Role of Baroreflex Sensitivity in Predicting Tilt Training Response in Patients with Neurally Mediated Syncope

PURPOSE: An association between baroreflex sensitivity (BRS) and the response to tilt training has not been reported in patients with neurally mediated syncope (NMS). This study sought to investigate the role of BRS in predicting the response to tilt training in patients with NMS. MATERIALS AND METHODS: We analyzed 57 patients who underwent tilt training at our hospital. A responder to tilt training was defined as a patient with three consecutive negative responses to the head-up tilt test (HUT) during tilt training. RESULTS: After tilt training, 52 patients (91.2%) achieved three consecutive negative responses to the HUT. In the supine position before upright posture during the first session of tilt training for responders and non-responders, the mean BRS was 18.17+/-10.09 ms/mm Hg and 7.99+/-5.84 ms/mm Hg (p=0.008), respectively, and the frequency of BRS > or =8.945 ms/mm Hg was 45 (86.5%) and 1 (20.0%; p=0.004), respectively. Age, male gender, frequency of syncopal events before HUT, type of NMS, phase of positive HUT, total number of tilt training sessions, and mean time of tilt training did not differ between the study groups. In the multivariate analysis, BRS <8.945 ms/mm Hg in the supine position (odds ratio 23.10; 95% CI 1.20-443.59; p=0.037) was significantly and independently associated with non-response to tilt training. CONCLUSION: The BRS value in the supine position could be a predictor for determining the response to tilt training in patients with NMS who are being considered for inpatient tilt training.

Prevalence and Clinical Factors of Anxiety and Depression in Neurally Mediated and Unexplained Syncope

PURPOSE: Several studies have demonstrated that psychiatric disorders such as anxiety, depression and panic attack are associated with syncope, especially vasovagal and unexplained syncope (US). The aim of this study was to compare the prevalence of anxiety and depression between patients with neurally mediated syncope (NMS) and US and to investigate the clinical factors associated with anxiety and depression. MATERIALS AND METHODS: Between January 2009 and March 2010, 383 patients with syncopal episodes completed a Hospital Anxiety and Depression Scale questionnaire to assess symptoms of anxiety and depression. Inclusion criteria were NMS and US. Exclusion criteria were cardiac syncope, orthostatic hypotension and other disorders mimicking syncope. After exclusion, 199 patients were included. RESULTS: There were 176 (88.4%) NMS patients and 23 (11.6%) US patients. The prevalence of abnormal anxiety and depression were not significantly different between the NMS and US groups (10.2% vs. 8.7%, p=0.99; 8.5% vs. 17.4%, p=0.24). Clinical factors associated with anxiety were female gender (p=0.01) and six or more recurrent syncopal episodes (p=0.01) by univariate analysis. The only factor associated with abnormal anxiety score (OR=20.26, 95% CI: 1.4-291.6, p=0.01) was more than six recurrent syncopal episodes, while a positive head-up tilt table testing response was inversely associated with abnormal depression score (OR=0.28, CI: 0.08-0.97, p=0.04) in the multiple logistic regression analysis. CONCLUSION: Anxiety was associated with frequent syncopal episodes. Thus, anxiety might be considered in the management of syncope patients.

Predictors and Clinical Impact of Inappropriate Implantable Cardioverter-Defibrillator Shocks in Korean Patients

Limited data are available on inappropriate shocks in Korean patients implanted with an implantable cardioverter-defibrillator (ICD). We investigated the impact of inappropriate shocks on clinical outcomes. This retrospective, single-center study included 148 patients treated between October 1999 and June 2011. The primary outcome was a composite event of all-cause mortality or hospitalization for any cardiac reason. The median follow-up duration was 29 months (interquartile range: 8 to 53). One or more inappropriate shocks occurred in 34 (23.0%) patients. A history of atrial fibrillation was the only independent predictor of inappropriate shock (hazard ratio [HR]: 4.16, 95% confidence interval [CI]: 1.89-9.15, P < 0.001). Atrial fibrillation was the most common cause of inappropriate shock (67.7%), followed by supraventricular tachycardia (23.5%), and abnormal sensing (8.8%). A composite event of all-cause mortality or hospitalizations for any cardiac reason during follow-up was not significantly different between patients with or without inappropriate shock (inappropriate shock vs no inappropriate shock: 35.3% vs 35.4%, adjusted HR: 1.06, 95% CI: 0.49-2.29, P = 0.877). Inappropriate shocks do not affect clinical outcomes in patients implanted with an ICD, although the incidence of inappropriate shocks is high.

Eye Manifestations during the Syncopal Attack in Head-up Tilt Tests

PURPOSE: Recently syncope can be recored on video during head-up tilting table test (HUT). We assess the eye signs during the syncope to characterize eye signs of syncope.METHODS: We tried HUT based on the SMC protocol. The protocol includes video setting for eye observation. We included the subjects who had HUT at Samsung Medical Center, Seoul, Korea between October 2010 and June 2011. We investigated the video of the patients with positive results and syncope during HUT, especially focusing on the eye signs including eye opening and eyeball position. We analyzed the differences of hemodynamic parameters between eye-open and eye-close groups.RESULTS: Of 380 patients with positive HUT, 53 (13.9%) patients experienced syncope during the test. Among the syncope patients, 31 (58.5%) patients showed eye opening during the syncopal attack and 22 (41.5%) patients revealed eye closure. When the syncopal patient had eye open, the eyeball position was fixed in 22 patients. Upward deviation was most common position. Eye opening group showed significant decrease of systolic blood pressure and heart rate during syncopal attack compared with eye closing group (p=0.044, p=0.041).CONCLUSIONS: We concluded that eye opening state during syncopal attack can be the sign of more severe degree of cardiohemodynamic dysfunction.

Comparison of Recurrence Rate Based on the Frequency of Preceding Symptoms in Patients With Neurocardiogenic Syncope or Presyncope

BACKGROUND AND OBJECTIVES: In patients with neurocardiogenic syncope or presyncope, symptoms developed unpredictably and intermittently. The purpose of this study was to determine whether there was any significant difference in the recurrence rate of symptoms during the follow-up period between patients with many episodes of symptoms and those with fewer episodes of symptoms before diagnosis, as well as to assess the clinical significance of previous episodes of symptoms during treatment. SUBJECTS AND METHODS: A total of 100 patients with neurocardiogenic syncope or presyncope were divided in two groups (high episode group, n=54; low episode group, n=46) according to the frequency of symptoms before the head-up tilt test. We retrospectively analyzed the recurrence of symptoms using telephone interviews and medical record reviews. RESULTS: The clinical characteristics were not significantly different between the two groups. However, the recurrence rate was significantly lower in the high episode group than in the low episode group (5.6% vs. 19.6%, p=0.001). In the high episode group, patients treated with medication showed higher recurrence of symptoms than those without medication. In the lower episode group, a similar result was observed. CONCLUSION: The frequency of previous symptoms at the diagnosis of neurocardiogenic syncope or presyncope did not predict the occurrence of symptoms during the follow-up period. Therefore, to continue drug treatment based on the frequency of symptoms in patients with neurocardiogenic syncope or presyncope may not be the best option.

Eye Manifestations during the Syncopal Attack in Head-up Tilt Tests / 대한간질학회지

PURPOSE: Recently syncope can be recored on video during head-up tilting table test (HUT). We assess the eye signs during the syncope to characterize eye signs of syncope. METHODS: We tried HUT based on the SMC protocol. The protocol includes video setting for eye observation. We included the subjects who had HUT at Samsung Medical Center, Seoul, Korea between October 2010 and June 2011. We investigated the video of the patients with positive results and syncope during HUT, especially focusing on the eye signs including eye opening and eyeball position. We analyzed the differences of hemodynamic parameters between eye-open and eye-close groups. RESULTS: Of 380 patients with positive HUT, 53 (13.9%) patients experienced syncope during the test. Among the syncope patients, 31 (58.5%) patients showed eye opening during the syncopal attack and 22 (41.5%) patients revealed eye closure. When the syncopal patient had eye open, the eyeball position was fixed in 22 patients. Upward deviation was most common position. Eye opening group showed significant decrease of systolic blood pressure and heart rate during syncopal attack compared with eye closing group (p=0.044, p=0.041). CONCLUSIONS: We concluded that eye opening state during syncopal attack can be the sign of more severe degree of cardiohemodynamic dysfunction.

Gender Difference in Patients with Recurrent Neurally Mediated Syncope

PURPOSE: The gender difference of neurally mediated syncope is not well defined in a large patient population. The aim of this study was to evaluate the gender difference of clinical manifestations in patients with neurally mediated syncope who underwent head-up tilt test. MATERIALS AND METHODS: The medical records of 1,051 consecutive patients with two or more episodes of syncope, who were diagnosed as having neurally mediated syncope by head-up tilt test, were retrospectively reviewed. RESULTS: Of 1,051 patients, 497 (47.3%) patients were male and 554 (52.7%) patients were female. Female patients were experiencing syncopal episodes for longer periods of their lives (8.2 +/- 9.5 years vs. 6.8 +/- 9.2 years, p = 0.002) and more episodes of syncope prior to head-up tilt test (HUT) (7.2 +/- 9.4 vs. 5.0 +/- 6.4, p = 0.001) than male patients. Micturition syncope (20.0% vs. 5.2%, p < 0.001) was observed more frequently in male patients than in female patients. To the contrary, however, defecation syncope (16.3% vs. 9.3%, p < 0.001) was observed more frequently in female patients than in male patients. CONCLUSION: Female patients were experiencing syncopal episodes for longer periods of their lives and more episodes of syncope than male patients. Gender difference was also noted with regard to frequency of situational syncope.

Seizure-Like Activities during Head-Up Tilt Test-Induced Syncope

PURPOSE: Some patients with neurally mediated reflex syncope may be misdiagnosed as epilepsy because myoclonic jerky movements are observed during syncope. The seizure-like activities during the head-up tilt test (HUT) have been rarely reported. The purpose of this study was to assess the characteristics of these seizure-like activities and evaluate whether there are differences in the clinical characteristics and hemodynamic parameters of patients with neurally mediated reflex syncope with and without seizure-like activities during HUT-induced syncope. MATERIALS AND METHODS: The medical records of 1,383 consecutive patients with a positive HUT were retrospectively reviewed, and 226 patients were included in this study. RESULTS: Of 226 patients, 13 (5.75%) showed seizure-like activities, with 5 of these (2.21%) having multifocal myoclonic jerky movements, 5 (2.21%) having focal seizure-like activity involving one extremity, and 3 (1.33%) having upward deviation of eye ball. Comparison of patients with and without seizure-like activities revealed no significant differences in terms of clinical variables and hemodynamic parameters during HUT. CONCLUSION: Seizure-like activities occurred occasionally during HUT-induced syncope in patients with neurally mediated reflex syncope. The seizure-like activities during HUT might not be related to the severity of the syncopal episodes or hemodynamic changes during HUT.