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Cited by 114Cardiovascular Syncope and Autonomic DisordersAtrial Fibrillation Management and OutcomesHeart Rate Variability and Autonomic Control

Role of autonomic reflexes in syncope associated with paroxysmal atrial fibrillation

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Brignole, Michele, Gianfranchi, Lorella, Menozzi, Carlo, Raviele, Antonio, Oddone, Daniele, Lolli, Gino, Bottoni, Nicola·1993·Journal of the American College of Cardiology
DOI 10.1016/0735-1097(93)90426-2
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Abstract

Objectives The purpose of this study was to evaluate the role of autonomic reflexes in the genesis of syncope associated with the onset of paroxysmal atrial fibrillation.Background Syncope associated with paroxysmal atrial fibrillation has been interpreted as an ominous finding predictive of rapid ventricular rates. However, various mechanisms may be involved when heart rate is not particularly high.Methods Forty patients (age 60 +/- 14 years, 20 men, 20 women) with syncope and atrial fibrillation were compared with atrial fibrillation without syncope. Carotid sinus massage and head-up tilt testing (at 60 degrees for 60 min at baseline and during isoproterenol infusion) were performed during sinus rhythm. A positive response was defined as the induction of syncope. Atrial fibrillation was also induced on a tilt table at 60 degrees by means of short bursts of atrial pacing.Results Results of carotid sinus massage were positive in 15 (37%) of 40 patients but in no control subjects (p = 0.002). Head-up tilt test findings were positive in 25 (66%) of 38 patients and in 2 (12%) of 16 control subjects (p = 0.0004). The induction of atrial fibrillation in the upright position elicited syncope in 16 (42%) of 38 patients but in none of 16 control subjects (p = 0.001). At the beginning of atrial fibrillation, systolic blood pressure was lower in patients than in control subjects (88 +/- 32 vs. 127 +/- 32 mm Hg), whereas mean heart rate was similar (142 +/- 35 vs. 134 +/- 25 beats/min). The correlation between heart rate and systolic blood pressure was weak (r = 0.35), and in five patients syncope occurred at a heart rate < or = 130 beats/min. At the time of syncope, heart rate decreased (-12 +/- 21 beats/min) in patients with induced syncope, whereas it remained unchanged in patients without induced syncope (+1 +/- 17 beats/min, p = 0.04) or slightly increased in control subjects (+9 +/- 21 beats/min, p = 0.009).Conclusions Patients with syncope associated with paroxysmal atrial fibrillation are predisposed to an abnormal neural response during both sinus rhythm and arrhythmia. In some patients the onset of atrial fibrillation triggers vasovagal syncope.

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  • Tilt testing was positive in 45-47% of patients with true cardiac arrhythmic syncope.

    “and in 45-47% with true cardiac arrhythmic syncope. 130,131”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [130]

    The Results report positive head-up tilt tests in patients with paroxysmal atrial fibrillation and syncope, so the source supports the general point that tilt testing can be positive in arrhythmia-associated syncope. But the Discussion reports a positive tilt response in 11 of 15 (73%) patients whose syncope was induced by atrial fibrillation; it does not establish a 45–47% rate for patients with true cardiac arrhythmic syncope generally. Page numbers are unavailable in our indexed passages. (LLM, conf=0.84)

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  • In arrhythmic syncope caused by paroxysmal atrial tachyarrhythmias, the mechanism is a combination of onset of the arrhythmia itself and hypotensive susceptibility, corroborated by positive tilt testing.

    “For example, in arrhythmic syncope caused by paroxysmal atrial tachyarrhythmias, the mechanism is a combination of onset of the arrhythmia itself and hypotensive susceptibility, corroborated by positive tilt testing. 130,131”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [130]

    The Discussion (pp. 1126–1127) links syncope at the onset of paroxysmal atrial fibrillation to abnormal autonomic susceptibility, and reports positive head-up tilt responses in 11 of 15 patients whose syncope was induced by atrial fibrillation. The claim extends that finding from atrial fibrillation to paroxysmal atrial tachyarrhythmias generally and states the mechanism more definitively than the paper does. (LLM, conf=0.83)

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Research works printed but not linked: 1

  1. Gianfranchi L, Brignole M . Menozzi C. Oddone D, Lolli G . Petillo A . Syncope due to paroxysmal atrial fibrillaiionlflutter : usefulness of The electrophysiological study in the supine and upright position . G ltal Cardiol 1990 ;20:828-33 .

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Authors
Brignole, M., Gianfranchi, L., Menozzi, C., Raviele, A., Oddone, D., Lolli, G., & Bottoni, N.
Affiliations
Santa Maria Nuova Hospital (IT)
Corresponding author
Brignole, Michele
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
1993-10
Volume
22
Issue
4
Pages
1123-1129
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/0735-1097(93)90426-2
OpenAlex
W1989742523
Cited by
114
References
26
Citations by year
2026: 2 · 2025: 1 · 2024: 3 · 2022: 3 · 2020: 5 · 2019: 5 · 2018: 10 · 2017: 6 · 2016: 4 · 2015: 5 · 2014: 5 · 2013: 5 · 2012: 4
FWCI
2.62
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
Keywords
syncope, paroxysmal atrial fibrillation, autonomic reflexes, carotid sinus massage, head-up tilt, isoproterenol, atrial fibrillation induction, orthostatic hypotension, heart rate, systolic blood pressure, autonomic dysfunction, syncope pathophysiology
MeSH terms
Aged, Atrial Fibrillation, Autonomic Nervous System, Blood Pressure, Cardiac Pacing, Artificial, Carotid Sinus, Echocardiography, Electrophysiology, Female, Heart Rate, Humans, Infusions, Intravenous, Isoproterenol, Male, Massage, Middle Aged, Predictive Value of Tests, Reflex, Syncope, Systole, Vagus Nerve, Causality, Case-Control Studies, Tachycardia, Ventricular

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