptomatic orthostatic hypotension NO

Cardiac abnormalities which suggested

cardiac syncope

NO


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Tilt Test protocol

pre-tiltphase

5 minutes or 20 minutes if venouscannulation was undertaken

pasivephase

40 minutes

activephase

400 mcg of sublingual nitroglycerine

20 minutes

Continuous ECG and intermitent bloodpressure monitoring during the phases


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Tilt table test

The HUT was considered positive when

the patient developed syncope or

intolerable presyncope.

All patients were in sinus rhythm, free of

antiarrhythmic drug therapy.


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RESULTS:

Patients Characteristics

Characteristics

Age, yrs 49,36,8

Gender ratio (male/female) 16/16

History of syncope

Number of syncopes 20,16

Prodrome(%) 80

History of trauma(%) 33,3

ECG 1 patient with RBB without

Brugada pattern


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RESULTS:

32 patients

Junctionalrhythm

8

Sinus rhythm

10

Asystole

6

Tachycardia

2

6 negtive Tilt

testexcluded

26 patients


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RESULTS:Tilt Test events

Total end-points: 26

Asystole23%

Junctionalrhythm>40/min

15%Junctional

rhythm


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Gender-Rhythm types

no significant difference

p-value=0,62

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

Asytole

Tachycardia

Jonctional rhythm

Synus rhythm


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Age-rhythm


rhythm Total

Asystole Junctionalrhythm Sinusrhythm Tachycardia

Age 40 Count 5 4 8 1 18

Total 6 8 10 2 26

p-value=0,41


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Gender-active phase vs pasive phase


p-value=0,23

0

12

3

4

5

6

7

8

9

Pasive phase Active phase

Female

Male


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Tilt test responses:

Type of response Number of patients

1 Mixt 13 (50%)

2A Cardioinhibition without asystole 4 (15,3%)

2B Cardioinhibition with asystole 6 (23%)

3 Vasodepressor 3 (11,7%)


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Gender-type of response

Type of

response

Gender Total

Male Female

1 9 4 13

2A 1 3 4

2B 2 4 6

3 1 2 3

Total 13 13 26

p-value=0,27


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Gender-Syncope/Presyncope

Gender Total

Male Female

Presyncope 1 2 3

Syncope 12 11 23

Total 13 13 26

p-value=0,539


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Age-Syncope/Presyncope

Age Total40

Presyncope 0 3 3

Syncope 8 15 23

Total 8 18 26

p-value=0,22


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Jonctional bradicardia 47 beats/min

in a 23 year old female,

SBP


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Sinus rhythm 67/min in a 56 year old male

SBP


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Sinus tachycardia 114 beats/min

in a 18 year old male

SBP


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Asystole

mean age Male- 504 yrs

Female- 485,3yrs

Prolonged asystole in men (mean=13,47,8s)

vs female (5,50,8s)

2 patients with asystole of 18s and respectively

45s beneficiated from pacemaker implantation.


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Asystole of 5,7s in 49 year old female


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Asystole of 45s

in 58 year old male


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Test-related incidents:

1 patient with 45s asystole was placed inthe supine position and cardiac massage

was started, 2 mg atropine has been given.


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Discussion

A weak correlation

was found between the responses

to Tilt testing and the

mechanism of spontaneous

neurally mediated syncope .


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Asystolic syncope 3 s, or

Non-syncopal asystole 6 s


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We know from ILR experience that about half ofspontaneous neurally mediated episodes are

asystolic in nature.

The induction of an asystolic NMS during tilt tabletesting can predict the efficacy of pacemaker

therapy albeit to a lesser extent than thatexpected (ISSUE-3).

The vasovagal syncope and pacing trial(SyNPACE) had shown that the time to firstsyncope recurrence was longer in an asystolicventricular pause of 13 8 s response during tilttable testing in paced patients.


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Cardiac pacing should be the last choice in

highly selected patients affected by severe

NMS.

Other therapies, eg, physical counterpres-sure maneuvers, are more desirable in young

patients.


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CONCLUSIONS:

The heart rhythm observed during positiveHUT is sinus rhythm and in induced syncopeis most of the time junctional rhytm.

Some patients still present syncope with sinustachycardia and severe blood pressurediminuation.

Prolonged asystole can be the rhythmresponsible for syncope.In this case thepatient can beneficiate from pacemakerimplantation.


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Tilt Test is:

noninvasive

providing an immediate diagnosis

hampered by a significant risk of misdiagnosis

some patients can beneficiate from pacemaker

implantation

others can be reassured.


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Thank you for your attention!

Documents

Heart Rhythm Observed During Positive Head-Up Final