Dirk P Saal1, Roland D Thijs2, Erik W van Zwet3, Marianne Bootsma4, Michele Brignole5, David G Benditt6, J Gert van Dijk7. 1. Department of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, Leiden, the Netherlands. Electronic address: d.p.saal@lumc.nl. 2. Department of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland-SEIN, Heemstede, the Netherlands. 3. Department of Medical Statistics, Leiden University Medical Centre, Leiden, the Netherlands. 4. Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands. 5. Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy. 6. Department of Medicine, Cardiovascular Division, Cardiac Arrhythmia Centre, University of Minnesota Medical School, Minneapolis, Minnesota. 7. Department of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, Leiden, the Netherlands.
Abstract
OBJECTIVES: The purpose of this study was to investigate the relationship between the onset of asystole and transient loss of consciousness (TLOC) in tilt-induced reflex syncope and estimate how often asystole was the principal cause of TLOC. BACKGROUND: The presence of asystole in vasovagal syncope (VVS) may prompt physicians to consider pacemaker therapy for syncope prevention, but the benefit of pacing is limited in VVS. METHODS: We evaluated electrocardiography, electroencephalography, blood pressure, and clinical findings during tilt-table tests. Inclusion required TLOC (video), electroencephalographic slowing, accelerating blood pressure decrease, and an RR interval ≥3 s. We excluded cases with nitroglycerin provocation. Asystole after onset of TLOC (group A) or within 3 s before TLOC (group B) was unlikely to cause TLOC, but an earlier start of asystole (group C) could be the cause of TLOC. RESULTS: In one-third of 35 cases (groups A [n = 9] and B [n = 3]), asystole was unlikely to be the primary cause of TLOC. The median of the mean arterial pressure at the onset of asystole was higher when asystole occurred early (45.5 mm Hg, group C) than when it occurred late (32.0 mm Hg, groups A and B), which suggests that vasodepression was not prominent at the start of asystole in early asystole, further suggesting that early asystole was the prime mechanism of syncope. CONCLUSIONS: In one-third of cases of tilt-induced asystolic reflex syncope, asystole occurred too late to have been the primary cause of TLOC. Reliance on electrocardiography data only is likely to overestimate the importance of asystole.
OBJECTIVES: The purpose of this study was to investigate the relationship between the onset of asystole and transient loss of consciousness (TLOC) in tilt-induced reflex syncope and estimate how often asystole was the principal cause of TLOC. BACKGROUND: The presence of asystole in vasovagal syncope (VVS) may prompt physicians to consider pacemaker therapy for syncope prevention, but the benefit of pacing is limited in VVS. METHODS: We evaluated electrocardiography, electroencephalography, blood pressure, and clinical findings during tilt-table tests. Inclusion required TLOC (video), electroencephalographic slowing, accelerating blood pressure decrease, and an RR interval ≥3 s. We excluded cases with nitroglycerin provocation. Asystole after onset of TLOC (group A) or within 3 s before TLOC (group B) was unlikely to cause TLOC, but an earlier start of asystole (group C) could be the cause of TLOC. RESULTS: In one-third of 35 cases (groups A [n = 9] and B [n = 3]), asystole was unlikely to be the primary cause of TLOC. The median of the mean arterial pressure at the onset of asystole was higher when asystole occurred early (45.5 mm Hg, group C) than when it occurred late (32.0 mm Hg, groups A and B), which suggests that vasodepression was not prominent at the start of asystole in early asystole, further suggesting that early asystole was the prime mechanism of syncope. CONCLUSIONS: In one-third of cases of tilt-induced asystolic reflex syncope, asystole occurred too late to have been the primary cause of TLOC. Reliance on electrocardiography data only is likely to overestimate the importance of asystole.
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