The Medical Therapy of Cardioinhibitory Syncope in Pediatric Patients

Abstract

A small percentage of pediatric patients with neurally mediated syncope will have an asystolic response during upright tilt table testing. The purpose of this study is to evaluate the incidence of asystole during tilt table testing, and to assess the outcome of medical management of such patients. Of 398 patients undergoing evaluation for recurrent syncope between January 1989 and 1994, 18 (4.5%) experienced asystole lasting > or = 5 seconds during baseline tilt test. Patients had experienced a mean of four episodes of syncope, with a mean age at the time of tilt test of 11.1 +/- 4.0 years. The median duration of asystole was 10 seconds (range 5-40 s). Treatment was individualized to increased fluids and salt intake (3 patients), metoprolol (8 patients), pseudoephedrine (4 patients), disopyramide (1 patient), or combination therapy with fludrohydrocortisone (2 patients). During a median duration of follow-up of 31 months, no additional syncope was experienced by 78% of patients. Recurrent syncope in 4 patients was associated with either noncompliance or discontinuation of therapy in 3 patients; in 1 patient, increasing the dose of metoprolol was effective in preventing recurrences. We conclude that young patients with recurrent syncope and asystole during tilt test may be safely and effectively managed with pharmacological therapy, without resorting to pacemaker implantation.

Long-term outcome of patients with asystole induced by head-up tilt test

“…Our data indicate a relationship between recurrences and the number of previous syncopes but not the chosen therapy. Thus, in agreement with other authors [3,13,18,21,27,28] and considering our large cohort of patients (with a mean time free of recurrence of 92·6 months and without any cardiac death), we do not believe that pacemakers should be considered routinely as first choice therapy. This is substantiated by the fact that we and other authors (e.g.…”

“…Furthermore, Grubb et al [19] described an asystolic response (>4000 ms) in 10 (20%) of 50 patients with recurrent syncope, whereas Brignole et al [20] reported on 28 patients (18%) with asystole (d3000 ms) among 152 consecutive patients. Deal et al [21] described a lower (4·5%) incidence of asystole (d5000 ms) among 398 consecutive paediatric patients. In Spain, Pérez-Paredes et al [22] published their experience with a cohort of 12 patients with asystole.…”

“…For example, Dhala et al [9] found that two of 19 patients (11%) with asystole suffered recurrences during a follow-up of 2·1 1·4 years, whereas Pérez-Paredes et al [22] reported that recurrences occurred in four of 12 (36%) patients with the same characteristics during a mean follow-up of 34 20 months. In addition, Deal et al [21] described an incidence of 22·2% among 18 paediatric patients under different therapeutic regimens during 31 months of follow-up. Furthermore, Brignole et al [20] reported recurrences of syncope in five of 28 patients (18%) with asystolic responses and in 10 of 28 patients (36%) in the non-asystolic group during a follow-up of 17 14 and 16 12 months (P=ns).…”

Guidelines on management (diagnosis and treatment) of syncope

“…In uncontrolled studies, betablockers [399,402,404] , alpha-fludrocortisone [399,402] and alpha-agonists [405] have been supposed be efficacious in the paediatric age group (level B). Even in the instance of cardioinhibitory syncope with an exaggerated asystolic response, a pacemaker should be avoided whenever possible; as an alternative, effective management with pharmacological therapy without the need for pacemaker implantation has been shown [406] . Breath-holding spells generally do not require specific therapy unless connected with longer asystole associated with potential cerebral injury [22,392] .…”

Tilt-induced cardioinhibitory syncope: a follow-up study in 16 patients

“…The incidence was higher during nitrate provocation test (21%) than during passive head-up tilt test (14%) [4]. Up to now only two papers specifically examined the outcome of tilt-induced asystole in adult patients [5] and pediatric population [6] and the exact clinical and prognostic significance of this condition is still a matter of debate [7].…”