© 1999 by European Society of Cardiology
Is a pacemaker indicated for vasovagal patients with severe cardioinhibitory reflex as identified by the ATP test?
A preliminary randomized trial
Angoulême General Hospital Saint Michel, France;
*Medtronic Pacing Division Minneapolis, Minnesota, U.S.A.;
Division of Environmental and Occupational Health, School of Public Health, University of Minnesota Minneapolis, Minnesota, U.S.A.
BACKGROUND: A previous observational study suggested that, in syncopal elderly patients with vasovagal syndrome, a test using adenosine-5'-triphosphate (intravenous ATP 20 mg. 2 ml–1) could identify a subgroup of patients at high risk of severe cardioinhibitory response and guide the therapeutic strategy. To test one aspect of these results prospectively, we designed a small study focusing only on vasovagal patients with abnormal response to ATP testing.
METHODS: Twenty patients hospitalized for syncope, which was considered to be vasovagal, and exhibiting an abnormal ATP test—defined by a longer than 10 s cardiac pause—were randomized to two groups: half to implan-tation with a dual-chamber pacemaker and half to usual medical care. All patients who were not hospitalized for recurrences were assessed every 6 months in the clinic or by telephone.
RESULTS: At baseline, the randomized patient groups were similar in their demographic and health characteristics and in the results of their ATP tests, for example the mean cardiac pause (21·4±9·3 vs 15·9±3·7 s) and the mean interval between escape beats during the pause (7·29±4·2 vs 7·48±3·3 s). During a mean follow-up of 52 months, recurrences appeared in six of the 10 usual-care patients (range 0·2–29 months) but in none of the implanted patients (P<0·02).
CONCLUSIONS: This limited trial (1) supports the conclusion that patients with an abnormal ATP test who receive a dual-chamber pacemaker suffer fewer recurrences than those who are monitored only; and (2) consequently further supports the hypothesis that, among vasovagal patients, a cardiac pause of longer than 10 s in patients administered ATP identifies those at high risk of symptomatic vagal cardiac inhibition.
Key Words: ATP, syncope, vasovagal syndrome, neuro-cardiogenic syncope, pacemaker, randomized trial
Correspondence: Daniel Flammang, MD, Department of Cardiology, Angoulême General Hospital, 16470 Saint Michel, France.
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