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      Cardiovascular Autonomic Dysfunction Is the Most Common Cause of Syncope in Paced Patients

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          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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          Most cited references13

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          'The Italian Protocol': a simplified head-up tilt testing potentiated with oral nitroglycerin to assess patients with unexplained syncope.

          Head-up tilt testing potentiated by sublingual nitroglycerin (NTG), advocated by an Italian group, is a simple and safe but still not a standardized, diagnostic tool for the investigation of syncope. In fact, owing to its rapid spread, the original protocol received, often arbitrarily, many subsequent modifications. We now define the best methodology of the test on strictly evidence-based criteria as: stabilization phase of 5 min in the supine position; passive phase of 20 min at a tilt angle of 60 degrees; provocation phase of further 15 min after 400 micrograms NTG sublingual spray. Test interruption is made when the protocol is completed in the absence of symptoms, or there is occurrence of syncope, or occurrence of progressive (> 5 min) orthostatic hypotension. We intend that this protocol, named by us as 'The Italian Protocol', will be accepted as the standard methodology of the tilt test potentiated by sublingual nitrates.
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            2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary

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              Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis.

              There is growing scepticism over utility of tilt-testing for syncope diagnosis, which has been shown unable to distinguish vasovagal from other syncope, especially cardiac, despite its acceptable sensitivity and specificity in true positive and negative subjects. The new interpretation is that the test reveals a susceptibility to reflex hypotension, which may exist in coincidence with any cause of syncope. This implies an important change in patient management including selecting effective therapy, in particular in guiding pacemaker therapy in patients affected by reflex syncope.
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                Author and article information

                Contributors
                Journal
                Front Cardiovasc Med
                Front Cardiovasc Med
                Front. Cardiovasc. Med.
                Frontiers in Cardiovascular Medicine
                Frontiers Media S.A.
                2297-055X
                25 October 2019
                2019
                : 6
                : 154
                Affiliations
                [1] 1Department of Clinical Sciences, Lund University , Malmö, Sweden
                [2] 2Department of Cardiology, Skåne University Hospital , Malmö, Sweden
                [3] 3Institute of Cardiology, University “G. d'Annunzio” , Chieti, Italy
                [4] 4Department of Neuroscience and Imaging, ITAB - Institute Advanced Biomedical Technologies, University “G. d'Annunzio” , Chieti, Italy
                [5] 5Department of Internal Medicine, Skåne University Hospital , Malmö, Sweden
                [6] 6National Heart and Lung Institute, Imperial College, Hammersmith Hospital , London, United Kingdom
                Author notes

                Edited by: Marina Cerrone, New York University, United States

                Reviewed by: Silvia Magnani, New York University, United States; Anna Pfenniger, Northwestern Medicine, United States

                *Correspondence: Viktor Hamrefors viktor.hamrefors@ 123456med.lu.se

                This article was submitted to Cardiac Rhythmology, a section of the journal Frontiers in Cardiovascular Medicine

                †Shared senior authorship

                Article
                10.3389/fcvm.2019.00154
                6823818
                dcbcb4a0-4f0b-41bb-9a24-0faa4a2d41db
                Copyright © 2019 Yasa, Ricci, Holm, Persson, Melander, Sutton, Fedorowski and Hamrefors.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 04 August 2019
                : 09 October 2019
                Page count
                Figures: 1, Tables: 1, Equations: 0, References: 15, Pages: 6, Words: 3784
                Categories
                Cardiovascular Medicine
                Original Research

                pacemaker,pacing,syncope,orthostatic intolerance,cardiovascular autonomic tests

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