“Complex” Vasovagal Syncope: A Zebra Among Horses

Background: Vasovagal syncope (VVS) occurs due to cerebral hypoperfusion from a fall in blood pressure, with accompanying bradycardia in most cases. Seizure and/or asystole may accompany VVS, though their prediction within the VVS cohort remains elusive.Objective: To further characterize VVS and to find predictive features of “complex” VVS (defined as VVS associated with seizures and/or asystole).Methods: We reviewed medical records of all patients who were referred for orthostatic intolerance and had a definite VVS during the head-up tilt table testing (HUTT). The following variables were recorded: cardiovascular indices during HUTT, autonomic testing results, and semiology of asystole and/or seizure when present. Simple frequency and correlation analysis were performed using the ANOVA.Results: A total of 78 independent VVS were recorded in 60 patients of which 24% were not preceded by presyncope. Vasodepressor (45%) and mixed (38%) VVS were the most prevalent types. Eighteen (23%) were complex VVS; five had an associated seizure (SySz), nine were accompanied by asystole (SyAs), and four had both (SySzAs). Males were significantly more likely to have complex VVS. Mean asystole duration was somewhat longer in the SyAsSz group. The severity of bradycardia significantly correlated with complex VVS and was a predictor of SySz. Autonomic abnormalities were frequent but did not distinguish the two VVS subgroups. Seizures had multiple distinguishing features from those typically associated with epileptic seizures.Conclusions: The underlying pathophysiologic mechanisms of complex VVS remain unclear, but the severity of cerebral hypoperfusion due to bradycardia likely plays a key role in seizure generation.

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The Differences in the Diagnostic Profile in Children with Vasovagal Syncope between the Result of Head-Up Tilt Table Test

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17124524 ◽

2020 ◽

Vol 17 (12) ◽

pp. 4524

Author(s):

Ewelina Kolarczyk ◽

Lesław Szydłowski ◽

Agnieszka Skierska ◽

Grażyna Markiewicz-Łoskot

Keyword(s):

Medical Records ◽

Vasovagal Syncope ◽

Speech Disorders ◽

Tilt Table Test ◽

Tilt Table ◽

Prodromal Symptoms ◽

Close Relationship ◽

Head Up Tilt ◽

Diagnostic Profile ◽

Positive Results

(1) Background: The features characterizing vasovagal syncope (VVS) are an important factor in the correct evaluation of diagnostic risk stratification in children and adolescents. The aim of the study was to determine the value of identifying the clinical characteristics in children with VVS. (2) Methods: We made a retrospective analysis of the medical records of 109 children with diagnosed VVS. We investigated the specific characteristics of syncope in children with VVS including the positive VVS (+) and negative VVS (−) result of the Head-Up Tilt Table Test (HUTT). (3) Results: We did not observe significant differences in the prodromal symptoms of VVS with HUTT response. In addition to typical prodromal symptoms, no difference in statistically reported palpitations (35/109 or 32.1%) and chest discomfort (27/109 or 27.7%) were recorded. Fear–pain–stress emotions as circumstances of syncope were more often reported by children with a negative HUTT (p = 0.02). Cramps–contractures (p = 0.016) and speech disorders (p = 0.038) were significantly higher in the group with negative HUTT. (4) Conclusions: There is a close relationship in the diagnostic profile between the negative and positive results of head-up tilt table test in children with vasovagal syncope.

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A clinical manifestation-based prediction of haemodynamic patterns of orthostatic intolerance in children: a multi-centre study

Cardiology in the Young ◽

10.1017/s1047951113000929 ◽

2013 ◽

Vol 24 (4) ◽

pp. 649-653 ◽

Cited By ~ 6

Author(s):

Li Chen ◽

Xueying Li ◽

Ochs Todd ◽

Cheng Wang ◽

Hongfang Jin ◽

...

Keyword(s):

Clinical Study ◽

Diagnostic Accuracy ◽

Clinical Manifestation ◽

Orthostatic Intolerance ◽

Vasovagal Syncope ◽

Postural Orthostatic Tachycardia Syndrome ◽

Tilt Table Test ◽

Tilt Table ◽

Multi Centre Study ◽

Head Up Tilt

AbstractObjective: At present, the haemodynamic diagnosis of orthostatic intolerance is based mainly on the head-up tilt table test, which is sometimes risky for patients. Thus, it is important to find objective and safe methods to differentiate haemodynamic patterns of orthostatic intolerance cases. Methods: In all, 629 children with orthostatic intolerance, either vasovagal syncope or postural orthostatic tachycardia syndrome, were included in the multi-centre clinical study. We analysed the association between the clinical manifestation and haemodynamic patterns of the patients. Results: Syncope after motion with a prodrome of chest distress or palpitations and the concomitant symptom(s) after a syncopal attack, with debilitation, dizziness or headache, were the most important variables in predicting the diagnosis of vasovagal syncope. The overall diagnostic accuracy was 71.5%. Conclusion: Complaint of syncope after motion with prodromal chest distress or palpitation and the concomitant symptom after a syncopal attack, with subsequent debilitation, dizziness or headache, were the most important variables in the diagnosis of vasovagal syncope in children with orthostatic intolerance.

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Early Cerebral Hypoperfusion in Patients with Orthostatic Intolerance Without Tachycardia During Head-Up Tilt Test is Independent of Vasovagal Response

Revista de investigaci�n Cl�nica ◽

10.24875/ric.21000199 ◽

2021 ◽

Author(s):

J. Antonio González-Hermosillo ◽

Alan Rubio-Vega ◽

Karla A. F. González-Olvera ◽

Manuel Sierra-Beltrán ◽

Andrei Kostine ◽

...

Keyword(s):

Orthostatic Intolerance ◽

Cerebral Hypoperfusion ◽

Tilt Test ◽

Head Up Tilt ◽

Head Up Tilt Test ◽

Vasovagal Response

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Prolongation of Electrocardiographic T Wave Parameters Recorded during the Head-Up Tilt Table Test as Independent Markers of Syncope Severity in Children

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17186441 ◽

2020 ◽

Vol 17 (18) ◽

pp. 6441

Author(s):

Grażyna Markiewicz-Łoskot ◽

Ewelina Kolarczyk ◽

Bogusław Mazurek ◽

Marianna Łoskot ◽

Lesław Szydłowski

Keyword(s):

Vasovagal Syncope ◽

The Other ◽

Control Group ◽

Tilt Table Test ◽

Tilt Table ◽

T Wave ◽

Good Discriminator ◽

Wave Morphology ◽

Head Up Tilt ◽

T Waves

The head-up tilt table test (HUTT) with the upright phase is used to help determine an imbalance of the sympathetic nervous system that is related to abnormal electrocardiographic repolarization in children with vasovagal syncope (VVS) and also in patients with the long QT syndrome (LQTS). The study attempted to evaluate T wave morphology and QT and TpTe (Tpeak–Tend) intervals recorded in ECG during the HUTT for a more accurate diagnosis of children with VVS. The group investigated 70 children with a negative HUTT result: 40 patients with VVS and 30 healthy volunteers without syncope. The RR interval as well as TpTe, and QTc intervals were measured in lead V5 of electrocardiogram (ECG) on admission to the hospital and during three phases of the HUTT. In syncopal children, which included 23 children with bifid or flat T waves and 17 patients with normal T waves in the upright phase, the QTc and TpTe were longer (p < 0.001) compared to the other test phases and longer (p < 0.001) than in the control group, respectively, with the risk of arrhythmias. Only in the control group, the TpTe was shorter (p < 0.001) in the upright phase than in the other tilt phases. The TpTe in the upright phase (>70 ms) was a good discriminator, and was better than the QTc (>427 ms). Prolongation of electrocardiographic TpTe and QT intervals, in addition to the (abnormal T wave morphology recorded during the HUTT, are helpful for identifying VVS children more predisposed to ventricular arrhythmias with a latent risk of LQTS. Further studies are required to assess the value of these repolarization parameters in clinical practice.

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The Newcastle protocols 2008: an update on head-up tilt table testing and the management of vasovagal syncope and related disorders

Heart ◽

10.1136/hrt.2007.136457 ◽

2008 ◽

Vol 95 (5) ◽

pp. 416-420 ◽

Cited By ~ 62

Author(s):

S W Parry ◽

P Reeve ◽

J Lawson ◽

F E Shaw ◽

J Davison ◽

...

Keyword(s):

Vasovagal Syncope ◽

Tilt Table ◽

Tilt Table Testing ◽

Head Up Tilt

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

Age and Ageing ◽

10.1093/ageing/afn098 ◽

2008 ◽

Vol 37 (4) ◽

pp. 411-415 ◽

Cited By ~ 29

Author(s):

Steve W. Parry ◽

Janine C. Gray ◽

Julia L. Newton ◽

Pamela Reeve ◽

Diarmuid O'shea ◽

...

Keyword(s):

Vasovagal Syncope ◽

First Line ◽

Tilt Table ◽

Tilt Table Testing ◽

Head Up Tilt

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Assessment of therapeutic biomarkers in the treatment of children with postural tachycardia syndrome and vasovagal syncope

Cardiology in the Young ◽

10.1017/s1047951114000316 ◽

2014 ◽

Vol 24 (5) ◽

pp. 792-796 ◽

Cited By ~ 9

Author(s):

Jing Lin ◽

Hongfang Jin ◽

Junbao Du

Keyword(s):

Orthostatic Intolerance ◽

Vasovagal Syncope ◽

Urinary Sodium Excretion ◽

Tilt Test ◽

Postural Tachycardia Syndrome ◽

Postural Tachycardia ◽

Ovid Medline ◽

Head Up Tilt ◽

Head Up Tilt Test ◽

Flow Mediated Vasodilation

AbstractBackground: Postural tachycardia syndrome and vasovagal syncope are common causes of orthostatic intolerance in children. The supplementation with water, or salt, or midodrine, or β-blocker was applied to children with postural tachycardia syndrome or vasovagal syncope. However, the efficacy of such medication varied and was not satisfied. This review aimed to summarise the current biomarkers in the treatment of the diseases. Data sources: Studies were collected from online electronic databases, including OVID Medline, PubMed, ISI Web of Science, and associated references. The main areas assessed in the included studies were clinical improvement, the cure rate, and the individualised treatment for postural tachycardia syndrome and vasovagal syncope in children. Results: Haemodynamic change during head-up tilt test, and detection of 24-hour urinary sodium excretion, flow-mediated vasodilation, erythrocytic H2S, and plasma pro-adrenomedullin as biological markers were the new ways that were inexpensive, non-invasive, and easy to test for finding those who would be suitable for a specific drug and treatment. Conclusion: With the help of biomarkers, the therapeutic efficacy was greatly increased for children with postural tachycardia syndrome and vasovagal syncope.

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Orthostatic Headaches Associated With Spontaneous Intracranial Hypotension and Autonomic Dysfunction—A Case Series in Young Patients

Child Neurology Open ◽

10.1177/2329048x211056709 ◽

2021 ◽

Vol 8 ◽

pp. 2329048X2110567

Author(s):

Ankita Ghosh ◽

Yen X. Tran ◽

Leon Grant ◽

Mohammed T. Numan ◽

Rajan Patel ◽

...

Keyword(s):

Autonomic Dysfunction ◽

Intracranial Hypotension ◽

Orthostatic Intolerance ◽

Spontaneous Intracranial Hypotension ◽

Young Patients ◽

Case Series ◽

Tilt Table ◽

Epidural Blood Patching ◽

Persistent Symptoms ◽

Head Up Tilt

Background: Orthostatic headaches can be noted in spontaneous intracranial hypotension and orthostatic intolerance. We present a case series of young patients diagnosed with spontaneous intracranial hypotension and were treated for the same but subsequently developed orthostatic intolerance. Methods: We retrospectively reviewed charts for seven young patients with orthostatic headaches related to spontaneous intracranial hypotension and orthostatic intolerance. Results: Patients were diagnosed with spontaneous intracranial hypotension. Diagnosis was confirmed by identifying epidural contrast leakage and three of seven patients were noted to have early renal contrast excretion on computerized tomography myelography. Patients were treated with epidural blood patches. All patients showed persistent symptoms of autonomic dysfunction after treatment of spontaneous intracranial hypotension and orthostatic intolerance was confirmed with head-up tilt table test. Conclusions: Patients with spontaneous intracranial hypotension failing to improve following epidural blood patching should be evaluated for orthostatic intolerance.

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Case 69: Small Fiber Neuropathy, Hypocapnic Cerebral Hypoperfusion, and Generalized Hypermobility Spectrum Disorder

Autonomic Testing ◽

10.1093/med/9780190889227.003.0074 ◽

2019 ◽

pp. 357-360

Author(s):

Peter Novak

Keyword(s):

Orthostatic Intolerance ◽

Small Fiber Neuropathy ◽

Spectrum Disorder ◽

Cerebral Hypoperfusion ◽

Autonomic Testing ◽

Small Fiber ◽

Generalized Hypermobility

Autonomic testing showed mixed small fiber neuropathy, which can be responsible for both sensory complaints and dysautonomia. Dysautonomia was generalized, but mild and was associated with mild orthostatic intolerance. The patient has generalized hypermobility spectrum disorder (GHSD).

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