Update on Cardiac Pacing in Reflex Syncope

Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study

EP Europace ◽

10.1093/europace/euv343 ◽

2015 ◽

Vol 18 (9) ◽

pp. 1427-1433 ◽

Cited By ~ 38

Author(s):

Michele Brignole ◽

Francesco Arabia ◽

Fabrizio Ammirati ◽

Marco Tomaino ◽

Fabio Quartieri ◽

...

Keyword(s):

Older Patients ◽

Cardiac Pacing ◽

Reflex Syncope

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Reflex syncope

ESC CardioMed ◽

10.1093/med/9780198784906.003.0470 ◽

2018 ◽

pp. 2024-2028

Author(s):

Jean-Claude Deharo

Keyword(s):

Carotid Sinus ◽

Vasovagal Syncope ◽

Cardiac Pacing ◽

Tilt Test ◽

Specific Situation ◽

Diagnostic Strategy ◽

Reflex Syncope ◽

Specific Subgroup ◽

Recent Developments ◽

Head Up Tilt Test

Reflex syncope, also called neurally mediated syncope, accounts for 56–73% of the aetiologies of syncope, with a balanced incidence over the various age categories. The most common form is ‘vasovagal syncope’ where the trigger is pain, fever, instrumentation, emotion, or orthostatic stress; ‘situational syncope’ refers to syncope triggered by a specific situation, that is, micturition, defecation, swallowing, cough; and ‘carotid sinus syncope’, which may be triggered by carotid sinus manipulation or diagnosed in patients with syncope and positive carotid sinus massage. The term ‘atypical reflex syncope’ is used to describe reflex syncope occurring without an apparent trigger: the diagnosis is mainly based on history, exclusion of other causes of syncope, and a positive head-up tilt test. Although recent developments have prompted new pathophysiological hypotheses, including the adenosine pathway, the diagnostic strategy for reflex syncope remains mainly based on clinical evaluation and very few ancillary diagnostic tests. The pharmacological armament is still very limited while new perspectives have been opened for specific subgroup of patients. Regarding the very rare patients who are candidates for permanent cardiac pacing, a new pragmatic approach may help their selection and the prediction of the effect of pacing.

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Permanent cardiac pacing as primary therapy for neurocardiogenic (reflex) syncope

Clinical Autonomic Research ◽

10.1007/s10286-004-1011-3 ◽

2004 ◽

Vol 14 (S1) ◽

pp. i76-i79 ◽

Cited By ~ 10

Author(s):

Daniel J. Kosinski ◽

Blair P. Grubb ◽

Douglas A. Wolfe

Keyword(s):

Cardiac Pacing ◽

Primary Therapy ◽

Reflex Syncope

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Cardiac Pacing in Cardioinhibitory Reflex Syncope: Clinical Use of Closed-loop Stimulation

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2021.45 ◽

2021 ◽

Vol 10 (4) ◽

pp. 244-249

Author(s):

Marco Tomaino ◽

Vincenzo Russo ◽

Daniele Giacopelli ◽

Alessio Gargaro ◽

Michele Brignole

Keyword(s):

Closed Loop ◽

Carotid Sinus ◽

Clinical Manifestations ◽

Cardiac Pacing ◽

Cardiac Monitoring ◽

The Past ◽

Reflex Syncope ◽

Pacing Mode ◽

New Evidence ◽

Closed Loop Stimulation

Cardiac pacing has been studied extensively in patients with reflex syncope over the past two decades. The heterogeneity of the forms and clinical manifestations of reflex syncope explain the controversial results of older randomised clinical trials. New evidence from recent trials has changed medical practice, now leading to clear indications for pacing in patients with asystolic syncope documented during carotid sinus massage, implantable cardiac monitoring or tilt testing. Given that recent trials in reflex syncope have been performed using the closed-loop stimulation algorithm, the authors will briefly discuss this pacing mode, review hypotheses about the mechanisms underlying its activation during syncope and provide practical instructions for programming and troubleshooting.

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Cardiac pacing in severe recurrent reflex syncope and tilt-induced asystole

European Heart Journal ◽

10.1093/eurheartj/ehaa936 ◽

2020 ◽

Cited By ~ 1

Author(s):

Michele Brignole ◽

Vincenzo Russo ◽

Francesco Arabia ◽

Mario Oliveira ◽

Alonso Pedrote ◽

...

Keyword(s):

Cardiac Pacing ◽

Hazard Ratio ◽

Control Group ◽

Dual Chamber ◽

Dual Chamber Pacemaker ◽

Tilt Testing ◽

Reflex Syncope ◽

First Recurrence ◽

To Receive

Abstract Aim The benefit of cardiac pacing in patients with severe recurrent reflex syncope and asystole induced by tilt testing has not been established. The usefulness of tilt-table test to select candidates for cardiac pacing is controversial. Methods and results We randomly assigned patients aged 40 years or older who had at least two episodes of unpredictable severe reflex syncope during the last year and a tilt-induced syncope with an asystolic pause longer than 3 s, to receive either an active (pacing ON; 63 patients) or an inactive (pacing OFF; 64 patients) dual-chamber pacemaker with closed loop stimulation (CLS). The primary endpoint was the time to first recurrence of syncope. Patients and independent outcome assessors were blinded to the assigned treatment. After a median follow-up of 11.2 months, syncope occurred in significantly fewer patients in the pacing group than in the control group [10 (16%) vs. 34 (53%); hazard ratio, 0.23; P = 0.00005]. The estimated syncope recurrence rate at 1 year was 19% (pacing) and 53% (control) and at 2 years, 22% (pacing) and 68% (control). A combined endpoint of syncope or presyncope occurred in significantly fewer patients in the pacing group [23 (37%) vs. 40 (63%); hazard ratio, 0.44; P = 0.002]. Minor device-related adverse events were reported in five patients (4%). Conclusion In patients aged 40 years or older, affected by severe recurrent reflex syncope and tilt-induced asystole, dual-chamber pacemaker with CLS is highly effective in reducing the recurrences of syncope. Our findings support the inclusion of tilt testing as a useful method to select candidates for cardiac pacing. Study registration ClinicalTrials.gov identifier NCT02324920, Eudamed number CIV-05-013546.

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