Head-upright tilt-table testing in evaluation and management of the malignant vasovagal syndrome

doi:10.1016/0002-9149(92)90790-6

The American Journal of Cardiology

Volume 69, Issue 9, 1 April 1992, Pages 904-908

https://doi.org/10.1016/0002-9149(92)90790-6 Get rights and content

Abstract

Vasovagally mediated cardiac asystole has been proposed as a potential cause of sudden cardiac death. To assess this possibility and identify characteristics that define patients with vasovagally mediated asystole, head-upright tilt-table testing was performed in 50 consecutive patients (26 women and 24 men, mean age 42 ± 10 years) with recurrent unexplained syncope. The upright tilt-table test was performed in the fasting state for 30 minutes, with or without the use of intravenous isoproterenol (1 to 3 μg/min). The production of ventricular asystole lasting >4 seconds was considered a positive result. All patients with tiltinduced asystole received therapy with either β blockers, disopyramide, transdermal scopolamine or atrioventricular permanent pacing, the efficacy of which was evaluated with serial tilt-table tests. Reproducible tilt-induced asystole occurred in 10 patients (7 men and 3 women, mean age 23 ± 12 years) (7 patients during baseline tilt, and 3 during isoproterenol infusion). Analysis of this group revealed that they had significantly more frequent and severe syncopal episodes (3 patients had episodes needing bystander cardiopulmonary resuscitation) than did those patients with tilt-induced syncope without asystole. All patients who had tilt-induced asystole eventually became tilt-table negative with therapy (4 with β blockers, 2 with disopyramide, and 4 with atrioventricular permanent pacing), and over a mean follow-up of 21 ±6 months no further syncopal episodes occurred. It is concluded that patients with recurrent tilt-induced asystole represent a distinct subgroup that has recurrent severe syncope that may mimic or result in sudden cardiac death. Head-upright tilttable testing is clinically useful in the diagnosis of this malignant vasovagal syndrome and in the evaluation of prophylactic therapy.

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Furthermore, myocardial ischaemia due to under perfusion seems also to play a role in bradyarrhythmias and hypotension commonly seen in human patients with inferior or posterior wall myocardial ischaemia, which are locations with a high concentration of cardiac inhibitory receptors, and this mechanism could also have played a role in the suspected inappropriate vagal reflexes reported in our cases [47]. Vasovagal reflexes in people lead to loss of consciousness because of prolonged asystole and hypotension, which can produce a serious outcome, such as SCD [48]. The cardioinhibitory response is characterized by prolonged asystole and has been treated successfully with pacemaker implantation, whereas the vasodepressor response provides prevalently vasodilation [49].
Inherited or acquired arrhythmic disorders and cardiac disease have been associated with sudden cardiac death (SCD) in dogs. The electrical mechanism related to death in most of these cases is unknown. This retrospective study aimed to describe arrhythmic events in dogs that experienced SCD during Holter monitoring.
Nineteen client-owned dogs that experienced SCD during Holter examination were included. Clinical records from a Holter service database were reviewed, and both the rhythm preceding death and the dominant rhythm causing SCD were analysed. Clinical data, Holter diaries and echocardiographic diagnosis were also evaluated.
Structural heart disease was identified in 12/19 dogs (dilated cardiomyopathy in five dogs, arrhythmogenic right ventricular cardiomyopathy in four dogs, myxomatous mitral valve disease in two dogs, and suspected myocarditis in one dog), five of which had concurrent congestive heart failure. Sudden cardiac death was related to ventricular premature complexes or monomorphic ventricular tachycardia degenerating into ventricular fibrillation in 42% of dogs, polymorphic ventricular tachycardia, or torsade de pointes-like inducing ventricular fibrillation in 21%, and asystole or presumptive agonal pulseless electrical activity triggered by malignant bradyarrhythmias in 37%.
The most common rhythm associated with SCD in our population of dogs was ventricular tachycardia leading to ventricular fibrillation, although bradyarrhythmia-related SCD, possibly related to inappropriate vagal reflexes, was also a notable cause.
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On the basis of the high frequency of death in the bathtub, they assume that one of the causes of sudden death might be related to orthostatic hypotension, because the vasodilation effect experienced in the bathtub could lead to fatal syncope in patients with severe orthostatic hypotension [13]. It is reported that severe syncope can cause cardiac sudden death [17]. Moreover, anti-Parkinsonian medicines such as levodopa and dopamine receptor agonists can exacerbate orthostatic hypotension [18,19].
The aim of this paper is to reveal the causes of death and to verify sudden death of Parkinson's disease (PD) in an autopsy study. We reviewed the clinical data and the causes of death in 16 PD patients who had postmortem examinations. Prior to autopsy, nine patients died of known causes: five patients died of aspiration pneumonia, two of myocardial infarction, one of asphyxia, and one of dilated cardiomyopathy. Autopsy confirmed that the putative causes of death were compatible with the pathological ones. The remaining seven patients died suddenly of unknown causes. Autopsy revealed that the causes of death were asphyxia in two patients and perforation of a duodenal ulcer in one patient. Autopsy did not determine the causes of unknown death in the remaining four patients. Consequently, autopsy revealed that eight patients died of swallowing problems such as aspiration pneumonia and asphyxia, four of sudden death, three of cardiac problems, and one of a gastrointestinal problem. Although there was a bias that all patients had a postmortem examination, our study revealed that several PD patients died of sudden death without any satisfactory causes of death determined even by autopsy. Therefore, we propose that a non-negligible number of PD patients die of sudden death.
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Syncope, presyncope and dizziness in the elderly: Usefulness of the head-up tilt test in the diagnostic process
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evaluar la utilidad de la prueba de inclinación (PI) en el adulto mayor con historia de síncope, presíncope o mareo de causa no aclarada. Secundariamente, describir el patrón hemodinámico durante la PI para subclasificar en diferentes grupos a los pacientes.
pacientes mayores de 60 años con historia de síncope o mareos que acudieron consecutivamente al Servicio de Arritmias de nuestro centro. Determinación de la aparición de alteraciones hemodinámicas y/o reproducción de la sintomatología a través de la PI. Se realizó masaje carotídeo en pacientes seleccionados.
el número total de pacientes fue de 141, edad media ± desviación estándar 74,0 ± 7,1 años (intervalo, 61-93), 51,1% mujeres. Ciento cuatro pacientes tenían historia de síncope previo (89 casos tuvieron 2 o más episodios). La PI fue positiva por síntomas en el 41,8% de pacientes: 36 presentaron mareos y 23, síncope. En 82 pacientes no se apreciaron síntomas, pero el comportamiento hemodinámico fue anormal en 9 casos. Se pudo identificar un patrón hemodinámico típico en el 61,7% de las PI: hipotensión ortostática en 63 pacientes y síncope mediado neuralmente en 24 pacientes.
la PI aportó un diagnóstico probable en dos tercios de los pacientes estudiados (suma del patrón hemodinámico típico más pruebas anormales), lo que permite documentar, medir y analizar estos cambios para orientar el tratamiento. La PI muestra gran utilidad en pacientes con síncope y otras manifestaciones clínicas inducidas por el ortostatismo.
the primary aim of this study was to evaluate the usefulness of the head-up tilt (HUT) test in the diagnosis of patients with history of syncope, presyncope or dizziness of unknown origin. A secondary aim was to describe the hemodynamic pattern during the HUT test in order to subclassify patients into distinct groups.
patients aged more than 60 years old with a history of syncope or dizziness consecutively attending the arrhythmia unit in our center. The development of hemodynamic alterations and/or symptom reproduction was determined through the HUT test. Selected patients underwent carotid sinus massage.
we studied 141 patients. The mean age and standard deviation was 74 ± 7.1 years (range, 61-93); 72 (51.1%) were women. Of 104 patients with a history of syncope, 89 had had two or more episodes. The HUT test was positive for symptoms in 59/141 (41.8%) patients: 36 developed dizziness and 23 syncope. Eighty-two patients showed no symptoms, but hemodynamic abnormalities were observed in 9/82 (11%). A typical hemodynamic pattern was identified in 87/141 (61.7%): 63 patients developed orthostatic hypotension, and 24 patients developed neurally mediated syncope.
the HUT test gave a probable diagnosis in two-thirds of the patients studied (typical hemodynamic pattern plus an abnormal test) and allowed hemodynamic changes to be measured and analyzed with a view of guiding treatment. This test was highly useful in patients with syncope and symptoms related to orthostatic stress.
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Head-upright tilt-table testing in evaluation and management of the malignant vasovagal syndrome

Abstract

J Am Coll Cardiol

Am J Med

Am J Cardiol

Lancet

Am Heart J

Am J Med

Am J Cardiol

Diagnostic evaluation of syncope

Am J Med

Malignant vasovagal syndrome: prolonged asystole provoked by head up tilt

Cleve Clin J Med

Role of electrophysiologic study in patients with unexplained recurrent syncope

PACE