Perfil Clínico, Autonômico e Escore de Calgary Modificado de Crianças e Adolescentes com Presumida Síncope Vasovagal Submetidos ao Teste de Inclinação / Clinical and Autonomic Profile, and Modified Calgary Score for Children and Adolescents with Presumed Vasovagal Syncope Submitted to the Tilt Test

Resumo Fundamento A síncope, na população pediátrica, tem como sua principal causa, a vasovagal (SVV). Sua avaliação deve ser feita por métodos clínicos e o teste de inclinação (TI) pode contribuir para seu diagnóstico. Objetivos Analisar o perfil clínico, os escores de Calgary e de Calgary modificado, a resposta ao TI e a variabilidade da frequência cardíaca (VFC) de pacientes ≤ 18 anos de idade, com presumida SVV. Comparar as variáveis entre pacientes com resposta positiva e negativa ao TI. Método Estudo observacional e prospectivo, com 73 pacientes com idades entre 6 e 18 anos, submetidos à avaliação clínica e ao cálculo dos escores, sem o conhecimento do TI. Este foi feito a 70º sob monitoramento para análise da VFC. Valor-p < 0,05 foi considerado como o critério de significância estatística. Resultados A mediana de idade foi de 14,0 anos, sendo que 52% eram no sexo feminino, 72 apresentaram Calgary ≥ -2 (média 1,80) e 69 com Calgary modificado ≥ -3 (média 1,38). Ocorreram pródromos em 59 pacientes, recorrência em 50 e trauma em 19. A resposta ao TI foi positiva em 54 (49 vasovagal, com 39 vasodepressora), com aumento do componente de baixa frequência (BF) e diminuição da alta frequência (AF) (p < 0,0001). Na posição supina, o BF foi de 33,6 no sexo feminino e 47,4 em unidades normalizadas no sexo masculino (p = 0,02). Aplicando-se a curva de operação característica para TI positivo, não houve significância estatística para VFC e os escores. Conclusões A maioria das crianças e adolescentes com diagnóstico presumido de SVV apresentaram um cenário clínico típico, com escore de Calgary ≥ -2, e resposta vasodepressora predominante ao TI. Verificou-se uma maior ativação simpática na posição supina no sexo masculino. Os escores de Calgary e a ativação simpática não permitiram predizer a resposta ao TI.

Abstract Background In the pediatric population, syncope is mainly from vasovagal (VVS) origin. Its evaluation must be done by clinical methods, and the tilt test (TT) can contribute to the diagnosis. Objectives To analyze the clinical profile, Calgary and modified Calgary scores, response to TT and heart rate variability (HRV) of patients aged ≤ 18 years with presumed VVS. To compare the variables between patients with positive and negative responses to TT. Method Observational and prospective study, with 73 patients aged between 6 and 18 years, submitted to clinical evaluation and calculation of scores without previous knowledge of the TT. It was done at 70º under monitoring for HRV analysis. P-value < 0.05 was the statistical significance criterion. Results Median age was 14.0 years; 52% of participants were female, 72 had Calgary ≥ -2 (mean 1.80), and 69 had modified Calgary ≥ -3 (mean 1.38). Prodromes were observed in 59 patients, recurrence in 50 and trauma in 19. The response to TT was positive in 54 participants (49 vasovagal, with 39 vasodepressor responses), with an increase in the low frequency (LF) component and a decrease in the high frequency (HF) component (p < 0,0001). In the supine position, LF was 33.6 in females and 47.4 in normalized units for males (p = 0.02). When applying the operating characteristic curve for positive TT, there was no statistical significance for HRV and scores. Conclusion Most children and adolescents with a presumed diagnosis of VVS presented a typical clinical scenario, with a Calgary score ≥ -2, and a predominant vasodepressor response to TT. Greater sympathetic activation was observed in the supine position in males. Calgary scores and sympathetic activation did not predict the response to TT.

Effect of Shenfu injection on prognosis and quality of life of patients with vasovagal syncope / 国际中医中药杂志

Objective@#To observe the effect of different doses of Shenfu injection on prognosis and quality of life for patients with vasovagal syncope (VVS).@*Methods@#A total of 126 patients were randomly divided into 3 groups. The control group (n=38) were treated by western medicine comprehensive therapy with tilting training. The low and high dose Shenfu injection groups were treated by Shenfu injection 40 ml/d (n=44) and 120 ml/d (n=44) on the treatment basis of control group. All the groups were treated for 14 days. The patients were followed up for 1 year after discharge. The relapse rate of syncope, quality of life social support rating scale (SSRS), effective rate of treatment, time of stable blood pressure, time of stable heart rate, recovery time of autonomic nervous disorder and adverse reactions were observed in each groups.@*Results@#The total effective rate was 47.4% (18/38) in the control group, 72.7% (32/44) in the low dose group, and 90.9% (40/44) in the high dose group. The difference between the three groups was statistically significant (χ2=18.997, P<0.01), and the total effective rate of Shenfu injection high-dose group was significantly higher than that of low-dose group (P<0.05). After treatment, there were significant differences in the recovery time of blood pressure, heart rate and autonomic nervous disorder among the three groups (F=19.165, 158.428, 33.405, P<0.01). The above indicators in the high dose group of Shenfu injection were significantly higher than the low dose group (t=-4.020, -5.180, -5.307, P<0.05). After 1 year of follow-up, the recurrence rate of the control group was 61.1% (11/18), the low-dose group was 18.8% (6/32), and the high-dose group was 5% (2/40), where there was significant difference among all the groups (χ2=20.886, P<0.01). The quality of life scores were compared for 1 year among the 3 groups, and the difference was statistically significant (F=23.025, P<0.01).@*Conclusions@#The Shenfu injection combined with Western medicine comprehensive therapy can improve the prognosis and quality of life of patients with VVS, and the improvement of each indicator of daily dosage of 120 ml is better than the daily dosage of 40 ml Shenfu injection.

Effect of Shenfu injection on prognosis and quality of life of patients with vasovagal syncope / 国际中医中药杂志

Objective To observe the effect of different doses of Shenfu injection on prognosis and quality of life for patients with vasovagal syncope (VVS). Methods A total of 126 patients were randomly divided into 3 groups. The control group (n=38) were treated by western medicine comprehensive therapy with tilting training. The low and high dose Shenfu injection groups were treated by Shenfu injection 40 ml/d (n=44) and 120 ml/d (n=44) on the treatment basis of control group. All the groups were treated for 14 days. The patients were followed up for 1 year after discharge. The relapse rate of syncope, quality of life social support rating scale (SSRS), effective rate of treatment, time of stable blood pressure, time of stable heart rate, recovery time of autonomic nervous disorder and adverse reactions were observed in each groups. Results The total effective rate was 47.4% (18/38) in the control group, 72.7% (32/44) in the low dose group, and 90.9% (40/44) in the high dose group. The difference between the three groups was statistically significant (χ2=18.997, P<0.01), and the total effective rate of Shenfu injection high-dose group was significantly higher than that of low-dose group (P<0.05). After treatment, there were significant differences in the recovery time of blood pressure, heart rate and autonomic nervous disorder among the three groups (F=19.165, 158.428, 33.405, P<0.01). The above indicators in the high dose group of Shenfu injection were significantly higher than the low dose group (t=-4.020, -5.180, -5.307, P<0.05). After 1 year of follow-up, the recurrence rate of the control group was 61.1% (11/18), the low-dose group was 18.8% (6/32), and the high-dose group was 5% (2/40), where there was significant difference among all the groups (χ2=20.886, P<0.01). The quality of life scores were compared for 1 year among the 3 groups, and the difference was statistically significant (F=23.025, P<0.01). Conclusions The Shenfu injection combined with Western medicine comprehensive therapy can improve the prognosis and quality of life of patients with VVS, and the improvement of each indicator of daily dosage of 120 ml is better than the daily dosage of 40 ml Shenfu injection.

Cardiac and Musculoskeletal Responses to the Effects of Passive and Active Tilt Test in Healthy Subjects / Respostas Cardíacas e Musculoesqueléticas aos Efeitos do Tilt Test Passivo e Ativo em Indivíduos Saudáveis

Abstract Background: Maintenance of orthostatism requires the interaction of autonomic and muscle responses for an efficient postural control, to minimize body motion and facilitate venous return in a common type of syncope called neurocardiogenic syncope (NCS). Muscle activity in standing position may be registered by surface electromyography, and body sway confirmed by displacement of the center of pressure (COP) on a force platform. These peripheral variables reflect the role of muscles in the maintenance of orthostatism during the active tilt test, which, compared with muscle activity during the passive test (head-up tilt test), enables the analyses of electromyographic activity of these muscles that may anticipate the clinical effects of CNS during these tests. Objective: to evaluate and compare the effects of a standardized protocol of active and passive tests for CNS diagnosis associated with the effects of Valsalva maneuver (VM). Methods: twenty-thee clinically stable female volunteers were recruited to undergo both tests. EMG electrodes were placed on muscles involved in postural maintenance. During the active test, subjects stood on a force platform. In addition to electromyography and the platform, heart rate was recorded during all tests. Three VMs were performed during the tests. Results: progressive peripheral changes were observed along both tests, more evidently during the active test. Conclusion: the active test detected changes in muscle and cardiovascular responses, which were exacerbated by the VM.

Resumo Fundamento: A manutenção do ortostatismo requer interação das respostas autonômicas e musculares para um controle postural eficiente e minimizar oscilações do corpo e facilitar o retorno venoso frente a um tipo comum de síncope chamada neurocardiogênica (SNC). A atividade da musculatura na posição de pé pode ser documentada por meio da eletromiografia de superfície (EMG) e as oscilações do corpo confirmadas pelo deslocamento do centro de pressão (CP) sobre uma plataforma de força. Estas variáveis periféricas mostram o papel muscular na manutenção do ortostatismo durante o tilt test ativo bem como esta atividade muscular ser comparada durante o teste passivo, Head-Up Tilt test, na tentativa de verificar alterações na atividade eletromiográfica destes músculos que podem antecipar os efeitos clínicos da SNC durante estes testes. Objetivo: Avaliar e comparar os efeitos de um protocolo padronizado para testes ativo e passivo de detecção da SNC associado ao efeito da manobra de valsalva (MV). Métodos: 23 voluntárias mulheres clinicamente saudáveis foram recrutadas para realizar ambos os testes. Os eletrodos da EMG foram posicionados em músculos associados com a manutenção postural, além de durante o teste ativo os sujeitos realizarem a postura ortostática sobre uma plataforma de força. Foi registrado além da EMG e da plataforma, a frequência cardíaca durante todo o teste. Três MV foram realizadas durante os testes. Resultados: Alterações periféricas foram verificadas de maneira progressiva ao longo dos testes, sendo mais evidente durante o teste ativo. Conclusão: o teste ativo verificou mudanças mais evidentes nas respostas musculares e cardiovasculares, amplificadas pela MV.

Evaluation of Adrenergic Function: Tilt-Table and Valsalva Test / 대한평형의학회지

Orthostatic dizziness is a common dizziness syndrome characterized by nonvertiginous lightheadedness when patients rise to stand from a sitting or supine position. Orthostatic dizziness is commonly believed to derive from orthostatic hypotension (OH) or postural tachycardia syndrome (POTS). Tilt-table test and Valsalva maneuver are standardized methods for evaluating of adrenergic autonomic function and essential for diagnosis of OH and POTS. We described the guidelines and interpretations of the tilt-table test and Valsalva maneuver.

Patterns of Orthostatic Blood Pressure Changes in Patients with Orthostatic Hypotension

BACKGROUND AND PURPOSE: The objective of this study was to determine the patterns of blood pressure (BP) changes during the head-up tilt (HUT) test, particularly in terms of its clinical significance for patients with orthostatic hypotension (OH). METHODS: OH was divided into four categories based on systolic BP changes occurring within the first 10 minutes of the HUT test: sustained orthostatic hypotension (SOH), progressive orthostatic hypotension (POH), orthostatic hypotension with partial recovery (OHPR), and transient orthostatic hypotension (TOH). RESULTS: In total, 151 patients were analyzed: 65 with SOH, 38 with POH, 21 with OHPR, and 27 with TOH. POH patients exhibited the greatest reduction in systolic BP after HUT and were also the most likely to develop symptoms requiring early termination of the HUT test (42.1%, p < 0.001). Additionally, SOH patients exhibited smaller heart-rate variation with deep breathing values (p=0.003) and Valsalva ratios (p=0.022) compared to POH patients. The sweat volume was greatest in OHPR patients. CONCLUSIONS: Clinical characteristics, including the findings of autonomic function tests, differed between the OH patient groups. This might reflect differences in the underlying pathophysiologic mechanisms. Determining the patterns of BP changes during the HUT test may facilitate the development of effective management strategies in patients with OH.

Etiology and prognosis of children and adolescents with situational syncope / 中华实用儿科临床杂志

Objective To retrospectively analyze the etiology and prognosis of the children and adolescents with situational syncope in a single center.Methods There were 4 274 cases of children and adolescents [aged from 2 to 18 years old,the average age being (10.82 ± 3.13)years old],male 2 208 cases,female 2 066 cases with ortho-static intolerance syndromes,such as unexplained syncope or symptoms of presyncope,etc,who were treated at Children's Syncope Outpatient Department or Inpatient Department in the Second Xiangya Hospital,Central South University from January 2000 to November 2017.All subjects underwent detailed history investigation,careful physical examinations, routine 12-lead electrocardiogram,Holter electrocardiogram(ECG),chest X-ray,echocardiography,electroencephalo-gram(EEG)and head computerized tomography(CT)or magnetic resonance imaging(MRI),blood biochemical exami-nation (including fasting glucose,myocardial enzymes)and organic diseases in the heart,brain,blood vessels were ex-cluded,but the cause of syncope was still not clear.The head-up tilt table test (HUTT)was performed after the pa-tients or/and the families wrote the informed consent agreement.Results A total of 177 (4.14%)patients with situa-tional syncope were diagnosed among 4 274 cases.Etiology included the abdominal musecle exercise (35.59%,63/177 cases),urination (24.29%,43/177 cases),bathing (9.60%,17/177 cases),defecation (7.34%,13/177 cases), singing (5. 08%,9/177 cases),rides (4.52%,8/177 cases),blood-injection-injury phobia (3.95%,7/177 ca-ses),swallowing (3.39%,6/177 cases),and hair-grooming (2. 82%,5/177 cases),syncope during acupuncture treatment (2. 26%,4/177 cases),and cough (1.13%,2/177 cases). The common positions were upright position (84.18%,149/177 cases),squatting to standing position (8.47%,15/177 cases),sitting position (5.08%,9/177 cases),and squatting position (2.26%,4/177 cases).HUTT positive rate was 69.49%(123/177 cases),common type of hemodynamic were the vasodepressive type of vasovagal syncope (45.20%,80/177 cases),mixed type of vaso-vagal syncope (19.77%,35/177 cases),postural orthostatic tachycardia syndrome (3.39%,6/177 cases)and the cardiac suppressive type of vasovagal syncope (1.13%,2/177 cases).In 35 cases of situational syncope,the number of children and adolescents with syncope was significantly reduced by health education and upstanding training.By the first follow-up review,the cases were reduced from (2.69 ± 1.81)times to (0.59 ± 0.96)times after healthy edu-cation of 2-16 weeks [(4.97 ± 3.16)weeks].By the second follow-up review,3 out of 8 cases did not faint,3 cases fainted 1 time,1 case fainted 2 times,and 1 case fainted 4 times.The outcomes of the first reexamination of HUTT in 16 cases were negative,and other 3 cases were negative by twice visit.Conclusions The etiology of children and adoles-cents are flag-raising(abdominal muscle exercise),urination,bathing,defecation,singing,riding,blood-injection-injury phobia,swallowing,hair -grooming,syncope during acupuncture treatment and coughing. Healthy education is good for situational syncope.

Analysis of Heart Rate Variability Before and During Tilt Test in Patients with Cardioinhibitory Vasovagal Syncope / Análise da Variabilidade de Frequência Cardíaca antes e durante o Teste de Inclinação em Pacientes com Síncope Vasovagal Tipo Cardioinibitória

Abstract Background: Cardioinhibitory vasovagal response is uncommon during the tilt test (TT). Heart rate variability (HRV) by use of spectral analysis can distinguish patients with that response. Objective: To compare the HRV in patients with cardioinhibitory vasovagal syncope (case group - G1) with that in patients without syncope and with negative response to TT (control group - G2). Methods: 64 patients were evaluated (mean age, 36.2 years; 35 men) and submitted to TT at 70 degrees, under digital Holter monitoring. The groups were paired for age and sex (G1, 40 patients; G2, 24). Results: In G1, 21 patients had a type 2A response and 19 had type 2B, with mean TT duration of 20.4 minutes. There was a greater low frequency (LF) component (11,6 versus 4,5 ms2, p=0.001) and a lower low/high frequency ratio in the supine position (3,9 versus 4,5 ms2, p=0.008) in G1, with no difference during TT between the groups. Applying the receiver operating characteristic curve for cardioinhibitory response, the area under the curve was 0.74 for the LF component in the supine position (p = 0.001). The following were observed for the cutoff point of 0.35 ms(2) for the LF component: sensitivity, 97.4%; specificity, 83.3%; positive predictive value, 85.3%; negative predictive value, 96.9%; and positive likelihood ratio, 5.8. Conclusion: HRV in the supine position allowed identifying patients with syncope and cardioinhibitory response with a high negative predictive value and likelihood ratio of 5.8.

Resumo Fundamento: A resposta cardioinibitória vasovagal ao teste de inclinação (TI) é pouco frequente. A variabilidade da frequência cardíaca (VFC) por meio da análise espectral pode discernir os pacientes (pts) com aquela resposta. Objetivo: Avaliar a VFC em pts com síncope vasovagal cardioinibitória (grupo caso - G1), comparando-a com a VFC de pts sem síncope e com resposta negativa ao TI (grupo controle - G2). Métodos: foram avaliados 64 pts, média de idade 36,2 anos, 35 homens, submetidos ao TI a 70º, sob monitoramento pelo Holter digital. Os grupos foram pareados por idade e sexo, sendo 40 pts do G1 e 24 do G2. Resultados: No G1, 21 pts apresentaram resposta tipo 2A e 19, tipo 2B, com média do TI de 20,4 min. Houve maior valor do componente de baixa frequência (BF) (11,6 versus 4,5 ms2, p=0,001) e menor relação baixa/alta frequência na posição supina (3,9 versus 4,5 ms2, p=0,008) no G1, sem diferença durante o TI. Aplicando-se a curva de operação característica para resposta cardioinibitória, foi obtida a área abaixo da curva de 0,74 para o componente BF na posição supina (p=0,001). Para o ponto de corte de 0,35 ms2 para BF observaram-se: sensibilidade, 97,4%; especificidade, 83,3%; valor preditivo positivo, 85,3%; valor preditivo negativo, 96,9%; e razão de probabilidade positiva, 5,8. Conclusão: A VFC na posição supina permitiu identificar os pts com síncope e com resposta cardioinibitória, com um alto valor preditivo negativo e uma razão de probabilidade de 5,8.

Value of head-up tilt table test in the diagnosis of syncope in children / 中华实用儿科临床杂志

Syncope is a common emergency condition,which can cause harmful danger to the physical and mental health,quality of living and learning of children.Even,syncope -related body traumatic injuries and anxiety and depression often occur in these children,and some have a high risk of sudden death.So,early diagnosis is of great sig-nificance.Head -up tilt table test is considered the gold standard for the diagnosis of syncope,it plays a significant role in diagnosis,differential diagnosis,treatment and evaluation of therapeutic effects.

Diagnostic value of basic HUT and SNHUT on vasovagal syncope / 心血管康复医学杂志

Objective:To explore diagnostic value of basic head-up tilt table test (HUT)and sublingual nitroglycerin head-up tilt table test (SNHUT)on vasovagal syncope (VVS).Methods:A total of 61 patients,who collapsed be-cause of unknown causes and were highly suspected as VVS,were regarded as VVS group,received HUT,and an-other 22 healthy subjects were regarded as healthy control group.Results:Among the 61 cases of VVS group,57 ca-ses were tilt test positive and the positive rate was 93.44%.Among them,there were 16 cases (26.23%)with posi-tive basic HUT and 41 cases (67.21%)with positive SNHUT.The 22 cases in healthy control group also received basic HUT and SNHUT,one case (4.54%)was basic HUT positive and three cases were SNHUT positive.Positive rates of SNHUT was higher than that of HUT,but there was no significant difference in VVS group (χ2 =0.175,P =0.683).Conclusion:HUT is a noninvasive,repeatable method easily accepted by patients for diagnosing VVS currently.It can elevate positive rate of test when combined with SNHUT.

Fast tilt test: tras un nuevo paradigma en el manejo del síncope reflejo / Fast Tilt Test: a New Paradigm in the Management of Reflex Syncope

Introducción El 20% a 30% de la población presenta episodios sincopales a lo largo de la vida y el mecanismo reflejo representa la causa más común. Su diagnóstico diferencial se basa en el interrogatorio de las características del episodio y en la reproducibilidad de los síntomas con el tilt test. Sin embargo, este último tiene limitaciones importantes, lo que nos ha llevado a explorar en sucesivas etapas de investigación un nuevo parámetro, al que denominamos “retraso de la onda de pulso carotídeo”. Objetivos Presentar los resultados de la investigación sobre el descubrimiento, el desarrollo y la aplicación clínica del parámetro “retraso de la onda de pulso carotídeo”, capaz de identificar a pacientes con síncope reflejo. Material y métodos Se describen el nacimiento de la idea, los resultados del análisis de la correlación entre el parámetro con el tilt test mediante un estudio piloto en 43 pacientes con síncope, la confirmación de su correlación en 100 pacientes con síncope y grupo control, el estudio del mecanismo fisiopatológico del parámetro, el diseño y la validación de un equipo de adquisición automática en un estudio multicéntrico sobre 100 pacientes con historia de síncope mediante tilt test sensibilizado y la búsqueda de un nuevo patrón oro del síncope reflejo. Resultados El análisis estadístico mediante modelos univariados y multivariados y la construcción de curvas ROC sobre 243 pacientes sometidos a tilt test mostró que, a pesar de diferentes edades o métodos empleados, el parámetro clasificó correctamente a más del 80% de los pacientes con historia de síncope y tilt test positivos y al 100% de los voluntarios (2/30) sin historia de síncope que presentaron tilt test positivo. La medición del parámetro prescindiendo de la camilla basculante identificó al 100% de los voluntarios que refirieron historia de síncope (7/30). Conclusiones Desarrollamos un parámetro de medición s imple y no invasiva capaz de predecir en 5 minutos el resultado del tilt test en pacientes con síncope e identificar a personas con historia de síncope reflejo prescindiendo de la camilla basculante. El parámetro podría ayudar a la rápida toma de decisión diagnóstica en pacientes con síncope, a comprender aspectos fisiopatológicos y a evaluar intervenciones terapéuticas.

Introduction Between 20% and 30% of persons present syncope throughout their lives and reflex syncope represents the most common cause. The differential diagnosis of syncope is based on the characteristics of the episode and on the reproducibility of symptoms with the head-up tilt test. Yet, as tilt test has important limitations, we began exploring a new parameter in successive stages of investigation, which we called “delay of the carotid pulse wave”. Objectives To present the results of the investigation about the discovery, development and clinical applicability of the parameter: “delay of the carotid pulse wave”, capable of identifying patients with reflex syncope. Methods The development of the idea and the results of the analysis of the correlation between the parameter and the tilt test evaluated in a pilot study of 43 patients with syncope are described. The correlation is confirmed in 100 patients with syncope and in controls; the pathophysiological mechanism of the parameter is evaluated; the design of an automated device is described and its validation is confirmed in a multicenter study of 100 patients with history of syncope using drug-stimulated head-up tilt test. The search of a new gold standard for reflex syncope is described. Results The statistical analysis performing univariate and multivariate models and the construction of ROC curves on 243 patients undergoing head-up tilt test showed that, despite the different ages or methods used, the parameter classified in a correct fashion more than 80% of patients with history of syncope and positive head-up tilt test and 100% of volunteers without history of syncope who presented positive head-up tilt test. The measurement of the parameter without using a tilt table identified 100% of volunteers with history of syncope (7/30). Conclusions We developed a simple and noninvasive measurement parameter, capable of predicting a positive head-up tilt test within 5 minutes in patients with syncope and of identifying people with history of syncope without using the tilt table. The parameter could help to make rapid diagnostic decisions in patients with syncope, to understand the pathophysiological aspects and to evaluate the therapeutic interventions.

Hyperventilation Induced Syncope: Differential Feature of Head-up Tilt Table Test with Transcranial Doppler in Patient with Hyperventilation Syndrome from True Syncope

The causes of a transient loss of consciousness (TLOC) are divided into syncope, epileptic seizures, cerebrovascular diseases and functional disorders such as hyperventilation (HV) syndrome, psychogenic pseudosyncope. The differential diagnosis of TLOC is may be difficult due to lack of history, misleading features, or confusion over the definition of syncope. We have experienced a rare case of HV syncope that TLOC developed after HV from mental stress, and differentiated by head-up tilt table test with transcranial doppler.

Orthostatic symptoms does not always manifest during tilt-table test in pediatric postural orthostatic tachycardia syndrome patients / 소아과

PURPOSE: Chronic day-to-day symptoms of orthostatic intolerance are the most notable features of postural orthostatic tachycardia syndrome (POTS). However, we have encountered patients with such symptoms and excessive tachycardia but with no symptoms during the tilt-table test (TTT). We aimed to investigate whether POTS patients with chronic orthostatic intolerance always present orthostatic symptoms during the TTT and analyze the factors underlying symptom manifestation during this test. METHODS: We retrospectively examined patients who presented with POTS at the Gyeongsang National University Hospital between 2008 and 2011. Diagnosis of POTS was based on chronic day-to-day orthostatic intolerance symptoms as well as excessive tachycardia during the TTT. The patients were divided two groups depending on the presentation of orthostatic symptoms during the TTT. Clinical data and the results of the TTT were compared between these groups. RESULTS: In 22 patients, 7 patients (31.8%) did not present orthostatic symptoms during the test. Diastolic blood pressure (BP) was significantly lower in the symptom-positive group. The head-up tilt resulted in a significant increase in diastolic BP in the symptom-negative group (P=0.04), while systolic BP had a tendency to decrease in the symptom-positive group (P=0.06). CONCLUSION: Significant patients with POTS did not present orthostatic symptoms during the TTT despite having chronic daily symptoms. This finding may be important for establishing definitive diagnostic criteria for pediatric POTS. Development of symptoms during TTT might be related to low diastolic BP and abnormal compensatory responses to orthostasis.

Diagnostic value of head-up tilt test with sublingual isosorbide dinitrate in patients with vasovagal syncope / 心血管康复医学杂志

Objective: To explore the diagnostic value of head-up tilt test with sublingual isosorbide dinitrate （HUTSI）in patients with vasovagal syncope (VVS). Methods: A total of fifty-two consecutive patients with clinically vasovagal syncope (VVS group) and thirty-eight control subjects without prior experience of syncope (normal control group) were evaluated by baseline head-up tilt table test (BHUT) , then the BHUT negative subjects underwent HUTSI test. . Results: (1) Positive BHUT test rate of VVS group and normal control group were 25% (13/52) and 0 respectively; from supine to HUT positive, there were significant decrease in heart rate [(73.1±8.5) times/min vs. (56.2±11.2) times/min] and mean arterial pressure [MAP, (81.2± 10.8) mmHg vs. (50.2±10.4) mmHg，P<0.05 both] in BHUT positive subjects. There were 21 HUTSI positive cases（53.9%）among the other 39 VVS patients, and two cases（5.3%）among the 38 subjects of normal control group. From supine to HUTSI positive, there were significant decrease in heart rate [(65.2±7.5) times/min vs. (52.9±10.5) times/min] and MAP [(78.3±10.7) mmHg vs. (48.8±11.2) mmHg, P<0.05 both] in HUTSI positive subjects. Duration from tilt started to positive reaction occurred in HUTSI positive group was significantly shorter than that of BHUT positive group [(10.8±9.3) min vs. (21.1±11.5) min，P<0.05]. All subjects can tolerate the test and only two cases in VVS group and one case in normal control group occurred headache and face red. Conclusion: Head-up tilt test with sublingual isosorbide dinitrate is a practical and easy-to- perform method with high sensitivity, specificity and few side effects for diagnosis of vasovagal syncope.

Taquicardia postural ortostática en 15 pacientes: disautonomía compleja / Postural orthostatic tachycardia syndrome (POTS): Report of 15 cases

Background: Patients with postural orthostatic tachycardia syndrome (POTS) report dizziness, lightheadedness, weakness, blurred vision, and fatigue upon standing. The diagnosis of the syndrome is made when an orthostatic intolerance and tachycardia appear in the standing position. Aim: To report 15 patients with POTS. Material and Methods: Review of Tilt test reports in a period of 15 years. Those reports in which orthostatic postural tachycardia and symptoms compatible with POTS appeared, were selected for analysis. Results: We identified 15 patients (3.1% of all positive Tilt test reports) with compatible signs and symptoms. There was a lag of 8 -10 years between the onset of symptoms and the time of diagnosis. Most patients complained of orthostatic intolerance, dizziness and frequent fainting. Orthostatic tachycardia and symptoms occurred on average after 2.9 and 6.1 minutes, respectively,of staying in the standing position. These patients had a high frequency of family history of syncope orpresyncope (66% frequency) and hyper mobility syndrome (53% prevalence). Only 33% of the patients reported relief of their symptoms after being treated (most of them with fludrocortisone). Most patients that reported little or no relief, did not use medications or were treated for a short period. Conclusions: POTS syndrome is uncommon but disturbs quality of life of those who suffer it. Its association with hyper mobility syndromes must be investigated.

Positive Result in the Early Passive Phase of the Tilt-table Test: A Predictor of Neurocardiogenic Syncope in Young Men

BACKGROUND/AIMS: This study elucidated the prognostic factors for neurocardiogenic syncope in males in their late teens and early twenties. METHODS: Tilt-table testing (TTT) was performed on 665 males (age range, 17 to 27 years) following the Italian protocol. The subjects were tilted head-up at a 70degrees angle on a table for 30 minutes during the passive phase. If the passive phase was negative, the subjects were given sublingual nitroglycerin and tilted to the same angle for 20 minutes during the drug-provocation phase. The subjects with positive results were followed without medication. We analyzed factors related to the recurrence rate of syncope. RESULTS: Of 305 subjects (45.8%) with positive results, 223 (age range, 18 to 26 years) were followed for 12 months. The frequency of previous syncopal episodes > or = 4 (p = 0.001) and a positive result during the passive phase (p = 0.022) were significantly related to a high recurrence rate. A positive result during the early passive phase ( 12 minutes; p = 0.011). CONCLUSIONS: A positive result during the early passive phase of TTT and frequent previous syncopal episodes were prognostic factors for neurocardiogenic syncope in men in their late teens and early twenties.

Initial Orthostatic Hypotension is Possibly Associated with Autonomic Dysfunction when Diagnosed with a Tilt Table Test

PURPOSE: Initial orthostatic hypotension is typically associated with active standing and normal autonomic function. Some adolescents in the present study displayed initial orthostatic hypotension during passive tilting, and we hypothesized that this condition was due to abnormal autonomic function. METHODS: The present study compared autonomic functioning in two groups of adolescents: patients with a diagnosis of initial orthostatic hypotension according to the tilt table test and patients with typical symptoms of initial orthostatic hypotension but normal tilt table test results. RESULTS: Significantly higher total composite autonomic severity scores and considerably higher adrenergic index were noted in the tilt table tested group. CONCLUSION: Initial orthostatic hypotension is possibly associated with autonomic dysfunction, especially abnormal vasoconstrictive ability, in individuals diagnosed with a tilt table test. Clinicians should take note of autonomic function when performing diagnoses of initial orthostatic hypotension using the tilt table test.

The Comparison of the Ocular Compression Test and the Tilt-table Test in the Suspected Patient of Vasovagal Syncope in Children and Adolescence

PURPOSE: Vasovagal syncope (VVS) is a relatively common disease in children and adolescence. The aim of this study was to compare the tilt-table test (TTT) and the ocular compression test (OCT) in patients who were clinically suspected to VVS. METHODS: We searched the medical records of patients who were clinically suspected to VVS during the period from March 2009 to March 2012 at Korea University Guro hospital. Orthostatic hypotension, postural orthostatic tachycardia syndrome and epilepsy were excluded. We also analyzed complete blood test, electrolytes and thyroid function test to exclude other medical conditions that could potentially affect the result TTT or OCT. RESULTS: Forty-six patients who were clinically suspected to VVS were selected. The mean age was 13.6+/-3.1 years (range, 3-21 years). Fifteen (32.6%) patients were males and thirty-one (67.4%) females. Among the selected patients, eighteen (39.1%) patients were TTT positive and thirty-one (67.4%) were OCT positive. In the McNemar's test, the P value was 0.02 (P<0.05) which meant there was a difference between two tests to diagnose VVS. In addition, there were 22 patients who were positive for OCT and negative for TTT. During TTT, forty-three (93.5%) patients had to be stopped due to severe symptoms such as nausea, vomiting, dizziness and near fainting, but no patient had any complication during and after OCT. CONCLUSION: We suggest that OCT is a relatively safe and useful test for diagnosing patients with VVS in children and adolescence in addition to TTT.

¿Es necesaria la prueba de inclinación en pacientes con diagnóstico clínico de síncope vasovagal?: Resultados utilizando un protocolo no sensibilizado / Is the head-up tilt-test necessary in patients whit clinical diagnosis of vasovagal syncope?: Results using a non-sensitized protocol

Introducción:La prueba de inclinación es un estudio no invasivo, sencillo y de bajo riesgo, donde la utilización de protocolos no sensibilizados sirven para acortar los tiempos de la prueba. Objetivo:Determinar en pacientes con síncope la utilidad de la prueba de inclinación no sensibilizada con fármacos y comparar los resultados con la probabilidad clínica pre-test. Métodos:Se incluyeron pacientes >15 años de edad, con síncope o presíncope, con clínica sugestiva de origen vasovagal, utilizando la escala de Calgary. Resultados:Se analizaron 70 pacientes; edad: 39 ± 20 años, 66% mujeres. De los pacientes, 94% presentó una puntuación >-1, pero sólo 30% de las pruebas fueron positivas. Una puntuación >-2 no se asoció con el resultado de la prueba. La mayoría de los pacientes presentaron una puntuación de 1 (52) y 2 (11), resultando en una prueba positiva en 32% y 9%, respectivamente. En pacientes con probabilidad pre-test baja, hubo mayor número de pruebas negativas (100% con una puntuación de -2 y 50% con puntuación de -5). Conclusiones:El estudio mostró que en pacientes con síncope vasovagal, sugerido por la evaluación clínica, la prueba de inclinación no sensibilizada no proporcionó información adicional, con un número significativo de falsos negativos.

Introduction:Tilt table testing is a simple, non-invasive, low risk test. A not sensitized protocol has been presented in order to shorten the duration of the test. Objective:To determine the usefulness of a not sensitized tilt table testing and to compare the results with the pre-test probability, given by the Calgary's score. Methods:We included patients >15 years-old with syncope or presyncope with high probability pretest for a vasovagal origin, using the Calgary' score. Results:Seventy patients were analyzed; age 39 ± 20 years old, 66% female. More than 94% of the patients presented a score >-1, but only 30% of the tilt tests were positive. A score >-2 was not associated with the result of tilt test. Most of the patients presented a score of 1 (52) and 2 (11), resulting in positive tilt test 32% y 9%, respectively. Among patients with low pre-test probability there was a greater number of negative results (100% with a score of -2 and 50% with score of -5). Conclusions: This study showed that in patients with vasovagal syncope suggested by clinical assessment, a not sensitized tilt test did not provide additional information, with a significant number of false negatives.

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.