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Kronborg MB, Frausing MHJP, Malczynski J, Riahi S, Haarbo J, Holm KF, Larroudé CE, Albertsen AE, Svendstrup L, Hintze U, Pedersen OD, Davidsen U, Fischer T, Johansen JB, Kristensen J, Gerdes C, Nielsen JC. Atrial pacing minimization in sinus node dysfunction and risk of incident atrial fibrillation: a randomized trial. Eur Heart J 2023; 44:4246-4255. [PMID: 37638973 PMCID: PMC10590128 DOI: 10.1093/eurheartj/ehad564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS High percentages of atrial pacing have been associated with an increased risk of atrial fibrillation. This study is aimed at evaluating whether atrial pacing minimization in patients with sinus node dysfunction reduces the incidence of atrial fibrillation. METHODS In a nationwide, randomized controlled trial, 540 patients with sinus node dysfunction and an indication for first pacemaker implantation were assigned to pacing programmed to a base rate of 60 bpm and rate-adaptive pacing (DDDR-60) or pacing programmed to a base rate of 40 bpm without rate-adaptive pacing (DDD-40). Patients were followed on remote monitoring for 2 years. The primary endpoint was time to first episode of atrial fibrillation longer than 6 min. Secondary endpoints included longer episodes of atrial fibrillation, and the safety endpoint comprised a composite of syncope or presyncope. RESULTS The median percentage of atrial pacing was 1% in patients assigned to DDD-40 and 49% in patients assigned to DDDR-60. The primary endpoint occurred in 124 patients (46%) in each treatment group (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.76-1.25, P = .83). There were no between-group differences in atrial fibrillation exceeding 6 or 24 h, persistent atrial fibrillation, or cardioversions for atrial fibrillation. The incidence of syncope or presyncope was higher in patients assigned to DDD-40 (HR 1.71, 95% CI 1.13-2.59, P = .01). CONCLUSIONS Atrial pacing minimization in patients with sinus node dysfunction does not reduce the incidence of atrial fibrillation. Programming a base rate of 40 bpm without rate-adaptive pacing is associated with an increased risk of syncope or presyncope.
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Affiliation(s)
- Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle-Juul Jensens Bvld. 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle-Juul Jensens Bvld. 99, 8200 Aarhus, Denmark
| | - Maria Hee Jung Park Frausing
- Department of Cardiology, Aarhus University Hospital, Palle-Juul Jensens Bvld. 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle-Juul Jensens Bvld. 99, 8200 Aarhus, Denmark
| | - Jerzy Malczynski
- Department of Cardiology, Goedstrup Hospital, 7400 Herning, Denmark
| | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, 9100 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Jens Haarbo
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Copenhagen, Denmark
| | - Katja Fiedler Holm
- Department of Cardiology, Aalborg University Hospital, 9100 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Charlotte Ellen Larroudé
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, 2900 Copenhagen, Denmark
| | | | - Lene Svendstrup
- Department of Cardiology, Aabenraa Hospital, 6200 Aabenraa, Denmark
| | - Ulrik Hintze
- Department of Cardiology, Esbjerg Hospital, 6700 Esbjerg, Denmark
| | - Ole Dyg Pedersen
- Department of Cardiology, Roskilde Hospital, 4000 Roskilde, Denmark
| | - Ulla Davidsen
- Department of Cardiology, Bispebjerg Hospital, 2400 Copenhagen, Denmark
| | - Thomas Fischer
- Department of Cardiology, Vejle Hospital, 7100 Vejle, Denmark
| | | | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Palle-Juul Jensens Bvld. 99, 8200 Aarhus, Denmark
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Palle-Juul Jensens Bvld. 99, 8200 Aarhus, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle-Juul Jensens Bvld. 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle-Juul Jensens Bvld. 99, 8200 Aarhus, Denmark
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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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Zhang X, Zhao Y, Zhou Y, Lv J, Peng J, Zhu H, Liu R. Trends in research on sick sinus syndrome: A bibliometric analysis from 2000 to 2022. Front Cardiovasc Med 2022; 9:991503. [DOI: 10.3389/fcvm.2022.991503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/19/2022] [Indexed: 11/11/2022] Open
Abstract
Sick sinus syndrome (SSS) is a refractory arrhythmia disease caused by the pathological changes of sinoatrial node and its adjacent tissues. 2,251 publications related to SSS were retrieved from Web of Science database from 2000 to 2022 and analyzed by using VOS viewer and CiteSpace software. The results showed the United States dominated the field, followed by Japan, Germany, and China. SSS was closely related to risk factors such as atrial fibrillation and aging. Sick sinus syndrome, atrial fibrillation and sinus node dysfunction were the top three keywords that had the strongest correlation with the study. Pacemaker implantation, differentiation and mutation are research hotspots currently. Clinical studies on SSS found that sick sinus syndrome, atrial fibrillation, and pacemakers were the top three keywords that had the largest nodes and the highest frequency. In the field of basic applied research and basic research, atrial fibrillation and pacemaker cells were the focus of research. In conclusion, bibliometric analysis provided valuable information for the prevention, treatment and future research trends of SSS.
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Rocha EA, Cunha GS, Tavares AB, Viana AB, Quidute ARP, Pereira FTM, Monteiro MDPM, Rocha MEQA, Gomes CRF, Rodrigues CRM. Syncope in Patients with Cardiac Pacemakers. Braz J Cardiovasc Surg 2021; 36:18-24. [PMID: 33594860 PMCID: PMC7918387 DOI: 10.21470/1678-9741-2020-0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction It is challenging to diagnose syncope in patients with pacemakers. Because these patients have increased morbidity and mortality risks, they require immediate attention to determine the causes in order to provide appropriate treatment. This study aimed to investigate the causes and predictive factors of syncope as well as the methods used to diagnose syncope in cardiac pacemaker patients. Methods Patients with pacemakers implanted owing to sinus node disease or atrioventricular block were evaluated with standardized questionnaires, endocavitary electrograms, and other tests based on the suspected causes of syncope. Mann-Whitney U tests were used to analyze continuous variables and Chi-squared or Fisher’s exact tests were used for categorical variables. Logistic regression was used for multivariate analyses. Statistical significance was P<0.05. Results The study included 95 patients with pacemakers: 47 experienced syncope in the last 12 months and 48 did not. Of the 100 documented episodes of syncope, 48.9% were vasovagal syncopes, 17% had cardiac-related causes, 10.6% had unknown causes, and 8.5% had pacemaker failure. The multivariate analysis showed that a New York Heart Association (NYHA) Functional Class II was a significant factor for developing syncope (P<0.01). Conclusion While the most common type of syncope in pacemaker patients was neurally mediated, it is important to perform detailed evaluations in this population as the causes of syncope can be life-threatening. The best diagnostic methods were stored electrogram analysis and the tilt table test. NYHA Functional Class II patients were found to have a higher risk for syncope.
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Affiliation(s)
- Eduardo Arrais Rocha
- Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | | | - Aline Bezerra Tavares
- Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Antônio Brazil Viana
- Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Ana Rosa Pinto Quidute
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Ceará, Brazil
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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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7
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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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Hu T, Noheria A, Asirvatham SJ. Atrial Fibrillation and Falls: A Mechanistic or Age-Confounded Relationship? Mayo Clin Proc 2020; 95:632-635. [PMID: 32247334 DOI: 10.1016/j.mayocp.2020.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Tiffany Hu
- Department of Cardiovascular Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Amit Noheria
- Department of Cardiovascular Medicine, Division of Electrophysiology, University of Kansas, Kansas City, KS
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN.
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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: 935] [Impact Index Per Article: 155.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
Sick sinus syndrome (SSS) is a type of bradyarrhythmia that can lead to syncope. Cilostazol has been reported to be an effective treatment for human patients with SSS and other bradyarrhythmias. This report describes the successful long-term treatment with cilostazol in a dog with SSS. A nine-year old intact male Miniature Schnauzer presented with a history of syncopal episodes and unsteady gait. After cilostazol treatment, the total heart rate (HR), mean HR, and frequency of premature ventricular contractions (PVCs) increased, while the maximum HR and maximum pause time decreased. Additionally, the number of syncopal episodes decreased. The dog died suddenly, 1,418 days after the start of cilostazol treatment. Cilostazol may be a useful therapeutic agent in canines with SSS.
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Affiliation(s)
- Nobuyuki Kanno
- Division of Veterinary Cardiovascular Medicine and Surgery, Laboratory of Veterinary Medical Therapeutics, Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa-shi, Kanagawa 252-0880, Japan
| | - Tomohiro Suzuki
- Ikime Animal Hospital, 3036-4 Ukita, Ooaza, Miyazakishi, Miyazaki 880-2104, Japan
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Brenner R, Ammann P, Yoon SI, Christen S, Hellermann J, Girod G, Knaus U, Duru F, Krasniqi N, Ramsay D, Sticherling C, Lippuner K, Kühne M. Reduction of falls and fractures after permanent pacemaker implantation in elderly patients with sinus node dysfunction. Europace 2016; 19:1220-1226. [DOI: 10.1093/europace/euw156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 05/05/2016] [Indexed: 11/13/2022] Open
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Aste M, Oddone D, Donateo P, Solano A, Maggi R, Croci F, Solari D, Brignole M. Syncope in patients paced for atrioventricular block. Europace 2016; 18:1735-1739. [DOI: 10.1093/europace/euv425] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/18/2015] [Indexed: 11/15/2022] Open
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Abstract
Syncope in a pacemaker patient is a serious symptom but it is rarely due a pacemaker system malfunction. Syncope occurs in about 5 % of patients paced for atrioventricular (AV) block in 5 years, 18% in those paced for sinus node disease in 10 years, 20 % of those paced for carotid sinus syndrome in 5 years and 5-55 % of those older patients paced for vasovagal syncope in 2 years. The vastly different results in vasovagal syncope depend on the results of tilt testing, where those with negative tests approach results in pacing for AV block and those with a positive tilt test show no better results than with no pacemaker. The implication of tilt results is that a hypotensive tendency is clearly demonstrated by tilt positivity pointing to syncope recurrence with hypotension. This problem may be addressed by treatment with vasoconstrictor drugs in those who are suited or, more commonly, a reduction or cessation of hypotensive therapy in hypertensive patients. Other causes of syncope such as tachyarrhythmias are rare. The clinical approach to patients who report syncope is detailed.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, London, UK
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14
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Brignole M, Arabia F, Ammirati F, Tomaino M, Quartieri F, Rafanelli M, Del Rosso A, Rita Vecchi M, Russo V, Gaggioli G. Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study. Europace 2015; 18:1427-33. [DOI: 10.1093/europace/euv343] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/07/2015] [Indexed: 11/12/2022] Open
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16
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Brignole M, Ammirati F, Arabia F, Quartieri F, Tomaino M, Ungar A, Lunati M, Russo V, Del Rosso A, Gaggioli G. Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes. Eur Heart J 2015; 36:1529-35. [PMID: 25825044 DOI: 10.1093/eurheartj/ehv069] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 03/02/2015] [Indexed: 12/17/2022] Open
Abstract
AIMS Opinions differ regarding the effectiveness of cardiac pacing in patients affected by reflex syncope. We assessed a standardized guideline-based algorithm in different forms of reflex syncope. METHODS AND RESULTS In this prospective, multi-centre, observational study, patients aged >40 years, affected by severe unpredictable recurrent reflex syncopes, underwent carotid sinus massage (CSM), followed by tilt testing (TT) if CSM was negative, followed by implantation of an implantable loop recorder (ILR) if TT was negative. Those who had an asystolic response to one of these tests received a dual-chamber pacemaker. POPULATION 253 patients, mean age 70 ± 12 years, median 4 (3-6) syncopes, 89% without or with short prodromes. Of these patients, 120 (47%) received a pacemaker and 106 were followed up for a mean of 13 ± 7 months: syncope recurred in 10 (9%). The recurrence rate was similar in 61 CSM+ (11%), 30 TT+ (7%), and 15 ILR+ (7%) patients. The actuarial total syncope recurrence rate was 9% (95% confidence interval (CI), 6-12) at 1 year and 15% (95% CI, 10-20) at 2 years and was significantly lower than that observed in the group of 124 patients with non-diagnostic tests who had received an ILR: i.e. 22% (95% CI, 18-26) at 1 year and 37% (95% CI, 30-43) at 2 years (P = 0.004). CONCLUSION About half of older patients with severe recurrent syncopes without prodromes have an asystolic reflex for which cardiac pacing goes along with a low recurrence rate. The study supports the clinical utility of the algorithm for the selection of candidates to cardiac pacing in everyday clinical practice. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Unique identifier: NCT01509534.
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Affiliation(s)
- Michele Brignole
- Arrhythmology Centre, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy
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Sutton R. Carotid sinus syndrome: Progress in understanding and management. Glob Cardiol Sci Pract 2014; 2014:1-8. [PMID: 25405171 PMCID: PMC4220427 DOI: 10.5339/gcsp.2014.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 05/28/2014] [Indexed: 12/19/2022] Open
Abstract
Carotid sinus syndrome (CSS) is a disease of the autonomic nervous system presenting with syncope, especially in older males who often have cardiovascular disease. The aetiology is unknown and epidemiological data is limited. Forty new patients/million population have been estimated to require pacing for CSS and these patients represent ∼9% of those presenting syncope to a specialist facility. CSS is defined as a response to carotid sinus massage (CSM) that includes reproduction of spontaneous symptoms. Cardioinhibitory CSS shows 3s asystole on CSM and vasodepressor CSS shows >50 mmHg fall in blood pressure (BP), there are mixed forms. The methodology of CSM requires correct massage in the supine and upright with continuous ECG and BP. Assessment of the vasodepressor component implies the ‘method of symptoms’ using atropine to prevent asystole. Carotid sinus hypersensitivity (CSH) is a related condition where CSM is positive in an asymptomatic patient. CSH cannot be assumed to respond to pacing. CSS patients present syncope with little or no warning. If no cause is revealed by the initial evaluation, CSM should be considered in all patients >40 years. CSM carries a small risk of thromboembolism. Therapy for cardioinhibitory CSS is dual chamber pacing, which is most effective in patients with a negative tilt test. Syncope recurrence is ∼20% in 5 years in paced patients. Therapy for the vasodepressor component of CSS, as pure vasodepression or mixed, where tilt testing will likely be positive, is often unrewarding: alternative therapeutic measures may be needed including discontinuation/reduction of hypotensive drugs.
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Affiliation(s)
- Richard Sutton
- Emeritus Professor of Clinical Cardiology, National Heart & Lung Institute, Imperial College, London, UK
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