Effectiveness of cardioneuroablation in different subtypes of vasovagal syncope

BACKGROUND Cardioneuroablation(CNA)has shown encouraging results in patients with vasovagal syncope(VVS).However,data on different subtypes was scarce.METHODS This observational study retrospectively enrolled 141 patients[mean age:40±18 years,51 males(36.2%)]with the diagnosis of VVS.The characteristics among different types of VVS and the outcomes after CNA were analyzed.RESULTS After a mean follow-up of 4.3±1.5 years,41 patients(29.1%)experienced syncope/pre-syncope events after CNA.Syncope/pre-syncope recurrence significantly differed in each subtype(P=0.04).The cardioinhibitory type of VVS had the lowest recurrence rate after the procedure(n=6,16.7%),followed by mixed(n=26,30.6%)and vasodepressive(n=9,45.0%).Additionally,a significant difference was observed in the analyses of the Kaplan-Meier survival curve(P=0.02).Syncope/pre-syncope burden was significantly reduced after CNA in the vasodepressive type(P<0.01).Vasodepressive types with recurrent syncope/pre-syncope after CNA have a lower baseline deceleration capacity(DC)level than those without(7.4±1.0 ms vs.9.0±1.6 ms,P=0.01).Patients with DC<8.4 ms had an 8.1(HR=8.1,95%CI:2.2-30.0,P=0.02)times risk of syncope/pre-syncope recurrence after CNA compared to patients with DC≥8.4 ms,and this association still existed after adjusting for age and sex(HR=8.1,95%CI:2.2-30.1,P=0.02).CONCLUSIONS Different subtypes exhibit different event-free rates.The vasodepressive type exhibited the lowest event-free rate,but those patients with DC≥8.4 ms might benefit from CNA.

A Case Report of Recurrent Guillain-Barré Syndrome with Orthostatic Hypotension Syncope as the First Symptom

Guillain⁃Barré syndrome (GBS) is an immune-mediated peripheral neuropathy with acute or subacute onset of flaccid paralysis of the limbs with symmetrical hypesthesia and autonomic nerve involvement [1]. The clinical manifestations of autonomic nerve damage are complex and varied, which may involve extensive or limited autonomic function damage, including abnormalities of the skin, pupil, urinary tract, gastrointestinal tract, cardiovascular system, body temperature, lacrimal and salivary glands, and sexual function, etc. [2], and some patients may even have autonomic nerve damage as the only symptom, which is a variant of GBS and is prone to misdiagnosis or underdiagnosis. Recurrence of GBS is rare, and the manifestations of recurrence are often similar to those of the first symptoms [3], but the patient admitted to our hospital had syncope as the main clinical manifestation of recurrence, which was completely different from that of the first incidence, and syncope is not a common and typical clinical manifestation of GBS, so misdiagnosis is highly likely.

Predicting short-term adverse outcomes in the geriatric population presenting with syncope:a comparison of existing syncope rules and beyond

OBJECTIVES Syncope at age 65+is associated with increased mortality,irrespective of cause.Syncope rules were designed to aid in risk-stratification but were only validated in the general adult population.Our objective was to determine if they can be applied to a geriatric population in predicting short-term adverse outcomes.METHODS In this single-center retrospective study,we evaluated 350 patients aged 65+presenting with syncope.Exclusion criteria included confirmed non-syncope,active medical condition,drug or alcohol-related syncope.Patients were stratified into high or low risk based on Canadian Syncope Risk Score(CSRS),Evaluation of Guidelines in Syncope Study(EGSYS),San Francisco Syncope Rule(SFSR),and Risk Stratification of Syncope in the Emergency Department(ROSE).Composite adverse outcomes at 48-hour and 30-day included all-cause mortality,major adverse cardiac and cerebrovascular events(MACCE),return emergency department visit,hospitalization,or medical intervention.We assessed each score's ability to predict the outcomes using logistic-regression and compared performances using receiver-operator curves.Multivariate analyses were performed to study the associations between recorded parameters and outcomes.RESULTS CSRS outperformed with AUC of 0.732(95%CI:0.653-0.812)and 0.749(95%CI:0.688-0.809)for 48-h and 30-day outcomes,respectively.Sensitivities for CSRS,EGSYS,SFSR,and ROSE for 48-hour outcomes were 48%,65%,42% and 19%;and for 30-day outcomes were 72%,65%,30% and 55%,respectively.Atrial fibrillation/flutter on EKG,congestive heart failure,antiarrhythmics,systolic blood-pressure<90 at triage,and associated chest pain highly correlated with 48-h outcomes.An EKG abnormality,heart disease history,severe pulmonary hypertension,BNP>300,vasovagal predisposition,and antidepressants highly correlated with 30-day outcomes.CONCLUSIONS Performance and accuracy of four prominent syncope rules were suboptimal in identifying high-risk geriatric patients with short-term adverse outcomes.We identified some significant clinical and laboratory information that may play a role in predicting short-term adverse events in a geriatric cohort.

Improving the approach to non-cardiac syncope in the emergency department observation unit

Syncope is a rather frequent condition,responsible for1.0%–1.5%of emergency department (ED) visits.[1]Even if the development of clinical guidelines has improved the ED management of syncope,[2]the hospitalization rate is still very high (up to 50%),especially compared with the incidence of short-term adverse events,which is11%globally,but decreases to less than 4%when events already diagnosed in the ED are excluded,[1]meaning that most patients will not benefit from admission.

Arrhythmic syncope: From diagnosis to management

Syncope is a concerning symptom that affects a large proportion of patients.It can be related to a heterogeneous group of pathologies ranging from trivial causes to diseases with a high risk of sudden death.However,benign causes are the most frequent,and identifying high-risk patients with potentially severe etiologies is crucial to establish an accurate diagnosis,initiate effective therapy,and alter the prognosis.The term cardiac syncope refers to those episodes where the cause of the cerebral hypoperfusion is directly related to a cardiac disorder,while arrhythmic syncope is cardiac syncope specifically due to rhythm disorders.Indeed,arrhythmias are the most common cause of cardiac syncope.Both bradyarrhythmia and tachyarrhythmia can cause a sudden decrease in cardiac output and produce syncope.In this review,we summarized the main guidelines in the management of patients with syncope of presumed arrhythmic origin.Therefore,we presented a thorough approach to syncope work-up through different tests depending on the clinical characteristics of the patients,risk stratification,and the management of syncope in different scenarios such as structural heart disease and channelopathies.

Management and therapy of vasovagal syncope: A review

Vasovagal syncope is a common cause of recurrent syncope. Clinically, these episodes may present as an isolated event with an identifiable trigger, or manifest as a cluster of recurrent episodes warranting intensive evaluation. The mechanism of vasovagal syncope is incompletely understood. Diagnostic tools such as implantable loop recorders may facilitate the identification of patients with arrhythmia mimicking benign vasovagal syncope. This review focuses on the management of vasovagal syncope and discusses the non-pharmacological and pharmacological treatment options, especially the use of midodrine and selective serotonin reuptake inhibitors. The role of cardiac pacing may be meaningful for a subgroup of patients who manifest severe bradycardia or asystole but this still remains controversial.

Deceleration Capacity--A Novel Measure for Autonomic Nervous System in Patients with Vasovagal Syncope on Tilt-table Testing

This study was to investigate the changes of autonomic nerve function and hemodynamics in patients with vasovagal syncope(VVS) during head-up tilt-table testing(HUT). HUT was performed in 68 patients with unexplained syncope and 18 healthy subjects served as control group. According to whether bradycardia, hypotension or both took place during the onset of syncope, the patients were divided during the test into three subgroups: vasodepressor syncope(VD), cardioinhibitory syncope(CI) and mixed syncope(MX) subgroups. Heart rate, blood pressure, heart rate variability(HRV), and deceleration capacity(DC) were continuously analyzed during HUT. For all the subjects with positive responses, the normalized low frequency(LFn) and the LF/HF ratio markedly decreased whereas normalized high frequency(HFn) increased when syncope occurred. Syncopal period also caused more significant increase in the power of the DC in positive groups. These changes were more exaggerated compared to controls. All the patients were indicative of a sympathetic surge in the presence of withdrawal vagal activity before syncope and a sympathetic inhibition with a vagal predominance at the syncopal stage by the frequency-domain analysis of HRV. With the measurements of DC, a decreased vagal tone before syncope stage and a vagal activation at the syncopal stage were observed. The vagal tone was higher in subjects showing cardioinhibitory responses at the syncopal stage. DC may provide an alternative method to understand the autonomic profile of VVS patients.

Syncope as a health risk for soldiers: Influence of medical history and clinical findings on the sensitivity of head-up tilt table testing

Background: Syncope is a relevant health problem in military environments. Reliable diagnosis is challenging. Tilt table testing is an important tool for syncope diagnosis. The aim of this study was to determine whether signs such as prodromal symptoms, co-morbidity, frequency of syncopal events, body length, body mass index, and electrocardiography(ECG) abnormalities can be used to predict the success of tilt table testing at diagnosing syncope.Methods: Data from 100 patients with histories of syncope or pre-syncope, who were diagnosed using head-up tilt table testing, were retrospectively analyzed in a cross-sectional analysis. The diagnostic procedure was based upon a modified version of the Westminster protocol without any pharmacological provocation. Results: Patients showing pathological reaction patterns during tilt table testing suffered from prodromal symptoms, such as dizziness and sweating, significantly more often. The patients reported more injuries resulting from syncopal events and more previous syncopal events, and the prevalence of co-morbidity was greater among patients presenting negative findings during tilt testing. An asthenic-leptosomal physique was not confirmed as a risk factor for syncopal events as is the case for idiopathic arterial hypotension. However, patients with pathological reaction patterns during tilt table testing were significantly taller. This finding was detected for both females and males. No significant predictors were found in the ECG patterns of patients showing syncope during tilt table testing.Conclusions: Frequency of prior syncope and prodromal symptoms, and increased body length with an otherwise good state of health influence the predictive value of tilt table testing for syncope diagnosis. In particular, if these factors are present, tilt table testing should be considered part of the diagnostic algorithm for soldiers with recurrent syncope.

Trauma and syncope-evidence for further sleep study? A case report

We report on an 83-year-old male with traumatic brain injury after syncope with a fall in the morning. He had a history of seizures, coronary artery disease and paroxysmal atrial fibrillation(AF). No medical cause for seizures and syncope was determined. During rehabilitation, the patient still complained of seizures, and also reported sleepiness and snoring. Sleep apnea diagnostics revealed obstructive sleep apnea(SA) with an apnea-hypopnoea index of 35/h, and sudden onset of tachycardia with variations of heart rate based on paroxysmal atrial fibrillation. Additional tests showed nocturnal AF which spontaneously converted to sinus rhythm mid-morning with an arrest of 5 s(sick sinus syndrome) and seizures. A DDD-pacer was implanted and no further seizures occurred. SA therapy with nasal continuous positive airway pressure was refused by the patient. Our findings suggests that screening for SA may offer the possibility to reveal causes of syncope and may introduce additional therapeutic options as arrhythmia and SA often occur together which in turn might be responsible for trauma due to syncope episodes.

Late-onset multiple acyl-CoA dehydrogenase deficiency with cardiac syncope: A case report

BACKGROUND Multiple acyl-CoA dehydrogenase deficiency(MADD)is an uncommon autosomal recessive disorder of mitochondrial fatty acid beta-oxidation.Syncope is a transient loss of consciousness due to acute global cerebral hypoperfusion.Late-onset MADD with syncope has not been reported previously.CASE SUMMARY We report a 17-year-old girl with exercise intolerance and muscle weakness.She felt palpitation and shortness of breath after short bouts of exercise.She also suffered from a transient loss of consciousness many times.Muscle biopsy showed lipid storage.Genetic mutation analysis indicated a compound heterozygous mutation c.250G>A(p.A84T)and c.872T>G(p.V291G)in the ETFDH gene.The results of Holter electrocardiogram monitoring showed supraventricular tachycardia when the patient experienced a loss of consciousness.After treatment with riboflavin and carnitine,muscle weakness and palpitation symptoms improved rapidly.No loss of consciousness occurred,and the Holter electrocardiogram monitoring was normal.CONCLUSION Late-onset MADD with supraventricular tachycardia can cause cardiac syncope.Carnitine and riboflavin supplement were beneficial for treating the late-onset MADD with cardiac syncope.Attention should be paid to the prevention of cardiac syncope when diagnosing late-onset MADD.

Neurogenic orthostatic hypotension with Parkinson's disease as a cause of syncope:A case report

BACKGROUND Syncope presents with diagnostic challenges and is associated with high healthcare costs.Neurogenic orthostatic hypotension(nOH)as one cause of syncope is not well established.We review a case of syncope caused by nOH in a patient with Parkinson's disease.CASE SUMMARY We describe a case of syncope caused by nOH in Parkinson's disease and review the literature.A 70-year-old man with Parkinson's disease had uncontrolled blood pressure for 1 mo,with blood pressure ranging from 70/40 to 220/112 mmHg,and once lost consciousness lasting for several minutes after getting up.Ambulatory blood pressure monitoring indicated nocturnal hypertension(up to 217/110 mmHg)and morning orthostatic hypotension(as low as 73/45 mmHg).Seated-to-standing blood pressure measurement showed that the blood pressure dropped from 173/96 mmHg to 95/68 mmHg after standing for 3 min from supine position.A diagnosis of nOH with supine hypertension was made.During the course of treatment,Midodrine could not improve the symptoms.Finally,the patient's blood pressure stabilized with simple strategies by strengthening exercises,reducing the duration of lying in bed in the daytime,and consuming water intake before getting up.CONCLUSION nOH is one of the causes of syncope.Ambulatory blood pressure monitoring is a cost-effective method for its diagnosis,and non-pharmacological measures are still the primary management methods.

Different treatments for different mechanisms in vasovagal syncope

The treatment of vasovagal syncope has been by far unsatisfactory. Beta-blockers may prevent vasovagal syncope, but they exacerbates heart asystole. Cardiac pacing prevents syncope but notpresyncope. The frequent, serious vasovagal syncope attacks of a 63- year-old woman patient were completely prevented by administration of 100 mg metoprolol (b.i.d) for 3 months until the patient experienced a complete heart block. A DDD pacemaker implantation abolished syncope but not the presyncope, which was eventually prevented in a follow-up period of 24 months by adding 75 mg atenalol twice a day. This case suggests a different mechanism involved in vasovagal syncope.

ACUPUNCTURE TREATMENT OF SYNCOPE BASED ON DIFFERENTIATION OF SIGNS AND SYMPTOMS

Syncope is one of the critical emergen-cies commonly encountered in clinic.Awell-known historical story related that thefamous physician Bian Que(扁鹊,the fifthcentury B.C.)successfully treated the deeplycomatosed Prince Guo(虢太子)withacupuncture.I have often treated patientswith syncope via acupuncture andmoxibustion,and have achieved very satis-factory therapeutic results.These are sum-marized and presented as follows.

Significance of ambulatory electroencephalography for differential diagnosis of epilepsy and syncope

BACKGROUND： Twenty-four hour ambulatory electroencephatography （AEEG） provides advantages for continuous electroencephalogram, monitoring brief loss of consciousness complicated by suspect or mild limb spasm. OBJECTIVE： To explore the significance of AEEG for differentially diagnosing epilepsy and syncope, compared to EEG. DESIGN, TIME AND SETTING： Sixty patients with brief loss of consciousness, complicated by suspect or mild limb spasm, were selected from Suqian People＇s Hospital between January 2006 and June 2007. PARTICIPANTS： Sixty participants comprised 34 males and 26 females, aged 13-64 years. According to clinical symptoms prior to the study, 36 patients were initially diagnosed with epilepsy and 24 with syncope. METHODS AND MAIN OUTCOME MEASURES： Abnormalities and epileptiform discharge were detected using EEG and AEEG, and the diagnostic value of the two methods for epilepsy and syncope was compared. RESULTS： A total of sixty patients were included in the final analysis. Abnormal AEEGs were observed in 37 cases （62%） and epileptiform discharge AEEGs in 23 cases （38%）, both of which were significantly greater than EEGs [37% （22/60）, 18% （11/60）, respectively, P 〈 0.01, 0.05]. The detection rate of abnormal AEEG and epileptiform discharge in the epilepsy group [75% （27/36）, 47% （17/36）, respectively was significantly greater than in the syncope group [42% （10/24）, 25% （6/24）, respectively, P 〈 0.01, 0.05]. CONCLUSION： AEEG can improve detection probability of epileptiform discharge and exhibits significant differences in the differential diagnosis of epilepsy and syncope.

Syncope as a health risk for soldiers-influence of medical history and clinical findings on the sensitivity of head-up tilt table testing

Background:Syncope is a relevant health problem in military environments.Reliable diagnosis is challenging.Tilt table testing is an important tool for syncope diagnosis.The aim of this study was to determine whether signs such as prodromal symptoms,co-morbidity,frequency of syncopal events,body length,body mass index,and electrocardiography abnormalities can be used to predict the success of tilt table testing at diagnosing syncope.Methods:Data from 100 patients with histories of syncope or pre-syncope,who were diagnosed using head-up tilt table testing,were retrospectively analyzed in a cross-sectional analysis.The diagnostic procedure was based upon a modified version of the Westminster protocol without any pharmacological provocation.Results:Patients showing pathological reaction patterns during tilt table testing suffered from prodromal symptoms,such as dizziness and sweating,significantly more often.The patients reported more injuries resulting from syncopal events and more previous syncopal events,and the prevalence of co-morbidity was greater among patients presenting negative findings during tilt testing.An asthenic-leptosomal physique was not confirmed as a risk factor for syncopal events as is the case for idiopathic arterial hypotension.However,patients with pathological reaction patterns during tilt table testing were significantly taller.This finding was detected for both females and males.No significant predictors were found in the electrocardiogram patterns of patients showing syncope during tilt table testing.Conclusions:Frequency of prior syncope and prodromal symptoms,and increased body length with an otherwise good state of health influence the predictive value of tilt table testing for syncope diagnosis.In particular,if these factors are present,tilt table testing should be considered part of the diagnostic algorithm for soldiers with recurrent syncope.

Syncope and Early Repolarization:A Benign or Dangerous ECG Finding?

Early repolarization is a well-described,common electrocardiographic variant.It was initially felt to be benign,but in the last twenty years a suggested a link between specific types of early repolarization and sudden cardiac death has emerged.This association was has been termed the J wave syndrome and includes both the high risk early repolarization and Brugada ECG patterns.The odds of early repolarization change being associated with poor outcomes are still exceedingly small.Nevertheless,the association of a fairly ubiquitous ECG finding with fatal or near fatal clinical outcomes has raised concern.How can we identify the truly high-risk patients?If a patient has a signifi cant clinical event with a concerning ECG repolarization pattern,what should be done next?The authors of this review present current information regarding the Early Repolarization and Brugada Syndromes and how to proceed with diagnosis,management,and risk stratifi cation when early repolarization change is observed on ECG.

Syncope-related falls in the elderly

Age-related physiological impairments of heart rate, blood pressure and cerebral blood flow, in combination with comorbid conditions and concurrent medications, account for an increased susceptibility to syncope in older adults. Common causes of syncope are orthostatic hypotension, neurally-mediated syncope (including carotid sinus syndrome) and cardiac arrhythmias. A high proportion of older patients with cardiovascular syncope present with falls and deny loss of consciousness. Patients who are cognitively normal and have unexplained falls should have a detailed cardiovascular assessment.

Risk of pacemaker implantation after femur fracture in patients with and without a history syncope: a Danish nationwide registry-based follow-up study

BACKGROUND It has previously been described that fall-associated injuries including fractures are commonly observed among patients with bradyarrhythmia.However,knowledge on the risk of pacemaker implantation after admission due to femur fracture from large population-based epidemiologic data is lacking.Therefore,we investigated the risk of pacemaker implanta-tion following femur fracture in patients with and without a history of previous syncope.METHODS All patients with femur fracture between 2005-2017 were identified using the Danish Nationwide Patient Registry.Among these,patients already having a pacemaker were excluded.Primary outcome was one-year risk of pacemaker implanta-tion and secondary outcome was one-year all-cause mortality.Multivariable logistic regression was used to obtain absolute and relative risks of the study endpoint in relation to patients with versus without history of syncope and standardized to the age,sex,selected comorbidity and pharmacotherapy distribution of all patients.RESULTS Of 93,093 patients with femur fracture,5508(5.9%)had a history of syncope within five years.Patients with prior syn-cope were slightly older(84 vs.83 years),more often male(33.6%vs.29.4%),and had more often comorbidities relative to those without history of syncope.All-cause mortality was significantly higher among those with previous history of syncope com-pared to those without previous syncope(29.9%vs.28.6%,P=0.021).The relative mortality risk was 1.05(95%CI:1.01−1.09,P=0.021).A total of 695(0.8%)patients underwent pacemaker implantation within 5 years following femur fracture,and a signific-antly higher proportion of patients with syncope had a pacemaker implanted within one year(1.6%vs.0.7%,P<0.001;relative risk,2.01[95%CI:1.55−2.46]).CONCLUSIONS In patients with femur fracture,a history of syncope was significantly associated with a higher one-year risk of pacemaker implantation.

Pacemaker electrode rupture causes recurrent syncope:A case report

BACKGROUND Currently,the implantation of permanent cardiac pacemakers entails mostly subclavian vein puncture,which is relatively simpler and easier to master.However,due to individual differences,some patients carry a narrow space between the clavicle and the first rib.If the range of activity of the upper limb is increased,the friction between the electrode wire and the bone gap leads to the breakage of the electrode wire,which is manifested by poor pacemaker perception and pacing.CASE SUMMARY A 68-year-old woman underwent permanent pacemaker implantation in our hospital because of third-degree atrioventricular block 6 years ago.At that time,the patient was recommended to have a dual-chamber permanent pacemaker implantation,and finally chose a single-chamber permanent pacemaker because she could not afford the cost.The patient has repeatedly lost consciousness for no obvious reason in the past 3 d,and went to our hospital for treatment.The chest X-ray showed that the pacemaker electrode was broken.After the patient was given a pacemaker electrode replacement,the patient did not continue to lose consciousness.CONCLUSION Because the electrodes implanted in the subclavian approach are close to the clavicle and the first rib,the pacemaker electrodes may wear out.If the patient loses consciousness again after the pacemaker is implanted,we should consider whether there is a pacemaker.The possibility of electrode breakage,and timely help the patient to replace the new pacemaker electrodes.

Results of Invasive Electrophysiologic Evaluation in 268 Patients with Unexplained Syncope

In order to assess the diagnostic value of invasive electrophysiologic study (EPS) in the patients with unexplained syncope, the electrophysiologic findings of 268 patients with unexplained syncope despite a complete clinical evaluation were analyzed Results showed positive EPS finding was 38% in total patients and 50% in the patients aged >70 years With increasing age, the diagnostic yield of EPS also increased No significant differences of complication rate were found among the different age groups It was concluded that EPS havd high diagnostic value in the patients with unexplained syncope Its complications are few and mild EPS may be recommended in elderly patients with unexplained syncope