Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes

Brignole, Michele; Ammirati, Fabrizio; Arabia, Francesco; Quartieri, Fabio; Tomaino, Marco; Ungar, Andrea; Lunati, Maurizio; Russo, Vitantonio; Rosso, Attilio Del; Gaggioli, Germano

doi:10.1093/eurheartj/ehv069

Cited by 71 publications

(42 citation statements)

References 25 publications

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“…A possible solution to this problem has been presented by an Italian group, where a systematic approach to unexplained syncope in patients above 40 years of age resulted in pacemaker implantation in about half, with subsequent resolution of syncopal episodes. 20 On the other hand, there is a huge gap in knowledge of whether syncope apparently due to vasovagal reflex or OH, especially in older, diabetic or hypertensive patients, should stimulate a more proactive approach to cardiac risk assessment. This approach could include long-term invasive cardiac monitoring, the application of specific and otherwise rarely used diagnostic modalities, and, finally, prophylactic measures.…”

Section: Discussionmentioning

confidence: 99%

Prognostic significance of noncardiac syncope in the general population: A systematic review and meta‐analysis

Ricci

Sutton

Palermi

et al. 2018

Cardiovasc electrophysiol

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Section: Discussionmentioning

confidence: 99%

Prognostic significance of noncardiac syncope in the general population: A systematic review and meta‐analysis

Ricci

Sutton

Palermi

et al. 2018

Cardiovasc electrophysiol

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“…Subsequent data from the SUP-2 study in Italian Syncope Clinics [23,24] offered support for the above ISSUE-3 observations. Using a decision algorithm for older patients with syncope, involving first, carotid sinus massage and treating CSS if found, followed by a tilt test and treating the findings, if positive, and finally, implanting an ILR if both preliminary tests were negative, provided some succour for the tilt-positive patients as results for them were better in longer follow-up than for patients with unpaced VVS.…”

Section: Historical Developmentstudiesmentioning

confidence: 83%

Should we treat severe vasovagal syncope with a pacemaker?

Sutton

2017

J Intern Med

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Cardiac pacing for vasovagal syncope (VVS) addresses the cardioinhibitory component of the reflex but cannot directly affect vasodepression, which occurs in every reflex even when hidden by dominant cardioinhibition. The randomized controlled trials of pacing in VVS have, after almost 2 decades, determined that a small number of patients can benefit because their vasodepressor component is not severe. Early studies compared pacing with no therapy yielding highly significant benefits. Subsequently, all study patients had implanted devices with half being switched off. No benefit was seen. The ISSUE‐3 study found significant benefit (P < 0.039) in prevention of syncope recurrence in older patients. A sub‐study later showed those with negative tilt tests, otherwise indistinguishable from tilt‐positives, had 5% recurrence in 21 months (P < 0.004). There is acceptance that pacing must be dual chamber, but the question of how pacing is delivered remains open. Relying on falling heart rate is insufficient, probably because it occurs too late. Other algorithms which indirectly detect neuroendocrine changes earlier than heart rate fall may have useful application. In clinical terms, the patient to be considered for pacing should not be young and have severe symptoms. Ideally, tilt testing should be negative implying vasodepression of lesser severity and, therefore, yielding fewer syncope recurrences. When selecting pacing, additional concern must be given to regression to the mean of symptoms, severe to less severe. Patients seek help when they are at their worst. Moreover, many years of pacing are unlikely to be free of complications related to implanted hardware.

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“…The authors suggested that patients with positive TTT have a greater vasodepressor response during spontaneous events when compared to patients with negative TTT. Therefore, even in the presence of spontaneous reflex-mediated asystole, these patients are less likely to benefit from pacing [4,5]. This hypothesis was generated after learning from the ISSUE-3 trial that patients with positive TTT derived no benefit from cardiac pacing.…”

Section: Pathophysiology Of Ttt Induced Syncopementioning

confidence: 99%

The pathophysiologic mechanisms associated with hypotensive susceptibility

et al. 2016

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Introduction Patients with vasovagal syncope (VVS) and positive tilt table test (TTT) were not found to benefit from pacing in the ISSUE-3 trial despite the presence of spontaneous asystole during monitoring. "Hypotensive susceptibility" unmasked by TTT was reported as a possible explanation. The purpose of this study was to assess the pathophysiologic mechanisms associated with hypotensive susceptibility.

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Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes

Abstract: http://www.clinicaltrials.gov. Unique identifier: NCT01509534.

Cited by 71 publications

References 25 publications

Prognostic significance of noncardiac syncope in the general population: A systematic review and meta‐analysis

Prognostic significance of noncardiac syncope in the general population: A systematic review and meta‐analysis

Should we treat severe vasovagal syncope with a pacemaker?

The pathophysiologic mechanisms associated with hypotensive susceptibility

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