© 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.
[1] Sutton R, Petersen M, Brignole M, Raviele A, Menozzi C, Giani P. Proposed classification for tilt induced vasovagal syncope. Eur J Cardiac Pacing Electrophysiol 1992; 2: 180–183.
[2] Del Rosso A, Bartoli P, Bartoletti A. Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope. Am Heart J 1998; 135: 564–570.[CrossRef][Web of Science][Medline]
[3] Kurbaan AS, Franzén AC, Williams T, Kaddoura S, Sutton R. Usefulness of tilt test-induced patterns of heart rate and blood pressure using a two stage protocol with glyceryl trinitrate provocation in patients with syncope of unknown origin. Am J Cardiol 1999; 84: 665–670.[CrossRef][Web of Science][Medline]
[4] Brignole M, Menozzi C, Gianfranchi L, Oddone D, Lolli G, Bertulla A. Carotid sinus massage, eye-ball compression test and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J 1991; 122: 1644–1651.[CrossRef][Web of Science][Medline]
[5] Brignole M, Menozzi C, Bottoni N. Mechanisms of syncope caused by transient bradycardia and the diagnostic value of electrophysiologic testing and cardiovascular reflexivity maneuvers. Am J Cardiol 1995; 76: 273–278.[CrossRef][Web of Science][Medline]
[6] Kapoor W, Karpf M, Wieand S, Peterson JR, Levey GS. A prospective evaluation and follow-up of patients with syncope. N Engl J Med 1983; 309: 197–204.[Abstract]
[7] The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology 1996; 46: 1470.
[8] Krol R, Morady F, Flaker G. Electrophysiologic testing in patients with unexplained syncope: clinical and non-invasive predictors of outcome. J Am Coll Cardiol 1987; 10: 358–363.[Abstract]
[9] Raviele A, Menozzi C, Brignole M. Value of head-up tilt testing potentiated with sublingual nitroglycerin to assess the origin of unexplained syncope. Am J Cardiol 1995; 76: 267–272.[CrossRef][Web of Science][Medline]
[10] Friedman DB, Jensen FB, Matzen S, Secher NH. Non-invasive blood pressure monitoring during head-up tilt test using the Penaz principle. Acta Anestesiol Scand 1990; 34: 519–522.
[11] Petersen MEV, Williams TR, Sutton R. A comparison of non-invasive continuous finger blood pressure measurements (Finapres) with intra-arterial pressure during prolonged head-up tilt. Eur Heart J 1995; 16: 1647–1654.
[12] Grubb B and Samoil D. Neurocardiogenic syncope. In Kenny RA (Ed.). Syncope in the older patient 1996; London Chapman & Hall pp. 91–106.
[13] Schutzman J, Jaeger F, Maloney J, Fouad-Tarazi F. Head-up tilt and hemodynamic changes during orthostatic hypotension in patients with supine hypertension. J Am Coll Cardiol 1994; 24: 454–461.[Abstract]
[14] Betkoski A, Patei C, Halperin A, Jaeger F, Goren H, Fouad-Tarazi F. Reporting on the results of tilt patterns of response offer more information than changes at end-point (Abstr). Circulation 1995; 92: I–203.
[15] Morillo C, Eckberg D, Ellenbogen K. Vagal and sympathetic mechanisms in patients with orthostatic vasovagal syncope. Circulation 1997; 96: 2509–2513.
[16] Novak V, Novak P, Kus T, Nadeau R. Slow cardiovascular rhythms in tilt and syncope. J Clin Neurophysiol 1995; 12: 64–71.[Web of Science][Medline]
[17] Glick G and Yu PN. Hemodynamic changes during spontaneous vasovagal reactions. Am J Med 1963; 34: 42–51.[CrossRef][Web of Science][Medline]
[18] Gaggioli G, Bottoni N, Mureddu R, Foglia-Manzillo G, Mascioli G, Bartoli P, Musso G, Menozzi C MD, Brignole M. Effects of chronic vasodilator therapy to enhance susceptibility to vasovagal syncope during upright tilt testing. Am J Cardiol 1997; 80: 1092–1094.[CrossRef][Web of Science][Medline]
[19] Narkiewicz K and Somers V. Chronic orthostatic intolerance. Part of a spectrum of dysfunction in orthostatic cardiovascular homeostasis. Circulation 1998; 98: 2105–2107.
[20] Furlan R, Jacob G, Snell M. Chronic orthostatic intolerance. A disorder with discordant cardiac and vascular sympathetic control. Circulation 1998; 98: 2154–2159.
[21] Bou-Holaigh I, Rowe P, Kan J, Calkins H. The relationship between neurally mediated hypotension and chronic fatigue syndrome. JAMA 1995; 274: 961–967.
[22] Low P, Gilden J, Freeman R, Sheng KN, McElligott J. Efficacy of midodrine vs placebo in neurocardiogenic orthostatic hypotension. JAMA 1997; 277: 1046–1051.
[23] Ward CR, Gray JC, Gilroy JJ, Kenny RA. Midodrine: a role in the management of neurocardiogenic syncope. Heart 1998; 79: 45–49.
[24] Brignole M, Menozzi C, Lolli G, Bottoni N, Gaggioli G. Long-term outcome of paced and non-paced patients with severe carotid sinus syndrome. Am J Cardiol 1992; 69: 1039–1043.[CrossRef][Web of Science][Medline]
[25] Gaggioli G, Brignole M, Menozzi C. A positive response to head-up tilt test predicts syncopal recurrence in carotid sinus syndrome patients treated with permanent pacemakers. Am J Cardiol 1995; 76: 720–722.[CrossRef][Web of Science][Medline]
[26] Brignole M, Menozzi C, Gianfranchi L, Lolli G, Bottoni N, Oddone D. A controlled trial of acute and long-term medical therapy in tilt-induced neurally-mediated syncope. Am J Cardiol 1992; 70: 339–342.[CrossRef][Web of Science][Medline]
[27] Morillo C, Leitch J, Yee R, Klein G. 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]
[28] Di Gerolamo E, Di Iorio C, Sabatini P, Leonzio I, Barsotti A. Effects of different treatments versus no treatment on neurocardiogenic syncope. Cardiologia 1998; 43: 833–837.[Medline]
[29] Raviele A, Brignole M, Sutton R. Effect of etilefrine in preventing syncopal recurrence in patients with tilt-induced vasovagal syncope. A double-blind, randomized, placebo-controlled trial. Circulation 1999; 99: 1452–1457.[Medline]
[30] Ector H, Reybrouck T, Heidbuchel H, Van de Werf F. Tilt training: a new treatment for neurocardiogenic syncope (Abstr). Arch Mal Coeur Vaisseaux 1998; 91: 32.
[31] Mathias CJ. The classification and nomenclature of autonomic disorders: Ending chaos, restoring conflict, and hopefully achieving clarity. Clin Auton Res 1995; 5: 307–310.[CrossRef][Web of Science][Medline]
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|
|
|
|
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