© 2000 by European Society of Cardiology
New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification
Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge
1Arrhythmologic Centre, Ospedali Riuniti Lavagna, Italy; 2Arrhythmologic Centre, Ospedale S. Maria Nuova Reggio Emilia, Italy; 3Department of Cardiology, Ospedale S. Pietro Igneo Fucecchio, Italy; 4Department of Pacing and Electrophysiology, Royal Brompton Hospital London, U.K.
We believe that the pattern of blood pressure response to tilt during the time preceding the development of the vasovagal reaction may provide adjunctive diagnostic information. A group of 101 consecutive patients affected by syncope of uncertain origin underwent passive tilt testing for 45 min at 60° followed, if negative, by oral (sublingual) trinitroglycerin (TNG) 0·4 µg with continuation of the test for 20 min. Three main patterns were observed: the classic (vasovagal) syncope pattern was observed in 36 patients who, during the preparatory phase, had a rapid and full compensatory reflex adaptation to upright position, resulting in stabilization of their blood pressure values until abrupt onset of the vasovagal reaction; the dysautonomic (vasovagal) syncope pattern was observed in 47 patients in whom steady-state adaptation to upright position was not possible. There was thus a progressive fall in their blood pressure until the occurrence of a typical vasovagal reaction; the orthostatic intolerance pattern was observed in 18 patients in whom there was a progressive fall in blood pressure, similar to that of the dysautonomic group, but this was not followed by a clear vasovagal reaction. Compared with the classic, the dysautonomic patients were older, had a higher prevalence of co-morbidities, a very much shorter history of syncopal episodes, and a prevalence of mixed and vasodepressor forms of the VASIS classification. The patients with orthostatic intolerance had clinical characteristics similar to the dysautonmic group but they could not be classified according to the VASIS classification. In conclusion, in patients with syncope, a variety of abnormal responses is observed during tilt testing, suggesting that different syndromes can be diagnosed by the test. A more detailed, although still arbitrary, classification may form the basis of a number of future drug and pacemaker trials, as well as help towards a greater understanding of the different mechanisms of tilt-induced syncope.
Key Words: Tilt testing, vasovagal syncope, autonomic nervous system, haemodynamics of vasovagal syncope
Correspondence: Michele Brignole, MD FESC, Via A Grilli 164, 16041 Borzonasca, Italy.
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