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

Yasa, Ekrem; Ricci, Fabrizio; Holm, Hannes; Persson, Torbjörn; Melander, Olle; Sutton, Richard; Fedorowski, Artur; Hamrefors, Viktor

doi:10.3389/fcvm.2019.00154

Cited by 16 publications

(8 citation statements)

References 17 publications

(30 reference statements)

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“…The report of Palmisano et al in 2020 [ 13 ] demonstrated the importance of autonomic status assessment before implantation to predict the likelihood of syncope recurrence after pacing, a subject also covered by the 2018 ESC guidelines [ 1 ]. Further supporting this, in the same cohort as in the current study, the most common causes of syncope recurrence in paced patients were orthostatic hypotension and vasovagal syncope [ 16 ], which can be diagnosed by CAT. This further emphasizes the use of the dual strategy in which CAT is preferably done prior to ILR implantation unless there are specific signs, such as conduction abnormalities or high-risk settings suggesting cardiac arrhythmia supporting a primary ILR implantation.…”

Section: Discussionsupporting

confidence: 77%

Outcomes of Primary vs. Delayed Strategy of Implanting a Cardiac Monitor for Unexplained Syncope

Yasa

Intzilakis

Ricci

et al. 2022

JCM

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Objective: Implantable cardiac monitors (ILR) have an important role in diagnosing unexplained syncope. However, outcomes of primary vs. delayed ILR implantation after initial syncope evaluation have not been explored. Methods: A total of 1705 patients with unexplained syncope were prospectively enrolled in the SYSTEMA (Syncope Study of Unselected Population in Malmö) cohort. Patients who underwent cardiovascular autonomic testing (CAT) and ILR were grouped into those referred to CAT after ILR implantation (primary ILR) and those in whom ILR was indicated after CAT (post-CAT ILR). Results: One-hundred-and-fifteen patients (6.7%) received ILRs. ILR recipients were older (58 vs. 52 years; p = 0.002), had more syncope recurrences (6 vs. 4; p < 0.001), more traumatic falls (72% vs. 53%; p < 0.001), and less prodrome (40% vs. 55%; p = 0.005) than patients without ILRs. During follow-up ≥16 months after ILR, 67 (58%) had normal sinus rhythm, 10 (8.7%) had sinus arrest, 10 (8.7%) AV-block, 13 (11.3%) atrial fibrillation, 9 (7.8%) supraventricular tachycardia, 4 (3.5%) sinus tachycardia and 2 (1.7%) ventricular tachycardia with clinical symptom reproduction. There were 52 patients (45%) in the primary-ILR group and 63 (55%) in the post-CAT ILR group. Proportions of negative ILR monitoring (17/52 vs. 25/63; p = 0.56) and pacemaker implantations (7/52 vs. 15/63; p = 0.23) did not differ between groups. Baseline ECG conduction disorders predicted pacemaker implantation (n = 11/17; odds ratio:10.6; 95%CI: 3.15–35.3; p < 0.001). CAT was more often positive (73% vs. 40%; p < 0.001) in primary-ILR group. Conclusions: Primary ILR implantation was associated with more positive CAT compared with delayed ILR implantation, but negative monitoring and pacemaker implantations were not different between groups. ECG conduction disorders predicted subsequent pacemaker implantation.

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Section: Discussionsupporting

confidence: 77%

Outcomes of Primary vs. Delayed Strategy of Implanting a Cardiac Monitor for Unexplained Syncope

Yasa

Intzilakis

Ricci

et al. 2022

JCM

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“…A likely cause may be nonarrhythmic successfully identified by cardiovascular autonomic testing. 102 A common cause is OH (preferentially, in older subjects).…”

Section: Pacingmentioning

confidence: 99%

Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem

Fedorowski

Ricci

Hamrefors

et al. 2022

Circ: Arrhythmia and Electrophysiology

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Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We (1) propose a novel streamlined pathophysiological classification of OH; (2) review the relationship between the cardiovascular disease continuum and OH; (3) discuss OH-mediated end-organ damage; (4) provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; (5) identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.

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“…This study group primarily included older patients with a high incidence of structural heart disease and comorbidities who are generally patients with high morbidity and mortality risks. The most frequent cause of syncope appears to be reflex syncope or dysautonomia [ 15 ] ; however, life-threatening issues may also cause syncope in PM patients.…”

Section: Discussionmentioning

confidence: 99%

Syncope in Patients with Cardiac Pacemakers

Rocha¹,

Cunha²,

Tavares³

et al. 2021

Braz J Cardiovasc Surg

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

Cited by 16 publications

References 17 publications

Outcomes of Primary vs. Delayed Strategy of Implanting a Cardiac Monitor for Unexplained Syncope

Outcomes of Primary vs. Delayed Strategy of Implanting a Cardiac Monitor for Unexplained Syncope

Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem

Syncope in Patients with Cardiac Pacemakers

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