© 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.
[1] Kapoor WN, Hammill SC, Gersh BJ. Diagnosis and natural history of syncope and the role of invasive electrophysiologic testing. Am J Cardiol 1989; 63: 730–734.[CrossRef][Web of Science][Medline]
[2] Lurie KG and Benditt DG. Syncope and the autonomic nervous system. J Cardiovasc Electrophysiol 1996; 7: 760–766.[Web of Science][Medline]
[3] Benditt DG. Neurally mediated syncopal syndromes: pathophysiological concepts and clinical evaluation. PACE 1997; 20: 572–584.
[4] Grubb BP and Kosinski D. Tilt table testing: Concepts and limitations. PACE 1997; 20: 781–787.
[5] Kapoor WN and Brant N. Evaluation of syncope by upright tilt testing with isoproterenol: a nonspecific test. Ann Intern Med 1992; 116: 358–363.
[6] Benditt DG, Erickson M, Gammage MD. A Synopsis: Neurocardiogenic syncope. An international symposium, 1996. PACE 1997; 20: 851–860.
[7] Natale A, Sra J, Dhala A. Efficacy of different treatment strategies for neurocardiogenic syncope. PACE 1995; 18: 655–662.
[8] Fitzpatrick AP, Ahmed R, Williams S. A randomized trial of medical therapy in malignant vasovagal syndrome or neurally mediated bradycardia/hypotension syndrome. Eur J Cardiac Pacing Electrophysiol 1991; 1: 91–202.
[9] Brignole M, Menozzi G, Gianfranchi L. A controlled trial of acute and long-term therapy in tilt-induced neurally mediated syncope. Am J Cardiol 1992; 70: 339–342.[CrossRef][Web of Science][Medline]
[10] Morillo CA, Leitch JU, Yee R, et al. A placebo-controlled trial of intravenous and oral disopyramide for prevention of neurally mediated syncope induced by head-up tilt. J Am Coll Cardiol 1993; 22: 1843–1848.[Abstract]
[11] Moya A, Permanyer-Miralda G, Sagrista-Sauleda J. Limitations of head-up tilt test for evaluating the efficacy of therapueutic interventions in patients with vasovagal syncope: Results of a controlled study of etilefrine versus placebo. J Am Coll Cardiol 1995; 25: 65–69.[Abstract]
[12] Fitzpatrick AP, Theodorakis G, Ahmed R. Dual chamber pacing aborts vasovagal syncope induced by head-up 60° tilt. PACE 1991; 14: 13–19.
[13] Sra JS, Jazayeri MR, Avitall B. Comparison of cardiac pacing with drug therapy in the treatment of neurocardiogenic (vasovagal) syncope with bradycardia or asystole. N Engl J Med 1993; 328: 1085–1090.
[14] Petersen MEV, Chamberlain-Webber R, Fitzpatrick AP. Permanent pacing for cardioinhibitory malignant vasovagal syndrome. Br Heart J 1994; 71: 274–281.
[15] Flammang D, Church T, Waynberger M. Can adenosine-5'-triphosphate be used to select treatment in severe vasovagal syndrome? Circulation 1997; 26: 1201–1208.
[16] Belhassen B, llia R, Pelleg A. A comparative study of the electrophysiologic effects of striadyne, adenosine triphosphate and adenosine in the canine heart. Cardiology 1985; 72: 113–122.[Medline]
[17] Pelleg A, Belhassen B, llia R. Comparative electro-physiologic effects of adenosine triphosphate and adenosine in the canine heart: influence of atropine, propranolol, vagotomy, dipyridamole and aminophylline. Am J Cardiol 1985; 55: 571–576.[CrossRef][Web of Science][Medline]
[18] Katchanov G, Xu J, Clay A, Pelleg A. Electrophysiological-anatomic correlates of ATP-triggered vagal reflex in dogs. IV. Role of LV vagal afferents. Am J Physiol 1997; 272 (Heart Circ Physiol 41): H1898–H1903.
[19] Hughes FC, Jan Y, Bors V. Etude de l’action chronotrope de l’ATP chez l’homme. Coeur et Médecine Interne 1980; 19: 227–234.[Medline]
[20] Puech P, Sassine A, Munoz A. Electrophysiologic effectsof purine: clinical applications. In Zipes D and Jalife J (Eds.). Cardiac Electrophysiology and Arrhythmias, Orlando, Grune and Stratton 1985; pp. pp 443–450.
[21] Moller M, Oxho H, Mickley H. Posture-dependent chronotropic effect of carotid sinus massage. PACE 1987; 10: 1191–1193.
[22] SAS/STAT user’s guide, version 6. Cary, N.C: SAS Institute, 1989, 261, 8.
[23] Mehta C and Patel N. StatXact-Turbo user manual. 1992; Cambridge, MA Cytel Corporation 4·68–9.
[24] Recommendations for pacemaker prescription for symptomatic bracycardia. Report of a working party of the British Pacing and Electrophysiology Group. Br Heart J 1991; 66: 185–191.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  S.W. Parry, T. Chadwick, J.C. Gray, R.S. Bexton, M. Tynan, J.P. Bourke, and S. Nath The intravenous adenosine test: a new test for the identification of bradycardia pacing indications? A pilot study in subjects with bradycardia pacing indications, vasovagal syncope and controls QJM, July 1, 2009; 102(7): 461 - 468. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. P. Tan and S. W. Parry Vasovagal syncope in the older patient. J. Am. Coll. Cardiol., February 12, 2008; 51(6): 599 - 606. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Brignole, F. Giada, A. Raviele, and J. J. Blanc Pacing for syncope: what role? which perspective? Eur. Heart J. Suppl., December 1, 2007; 9(suppl_I): I37 - I43. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Authors/Task Force Members, P. E. Vardas, A. Auricchio, J.-J. Blanc, J.-C. Daubert, H. Drexler, H. Ector, M. Gasparini, C. Linde, F. B. Morgado, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in Collaboration with the European Heart Rhythm Association Europace, October 1, 2007; 9(10): 959 - 998. [Full Text] [PDF]
|
|
|
|
 |
|
 Authors/Task Force Members, P. E. Vardas, A. Auricchio, J.-J. Blanc, J.-C. Daubert, H. Drexler, H. Ector, M. Gasparini, C. Linde, F. B. Morgado, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in Collaboration with the European Heart Rhythm Association Eur. Heart J., September 2, 2007; 28(18): 2256 - 2295. [Full Text] [PDF]
|
|
|
|
|
|
S. W. Parry, S. Nath, J. P. Bourke, R. S. Bexton, and R. A. Kenny Adenosine test in the diagnosis of unexplained syncope: marker of conducting tissue disease or neurally mediated syncope? Eur. Heart J., June 2, 2006; 27(12): 1396 - 1400. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Donateo, M. Brignole, C. Menozzi, N. Bottoni, P. Alboni, M. Dinelli, A. Del Rosso, F. Croci, D. Oddone, A. Solano, et al. Mechanism of syncope in patients with positive adenosine triphosphate tests J. Am. Coll. Cardiol., January 1, 2003; 41(1): 93 - 98. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Brignole, P. Donateo, and C. Menozzi The diagnostic value of ATP testing in patients with unexplained syncope Europace, January 1, 2003; 5(4): 425 - 428. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||