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Fedorowski A, Kulakowski P, Brignole M, de Lange FJ, Kenny RA, Moya A, Rivasi G, Sheldon R, Van Dijk G, Sutton R, Deharo JC. Twenty-five years of research on syncope. Europace 2023; 25:euad163. [PMID: 37622579 PMCID: PMC10450792 DOI: 10.1093/europace/euad163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last 25 years, the Europace journal has greatly contributed to dissemination of research and knowledge in the field of syncope. More than 400 manuscripts have been published in the journal. They undoubtedly improved our understanding of syncope. This symptom is now clearly differentiated from other forms of transient loss of consciousness. The critical role of vasodepression and/or cardioinhibition as final mechanisms of reflex syncope is emphasized. Current diagnostic approach sharply separates between cardiac and autonomic pathways. Physiologic insights have been translated, through rigorously designed clinical trials, into non-pharmacological or pharmacological interventions and interventional therapies. The following manuscript is intended to give the reader the current state of the art of knowledge of syncope by highlighting landmark contributions of the Europace journal.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Piotr Kulakowski
- Department of Cardiology, Medical Centre for Postgraduate Education, Grochowski Hospital, Ul. Grenadierow 51/59, 04-073 Warsaw, Poland
| | - Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Piazzale Brescia 20, 20149 Milan, Italy
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, 152-160 Pearse St, Dublin, Ireland
- Mercer Institute for Successful Ageing, St. James Hospital, James St, Dublin 8, D08 NHY1Ireland
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, Carrer de Sabino Arana 5-19, 08028 Barcelona, Spain
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Robert Sheldon
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute, 3310 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Gert Van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, Du Cane Road, London, W12 0HS, United Kingdom
| | - Jean-Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France and Aix Marseille Université, C2VN, 264 Rue Saint-Pierre, 13005 Marseille, France
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Sutton R. The role of adenosine in syncope. Int J Cardiol 2022; 365:47-48. [PMID: 35870636 DOI: 10.1016/j.ijcard.2022.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 07/19/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Richard Sutton
- Emeritus Professor of Clinical Cardiology, Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London W12 0HS, United Kingdom.
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Dorogovtsev VN, Yankevich DS, Goswami N. Effects of an Innovative Head-Up Tilt Protocol on Blood Pressure and Arterial Stiffness Changes. J Clin Med 2021; 10:1198. [PMID: 33805654 PMCID: PMC7998828 DOI: 10.3390/jcm10061198] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/26/2021] [Accepted: 03/09/2021] [Indexed: 11/16/2022] Open
Abstract
The objective of our study was to identify blood pressure (BP) and pulse wave velocity (PWV) changes during orthostatic loading, using a new the head-up tilt test (HUTT), which incorporates the usage of a standardized hydrostatic column height. METHODS 40 healthy subjects 20-32 years performed HUTT, which was standardized to a height of the hydrostatic column at 133 cm. Exposure time was 10 min in each of 3 positions: horizontal supine 1, HUTT, and horizontal supine 2. The individual tilt up angle made it possible to set the standard value of the hydrostatic column. Hemodynamic parameters were recorded beat to beat using "Task Force Monitor 3040 i", pulse-wave velocity (PWV) was measured with a sphygmograph-sphygmomanometer VaSera VS1500N. RESULTS Orthostatic loading caused a significant increase in heart rate (HR) and a decrease in stroke volume (SV) (p < 0.05) but no significant reductions in cardiac output, changes in total vascular resistance (TVR), or BP. An analysis of personalized data on systolic blood pressure (SBP) changes in tilt up position as compared to horizontal position (ΔSBP) revealed non-significant changes in this index in 48% of subjects (orthostatic normotension group), in 32% there was a significant decrease in it (orthostatic hypotension group) and in 20% there was a significant increase in it (orthostatic hypertension group). These orthostatic changes were not accompanied by any clinical symptoms and/or syncope. During HUTT, all subjects had in the PWV a significant increase of approximately 27% (p < 0.001). CONCLUSION The new test protocol involving HUTT standardized to a height of hydrostatic column at 133 cm causes typical hemodynamics responses during orthostatic loading. Individual analysis of the subjects revealed subclinical orthostatic disorders (OSD) in up to 52% of the test persons. During HUTT, all test subjects showed a significant increase in PWV. The new innovative HUTT protocol can be applied in multi-center studies in healthy subjects to detect preclinical forms of orthostatic disorders under standard gravity load conditions.
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Affiliation(s)
- Victor N. Dorogovtsev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (V.N.D.); (D.S.Y.)
| | - Dmitry S. Yankevich
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (V.N.D.); (D.S.Y.)
| | - Nandu Goswami
- Gravitational Physiology and Medicine Research Unit, Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 3810 Graz, Austria
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Sutton R, Mears R, Kohno R, Benditt D. Ambulatory electrocardiogram monitoring for syncope and collapse: a comparative assessment of clinical practice in UK and Germany. Europace 2019; 20:2021-2027. [PMID: 30101353 DOI: 10.1093/europace/euy178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/18/2018] [Indexed: 01/29/2023] Open
Abstract
Aims Diagnostic ambulatory electrocardiogram (AECG) monitoring is widely used for evaluating syncope/collapse. In Europe, two sets of practice guidelines [National Institute for Health and Clinical Excellence (NICE) and European Society of Cardiology (ESC)] provide recommendations concerning optimal selection of AECG devices. However, whether practising physicians' select AECGs based on published guidelines is unclear. This study examined AECG use by Emergency Department (EDs) physicians and cardiologists in two European countries: Germany (D) and United Kingdom (UK). Methods and Results A quantitative survey was undertaken in which 177 respondents participated (ED: UK 33, Germany 40; Cardiology: UK 54, Germany 50). The choice of AECG technology varied by specialty. Thus, among EDs, despite patients having daily symptoms, 20% (UK), 31% (D) of respondents chose an AECG other than Holter monitor. Conversely, when monitoring for infrequent events (<monthly), 15-30% (UK and D) indicated choice of 24-48 h Holter, 15-30% (UK and D) a conventional event recorder, and only ∼50% select an insertable cardiac monitor (ICM). Among cardiologists, 6% (UK), 10% (D) would not choose a Holter for daily symptoms but, for infrequent symptoms, ∼80% would select an ICM (UK and D). However, many cardiologists (UK and D) persist with Holters for infrequent events despite repeated failure of that technology to provide a diagnosis. Conclusions In evaluation of syncope/collapse, most UK and German ED physicians and cardiologists use AECG's according to guidelines, but a substantial minority diverge from AECG guideline recommendations.
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Affiliation(s)
- Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Imperial College, Hammersmith Hospital, Ducane Road, London, UK
| | | | - Ritsuko Kohno
- Cardiovascular Division, The Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David Benditt
- Cardiovascular Division, The Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN, USA
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Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT, Singer W, Tarbell S, Chelimsky TC. Pediatric Disorders of Orthostatic Intolerance. Pediatrics 2018; 141:peds.2017-1673. [PMID: 29222399 PMCID: PMC5744271 DOI: 10.1542/peds.2017-1673] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 01/18/2023] Open
Abstract
Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.
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Affiliation(s)
| | | | | | | | - John E. Fortunato
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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Whinnery T, Forster EM. The first sign of loss of consciousness. Physiol Behav 2017; 179:494-503. [DOI: 10.1016/j.physbeh.2017.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/13/2017] [Accepted: 06/28/2017] [Indexed: 10/19/2022]
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Medow MS, Merchant S, Suggs M, Terilli C, O’Donnell-Smith B, Stewart JM. Postural Heart Rate Changes in Young Patients With Vasovagal Syncope. Pediatrics 2017; 139:peds.2016-3189. [PMID: 28351846 PMCID: PMC5369676 DOI: 10.1542/peds.2016-3189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Recurrent postural vasovagal syncope (VVS) is caused by transient cerebral hypoperfusion from episodic hypotension and bradycardia; diagnosis is made by medical history. VVS contrasts with postural tachycardia syndrome (POTS), defined by chronic daily symptoms of orthostatic intolerance with excessive upright tachycardia without hypotension. POTS has recently been conflated with VVS when excessive tachycardia is succeeded by hypotension during tilt testing. We hypothesize that excessive tachycardia preceding hypotension and bradycardia is part of the vasovagal response during tilt testing of patients with VVS. METHODS We prospectively performed head-up tilt (HUT) testing on patients with recurrent VVS (n = 47, 17.9 ± 1.1 y), who fainted at least 3 times within the last year, and control subjects (n = 15, 17.1 ± 1.0 y), from age and BMI-matched volunteers and measured blood pressure, heart rate (HR), cardiac output, total peripheral resistance, and end tidal carbon dioxide. RESULTS Baseline parameters were the same in both groups. HR (supine versus 5 and 10 minutes HUT) significantly increased in control (65 ± 2.6 vs 83 ± 3.6 vs 85 ± 3.7, P < .001) and patients with VVS (69 ± 1.6 vs 103 ± 2.3 vs 109 ± 2.4, P < .001). HUT in controls maximally increased HR by 20.3 ± 2.9 beats per minute; the increase in patients with VVS of 39.8 ± 2.1 beats per minute was significantly greater (P < .001). An increase in HR of ≥40 beats per minute by 5 and 10 minutes or before faint with HUT, occurred in 26% and 44% of patients with VVS, respectively, but not in controls. CONCLUSIONS Orthostasis in VVS is accompanied by large increases in HR that should not be construed as POTS.
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Affiliation(s)
- Marvin S. Medow
- Departments of Pediatrics, and,Physiology, New York Medical College, Valhalla, New York
| | | | | | | | | | - Julian M. Stewart
- Departments of Pediatrics, and,Physiology, New York Medical College, Valhalla, New York
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Vettor G, Zorzi A, Basso C, Thiene G, Corrado D. Syncope as a Warning Symptom of Sudden Cardiac Death in Athletes. Cardiol Clin 2016; 33:423-32. [PMID: 26115828 DOI: 10.1016/j.ccl.2015.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Clinical evaluation of syncope in the athlete remains a challenge. Although benign mechanisms predominate, syncope may be arrhythmic and precede SCD. Exercise-induced syncope should be regarded as an important alarming symptom of an underlying cardiac disease predisposing to arrhythmic cardiac arrest. All athletes with syncope require a focused and detailed workup for underlying cardiac causes, either structural or electrical. Major aim is to identify athletes at risk and to protect them from SCD. Athletes with potentially life-threatening etiologies of syncope should be restricted from competitive sports.
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Affiliation(s)
- Giulia Vettor
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova Medical School, Via Giustiniani, 2, Padova 35121, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova Medical School, Via Giustiniani, 2, Padova 35121, Italy
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Via A. Gabelli 61, Padova 35121, Italy
| | - Gaetano Thiene
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Via A. Gabelli 61, Padova 35121, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova Medical School, Via Giustiniani, 2, Padova 35121, Italy; Arrhythmogenic Inherited Cardiomyopathy Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova Medical School, Via Giustiniani, 2, Padova 35121, Italy.
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Yadav G, Loha S, Rath A, Meena R. Syncopal attack: A rare complication just after spinal needle insertion during spinal anesthesia. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2016. [DOI: 10.4103/2249-4472.181069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Meningioma of foramen magnum causing drop attacks. Case Rep Neurol Med 2015; 2015:214563. [PMID: 25793133 PMCID: PMC4352434 DOI: 10.1155/2015/214563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 01/20/2015] [Accepted: 02/06/2015] [Indexed: 11/17/2022] Open
Abstract
A 52-year-old female presented with frequent episodes of falls without loss of consciousness. These episodes lasted for brief period followed by full neurological recovery. Magnetic resonance imaging (MRI) of the brain showed foramen magnum meningioma encasing left vertebral artery. The patient had dramatic improvement after excision of the tumor.
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Watanabe N, Kawasaki S, Oonishi Y, Onuma Y, Munetsugu Y, Itou T, Onuki T, Miyoshi F, Minoura Y, Adachi T, Kawamura M, Asano T, Tanno K, Kobayashi Y. Characteristics of head-up tilt testing with additional adenosine compared with head-up tilt testing with isoproterenol and isosorbide dinitrate. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Oh SY, Kim DH, Yang TH, Shin BS, Jeong SK. Clinical classification and neuro-vestibular evaluation in chronic dizziness. Clin Neurophysiol 2014; 126:180-6. [PMID: 24794513 DOI: 10.1016/j.clinph.2014.03.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/12/2014] [Accepted: 03/31/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study attempts to clarify the clinical characteristics of chronic dizziness and its relationships with specific vestibular, oculomotor, autonomic and psychiatric dysfunctions. METHODS 73 Patients with idiopathic chronic dizziness were recruited and classified based on history taking and clinical examination into the following four clinical subgroups; vestibular migraine (VM), dysautonomia, psychogenic, and unspecified groups. They were also evaluated using oculomotor, otolithic and autonomic function tests, and psychologic investigation. RESULTS Patients in the VM group showed a high proportion of abnormality on smooth pursuit and otolithic function testing compared to the other groups. The dysautonomia group revealed significant abnormalities in sympathetic and cardiovagal autonomic function, while the psychogenic group had a high frequency of abnormality in sympathetic autonomic testing and in Beck's anxiety inventory scale. The unspecified group showed abnormalities on saccade, smooth pursuit and autonomic function testing. CONCLUSIONS Clinical classification of patients with chronic dizziness was relevant and they showed a correlation with disease-specific abnormal results in oculomotor, otolithic, autonomic function and psychology testing. SIGNIFICANCE Appropriate diagnostic investigation based on precise clinical diagnosis of chronic dizziness reduces the need for extensive laboratory testing, neuroimaging, and other low-yield tests.
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Affiliation(s)
- Sun-Young Oh
- Department of Neurology, Chonbuk National University College of Medicine, Jeonju, Republic of Korea; Research Institute of Clinical Medicine, Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea.
| | - Do-Hyung Kim
- Department of Neurology, Chonbuk National University College of Medicine, Jeonju, Republic of Korea
| | - Tae-Ho Yang
- Department of Neurology, Chonbuk National University College of Medicine, Jeonju, Republic of Korea
| | - Byoung-Soo Shin
- Department of Neurology, Chonbuk National University College of Medicine, Jeonju, Republic of Korea; Research Institute of Clinical Medicine, Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Seul-Ki Jeong
- Department of Neurology, Chonbuk National University College of Medicine, Jeonju, Republic of Korea; Research Institute of Clinical Medicine, Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
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van der Marck MA, Klok MP, Okun MS, Giladi N, Munneke M, Bloem BR. Consensus-based clinical practice recommendations for the examination and management of falls in patients with Parkinson's disease. Parkinsonism Relat Disord 2014; 20:360-9. [DOI: 10.1016/j.parkreldis.2013.10.030] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 09/13/2013] [Accepted: 10/02/2013] [Indexed: 11/27/2022]
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Ruhl DS, Ramsey MJ, Ruffin DM. A profound case of neurally mediated syncope with asystole after septoplasty. J Clin Anesth 2012; 24:310-4. [PMID: 22608586 DOI: 10.1016/j.jclinane.2011.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 09/24/2011] [Accepted: 10/07/2011] [Indexed: 10/28/2022]
Abstract
Vasovagal syncope (VVS) is an alarming yet benign condition that may present postoperatively for the first time in otherwise healthy patients. Although VVS is associated anecdotally with nasal manipulation, no data have been found to quantify this incidence with otolaryngology surgeries. We present a case of profound, recurrent syncope and documented asystole with an initial diagnosis of glossopharyngeal neuralgia. We conclude with a discussion of neurally mediated syncope particular to the perioperative setting. It is essential to recognize neurocardiogenic etiology to differentiate it from other more concerning causes of syncope and asystole.
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Affiliation(s)
- Douglas S Ruhl
- Department of Otolaryngology - Head and Neck Surgery, Tripler Army Medical Center, TAMC, HI 96859, USA.
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Ruwald MH, Hansen ML, Lamberts M, Hansen CM, Hojgaard MV, Kober L, Torp-Pedersen C, Hansen J, Gislason GH. The relation between age, sex, comorbidity, and pharmacotherapy and the risk of syncope: a Danish nationwide study. Europace 2012; 14:1506-14. [DOI: 10.1093/europace/eus154] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Vaddadi G, Corcoran SJ, Esler M. CLINICAL PERSPECTIVES: Management strategies for recurrent vasovagal syncope. Intern Med J 2010; 40:554-60. [DOI: 10.1111/j.1445-5994.2010.02295.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Fatigue and autonomic dysfunction in non-alcoholic fatty liver disease. Clin Auton Res 2010; 19:319-26. [PMID: 19768633 DOI: 10.1007/s10286-009-0031-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Accepted: 08/18/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fatigue is a significant symptom in nonalcoholic fatty liver disease (NAFLD) that impacts upon quality of life and is unrelated to liver disease severity. We examined the relationship between parameters of blood pressure regulation with perception of fatigue in NAFLD. METHODS Thirty-four non-diabetic subjects with histologically proven, non-cirrhotic NAFLD (26 [77%] males and 8 [23%] females) (mean +/- SD age 54 +/- 11) and 34 age, sex and BMI matched non-diabetic controls underwent subjective and objective evaluation of cardiovascular autonomic function (24 h blood pressure and head up tilt testing). All subjects completed the fatigue impact scale. RESULTS The NAFLD group had significantly higher autonomic symptom burden assessed using the orthostatic grading scale (OGS) compared to controls (4 +/- 4 vs. 1 +/- 2; p = 0.0003). Increasing orthostatic symptoms correlated with increasing fatigue (p = 0.006; r(2) = 0.3). Fatigue in NAFLD correlated inversely with 24 h measurement of systolic, diastolic and mean blood pressures (all p < 0.03; r(2) = 0.2). This relationship was predominantly related to lower blood pressure at night (p < 0.003; r(2) = 0.3). On head up tilt testing 57% of the NAFLD group had neurally-mediated hypotension (vasovagal syncope and/or orthostatic hypotension) (p = 0.006 compared to controls). The degree of blood pressure drop in response to standing correlated with fatigue severity (p = 0.008; r(2) = 0.3) and the autonomic symptom burden (OGS) (p = 0.03; r(2) = 0.2). CONCLUSION Autonomic symptoms are prevalent in NAFLD and associate with objective measures of autonomic dysfunction. Fatigue in NAFLD is associated with lower blood pressure and autonomic dysfunction. Studies are needed to determine whether this is a potential therapeutic target for fatigue in NAFLD.
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Evaluation of risk of falls and orthostatic hypotension in older, long-term topical beta-blocker users. Graefes Arch Clin Exp Ophthalmol 2009; 247:1235-41. [PMID: 19452162 PMCID: PMC2720583 DOI: 10.1007/s00417-009-1092-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 01/14/2009] [Accepted: 04/13/2009] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Falls are a serious problem in the elderly, and have recently been described as cardiovascular-mediated side effects of beta-blocker eye drops. Therefore, we investigated the possible association between the long-term use of beta-blockers, prostaglandins and their combinations in eye drops, and falls, dizziness and orthostatic hypotension in older patients. METHODS All participants were long-term users of eye drops containing beta-blockers, prostaglandins or their combinations. They underwent a structured falls interview and blood pressure measurement for testing of orthostatic hypotension. The odds ratio for presence of orthostatic hypotension or a positive falls history according to use of beta-blocker eye drops was calculated with a binary logistic regression analysis. The main outcome measures were a positive falls history and the presence of orthostatic hypotension. RESULTS In total, 148 of 286 subjects participated. After adjustment for age, gender, and use of fall-risk-increasing drugs other than beta-blocker eye drops, we found no significant difference in fall risk [odds ratio (OR): 0.60; 95% confidence interval (CI): 0.268-1.327] between patients using ophthalmic beta-blockers or a combination of ophthalmic beta-blockers and prostaglandins, and patients using ophthalmic prostaglandins only. Although prevalence of orthostatic hypotension was higher in the beta-blocker group (OR: 1.67; 95% CI: 0.731-3.793) compared to the prostaglandin group, this was a non-significant difference. CONCLUSIONS In our study, we did not find a significant association between long-term use of beta-blockers eye drops and falls, dizziness or orthostatic hypotension in older ophthalmic outpatients, compared to long-term use of prostaglandin eye drops.
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Graf D, Schlaepfer J, Gollut E, van Melle G, Mischler C, Fromer M, Kappenberger L, Pruvot E. Predictive models of syncope causes in an outpatient clinic. Int J Cardiol 2008; 123:249-56. [PMID: 17397948 DOI: 10.1016/j.ijcard.2006.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 11/03/2006] [Accepted: 12/11/2006] [Indexed: 11/20/2022]
Abstract
UNLABELLED The investigation of unexplained syncope remains a challenging clinical problem. In the present study we sought to evaluate the diagnostic value of a standardized work-up focusing on non invasive tests in patients with unexplained syncope referred to a syncope clinic, and whether certain combinations of clinical parameters are characteristic of rhythmic and reflex causes of syncope. METHODS AND RESULTS 317 consecutive patients underwent a standardized work-up including a 12-lead ECG, physical examination, detailed history with screening for syncope-related symptoms using a structured questionnaire followed by carotid sinus massage (CSM), and head-up tilt test. Invasive testings including an electrophysiological study and implantation of a loop recorder were only performed in those with structural heart disease or traumatic syncope. Our work-up identified an etiology in 81% of the patients. Importantly, three quarters of the causes were established non invasively combining head-up tilt test, CSM and hyperventilation testing. Invasive tests yielded an additional 7% of diagnoses. Logistic analysis identified age and number of significant prodromes as the only predictive factors of rhythmic syncope. The same two factors, in addition to the duration of the ECG P-wave, were also predictive of vasovagal and psychogenic syncope. These factors, optimally combined in predictive models, showed a high negative and a modest positive predictive value. CONCLUSION A standardized work-up focusing on non invasive tests allows to establish more than three quarters of syncope causes. Predictive models based on simple clinical parameters may help to distinguish between rhythmic and other causes of syncope.
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Affiliation(s)
- D Graf
- Service de Cardiologie, Centre Hospitalier Universitaire Vaudois, BH07, CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Vaddadi G, Lambert E, Corcoran SJ, Esler MD. Postural syncope: mechanisms and management. Med J Aust 2007; 187:299-304. [PMID: 17767437 DOI: 10.5694/j.1326-5377.2007.tb01248.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Accepted: 05/29/2007] [Indexed: 11/17/2022]
Abstract
Postural syncope is a transient loss of consciousness secondary to a reduction in cerebral blood flow and is typically precipitated by standing. It is the commonest cause of recurrent transient loss of consciousness. Recurrent unexplained postural syncope is most often due to one of the five disorders of circulatory control: vasovagal syncope, postural tachycardia syndrome, chronic autonomic failure, initial orthostatic hypotension, or persistently low supine systolic blood pressure. Failure to identify the underlying cause of postural syncope can result in ongoing morbidity, impaired quality of life and high health care costs. With a detailed history, examination, blood pressure assessment and electrocardiography, most disorders of circulatory control can be diagnosed. In difficult cases, analysis of sympathetic nervous system and circulatory responses during head-up tilting can aid diagnosis. Treatment is challenging and compounded by a lack of evidence. Most patients can be managed in an outpatient setting, and hospital admission or emergency department assessment is rarely warranted.
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Affiliation(s)
- Gautam Vaddadi
- Baker Heart Research Institute, Melbourne, VIC, Australia.
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21
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Miller VM, Kalaria RN, Hall R, Oakley AE, Kenny RA. Medullary microvessel degeneration in multiple system atrophy. Neurobiol Dis 2007; 26:615-22. [PMID: 17466525 DOI: 10.1016/j.nbd.2007.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 02/13/2007] [Accepted: 03/07/2007] [Indexed: 11/29/2022] Open
Abstract
Multiple system atrophy (MSA) is a rare and fatal early-onset autonomic disorder which is characterised by Parkinsonism and orthostatic hypotension (OH). The pathophysiology of MSA is not fully understood but key features include the depletion of medullary autonomic neurons and presence of glial cellular inclusions. We hypothesise that the degeneration of medullary autonomic microvessels is an additional finding in MSA. Using digital pathology we quantified basement membrane collagen (Coll IV), smooth muscle actin (alpha-actin) and endothelial glucose transporter (Glut 1) expression in medullary autonomic nuclei of 8 MSA and 8 OH cases, compared with 12 controls with no autonomic dysfunction. We found decreased Coll IV (p=0.000) and Glut 1 (p=0.000) but not alpha-actin expression, in medullary autonomic nuclei of MSA, but not OH cases compared with control subjects. Medullary microvessel degeneration in MSA may be secondary to the primary neuro-glial pathogenesis of the disorder, and could accelerate its ageing-related progression.
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Affiliation(s)
- V M Miller
- Neurovascular Research Unit, Sir James Spence Institute, Royal Victoria Hospital, Newcastle upon Tyne, NE1 4LP, UK.
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22
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Newton JL, Hudson M, Tachtatzis P, Sutcliffe K, Pairman J, Burt JA, Jones DEJ. Population prevalence and symptom associations of autonomic dysfunction in primary biliary cirrhosis. Hepatology 2007; 45:1496-505. [PMID: 17538969 DOI: 10.1002/hep.21609] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
UNLABELLED Patients with primary biliary cirrhosis (PBC) frequently experience significant fatigue thought to result from as-yet-unidentified central nervous system (CNS)-mediated processes. Pilot studies have suggested that autonomic dysfunction is a frequent occurrence in PBC and may contribute to the pathogenesis of this fatigue. The degree to which autonomic dysfunction affects the PBC population as a whole, and its interrelationship with other symptoms experienced by PBC patients remains unstudied. In this study, we used a geographically defined, fully representative PBC patient cohort to study the prevalence of symptoms of autonomic dysfunction and its relationship with other symptoms of PBC. Symptoms of cardiovascular autonomic dysfunction (as assessed using the Orthostatic Grading Scale [OGS]) were significantly more frequently reported and significantly more severe in PBC patients than in both matched normal controls (40% versus 6% with moderate or worse orthostasis (P < .0001), mean OGS score 3.2 +/- 3.4 versus 1.3 +/- 1.9, P < .005) and in patients with primary sclerosing cholangitis and in severity were independently associated with severity of fatigue and cognitive symptoms (both r2 = 0.3, P < .0001). Thirteen of 20 patients with an OGS value > 4 (moderate severity and worse) had significant abnormality in autonomic regulation of blood pressure, which was identified on dynamic testing. CONCLUSION Symptoms suggestive of autonomic dysfunction frequently occur in PBC patients and reflect dysregulation of actual blood pressure. Autonomic dysfunction is independently associated with both fatigue and, importantly, symptoms of cognitive dysfunction, suggesting the potential for significant organic sequelae.
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Affiliation(s)
- Julia L Newton
- Liver Research Group, Institute of Cellular Medicine, Newcastle University, The Medical School, Framlington Place, Newcastle-upon-Tyne, UK
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23
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Affiliation(s)
- Carol Chen-Scarabelli
- VA Ann Arbor Healthcare System, Division of Cardiology (111A), 2215 Fuller Road, Ann Arbor, MI 48105, USA.
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Khositseth A, Martinez MW, Driscoll DJ, Ackerman MJ. Syncope in children and adolescents and the congenital long QT syndrome. Am J Cardiol 2003; 92:746-9. [PMID: 12972126 DOI: 10.1016/s0002-9149(03)00846-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
From a population-based epidemiologic cohort of children and adolescents who sought medical attention for syncope (n = 151), screening 12-lead electrocardiograms were obtained from 118 patients (79 female) to determine the frequency of significant QT prolongation. The distribution of heart rate corrected QT intervals (QTc) was compared with age- and sex-matched controls. Only one patient had QTc >470 ms.
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Affiliation(s)
- Anant Khositseth
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Van Lieshout JJ, Wieling W, Karemaker JM, Secher NH. Syncope, cerebral perfusion, and oxygenation. J Appl Physiol (1985) 2003; 94:833-48. [PMID: 12571122 DOI: 10.1152/japplphysiol.00260.2002] [Citation(s) in RCA: 259] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
During standing, both the position of the cerebral circulation and the reductions in mean arterial pressure (MAP) and cardiac output challenge cerebral autoregulatory (CA) mechanisms. Syncope is most often associated with the upright position and can be provoked by any condition that jeopardizes cerebral blood flow (CBF) and regional cerebral tissue oxygenation (cO(2)Hb). Reflex (vasovagal) responses, cardiac arrhythmias, and autonomic failure are common causes. An important defense against a critical reduction in the central blood volume is that of muscle activity ("the muscle pump"), and if it is not applied even normal humans faint. Continuous tracking of CBF by transcranial Doppler-determined cerebral blood velocity (V(mean)) and near-infrared spectroscopy-determined cO(2)Hb contribute to understanding the cerebrovascular adjustments to postural stress; e.g., MAP does not necessarily reflect the cerebrovascular phenomena associated with (pre)syncope. CA may be interpreted as a frequency-dependent phenomenon with attenuated transfer of oscillations in MAP to V(mean) at low frequencies. The clinical implication is that CA does not respond to rapid changes in MAP; e.g., there is a transient fall in V(mean) on standing up and therefore a feeling of lightheadedness that even healthy humans sometimes experience. In subjects with recurrent vasovagal syncope, dynamic CA seems not different from that of healthy controls even during the last minutes before the syncope. Redistribution of cardiac output may affect cerebral perfusion by increased cerebral vascular resistance, supporting the view that cerebral perfusion depends on arterial inflow pressure provided that there is a sufficient cardiac output.
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Affiliation(s)
- Johannes J Van Lieshout
- Cardiovascular Research Institute Amsterdam and Departments of Medicine and Physiology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.
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