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Barón-Esquivias G, Barón-Solís C, Ordóñez A. Pacing for Patients Suffering From Cardioinhibitory Vasovagal Syncope Using the Closed-Loop System. Front Cardiovasc Med 2020; 6:192. [PMID: 32118042 PMCID: PMC7033422 DOI: 10.3389/fcvm.2019.00192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022] Open
Abstract
One in three vasovagal syncope (VVS) patients has syncopal recurrence after diagnosis, despite the standard recommendations for the avoidance of a recurrence, and one in five patients has more than one syncopal recurrence in the medium term. Given the high prevalence of VVS, there is a large population that continues to need effective treatment. There are numerous studies that use the implantable loop recorder (ILR) to document a cardioinhibitory response during VVS, with one study, ISSUE-3, demonstrating the efficacy of pacing using the rate-drop-response algorithm to trigger pacing and prevent syncopal recurrence in this population. There are more uncertainties in the studies that have used head-up tilt test (HUT) to select the population for pacing. We have recently performed the SPAIN randomized, controlled clinical trial using HUT to select the patients for pacing. The conclusion of the study was that, with the closed-loop system to introduce pacing, there was a significant reduction in the burden of syncope and a seven-fold increase in the time to first recurrence of syncope, which was greater than in the ISSUE-3 study. Since the completion of the SPAIN trial and its inclusion in the European guidelines, in our daily clinical practice, the use of this therapy is still recommended with caution in the context of the available literature, but it has increased our confidence in so doing. One in five patients with VVS needs treatment because of a high syncopal load. If an ILR is used to select the patients for pacing, the rate-drop-response algorithm can be recommended. In patients who have asystole on HUT, pacing with the closed-loop system has higher success and must now be considered as a tenable option for VVS patients.
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Affiliation(s)
- Gonzalo Barón-Esquivias
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain.,Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain.,Centro de Investigacion en Biomedicina en Red Cardiovascular (CIBER-CV), Madrid, Spain
| | - Carmen Barón-Solís
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain
| | - Antonio Ordóñez
- Cardiology and Cardiac Surgery Department, Virgen del Rocio University Hospital, Seville University, Seville, Spain.,Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain.,Centro de Investigacion en Biomedicina en Red Cardiovascular (CIBER-CV), Madrid, Spain.,Centro Superior de Investigaciones Científicas (CSIC), Madrid, Spain
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2
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Baron-Esquivias G, Morillo CA. La estimulación definitiva en el paciente con síncope neuromediado. Lecciones del estudio SPAIN. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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3
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Definitive Pacing Therapy in Patients With Neuromediated Syncope. Lessons From the SPAIN Study. ACTA ACUST UNITED AC 2018; 71:320-322. [PMID: 29295807 DOI: 10.1016/j.rec.2017.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 10/06/2017] [Indexed: 11/24/2022]
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da Silva RMFL. The Current Indication for Pacemaker in Patients with Cardioinhibitory Vasovagal Syncope. Open Cardiovasc Med J 2016; 10:179-87. [PMID: 27651841 PMCID: PMC5009292 DOI: 10.2174/1874192401610010179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 05/20/2016] [Accepted: 06/06/2016] [Indexed: 11/22/2022] Open
Abstract
The most frequent cause of syncope is vasovagal reflex. It is associated with worse quality of life, depression, fatigue and physical injury. Recurrence of vasovagal syncope is an aggravating, reaching the rate of 69%. Initial step and pharmacological treatment may not work, especially in patients with recurrent syncope without prodrome. These patients can present cardioinhibitory response with asystole. Studies were designed to analyses the effectiveness of pacemaker for prevention of syncope. In this review, nonrandomized clinical trials, open-label randomized, double-blind randomized, placebo-controlled, and studies based on tilt test or Implantable Loop Recorder findings will be discussed.
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Malm D, Svensson E, Karlsson JE, Fridlund B. Health-Related Quality of Life in Pacemaker Patients: A Single and Multidimensional Self-Rated Health Comparison Study. Eur J Cardiovasc Nurs 2016; 2:291-302. [PMID: 14667485 DOI: 10.1016/s1474-5151(03)00065-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since implantation of the first permanent pacemaker in 1958, significant advances have been made in pacemaker technology. To date, however, health-related quality of life (HRQoL) in a large pacemaker population has not been investigated. With dwindling clinical resources, it is important to study HRQoL in a pacemaker population in a reliable and straightforward manner. This study aimed to determine and compare single and multidimensional self-rated health (SRH) in a pacemaker population in terms of sociodemographic characteristics, pacemaker mode and symptoms. The findings showed that irrespective of whether the perspective was single or multidimensional, this Swedish pacemaker population (n=697) with a mean age of 76 years had an acceptable HRQoL. Men, aged 65-84 years, persons who were cohabiting, who had their own dwelling, who had a DDD or who had a pacemaker for <or=3 and 4-7 years experienced better HRQoL. Efforts need to be made for women, single persons, the elderly and retired persons. In conclusion, the SRH of a pacemaker population can be trustworthy established by means of a single-dimensional SRH question.
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Affiliation(s)
- D Malm
- Department of Cardiology, County Hospital Ryhov, Jönköping S-551 85, Sweden.
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Raj SR, Faris PD, Semeniuk L, Manns B, Krahn AD, Morillo CA, Benditt DG, Sheldon RS. Rationale for the Assessment of Metoprolol in the Prevention of Vasovagal Syncope in Aging Subjects Trial (POST5). Am Heart J 2016; 174:89-94. [PMID: 26995374 DOI: 10.1016/j.ahj.2016.01.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/20/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vasovagal syncope (VVS) is a common problem associated with a poor quality of life, which improves when syncope frequency is reduced. Effective pharmacological therapies for VVS are lacking. Metoprolol is a β-adrenergic receptor antagonist that is ineffective in younger patients, but may benefit older (≥40 years) VVS patients. Given the limited therapeutic options, a placebo-controlled clinical trial of metoprolol for the prevention of VVS in older patients is needed. STRUCTURE OF STUDY The POST5 is a multicenter, international, randomized, placebo-controlled study of metoprolol in the prevention of VVS in patients ≥40 years old. The primary endpoint is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive metoprolol 25 to 100 mg BID or matching placebo, and followed up for 1 year. Secondary end points include syncope frequency, presyncope, quality of life, and cost analysis. Primary analysis will be intention to treat, with a secondary on-treatment analysis. POWER CALCULATIONS A sample size of 222, split equally between the groups achieves 85% power to detect a hazard rate of 0.3561 when the event rates are 50% and 30% in the placebo and metoprolol arms. Allowing for 10% dropout, we propose to enroll 248 patients. IMPLICATIONS This study will be the first adequately powered trial to determine whether metoprolol is effective in preventing VVS in patients ≥40 years. If effective, metoprolol may become the first line pharmacological therapy for these patients.
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Affiliation(s)
- Satish R Raj
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada; Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, TN.
| | | | - Lisa Semeniuk
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Braden Manns
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Andrew D Krahn
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | | | - David G Benditt
- Cardiac Arrhythmia and Syncope Center, University of Minnesota, Minneapolis, MN
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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Sumiyoshi M. Role of permanent cardiac pacing for vasovagal syncope. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Coffin ST, Raj SR. Non-invasive management of vasovagal syncope. Auton Neurosci 2014; 184:27-32. [PMID: 24996861 DOI: 10.1016/j.autneu.2014.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/06/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
Vasovagal syncope (VVS) is a common disorder of the autonomic nervous system. While recurrent syncope can cause very impaired quality of life, the spells are not generally life-threatening. Both non-pharmacological and pharmacological approaches can be used to treat patients. Conservative management with education, exercise and physical maneuvers, and aggressive volume repletion is adequate for controlling symptoms in most patients. Unfortunately, a minority of patients will continue to have recurrent syncope despite conservative therapy, and they may require medications. These could include vasopressor agents, beta-blockers, or neurohormonal agents. Some patients may require more aggressive device based therapy with pacemakers or radiofrequency ablation, which are emerging therapies for VVS. This paper will review non-procedure based treatments for VVS.
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Affiliation(s)
- Samuel T Coffin
- Autonomic Dysfunction Center, Vanderbilt University School of Medicine, USA; Department of Medicine, Vanderbilt University School of Medicine, USA
| | - Satish R Raj
- Autonomic Dysfunction Center, Vanderbilt University School of Medicine, USA; Department of Medicine, Vanderbilt University School of Medicine, USA; Department of Pharmacology, Vanderbilt University School of Medicine, USA.
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Sousa PA, Candeias R, Marques N, Jesus I. Reflex vasovagal syncope--is there a benefit in pacemaker therapy? Rev Port Cardiol 2014; 33:297-303. [PMID: 24895017 DOI: 10.1016/j.repc.2014.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 01/28/2014] [Accepted: 02/02/2014] [Indexed: 11/16/2022] Open
Abstract
Reflex vasovagal syncope often affects young populations and is associated with a benign prognosis in terms of mortality. However, a minority of patients have recurrent episodes, with a considerable impact on their quality of life. Pacemaker therapy has been an option in these patients since the 1990s if a conservative strategy fails. Initially, non-randomized and open-label randomized trials showed promising results, but these studies were associated with a significant placebo effect. Recently, an approach based on the use of implantable loop recorders has shown that some patients with reflex vasovagal syncope could benefit from implantation with dual-chamber pacemakers, particularly patients aged >40 years, with recurrent syncopal episodes resulting in frequent injuries, in whom a long asystole (≥3 s asystole with syncope or ≥6 s asystole without syncope) has been documented with an implantable loop recorder. The authors present a literature review on the role of cardiac pacing in reflex vasovagal syncope and propose a diagnostic and therapeutic decision flowchart for patients with syncope of probable reflex etiology.
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Affiliation(s)
| | - Rui Candeias
- Serviço de Cardiologia, Hospital de Faro, E.P.E., Faro, Portugal
| | - Nuno Marques
- Serviço de Cardiologia, Hospital de Faro, E.P.E., Faro, Portugal
| | - Ilídio Jesus
- Serviço de Cardiologia, Hospital de Faro, E.P.E., Faro, Portugal
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Sousa PA, Candeias R, Marques N, Jesus I. Reflex vasovagal syncope – Is there a benefit in pacemaker therapy? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2014.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Russo V, Rago A, Papa AA, Golino P, Calabrò R, Russo MG, Nigro G. The effect of dual-chamber closed-loop stimulation on syncope recurrence in healthy patients with tilt-induced vasovagal cardioinhibitory syncope: a prospective, randomised, single-blind, crossover study. Heart 2013; 99:1609-13. [PMID: 23723446 DOI: 10.1136/heartjnl-2013-303878] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NAM, Ferguson TB, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AJ, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2012; 61:e6-75. [PMID: 23265327 DOI: 10.1016/j.jacc.2012.11.007] [Citation(s) in RCA: 552] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation 2012; 127:e283-352. [PMID: 23255456 DOI: 10.1161/cir.0b013e318276ce9b] [Citation(s) in RCA: 374] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Vyas A, Swaminathan PD, Zimmerman MB, Olshansky B. Are treatments for vasovagal syncope effective? A meta-analysis. Int J Cardiol 2012; 167:1906-11. [PMID: 22626839 DOI: 10.1016/j.ijcard.2012.04.144] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 04/28/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Therapies used to treat vaso-vagal syncope (VVS) recurrence have not been proven effective in single studies. METHODS Comprehensive search of PubMed, EMBASE and Cochrane Central databases of published trials was done. Randomized or non-randomized studies, comparing the intervention of interest to control group(s), with the endpoint of spontaneous recurrence or syncope on head-up tilt test, were included. Data were extracted on an intention-to-treat basis. Study heterogeneity was analyzed by Cochran's Q statistics. A random-effect analysis was used. RESULTS α-adrenergic agonists were found effective (n=400, OR 0.19, CI 0.06-0.62, p<0.05) in preventing VVS recurrence. β-blockers were not found to be effective when only randomized studies comparing β-blockers to non-pharmacologic agents were assessed (9 studies, n=583, OR 0.48, CI 0.22-1.04, p=0.06). Tilt-training had no effect when only randomized studies were considered (4 studies, n=298, OR 0.47, CI 0.21-1.05, p=0.07). Selective serotonin reuptake inhibitors were found effective (n=131, OR 0.28, CI 0.10-0.74, p<0.05), though the analysis contained only 2 studies. Pacemakers were found effective in preventing syncope recurrence when all studies were analyzed (n=463, OR 0.13, CI 0.05-0.36, p<0.05). However, studies comparing active pacemaker to sensing mode only did not show benefit (3 studies, n=162, OR 0.45, CI 0.09-2.14, p=0.32). CONCLUSIONS This meta-analysis highlights the totality of evidence for commonly used medications used to treat VVS, and the requirement for larger, double-blind, placebo controlled trials with longer follow-up.
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Affiliation(s)
- Ankur Vyas
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, United States.
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Raj SR, Faris PD, McRae M, Sheldon RS. Rationale for the prevention of syncope trial IV: assessment of midodrine. Clin Auton Res 2012; 22:275-80. [PMID: 22610268 DOI: 10.1007/s10286-012-0167-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 04/25/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Vasovagal syncope is a common problem associated with a poor quality of life, which improves when the frequency of syncope is reduced. Effective pharmacological therapies for vasovagal syncope have been elusive. Midodrine is a pro-drug whose primary metabolite is an alpha-1 adrenoreceptor agonist. A few studies have suggested that it may be beneficial in syncope, but all have had significant methodological limitations. A placebo-controlled clinical trial of midodrine for the prevention of vasovagal syncope is needed. STRUCTURE OF STUDY The prevention of syncope trial IV (POST 4) is a multicenter, international, randomized, placebo-controlled study of midodrine in the prevention of vasovagal syncope. The primary end point is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive midodrine 10-30 mg/day or matching placebo, and followed for 1 year. Secondary end points include syncope frequency, presyncope, and quality of life. Primary analysis will be performed with an intention-to-treat approach, with a secondary on-treatment analysis. POWER CALCULATIONS A total sample size of 112, split equally between the two groups, achieves 85 % power to detect a 50 % relative risk reduction when the event rates are 55 and 27.5 % in the placebo and midodrine arms. Allowing for 20 % dropout, we propose to enroll 140 patients. REGISTRATION POST 4 is registered with http://www.clinicaltrials.gov (NCT01456481). IMPLICATIONS This study will be the first adequately powered trial to determine whether midodrine is effective in preventing vasovagal syncope. If it is effective, then midodrine may become the first-line pharmacological therapy for this condition.
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Affiliation(s)
- Satish R Raj
- Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University, Nashville, TN 37232-2195, USA.
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Closed-loop cardiac pacing vs. conventional dual-chamber pacing with specialized sensing and pacing algorithms for syncope prevention in patients with refractory vasovagal syncope: results of a long-term follow-up. Europace 2012; 14:1038-43. [DOI: 10.1093/europace/eur419] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Arnaout R, Thorson A. Late Recognition of Malignant Vasovagal Syncope. Card Electrophysiol Clin 2010; 2:281-283. [PMID: 28770764 DOI: 10.1016/j.ccep.2010.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A 21-year-old female with a history of seizures since the age of 5 presented for long-term electroencephalographic (EEG) monitoring, but was found instead to have neurocardiogenic syncope. Is it appropriate for this patient to get a pacemaker?
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Affiliation(s)
- Rima Arnaout
- Cardiology Division, University of California, 505 Parnassus Avenue, Box 0214, Moffit 1180D, San Francisco, CA 94143-0214, USA
| | - Anne Thorson
- Cardiology Division, University of California, 505 Parnassus Avenue, Box 0214, Moffit 314A, San Francisco, CA 94143-0214, USA
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Preliminary observations on the use of closed-loop cardiac pacing in patients with refractory neurocardiogenic syncope. J Interv Card Electrophysiol 2009; 27:69-73. [DOI: 10.1007/s10840-009-9452-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 10/13/2009] [Indexed: 11/26/2022]
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SHELDON ROBERTS, AMUAH JOSEPHE, CONNOLLY STUARTJ, ROSE SARAH, MORILLO CARLOSA, TALAJIC MARIO, KUS TERESA, FOUAD-TARAZI FETNAT, KLINGENHEBEN THOMAS, KRAHN ANDREWD, KOSHMAN MARYLOU, RITCHIE DEBBIE. Effect of Metoprolol on Quality of Life in the Prevention of Syncope Trial. J Cardiovasc Electrophysiol 2009; 20:1083-8. [DOI: 10.1111/j.1540-8167.2009.01518.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Simantirakis EN, Arkolaki EG, Vardas PE. Novel pacing algorithms: do they represent a beneficial proposition for patients, physicians, and the health care system? Europace 2009; 11:1272-80. [DOI: 10.1093/europace/eup204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kaszala K, Huizar JF, Ellenbogen KA. Contemporary pacemakers: what the primary care physician needs to know. Mayo Clin Proc 2008; 83:1170-86. [PMID: 18828980 DOI: 10.4065/83.10.1170] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pacemaker therapy is most commonly initiated because of symptomatic bradycardia, usually resulting from sinus node disease. Randomized multicenter trials assessing the relative benefits of different pacing modes have made possible an evidence-based approach to the treatment of bradyarrhythmias. During the past several decades, major advances in technology and in our understanding of cardiac pathophysiology have led to the development of new pacing techniques for the treatment of heart failure in the absence of bradycardia. Left ventricular or biventricular pacing may improve symptoms of heart failure and objective measurements of left ventricular systolic dysfunction by resynchronizing cardiac contraction. However, emerging clinical data suggest that long-term right ventricular apical pacing may have harmful effects. As the complexity of cardiac pacing devices continues to grow, physicians need to have a basic understanding of device indications, device function, and common problems encountered by patients with devices in the medical and home environment.
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Affiliation(s)
- Karoly Kaszala
- Medical College of Virginia, PO Box 980053, Richmond, VA 23298-0053, USA.
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 51:e1-62. [PMID: 18498951 DOI: 10.1016/j.jacc.2008.02.032] [Citation(s) in RCA: 1090] [Impact Index Per Article: 68.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Executive Summary. Circulation 2008. [DOI: 10.1161/circualtionaha.108.189741] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm 2008; 5:e1-62. [PMID: 18534360 DOI: 10.1016/j.hrthm.2008.04.014] [Citation(s) in RCA: 196] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Indexed: 01/27/2023]
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Epstein AE, Dimarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: executive summary. Heart Rhythm 2008; 5:934-55. [PMID: 18534377 DOI: 10.1016/j.hrthm.2008.04.015] [Citation(s) in RCA: 267] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Indexed: 11/16/2022]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350-408. [PMID: 18483207 DOI: 10.1161/circualtionaha.108.189742] [Citation(s) in RCA: 935] [Impact Index Per Article: 58.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sud S, Klein GJ, Skanes AC, Gula LJ, Yee R, Krahn AD. Implications of mechanism of bradycardia on response to pacing in patients with unexplained syncope. Europace 2007; 9:312-8. [PMID: 17376795 DOI: 10.1093/europace/eum020] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIM Asystole >3 s or sinus bradycardia with a ventricular rate <40 in association with complete heart block or sinus node dysfunction are considered to be Class 1 indications for permanent cardiac pacing. Nevertheless, these phenomena may be observed in symptomatic patients with neurocardiogenic syncope, who may not respond to pacing therapy. We hypothesized that the pattern of spontaneous bradycardia in symptomatic patients would distinguish patients with sinus node dysfunction or conduction system disease who would benefit from pacing from patients with neurally-mediated syncope who would derive lesser benefit. METHODS AND RESULTS Patients with symptomatic spontaneous bradycardia during long-term monitoring for unexplained syncope who underwent pacemaker implantation were classified according to the ISSUE classification system and followed for recurrent syncope. Follow-up included review of medical records, pacemaker clinic visits, and telephone interviews. Loop recorder tracings were reviewed to identify characteristics potentially predicting a favourable response to pacing. Thirty-three patients (21 male; age, 70 +/- 14) were followed for 3.56 +/- 1.71 years. Six patients had a recurrence of syncope during the follow-up. All patients with recurrent syncope despite pacing demonstrated a Type 1A (n = 5) or 1B (n = 1) pattern with gradual onset of bradycardia at baseline, suggesting a neurocardiogenic mechanism. There was no difference in the severity of bradycardia or duration of asystole in baseline loop recorded events in responding and non-responding patients. Multivariate analysis using stepwise logistic regression revealed that the ISSUE classification and the absence of structural heart disease were the only independent predictors of treatment failure of cardiac pacing in patients with spontaneous symptomatic bradycardia. CONCLUSION Patients with syncope associated with abrupt bradycardia displayed a better response to cardiac pacing therapy than those with gradual onset bradycardia.
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Affiliation(s)
- Sachin Sud
- Division of Cardiology, University of Western Ontario, London Health Sciences Centre, University Campus, C6-113 339 Windermere road, London, Ontario N6A 5A5, Canada
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29
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Dixit S, Marchlinski FE. Cardiac Pacemakers. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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30
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Abstract
Sinus node disease and atrioventricular block are common etiologies of symptomatic bradyarrhythmias in the elderly and remain the leading indications for permanent pacemaker implantation. In fact, the vast majority (>80%) of all pacemakers are implanted in the elderly. Whereas indications of pacemaker therapy have been largely unchanged over the past several years, several questions, such as differences in pacemaker mode selection, remained unanswered. Recent large, randomized, multicenter trials have evaluated the benefits of pacemaker therapy in sinus node dysfunction and acquired atrioventricular block and have provided us with further insights into the difference between atrial- and ventricular-based pacing in these syndromes. Further evaluation of the most appropriate pacing mode in the elderly as well as the outcome of pacing in the elderly are addressed in this review.
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Affiliation(s)
- Karoly Kaszala
- Cardiac Electrophysiology Program, Division of Cardiology, McGuire VA Medical Center, Richmond, VA, USA
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31
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Raj SR, Rose S, Ritchie D, Sheldon RS. The Second Prevention of Syncope Trial (POST II)--a randomized clinical trial of fludrocortisone for the prevention of neurally mediated syncope: rationale and study design. Am Heart J 2006; 151:1186.e11-7. [PMID: 16781217 DOI: 10.1016/j.ahj.2006.03.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Accepted: 03/20/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND Neurally mediated syncope is a common and frequently distressing problem. It is associated with a poor quality of life, which improves when the frequency of syncope is reduced. Few therapies for neurally mediated syncope have been proven effective. Fludrocortisone is commonly used to prevent recurrences of syncope but with little evidence to support its use. A placebo-controlled clinical trial of fludrocortisone for the prevention of neurally mediated syncope is needed. STRUCTURE OF STUDY POST II is a multicenter, international, randomized, placebo-controlled study of fludrocortisone in the prevention of neurally mediated syncope. The primary end point is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive fludrocortisone 0.05 to 0.2 mg or matching placebo and followed for 1 year. Secondary end points include syncope frequency, presyncope, and quality of life. Primary analysis will be performed with an intention-to-treat approach, with a secondary on-treatment analysis. POWER CALCULATIONS Assuming a 40% risk of syncope in the control arm, a relative reduction of 40% by fludrocortisone, and a dropout rate of 20%, the enrollment of 310 patients will give an 80% power of reaching a positive conclusion about fludrocortisone therapy, with P = .05. REGISTRATION POST II is registered with both (ISRCTN 51802652) and (NCT00118482). IMPLICATIONS This study will be the first adequately powered trial to determine whether fludrocortisone is effective in preventing neurally mediated syncope. If it is effective, then fludrocortisone may become the first-line medical therapy for this condition.
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Affiliation(s)
- Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
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32
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Theodorakis GN, Leftheriotis D, Livanis EG, Flevari P, Karabela G, Aggelopoulou N, Kremastinos DT. Fluoxetine vs. propranolol in the treatment of vasovagal syncope: a prospective, randomized, placebo-controlled study. ACTA ACUST UNITED AC 2006; 8:193-8. [PMID: 16627439 DOI: 10.1093/europace/euj041] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS To compare the therapeutic efficacy of placebo, propranolol, and fluoxetine in patients with vasovagal syncope (VVS). METHODS AND RESULTS Ninety-six consecutive patients with VVS were randomized to treatment with placebo, propranolol, or fluoxetine and followed-up for 6 months. Before and during treatment, they reported their syncopal and presyncopal episodes and graded their well-being, expressed as the general evaluation of life, general activities, and everyday activities (each scaled from 1 = very good to 5 = very bad). Two patients refused follow-up. Among the remaining 94, no difference between groups was observed regarding the distribution of time of vasovagal events (syncopes or presyncopes) during follow-up (log-rank test). No difference was also observed when syncopes and presyncopes were assessed separately. Eighteen patients discontinued therapy. Among the remaining 76 ('on-treatment' analysis), the mean time to a vasovagal episode (syncope or presyncope) was significantly longer in the fluoxetine group when compared with the two other groups (log-rank test, P < 0.05). A significant difference in favour of fluoxetine was also observed regarding presyncopes. The difference between groups regarding the syncope-free period was not significant. During therapy, patients' well-being was improved (decreased) only in the fluoxetine-group (13.4 +/- 0.7 vs. 15.4 +/- 0.9 before treatment, P < 0.01). CONCLUSION Fluoxetine seems to be equivalent to propranolol and placebo in the treatment of VVS. However, it improves patients' well-being and might be more effective in reducing presyncopes and total vasovagal events in some patients with recurrent VVS.
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Affiliation(s)
- George N Theodorakis
- Second Department of Cardiology, Onassis Cardiac Surgery Center, 356 Syngrou Avenue, 17674 Athens Greece.
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33
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Fortrat JO, Lemarie C, Bellard E, Victor J. Do we need a reflex tachycardia to stand up? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:962-7. [PMID: 16176536 DOI: 10.1111/j.1540-8159.2005.00216.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sophisticated atrio-ventricular pacing models are designed to integrate the pacemaker into cardiovascular autonomic control to react appropriately to the cardiovascular demands. Such an approach might be beneficial for patients with vasovagal responses to counterbalance the upright fall in arterial blood pressure by a pacing rate increase. We hypothesized that this approach would improve the cardiovascular response to standing in comparison with a regular pacing mode. METHODS Two 5-minute tilt tests were performed in a random order in 5 patients with a pacemaker (CLS-INOS(2)) for sinus node disease and atrio-ventricular block. One tilt test was performed in fixed pacing rate (DDD), the other one was performed in close loop stimulation (CLS), which allowed an upright rate-rise pacing. Heart rate, systolic blood pressure, and cardiac output (modelflow) were recorded on a beat-by-beat basis. RESULTS Changes of systolic blood pressure and cardiac output in response to upright posture were not significantly different between DDD and CLS modes (2.7 +/- 13.2 vs 10.1 +/- 12.9 mmHg and -0.8 +/- 0.3 vs -1.1 +/- 0.4 L/min, respectively). But upright posture led to a tachycardia of more than 30 bpm in 3 patients in CLS mode and to a fall in systolic blood pressure greater than 20 mmHg in 3 patients in CLS mode and only in one patient in DDD mode. CONCLUSION Systolic blood pressure and cardiac output are not improved by the upright tachycardia and upright blood pressure response is actually worsened when an upright rate-rise pacing is used. Thus, it appears that tachycardia alone cannot compensate for an upright fall in blood pressure.
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Affiliation(s)
- Jacques-Olivier Fortrat
- Laboratoire de Physiologie, Faculté de Médecine, Centre Hospitalo-Universitaire, Faculté de Médecine, 49045 Angers Cedex, France.
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Stofmeel MAM, van Stel HF, van Hemel NM, Grobbee DE. The relevance of health related quality of life in paced patients. Int J Cardiol 2005; 102:377-82. [PMID: 16004880 DOI: 10.1016/j.ijcard.2004.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2004] [Revised: 08/17/2004] [Accepted: 10/04/2004] [Indexed: 11/18/2022]
Abstract
With the tremendous advances in cardiac pacing during the past four decades, cardiac pacemaker implantation is now a common clinical procedure. In recent years, the indications for permanent pacemakers have expanded. This increase in reasons for pacing and shift in mode of pacing have been caused by the evolution of pacemaker therapy from a life-saving measure (mortality), to one aimed at improving health-related quality of life (HRQoL). Until now the efficacy of pacing therapy has predominantly been measured using "objective" criteria. However, in recent years the importance of HRQoL as an outcome measure has increasingly been recognized as patients prefer quality over quantity of life. In this review we describe the development and testing of Aquarel, a new developed HRQoL questionnaire for pacemaker patients, composed of a generic core module with disease specific add-ons. Current and future research to improve the Aquarel questionnaire is also described.
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35
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Kosinski DJ, Grubb BP, Wolfe DA. Permanent cardiac pacing as primary therapy for neurocardiogenic (reflex) syncope. Clin Auton Res 2004; 14 Suppl 1:76-9. [PMID: 15480934 DOI: 10.1007/s10286-004-1011-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Recurrent reflex (or neurocardiogenic) syncope is a common clinical problem. Pacemaker therapy has been advocated as a potential therapy in severe or drug refractory cases of reflex syncope, while others have suggested that it may provide a benefit if employed as a primary therapeutic modality. The following paper reviews the concepts behind pacemaker therapy for reflex syncope and the results of various clinical trials that have evaluated its potential utility as a primary therapeutic modality.
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Affiliation(s)
- Daniel J Kosinski
- Electrophysiology Section, Division of Cardiology, Dept. of Medicine, Medical College of Ohio, Toledo, OH 43614, USA
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36
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Galtes I, Lamas GA. Cardiac pacing for bradycardia support: Evidence-based approach to pacemaker selection and programming. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:385-395. [PMID: 15324614 DOI: 10.1007/s11936-004-0022-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The vast majority of pacemakers implanted in the United States for the treatment of symptomatic bradycardia are dual-chamber systems with a complex array of functions, such as rate responsiveness, dynamic atrioventricular delay, and automatic mode switching. Basic hemodynamic studies have convincingly demonstrated the superiority of maintaining atrioventricular synchrony. However, clinical trials have failed to demonstrate the impressive results expected based on physiologic data. The most recent randomized clinical trials have demonstrated that dual-chamber devices, when compared with single-chamber ventricular pacing, do not prevent mortality or stroke, and lead to an unexpectedly small reduction in heart failure hospitalizations. Although improvements in quality of life have not been consistently found when comparing ventricular-based versus atrial-based pacing, a reduction in the incidence of newly diagnosed atrial fibrillation in dual chamber-paced patients has been reported by most trials. Dual-chamber pacing has been reported to reduce pacemaker syndrome in US trials. The addition of rate modulation, in spite of attempting to replicate the normal response to exercise, has not shown a consistently positive impact on quality of life or treadmill time. The use of pacemakers for the treatment of vasovagal syncope is controversial. Adding dual-chamber sensing ability to current implanted defibrillators considerably reduces the number of inappropriate shocks but may increase mortality if not programmed to minimize ventricular stimulation.
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Affiliation(s)
- Israel Galtes
- Mount Sinai Medical Center, Butler Building, 4300 Alton Road, Miami Beach, FL 33140, USA.
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37
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Barón-Esquivias G, Cayuela A, Gómez S, Aguilera A, Campos A, Fernández M, Cabezón S, Morán JE, Valle JI, Martínez A, Pedrote A, Errázquin F, Burgos J. [Quality of life in patients with vasovagal syncope. Clinical parameters influence]. Med Clin (Barc) 2003; 121:245-9. [PMID: 12975035 DOI: 10.1016/s0025-7753(03)75188-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The prevalence and morbidity of the vaso-vagal syncope are well-known. With the intention of measuring the Quality of Life (QoL) of patients with vaso-vagal syncope, as well as age and gender influence, we have used the Spanish version of Short form 36 (SF-36) questionnaire in those patients and have compared it with the general population and with patients with heart failure. PATIENTS AND METHOD All consecutive patients with vaso-vagal syncope submitted for head-up tilt test performance from January 2001 to December 2002 were included. SF-36 was self-administered prior to the head-up tilt test. RESULTS Two hundred and seventy one patients were included (50.5% females). In these patients, QoL scores were lower than those of the Spanish general population and similar to those in patients with heart failure. Women's scores were lower in eight dimensions, and only four were lower in men's. Women QoL was worst than men's (p < 0.05). Age had a negative influence on the eight dimensions of SF-36, especially in women. The number of syncopes was the most influential clinic parameter on the QoL of such patients. CONCLUSIONS In our series, patients suffering from vaso-vagal syncope had a poor QoL when compared with heart failure or control populations. Women had lower QoL than men, and there was an age-related worsening in both men and women. Our data show that the number of syncopes is the clinic parameter having the best correlation with QoL.
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38
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Raj SR, Koshman ML, Sheldon RS. Outcome of patients with dual-chamber pacemakers implanted for the prevention of neurally mediated syncope. Am J Cardiol 2003; 91:565-9. [PMID: 12615261 DOI: 10.1016/s0002-9149(02)03307-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Dual-chamber pacemaker insertion (PI) has been found to reduce the recurrence of neurally mediated syncope (NMS) in 3 randomized trials. However, the long-term benefits of PI are unknown. To assess the natural history of NMS, we followed a cohort of 40 patients who underwent PI for frequent NMS for 46 to 75 months. We assessed the reduction in syncope frequency after PI and the time to first recurrence of syncope. Sixty months after PI, 32.5% of patients remained free of NMS. The frequency of syncope decreased from 0.46 to 0.06 spells/month (before to after PI, p = 0.04). Two groups of patients were identified, with responders to PI defined as having a 75% decrease in the frequency of NMS. Responders (n = 22) experienced a significant decrease in the frequency of NMS (0.31 to 0.01 spells/month, p <0.0001), whereas nonresponders did not experience a similar reduction (p = 0.8). Responders could not be identified by either baseline or tilt-test parameters. Patients without an early recurrence of syncope after PI (within 6 months) experienced a significant reduction in the frequency of NMS (0.24 to 0.02 spells/month, p = 0.0002), although the reduction was not significant (p = 0.3) in patients with an early recurrence of syncope. Some, but not all, patients respond to permanent PI for NMS. The long-term benefit of permanent PI can be predicted by timing of the first recurrence of syncope, but not by preimplantation factors.
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Affiliation(s)
- Satish R Raj
- Cardiovascular Research Group, University of Calgary, Alberta, Canada
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39
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Abstract
Patients with frequent vasovagal syncope have a poor quality of life and often resist treatment with standard pharmacologic approaches. Clinical vasovagal syncope may be associated with some degree of bradycardia. Studies of temporary pacing during tilt table tests showed that pacing prevented syncope in a little more than half of patients who developed a vasovagal response. Six open-label studies of permanent pacing show that permanent pacemaker therapy is associated with substantial improvement over medical therapy. The roles of specific pacemaker modes have not been determined, although there is some evidence that rate-drop responsiveness helps. The second Vasovagal Pacemaker Study will quantify the true benefits of pacing for vasovagal syncope and assess the role of rate-drop response algorithms.
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Affiliation(s)
- Satish R Raj
- Cardiovascular Research Group, University of Calgary, Calgary, Alberta, Canada
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40
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Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, Kerber RE, Naccarelli GV, Schoenfeld MH, Silka MJ, Winters SL. ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). J Am Coll Cardiol 2002; 40:1703-19. [PMID: 12427427 DOI: 10.1016/s0735-1097(02)02528-7] [Citation(s) in RCA: 270] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Gabriel Gregoratos
- Resource Center, American College of Cardiology Foundation, 9111 Old Georgetown Road, Bethesda, MD 20814-1699, USA
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41
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Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, Kerber RE, Naccarelli GV, Schoenfeld MH, Silka MJ, Winters SL, Gibbons RJ, Antman EM, Alpert JS, Gregoratos G, Hiratzka LF, Faxon DP, Jacobs AK, Fuster V, Smith SC. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation 2002; 106:2145-61. [PMID: 12379588 DOI: 10.1161/01.cir.0000035996.46455.09] [Citation(s) in RCA: 534] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
The disorders of autonomic control associated with orthostatic intolerance are a diverse group of syndromes that can result in syncope and near-syncope. A basic understanding of the pathophysiology of these disorders is essential to diagnosis and proper treatment. It is especially important to recognise the difference between the effect of prolonged upright posture on a failing autonomic nervous system (a hyposensitive or dysautonomic response) and the vasovagal response (which may be a hypersensitive response). Vasovagal syncope is the most common abnormal response to upright posture and occurs in all age groups. The advent of tilt table testing has helped define a population with an objective finding during provocative testing that has enabled researchers to study the mechanism of vasovagal syncope and to evaluate the efficacy of treatments. In most patients, vasovagal syncope occurs infrequently and only under exceptional circumstances and treatment is not needed. Treatment may be indicated in patients with recurrent syncope or with syncope that has been associated with physical injury or potential occupational hazard. Based on study data, patients with vasovagal syncope can now be risk stratified into a high-risk group likely to have recurrent syncope and a low-risk group. Many patients with vasovagal syncope can be effectively treated with education, reassurance and a simple increase in dietary salt and fluid intake. In others, treatment involves removal or avoidance of agents that predispose to hypotension or dehydration. However, when these measures fail to prevent the recurrence of symptoms, pharmacological therapy is usually recommended. Although many pharmacological agents have been proposed and/or demonstrated to be effective based on nonrandomised clinical trials, there is a remarkable absence of data from large prospective clinical trials. Data from randomised placebo-controlled studies support the efficacy of beta-blockers, midodrine, serotonin reuptake inhibitors and ACE inhibitors. There is also considerable clinical experience and a consensus suggesting that fludrocortisone is effective. Encouraging new data suggest that a programme involving tilt training can effectively prevent vasovagal syncope. For patients with recurrent vasovagal syncope that is refractory to these treatments, implantation of a permanent pacemaker with specialised sensing/pacing algorithms appears to be effective. A number of larger clinical trials are underway which should help further define the efficacy of a number of different treatments for vasovagal syncope.
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Affiliation(s)
- Daniel M Bloomfield
- Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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43
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Abstract
Patients with frequent vasovagal syncope have a poor quality of life and often resist treatment with standard pharmacologic approaches. Although the evidence is weak, clinical vasovagal syncope is probably associated with some degree of bradycardia. Studies of temporary pacing during tilt table tests showed that pacing prevented syncope in a little over half of patients who developed a vasovagal response. Six open-label studies of permanent pacing show that permanent pacemaker therapy is associated with substantial improvement over medical therapy. The roles of specific pacemaker modes have not been determined, although there is some evidence that rate-drop responsiveness helps. The second Vasovagal Pacemaker Study will quantify the true benefits of pacing for vasovagal syncope and assess the role of rate-drop response algorithms.
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Affiliation(s)
- Satish R Raj
- Cardiovascular Research Group, University of Calgary, Calgary, Alberta, Canada
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44
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Nerheim P, Olshansky B. Syncope. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2001; 3:299-310. [PMID: 11445060 DOI: 10.1007/s11936-001-0092-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Successful treatment of patients with syncope depends on the accuracy of the diagnosis, because syncope is a symptom, not a disease; diagnosis of the cause for syncope therefore creates a blueprint for treatment. Most experienced practitioners can diagnose the cause of syncope for less than half of their patients. Excessive and repeat testing is expensive and may not improve the chance of a correct diagnosis. Patient history is the key to the diagnosis. Treatment may vary from a lifestyle change to open heart surgery. The great challenge of treating patients with syncope is to provide cost-effective, safe therapy to those with a benign course and still provide needed treatment for those whose syncope is life threatening.
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Affiliation(s)
- Pamela Nerheim
- Division of Cardiology, The University of Iowa Hospitals, 200 Hawkins Drive,Iowa City, IA 52242-1081, USA.
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45
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Slotwiner DJ, Stein KM, Markowitz SM, Mittal S, Iwai S, Das M, Lerman BB. Emerging indications for cardiac pacing. HEART DISEASE (HAGERSTOWN, MD.) 2001; 3:224-30. [PMID: 11975798 DOI: 10.1097/00132580-200107000-00004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Substantial data have been accumulated and indications have been well delineated for pacemaker implantation in the treatment of sinus node dysfunction and heart block. However, many other indications have been proposed for pacemaker implantation. In this review, the authors examine available data regarding pacemaker implantation for new indications: neurally mediated syncope, hypertrophic obstructive cardiomyopathy, congestive heart failure, prevention of atrial fibrillation, and the relative merits of single-chamber and dual-chamber pacemakers.
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Affiliation(s)
- D J Slotwiner
- Department of Medicine, Division of Cardiology, New York Hospital-Cornell University Medical College, New York, New York 10021, USA
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46
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Abstract
Pacing is a field of rapid clinical progress and technologic advances. Clinical progress in the 1990s included the refinement of indications for pacing as well as the use of pacemakers for new, nonbradycardiac indications, such as the treatment of cardiomyopathies and CHF and the prevention of atrial fibrillation. Important published data and studies in progress are shedding new light on issues of pacing mode selection, and they may influence future practice significantly. Important technologic advances include development of new rate-adaptive sensors and sensor combinations and the evolution of pacemakers into sophisticated diagnostic devices with the capability to store data and ECGs. Automatic algorithms monitor the patient for appropriate capture, sensing, battery status, and lead impedance, providing better patient safety and pacemaker longevity.
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Affiliation(s)
- M Glikson
- Pacemaker Service, Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
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47
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Stofmeel MA, Post MW, Kelder JC, Grobbee DE, van Hemel NM. Psychometric properties of Aquarel. a disease-specific quality of life questionnaire for pacemaker patients. J Clin Epidemiol 2001; 54:157-65. [PMID: 11166531 DOI: 10.1016/s0895-4356(00)00275-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In cardiac pacing current clinical practice permits the use of ventricular or atrioventricular-synchronous pacemakers. However, it is not known which type of pacemaker results in superior clinical and patient outcomes. To date, there is no feasible and validated disease-specific questionnaire for pacemaker patients to assess quality of life (QoL) available. The Aquarel questionnaire was developed as a disease-specific extension to the Short-Form-36 (SF-36). A cross-sectional study was carried out in 74 pacemaker patients to evaluate validity and reliability of this instrument. Items were selected and scales constructed based on factorial analysis. Internal consistency, content validity and test-retest reliability were moderate to excellent. Correlations with the SF-36 scales, pacing mode and functional tests were as hypothesized, demonstrating the individual value and distinctiveness of the Aquarel subscales. The results support the feasibility and usefulness of evaluating QoL in pacemaker patients when using Aquarel as an extension to the SF-36.
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Rose MS, Koshman ML, Spreng S, Sheldon R. The relationship between health-related quality of life and frequency of spells in patients with syncope. J Clin Epidemiol 2000; 53:1209-16. [PMID: 11146266 DOI: 10.1016/s0895-4356(00)00257-2] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Chronic syncope has a wide range of symptom burden, and anecdotal data suggest substantial but variable physical and psychosocial morbidity. We hypothesized that health-related quality of life (HRQL) is impaired in syncope patients and the degree of impairment is proportional to syncope frequency. The EuroQol EQ-5D was completed by 136 patients (79 female and 57 male) with mean age 40 (SD = 17) prior to assessment. HRQL was substantially impaired in syncope patients compared to population norms in all five dimensions of health measured by the EQ-5D. In patients with six or more lifetime syncopal spells there was a significant (P < 0.001) negative relationship between the frequency of spells and overall perception of health, which was not evident in those who had a history of less than six lifetime spells. These relationships were maintained after controlling for comorbid conditions.
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Affiliation(s)
- M S Rose
- Health Research Group, University of Calgary, 3330 Hospital Drive N. W., Calgary, T2N 4N1, Alberta, Canada
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Abstract
The automated measurement of the main electrical parameters of pacemakers, such as battery voltage, current drain, pacing impedance, sensing levels, and pacing thresholds enables a continuous monitoring of the adequate functioning of the implanted device. New technologies in device interrogation, data transfer, and patient alert functions will enhance therapy safety significantly by the immediate detection of all, including transient, device malfunctions. The introduction of this technology will result in major changes in follow-up of patients with pacemakers. Technically we are very close to the goal of a fully automated pacemaker, although clinical acceptance lags behind. Clinical studies are necessary to demonstrate the beneficial effects of automated device functions, with regard to the main rationales for pacemaker automatization: increased patient safety, improved quality of life, and an improvement in the cost-benefit ratio in pacemaker therapy.
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Affiliation(s)
- J Neuzner
- Department of Cardiology-Electrophysiology, Kerckhoff-Klinik, Bad Nauheim, Germany
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50
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Sutton R, Brignole M, Menozzi C, Raviele A, Alboni P, Giani P, Moya A. Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope : pacemaker versus no therapy: a multicenter randomized study. The Vasovagal Syncope International Study (VASIS) Investigators. Circulation 2000; 102:294-9. [PMID: 10899092 DOI: 10.1161/01.cir.102.3.294] [Citation(s) in RCA: 258] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND-This study was performed to compare implantation of a DDI pacemaker with rate hysteresis with no implant in respect to syncopal recurrences in patients with severe cardioinhibitory tilt-positive neurally mediated syncope. METHODS AND RESULTS-Forty-two patients from 18 European centers were randomized to receive a DDI pacemaker programmed to 80 bpm with hysteresis of 45 bpm (19 patients) or no pacemaker (23 patients). Inclusion criteria were >/=3 syncopes over the last 2 years and a positive cardioinhibitory (Vasovagal Syncope International Study types 2A and 2B) response to tilt testing. The median number of previous syncopal episodes was 6; asystolic response to tilt testing was present in 36 patients (86%) (mean asystole, 13.9+/-10.2 seconds). All patients were followed up for a minimum of 1.0 years and a maximum of 6.7 years (mean, 3.7+/-2.2). One patient (5%) in the pacemaker arm experienced recurrence of syncope compared with 14 patients (61%) in the no-pacemaker arm (P=0.0006). In the no-pacemaker arm, the median time to first syncopal recurrence was 5 months, with a rate of 0.44 per year. On repeated tilt testing performed within 15 days after enrollment, positive responses were observed in 59% of patients with pacemakers and in 61% of patients without pacemakers (P=NS). CONCLUSIONS-In a limited, select group of patients with tilt-positive cardioinhibitory syncope, DDI pacing with hysteresis reduced the likelihood of syncope. The benefit of the therapy was maintained over the long term. Even in untreated patients, the syncopal recurrence burden was low. A negative result of tilt testing was not a useful means to evaluate therapy efficacy.
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Affiliation(s)
- R Sutton
- Departments of Cardiology of Royal Brompton Hospital, London, UK
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