An Implantable Loop Recorder Study of Highly Symptomatic Vasovagal Patients
Open accessAbstract
Objectives The aim of this study was to analyze the heart rhythm during spontaneous vasovagal syncope (VVS) in highly symptomatic patients with implantable loop recorders (ILR) and to correlate this rhythm with the heart rhythm observed during head-up tilt test (HUT).Background Heart rhythm obtained during provocative condition is often used to guide therapy in VVS. To date there is no conclusive evidence that the heart rhythm observed during a positive HUT can predict heart rhythm during VVS or that the heart rhythm observed during a spontaneous syncope will be identical to the recurrent syncope.Methods Twenty-five consecutive VVS patients (age 60.2 +/- 17.1 years; 14 women,) presenting with frequent syncopes (6.9 +/- 4.6 episodes/year) and a positive HUT (cardioinhibitory in 8 patients) were implanted with an ILR. Seven of them also had a positive adenosine triphosphate (ATP) test.Results Follow-up was 17.0 +/- 3.6 months. Thirty VVS were observed in 12 patients. Nine episodes showed bradycardia of <40 beats/min or asystole; progressive sinus bradycardia preceding sinus arrest was the most frequent electrocardiographic finding. Twenty-one syncopes occurred without severe bradycardia. The heart rhythm observed during the first syncope was identical to the recurrence. No correlation was found between slow heart rate at the ILR interrogation and a cardioinhibitory HUT response (p = 1.0) or a positive ATP test (p = 1.0).Conclusions In highly symptomatic patients with VVS, the heart rhythm observed during spontaneous syncope does not correlate with the HUT. The heart rhythm during the first spontaneous syncope is identical to the recurrent syncope.
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A positive cardioinhibitory response to tilt testing predicts, with a high probability, an asystolic spontaneous syncope.
“While a positive cardioinhibitory response to tilt testing predicts, with a high probability, an asystolic spontaneous syncope, the presence of a positive vasodepressor, mixed response, or even a negative response, does not exclude the presence of asystole during spontaneous syncope. 122,123”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [122]
The Discussion says that the tilt-test response was not predictive of the mechanism of spontaneous syncope. It also reports spontaneous syncope without severe bradycardia in two of four patients with a type 2 (cardioinhibitory) tilt response, contrary to the claimed high-probability prediction of asystole. (LLM, conf=0.92)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredA positive cardioinhibitory response to tilt testing predicts, with high probability, asystolic spontaneous syncope.
“A positive cardioinhibitory response to tilt testing predicts, with high probability, asystolic spontaneous syncope; this finding is relevant for therapeutic implications when cardiac pacing is considered (see section 5.2.6).”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [122]
The Discussion states that the response during head-up tilt testing was not predictive of the mechanism of spontaneous syncope. It reports spontaneous syncope without severe bradycardia in two of four patients with a type 2 tilt response, contrary to the claimed high-probability prediction of asystole. The paper instead discusses documented rhythm during spontaneous syncope as relevant to pacing decisions (Discussion, p. 591). (LLM, conf=0.94)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredThe presence of a positive vasodepressor, mixed response, or even a negative response to tilt testing does not exclude the presence of asystole during spontaneous syncope.
“While a positive cardioinhibitory response to tilt testing predicts, with a high probability, an asystolic spontaneous syncope, the presence of a positive vasodepressor, mixed response, or even a negative response, does not exclude the presence of asystole during spontaneous syncope. 122,123”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [122]
The Discussion (pp. 587–593) says spontaneous severe bradycardia occurred after type 1 and type 3 tilt responses, not only cardioinhibitory type 2 responses; Table 2 also records sinus arrest after a type 3 response. But the Patients section required a positive tilt test for enrollment, so this study does not establish the claim about a negative tilt-test response. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe presence of a positive vasodepressor, a mixed response, or even a negative response to tilt testing does not exclude the presence of asystole during spontaneous syncope.
“Conversely, the presence of a positive vasodepressor, a mixed response, or even a negative response does not exclude the presence of asystole during spontaneous syncope. 122,123”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [122]
The Discussion reports that spontaneous severe bradycardia occurred after type 1 or type 3 tilt responses, and Table 2 documents sinus arrest after a type 3 response. But Table 2 does not document asystole after a type 1 response. The Patients section (p. 588) required a positive tilt test for enrollment, so the study does not establish the claim about negative tilt tests. (LLM, conf=0.87)
Experimental — accuracy not yet measuredPrevious studies showed no correlation between AV block induced by ATP and ECG findings documented by ILR during spontaneous syncope.
“previous studies showed no correlation between AV block induced by ATP and ECG findings (documented by ILR) during spontaneous syncope. 122,123,227”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [122]
The Results (labeled “Out”; page unavailable) report no statistical correlation between a positive ATP test and slow heart rate during ILR-documented recurrences. But the Study protocol defines a positive ATP test as a pause caused by either AV block or sinoatrial block, and the reported correlation concerns slow heart rate, not ECG findings generally. The paper therefore supports the broader lack of predictive correlation, but not an AV-block-specific claim. (LLM, conf=0.85)
Experimental — accuracy not yet measured
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- Authors
- Deharo, J.-C., Jego, C., Lanteaume, A., & Djiane, P.
- Affiliations
- Hôpital de la Timone (FR)
- Corresponding author
- Deharo, Jean-Claude
- ORCID
- Deharo, Jean-Claude
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2006-02
- Volume
- 47
- Issue
- 3
- Pages
- 587-593
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W24220055
- Cited by
- 110
- References
- 25
- Citations by year
- 2025: 2 · 2024: 4 · 2023: 1 · 2022: 1 · 2021: 2 · 2020: 1 · 2019: 1 · 2018: 4 · 2017: 3 · 2016: 3 · 2015: 6 · 2014: 9 · 2013: 12 · 2012: 8
- FWCI
- 12.43
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- 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 › Heart Rate Variability and Autonomic Control
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- vasovagal syncope, implantable loop recorder, head-up tilt, cardioinhibitory syncope, bradycardia, sinus arrest, asystole, cardiac rhythm, syncope recurrence
- MeSH terms
- Adenosine Triphosphate, Aged, Aged, 80 and over, Female, Heart Rate, Humans, Male, Middle Aged, Recurrence, Electrocardiography, Ambulatory, Tilt-Table Test, Syncope, Vasovagal
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