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Zangiabadian M, Soltani K, Gholinejad Y, Yahya R, Bastami S, Akbarzadeh MA, Sharifian Ardestani M, Aletaha A. Predictors of pacemaker requirement in patients with implantable loop recorder and unexplained syncope: A systematic review and meta-analysis. Clin Cardiol 2024; 47:e24221. [PMID: 38402528 PMCID: PMC10823547 DOI: 10.1002/clc.24221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 02/26/2024] Open
Abstract
Identifying the underlying cause of unexplained syncope is crucial for appropriate management of recurrent syncopal episodes. Implantable loop recorders (ILRs) have emerged as valuable diagnostic tools for monitoring patients with unexplained syncope. However, the predictors of pacemaker requirement in patients with ILR and unexplained syncope remain unclear. In this study, we shed light on these prognostic factors. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane CENTRAL were systematically searched until May 04, 2023. Studies that evaluated the predictors of pacemaker requirement in patients with implantable loop recorder and unexplained syncope were included. The "Quality In Prognosis Studies" appraisal tool was used for quality assessment. The pooled odds ratio (OR) with 95% confidence intervals (CIs) was calculated. The publication bias was evaluated using Egger's and Begg's tests. Ten studies (n = 4200) were included. Right bundle branch block (OR: 3.264; 95% CI: 1.907-5.588, p < .0001) and bifascicular block (OR: 2.969; 95% CI: 1.859-4.742, p < .0001) were the strongest predictors for pacemaker implantation. Pacemaker requirement was more than two times in patients with atrial fibrillation, sinus bradycardia and first degree AV block. Valvular heart disease, diabetes mellitus, and hypertension were also significantly more in patients with pacemaker implantation. Age (standardized mean difference [SMD]: 0.560; 95% CI: 0.410/0.710, p < .0001) and PR interval (SMD: 0.351; 95% CI: 0.150/0.553, p = .001) were significantly higher in patients with pacemaker requirement. Heart conduction disorders, atrial arrhythmias and underlying medical conditions are main predictors of pacemaker device implantation following loop recorder installation in unexplained syncopal patients.
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Affiliation(s)
- Moein Zangiabadian
- Endocrinology and Metabolism Re-search Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Kiarash Soltani
- Shahid Beheshti University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Yasaman Gholinejad
- Shahid Beheshti University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Reyhane Yahya
- Shahid Beheshti University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Shayan Bastami
- Shahid Beheshti University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Mohammad Ali Akbarzadeh
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Azadeh Aletaha
- Evidence Based Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Clinical Sciences Institute, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
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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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Francisco Pascual J, Jordan Marchite P, Rodríguez Silva J, Rivas Gándara N. Arrhythmic syncope: From diagnosis to management. World J Cardiol 2023; 15:119-141. [PMID: 37124975 PMCID: PMC10130893 DOI: 10.4330/wjc.v15.i4.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/02/2023] [Accepted: 04/10/2023] [Indexed: 04/20/2023] Open
Abstract
Syncope is a concerning symptom that affects a large proportion of patients. It can be related to a heterogeneous group of pathologies ranging from trivial causes to diseases with a high risk of sudden death. However, benign causes are the most frequent, and identifying high-risk patients with potentially severe etiologies is crucial to establish an accurate diagnosis, initiate effective therapy, and alter the prognosis. The term cardiac syncope refers to those episodes where the cause of the cerebral hypoperfusion is directly related to a cardiac disorder, while arrhythmic syncope is cardiac syncope specifically due to rhythm disorders. Indeed, arrhythmias are the most common cause of cardiac syncope. Both bradyarrhythmia and tachyarrhythmia can cause a sudden decrease in cardiac output and produce syncope. In this review, we summarized the main guidelines in the management of patients with syncope of presumed arrhythmic origin. Therefore, we presented a thorough approach to syncope work-up through different tests depending on the clinical characteristics of the patients, risk stratification, and the management of syncope in different scenarios such as structural heart disease and channelopathies.
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Affiliation(s)
- Jaume Francisco Pascual
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- Grup de Recerca Cardiovascular, Vall d’Hebron Institut de Recerca, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Pablo Jordan Marchite
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Jesús Rodríguez Silva
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Nuria Rivas Gándara
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
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Davidsen JM, Skals R, Dalgaard F, Tayal B, Torp-Pedersen C, Søgaard P, Lee CJY. Recurrent syncope in patients with a pacemaker and bradyarrhythmia. SCAND CARDIOVASC J 2023; 57:1-7. [DOI: 10.1080/14017431.2022.2139860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Regitze Skals
- Unit of Clinical Biostatistics Aalborg University Hospital, Aalborg, Denmark
| | - Frederik Dalgaard
- Department of Cardiology, Herlev & Gentofte Hospital, Hellerup, Denmark
| | - Bhupendar Tayal
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Research, Nordsjaellands University Hospital, Hillerød, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Ji-Young Lee
- Department of Cardiology and Clinical Research, Nordsjaellands University Hospital, Hillerød, Denmark
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Saal DP, Thijs RD, Bootsma M, Brignole M, van Dijk JG. Five cases of complete atrioventricular block induced by bending forward: unusual but not unique. Europace 2021; 23:1487-1492. [PMID: 33693701 DOI: 10.1093/europace/euab044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS We describe five patients with syncope caused by a complete atrioventricular block (AVB) while they were bending forward, not rising after bending, and aim to describe the occurrence and the association between bending forward and AVB. METHODS AND RESULTS In two patients, bending forward was the exclusive trigger for syncope, while in the remaining three, other postural changes (sitting down, standing up, and exertion) could also provoke syncope. Complete AVB as the cause of syncope was documented using ECG monitoring in two cases and an implantable loop recorder in the other three. Ectopic beats without preceding sinus slowing occurred before syncope in four cases. Two cases had a left bundle branch block. All patients responded favourably to cardiac pacing. CONCLUSION This is the first case series on complete AVB provoked by bending forward. Syncope during bending forward should suggest a search for an AVB. Arguments in favour of a vagal mechanism were syncope triggered by bending forward, and that other triggers could also evoke syncope. However, the absence of sinus slowing before syncope in some cases and the fact that bending forward did not seem to provoke reflex syncope without AVB, cast doubts on a reflex mechanism. There were also arguments favouring conduction disorder: i.e. ectopic beats before syncope and pre-existing conduction disturbances in two cases. The cases are reminiscent of paroxysmal AVB. Discrimination between paroxysmal AVB and vagal AVB is important because a pacemaker is warranted in arrhythmic complete AVB, while the benefit is limited or absent in reflex AVB.
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Affiliation(s)
- Dirk P Saal
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Neurology, Franciscus Gasthuis en Vlietland Hospital, PO 215, 3100 AE Rotterdam/Schiedam, The Netherlands
| | - Roland D Thijs
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Marianne Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - J Gert van Dijk
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands
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Palmisano P, Dell'Era G, Pellegrino PL, Ammendola E, Ziacchi M, Guerra F, Aspromonte V, Laffi M, Pimpini L, Santoro F, Boggio E, Guido A, Patti G, Brunetti ND, Nigro G, Biffi M, Russo AD, Gaggioli G, Accogli M. Causes of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: Findings from the SYNCOPACED registry. Heart Rhythm 2021; 18:770-777. [PMID: 33465512 DOI: 10.1016/j.hrthm.2021.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few studies have examined the causes of syncope/collapse recurrences in patients with a previously implanted pacemaker for bradyarrhythmic syncope. OBJECTIVE The purpose of this study was to assess the causes of syncope/collapse recurrences after pacemaker implantation for bradyarrhythmic syncope in a large patient population. METHODS The SYNCOpal recurrences in patients treated with permanent PACing for bradyarrhythmic syncope (SYNCOPACED) registry was a prospective multicenter observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for bradyarrhythmic syncope. During follow-up, the time to the first syncope/collapse recurrence was recorded. Patients with syncope/collapse recurrences underwent a predefined diagnostic workup aimed at establishing the mechanism of syncope/collapse. RESULTS During a median follow-up of 50 months, 213 patients (15.6%) reported at least 1 syncope/collapse recurrence. The risk of syncope/collapse recurrence was highest in patients who underwent implantation for cardioinhibitory vasovagal syncope (26.4%), followed by unexplained syncope and chronic bifascicular block (21.5%), cardioinhibitory carotid sinus syndrome (17.2%), atrial fibrillation needing pacing (15.5%), atrioventricular block (13.6%), and sinus node disease (12.5%) (P = .017). The most frequent cause of syncope/collapse recurrence was reflex syncope (27.7%), followed by orthostatic hypotension (26.3%), pacemaker or lead malfunction (5.6%), structural cardiac disease (5.2%), and atrial and ventricular tachyarrhythmias (4.7% and 3.8%, respectively). In 26.8% of cases, the mechanism of syncope/collapse remained unexplained. CONCLUSION In patients receiving a pacemaker for bradyarrhythmic syncope, reflex syncope and orthostatic hypotension are the most frequent mechanisms of syncope/collapse recurrence after implantation. Pacing system malfunction, structural cardiac diseases, and tachyarrhythmias are rare mechanisms. The mechanism remains unexplained in >25% of patients.
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Affiliation(s)
| | - Gabriele Dell'Era
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Ernesto Ammendola
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Matteo Ziacchi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi," Ancona, Italy
| | - Vittorio Aspromonte
- Cardiology - Coronary Care Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Mattia Laffi
- Cardiology Division, Villa Scassi Hospital, Genova ASL 3, Genova, Italy
| | - Lorenzo Pimpini
- Unit of Cardiology-CCU, Italian National Research Centre on Aging, Ancona, Italy
| | - Francesco Santoro
- Department of Cardiology, Bonomo Hospital, Andria, Italy; Department of Medical and Surgery Sciences, University of Foggia, Foggia, Italy
| | - Enrico Boggio
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Giuseppe Patti
- Azienda Ospedaliera Universitaria "Maggiore della Carità," Novara, Italy
| | | | - Gerardo Nigro
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Mauro Biffi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi," Ancona, Italy
| | - Germano Gaggioli
- Cardiology Division, Villa Scassi Hospital, Genova ASL 3, Genova, Italy
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Sutton R, Brignole M. Recurrent syncope in paced patients, hitherto ignored? Europace 2020; 22:1607-1608. [DOI: 10.1093/europace/euaa197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Michele Brignole
- Faint & Fall Programme, IRCCS, Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy
- Arrhythmology Centre, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
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Palmisano P, Pellegrino PL, Ammendola E, Ziacchi M, Guerra F, Aspromonte V, Laffi M, Pimpini L, Santoro F, Boggio E, Guido A, Patti G, Brunetti ND, Nigro G, Biffi M, Dello Russo A, Gaggioli G, Accogli M, Dell’Era G. Risk of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: role of correlation between symptoms and electrocardiogram findings. Europace 2020; 22:1729-1736. [DOI: 10.1093/europace/euaa188] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 06/12/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
To evaluate the risk of syncopal recurrences after pacemaker implantation in a population of patients with syncope of suspected bradyarrhythmic aetiology.
Methods and results
Prospective, multicentre, observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for syncope of bradyarrhythmic aetiology (proven or presumed). Before pacemaker implantation, all patients underwent a cardiac work-up in order to establish the bradyarrhythmic aetiology of syncope. According to the results of the diagnostic work-up, patients were divided into three groups: Group A, patients in whom a syncope-electrocardiogram (ECG) correlation was established (n = 329, 24.1%); Group B, those in whom clinically significant bradyarrhythmias were detected without a documented syncope-ECG correlation (n = 877, 64.3%); and Group C, those in whom bradyarrhythmias were not detected and the bradyarrhythmic origin of syncope remained presumptive (n = 158, 11.6%). During a median follow-up of 50 months, 213 patients (15.6%) reported at least one syncopal recurrence. Patients in Groups B and C showed a significantly higher risk of syncopal recurrences than those in Group A [hazard ratios (HRs): 1.60 and 2.66, respectively, P < 0.05]. Failure to establish a syncope-ECG correlation during diagnostic work-up before pacemaker implantation was an independent predictor of syncopal recurrence on multivariate analysis (HR: 1.90; P = 0.002).
Conclusion
In selecting patients with syncope of suspected bradyarrhythmic aetiology for pacemaker implantation, establishing a correlation between syncope and bradyarrhythmias maximizes the efficacy of pacing and reduces the risk of syncopal recurrences.
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Affiliation(s)
| | | | - Ernesto Ammendola
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Matteo Ziacchi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I—Lancisi—Salesi”, Ancona, Italy
| | - Vittorio Aspromonte
- Cardiology - Coronary Care Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Mattia Laffi
- Cardiology Division, Villa Scassi Hospital, Genova, ASL 3, Genova, Italy
| | - Lorenzo Pimpini
- Unit of Cardiology-CCU, Italian National Reserch Centre on Aging, Ancona, Italy
| | - Francesco Santoro
- Department of Cardiology, Bonomo Hospital, Andria, Italy
- Department of Medical and Surgery Sciences, University of Foggia, Foggia, Italy
| | - Enrico Boggio
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
| | | | - Giuseppe Patti
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
| | | | - Gerardo Nigro
- Dipartimento di Cardiologia, Università della Campania - L.Vanvitelli, Ospedale Monaldi, Napoli, Italy
| | - Mauro Biffi
- Institute of Cardiology, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I—Lancisi—Salesi”, Ancona, Italy
| | - Germano Gaggioli
- Cardiology Division, Villa Scassi Hospital, Genova, ASL 3, Genova, Italy
| | | | - Gabriele Dell’Era
- Division of Cardiology, Azienda Ospedaliera Universitaria “Maggiore della Carità”, Novara, Italy
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Mitro P, Šimurda M, Lazúrová Z, Jakubová M. Etiology of syncope in patients with preexisting atrioventricular conduction disorders. Pacing Clin Electrophysiol 2020; 43:1268-1272. [PMID: 32901951 DOI: 10.1111/pace.14064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/26/2020] [Accepted: 09/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The discussion about the feasibility of empiric pacemaker implantation in patients with preexisting atrioventricular (AV) conduction disorders continues. The aim of the study was to determine the etiology of syncope and the need for pacemaker insertion in patients with AV conduction impairment using implantable loop recorder (ILR). METHODS ILR was implanted after negative diagnostic workup in 37 patients with syncope (24 men, 13 women, age 72 ± 10 years) and preexisting impairment of AV conduction. First-degree AV block (AVB I) was present in 26 patients, and bundle branch block (BBB) in 17 patients. RESULTS ILR-based diagnosis was made in 28 patients (75%)-sinus arrest in 13 patients, complete AVB in 10 patients, and vasodepressor syncope in five patients. In patients with preexisting BBB, sinus arrest occurred during ILR monitoring significantly more frequently than in patients without BBB (53% vs 20%, P = .03). Complete AVB was significantly less common in patients with preexisting BBB than in patients without BBB (12% vs 40%, P = .04). On multivariate regression analysis, the only independent predictor of AVB occurrence during ILR monitoring was preexisting AVB I (P = .03). The only independent predictor of sinus arrest during ILR monitoring was preexisting BBB (P = .03). CONCLUSIONS In patients with preexisting AV conduction disorders, prevailing syncopal mechanism during ILR monitoring was asystole. However, sinus arrest occurred more often than complete AVB and was predicted by preexisting BBB. Preexisting AVB was a predictor of complete AVB during ILR monitoring.
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Affiliation(s)
- Peter Mitro
- Cardiology Clinic, Safarik University, VUSCH, Košice, Slovakia
| | - Miloš Šimurda
- Cardiology Clinic, Safarik University, VUSCH, Košice, Slovakia
| | - Zora Lazúrová
- Cardiology Clinic, Safarik University, VUSCH, Košice, Slovakia
| | - Marta Jakubová
- Cardiology Clinic, Safarik University, VUSCH, Košice, Slovakia
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de Jong JS, Jardine DL, Lenders JW, Wieling W. Pacing in vasovagal syncope: A physiological paradox? Heart Rhythm 2020; 17:813-820. [DOI: 10.1016/j.hrthm.2019.09.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Indexed: 10/26/2022]
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Sutton R, de Jong JSY, Stewart JM, Fedorowski A, de Lange FJ. Pacing in vasovagal syncope: Physiology, pacemaker sensors, and recent clinical trials-Precise patient selection and measurable benefit. Heart Rhythm 2020; 17:821-828. [PMID: 32036025 DOI: 10.1016/j.hrthm.2020.01.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
Abstract
The role of pacing in vasovagal syncope (VVS) is considered from a physiological basis. Most VVS patients lose consciousness due to hypotension before severe bradycardia/asystole occurs. Patients who benefit from dual-chamber pacing typically are older with highly symptomatic, late-onset, frequent and severe syncope with short/no prodrome and documented severe cardioinhibition. Tilt testing is of value in patients with recurrent unexplained syncope to identify important hypotensive susceptibility stemming from reduced venous return and stroke volume (SV). A negative tilt test in vasovagal patients with spontaneous asystole documented by an implantable/insertable loop recorder is associated with lower syncope recurrence rates after pacemaker implantation. Pacing may be more effective if triggered by sensor detection of a parameter changing earlier in the reflex than bradycardia when SV may still be relatively preserved. In this regard, detection of right ventricular impedance offers promise. Conservatism is recommended, limiting pacing in VVS to a small subset of symptomatic older patients with clearly documented cardioinhibition and paying particular attention to the timing of loss of consciousness in relation to asystole/bradycardia. Understanding VVS physiology permits application of well-timed, appropriate pacing that yields benefit for highly symptomatic patients.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, London, United Kingdom; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Jelle S Y de Jong
- Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Julian M Stewart
- Departments of Pediatrics, Physiology and Medicine. New York Medical College. Valhalla, New York
| | - Artur Fedorowski
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Frederik J de Lange
- Heart Centre, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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Yasa E, Ricci F, Holm H, Persson T, Melander O, Sutton R, Fedorowski A, Hamrefors V. Cardiovascular Autonomic Dysfunction Is the Most Common Cause of Syncope in Paced Patients. Front Cardiovasc Med 2019; 6:154. [PMID: 31709267 PMCID: PMC6823818 DOI: 10.3389/fcvm.2019.00154] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Syncope and orthostatic intolerance in paced patients constitute a common clinical dilemma. We, thus, aimed to determine the etiology of syncope and/or symptoms of orthostatic intolerance in paced patients. Methods: Among 1,705 patients with unexplained syncope and/or orthostatic intolerance that were investigated by cardiovascular autonomic tests, including Valsalva maneuver, active standing, carotid sinus massage, and tilt-testing, 39 patients (2.3%; age 65.6 years; 39% women) had a cardiac implantable electronic device (CIED). We explored past medical history, diagnoses found during cardiovascular autonomic tests, and the further clinical workup, in case of negative initial evaluation. Results: An etiology was identified during cardiovascular autonomic tests in 36 of the 39 patients. Orthostatic hypotension (n = 16; 41%) and vasovagal syncope (n = 12; 31%) were the most common diagnoses. There were no cases of pacemaker dysfunction. The original pacing indications followed guidelines (sick-sinus-syndrome in 16, atrioventricular block in 16, atrial fibrillation with bradycardia in five). Twenty-two of the 39 patients (56%) had experienced syncope prior to the original CIED implantation. Orthostatic hypotension was diagnosed in seven (32%) and vasovagal syncope in nine (41%) of these patients. Of the 17 patients that had not experienced syncope prior to the original CIED implantation, nine patients (53%) were diagnosed with orthostatic hypotension and vasovagal syncope was diagnosed in three (18%). Of the 39 patients, two had implantable cardioverter-defibrillators to treat malignant ventricular arrhythmias diagnosed after syncopal episodes. Conclusion: Cardiovascular autonomic tests reveal the etiology of syncope and/or orthostatic intolerance in the majority of paced patients. The most common diagnosis was orthostatic hypotension (40%) followed by vasovagal syncope (30%), whereas there were no cases of pacemaker dysfunction. Our results emphasize the importance of a complete diagnostic work-up, including cardiovascular autonomic tests, in paced patients that present with syncope and/or orthostatic intolerance.
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Affiliation(s)
- Ekrem Yasa
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Fabrizio Ricci
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Institute of Cardiology, University "G. d'Annunzio", Chieti, Italy.,Department of Neuroscience and Imaging, ITAB - Institute Advanced Biomedical Technologies, University "G. d'Annunzio", Chieti, Italy
| | - Hannes Holm
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Torbjörn Persson
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,National Heart and Lung Institute, Imperial College, Hammersmith Hospital, London, United Kingdom
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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13
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Syncope, conduction disturbance, and negative electrophysiological test: Predictive factors and risk score to predict pacemaker implantation during follow-up. Heart Rhythm 2019; 16:905-912. [PMID: 30576876 DOI: 10.1016/j.hrthm.2018.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Indexed: 12/27/2022]
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14
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Lee JZ, Mulpuru SK, Shen WK. The Role of Pacing in Elderly Patients with Unexplained Syncope. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0608-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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Yasa E, Ricci F, Holm H, Persson T, Melander O, Sutton R, Hamrefors V, Fedorowski A. Pacing therapy in the management of unexplained syncope: a tertiary care centre prospective study. Open Heart 2019; 6:e001015. [PMID: 30997138 PMCID: PMC6443123 DOI: 10.1136/openhrt-2019-001015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 12/22/2022] Open
Abstract
Objective Pacemaker (PM) therapy is effective when syncope is associated with bradycardia, but syncope recurrences and fall injuries after PM implantation may occur. We aimed to survey indications and outcomes of PM implantation, following evaluation of unexplained syncope. Methods Among 1666 consecutive unpaced patients investigated in a tertiary syncope unit by carotid-sinus massage (CSM), head-up tilt test (HUT) and ECG monitoring, 106 (6.4%; age, 65 ± 17 years) received a PM. We assessed bradycardia detection methods, PM implantation indications, and explored incidence of recurrent syncope, fall-related fractures and mortality. Results Indications for PM therapy were met in 32/106 patients (30%) by CSM, in 41/106 (39%) by HUT, in 14/106 patients (13%) by implantable loop-recorder (ILR) and in 19/106 (18%) by standard ECG. Sinus arrest with asystole was the predominant PM indication during CSM/HUT and external ECG monitoring, whereas ILR detected proportionally the same numbers o f asystole due to sinus arrest and atrioventricular block. During follow-up (median, 4.3 years), 15 patients (14%) had syncope recurrence, 15 suffered fall-related fractures and 9 died. Neither syncope recurrence nor fall-related fractures were dependent on initial PM indication. The composite endpoint of recurrent syncope/fall-related fracture was associated with treated hypertension (OR 2.45; 95% CI 1.00 to 6.0), reduced glomerular filtration rate (OR 1.63 per 10 mL/min↓; 95% CI 1.22 to 2.19) and atrial fibrillation (OR 3.98; 95% CI 1.11 to 14.3). Recurrent syncope predicted increased mortality (OR 9.20; 95% CI 1.89 to 44.8). Conclusions Cardiovascular autonomic testing and ECG monitoring effectively identify pacing indications in patients with unexplained syncope. After PM implantation, treated hypertension, renal failure and atrial fibrillation predict syncope recurrence and fall-related injury. Recurrent syncope predicts increased mortality.
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Affiliation(s)
- Ekrem Yasa
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Fabrizio Ricci
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Neuroscience, Imaging and Clinical Sciences, Universita degli Studi Gabriele d'Annunzio Chieti e Pescara, Chieti Scalo, Italy
| | - Hannes Holm
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Torbjörn Persson
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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Aksu T, Guler TE, Bozyel S, Yalin K. Potential usage of cardioneuroablation in vagally mediated functional atrioventricular block. SAGE Open Med 2019; 7:2050312119836308. [PMID: 30906551 PMCID: PMC6421594 DOI: 10.1177/2050312119836308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/14/2019] [Indexed: 12/14/2022] Open
Abstract
An increase in parasympathetic tone may be the main cause of some transient or permanent atrioventricular block cases. Some of these patients, defined as vagally mediated functional atrioventricular block, may be severely symptomatic and refractory to conventional therapies and may necessitate cardiac pacing. Cardioneuroablation is a relatively new strategy for management of patients with excessive vagal activation based on radiofrequency catheter ablation of main ganglionated plexi around the heart. Present review was dedicated to discuss potential usage of cardioneuroablation in patients with vagally mediated functional atrioventricular block.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Kocaeli Derince Training and Research Hospital, Derince, Turkey
| | - Tumer Erdem Guler
- Department of Cardiology, Kocaeli Derince Training and Research Hospital, Derince, Turkey
| | - Serdar Bozyel
- Department of Cardiology, Kocaeli Derince Training and Research Hospital, Derince, Turkey
| | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Usak University, Usak, Turkey
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17
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Sutton R, Deharo JC, Brignole M, Hamdan MH. Emerging concepts in diagnosis and treatment of syncope by pacing. Trends Cardiovasc Med 2018; 28:421-426. [DOI: 10.1016/j.tcm.2018.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 11/29/2022]
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18
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Sutton R. Pacing in neurocardiogenic/vasovagal syncope. Herzschrittmacherther Elektrophysiol 2018; 29:208-213. [PMID: 29802445 DOI: 10.1007/s00399-018-0564-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 06/08/2023]
Abstract
Pacing for neurocardiogenic or vasovagal syncope (VVS) has been practised for five decades, but the 1986 advent of tilt testing provided a means of diagnosis frequently revealing, in the early days, asystole caused by VVS. This was the basis for pacing these patients and the first studies created enthusiasm followed by randomised controlled trials, which were imperfectly designed, "confirming" benefit. When better trial design was employed, there was no obvious benefit. However, some cardiologists had seen patients experience a huge positive difference with pacing, so they set out to identify them. Two studies using ECG loop recorders to document heart rhythm during spontaneous attacks allowed better patient selection for pacing and appeared to achieve the aim. Further, it was noted in the second study, a randomised controlled trial (RCT) with good design, that tilt testing added a further dimension to the identification of the patient who would benefit. Thus, loop recorders are used to show asystole in spontaneous attacks and when tilt testing is negative, implying a lesser vasodepressor component, the patient will have the best outcome. From the available evidence, pacing should be dual-chamber in older patients (>40 years) with severe symptoms and in whom standard measures have demonstrably failed. The method of triggering pacing and its timing of introduction have not yet been resolved. Today's method is rate-hysteresis but there is another sensed event as an alternative: right ventricular impedance, which is now in RCT with substantial pilot evidence in its favour.
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Affiliation(s)
- Richard Sutton
- National Heart and Lung Institute, Hammersmith Hospital Campus, B block South, 2nd floor, NHLI-Cardiovascular Science, Imperial College, Du Cane Road, W12 0NN, London, UK.
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19
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Syncope and bundle branch block. Herzschrittmacherther Elektrophysiol 2018; 29:161-165. [PMID: 29696347 DOI: 10.1007/s00399-018-0560-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/03/2018] [Indexed: 01/14/2023]
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20
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 927] [Impact Index Per Article: 154.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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21
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Aste M, Brignole M. Syncope and paroxysmal atrioventricular block. J Arrhythm 2017; 33:562-567. [PMID: 29255501 PMCID: PMC5728706 DOI: 10.1016/j.joa.2017.03.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/20/2017] [Indexed: 12/22/2022] Open
Abstract
Current literature reveals three types of paroxysmal atrioventricular block (AVB) that can cause syncope: Intrinsic paroxysmal atrioventricular block is due to an intrinsic disease of the AV conduction system; this type of "cardiac syncope" is also called Stokes-Adams attack; Extrinsic vagal paroxysmal atrioventricular block is linked to the effect of the parasympathetic nervous system on cardiac conduction and is one of the mechanisms involved in "reflex syncope." Extrinsic idiopathic paroxysmal atrioventricular block is associated with low levels of endogenous adenosine and is supposed to be one of the mechanisms involved in "low-adenosine syncope." These three types of paroxysmal AVB present different clinical and electrocardiographic features. Additionally, the efficacy of cardiac pacing and theophylline therapy to prevent syncopal recurrences is also different for these three types of AVB.
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Affiliation(s)
- Milena Aste
- Arrhythmology Center, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy
| | - Michele Brignole
- Arrhythmology Center, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy
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KALSCHEUR MATTHEWM, DONATEO PAOLO, WENZKE KEVINE, ASTE MILENA, ODDONE DANIELE, SOLANO ALBERTO, MAGGI ROBERTO, CROCI FRANCESCO, PAGE RICHARDL, BRIGNOLE MICHELE, HAMDAN MOHAMEDH. Long-Term Outcome of Patients with Bifascicular Block and Unexplained Syncope Following Cardiac Pacing. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1126-1131. [DOI: 10.1111/pace.12946] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/05/2016] [Accepted: 08/18/2016] [Indexed: 12/15/2022]
Affiliation(s)
- MATTHEW M. KALSCHEUR
- Division of Cardiovascular Medicine; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
| | - PAOLO DONATEO
- Department of Cardiology, Arrhythmologic Centre; Ospedali del Tigullio; Lavagna Italy
| | - KEVIN E. WENZKE
- Division of Cardiovascular Medicine; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
| | - MILENA ASTE
- Department of Cardiology, Arrhythmologic Centre; Ospedali del Tigullio; Lavagna Italy
| | - DANIELE ODDONE
- Department of Cardiology, Arrhythmologic Centre; Ospedali del Tigullio; Lavagna Italy
| | - ALBERTO SOLANO
- Department of Cardiology, Arrhythmologic Centre; Ospedali del Tigullio; Lavagna Italy
| | - ROBERTO MAGGI
- Department of Cardiology, Arrhythmologic Centre; Ospedali del Tigullio; Lavagna Italy
| | - FRANCESCO CROCI
- Department of Cardiology, Arrhythmologic Centre; Ospedali del Tigullio; Lavagna Italy
| | - RICHARD L. PAGE
- Division of Cardiovascular Medicine; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
| | - MICHELE BRIGNOLE
- Department of Cardiology, Arrhythmologic Centre; Ospedali del Tigullio; Lavagna Italy
| | - MOHAMED H. HAMDAN
- Division of Cardiovascular Medicine; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
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