Vasovagal syncope in the older person: differences in presentation between older and younger patients.

BACKGROUND: vasovagal syncope (VVS) has been diagnosed with increasing frequency in older people since the description of the head-up tilt table test (HUTT). There is, however, a paucity of research describing the clinical features of VVS in this group. To address this issue, we investigated the age distribution and differences in clinical characteristics associated with age in patients diagnosed with VVS by HUTT at our tertiary referral centre. METHODS: 1,060 consecutive patients with tilt-positive VVS were identified from a prospective database containing the demographic and clinical information of individuals assessed in our unit over a 10-year period. VVS was diagnosed with appropriate haemodynamic changes during HUTT and accompanying symptom reproduction. RESULTS: we found a bimodal age distribution with a small peak at 20-29 years and a larger peak at 70-79 years. Patients aged > or =60 years were less likely to report total loss of consciousness [odds ratio (OR) 0.50, 95% confidence interval (CI) = 0.38-0.64], near loss of consciousness (OR 0.53, 95% CI = 0.40-0.70) or palpitations (OR 0.45, 95% CI = 0.28-0.72) and more likely to present with unexplained falls (OR 2.33, 95% CI = 1.36-4.32). The typical provoking factors of prolonged standing (OR 0.55, 95% CI = 0.40-0.72), posture change (OR 0.61, 95% CI = 0.46-0.82) and hot environments (OR 0.57, 95% CI = 0.42-0.78) were also less common in older patients. CONCLUSION: in our large study population, VVS was more common in older patients. The clinical presentation differed significantly between the two groups. Older patients were less likely to give a typical history and therefore clinicians need to have a high index of suspicion when evaluating the older patient presenting with collapse or unexplained falls.

'Front-loaded' head-up tilt table testing: validation of a rapid first line nitrate-provoked tilt protocol for the diagnosis of vasovagal syncope.

Head-up tilt testing is the investigation of choice in the diagnosis of vasovagal syncope. The test is time consuming and labour intensive, with conventional tilt testing taking up to 45 min. We compared a shortened 'front-loaded' 20-min glyceryl trinitrate-provoked head-up tilt (FLGTN-HUT) with the standard 40-min passive tilt (HUT) as first line investigations in patients with unexplained syncope and asymptomatic controls. In the study, 149 consecutive patients with unexplained syncope and 83 asymptomatic controls were enrolled. Subjects were randomly assigned to FLGTN-HUT (800 mcg, metred spray) or HUT, then the opposite tilt-test 1 week later. Seventeen (11.4%) patients had diagnostic haemodynamic changes and symptom reproduction during HUT and 54 (36.2%) during FLGTN-HUT. A total of 24.8% more patients had a positive test with FLGTN-HUT than with passive HUT (95% CI: 16.3%, 33.4%). Nine (10.8%) controls had significant haemodynamic changes during HUT and 23 (27.7%) during GTN provocation. Seven controls had haemodynamic changes on both HUT and FLGTN-HUT testing. The controls group had 16.8% more significant haemodynamic changes with FLGTN-HUT than with HUT (95% CI: 0.06, 27.4). The front-loaded GTN protocol provided a higher diagnostic rate than passive tilt testing, and provides a rapid alternative to conventional methods, though false positivity rates are higher.