Lack of correlation between the responses to tilt testing and adenosine triphosphate test and the mechanism of spontaneous neurally mediated syncope
Abstract
AIMS: We prospectively correlated the results of tilt testing (TT) and adenosine triphosphate test (ATP) with the findings observed during a spontaneous syncopal relapse by means of an implantable loop recorder (ILR) in patients with a clinical diagnosis of neurally mediated syncope. METHODS AND RESULTS: We included patients with three or more clinically severe syncopal episodes in the last 2 years without significant electrocardiographic and cardiac abnormalities. Patients with orthostatic hypotension and carotid sinus syncope were excluded. After ILR implantation, patients were followed until the first documented syncope. Among 392 enrolled patients, 343 underwent TT, which was positive in 164 (48%), and 180 ATP test, which was positive in 53 (29%). Syncope was documented by ILR in 106 (26%) patients after a median of 3 months. Patients with positive and negative TT had similar baseline characteristics, syncopal recurrence rate, and mechanism of syncope, but those with positive TT had more frequently no or slight rhythm variations during spontaneous syncope (45 vs. 21%, P=0.02). An asystolic pause was more frequently found during spontaneous syncope than during TT (45 vs. 21%, P=0.02), but there was a trend for those with an asystolic response during TT also to have an asystolic response during spontaneous syncope (75 vs. 37%, P=0.1). Patients with positive ATP test responses showed syncopal recurrence rates and mechanism of syncope similar to those with negative ATP tests. CONCLUSION: In patients with neurally mediated syncope, clinical characteristics, outcome, and mechanism of syncope are poorly correlated and not predicted by the results of TT and ATP test. Therefore, these tests are of little or no value in guiding specific therapy.
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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 [123]
The 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 [123]
The 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 [123]
A 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 [123]
Previous 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 [123]
Cites
Guidelines on management (diagnosis and treatment) of syncope
Brignole, M. (2001) · European Heart Journal · doi:10.1053/euhj.2001.2739 · Cited by 951 · see citing works
Self-citationGuidelines on Management (diagnosis and treatment) of syncope ? update 2004
Brignole, M., Alboni, P., Benditt, D. G., Bergfeldt, L., Blanc, J., Thomsen, P. E. B., van Dijk, J. G., Fitzpatrick, A. P., Hohnloser, S. H., Janousek, J., et al. (2004) · EP Europace · doi:10.1016/j.eupc.2004.08.008 · Cited by 648 · see citing works
Self-citationConnolly, S. J., Sheldon, R., Thorpe, K. E., Roberts, R. S., Ellenbogen, K. A., Wilkoff, B. L., Morillo, C., Gent, M., & for the VPS II Investigators (2003) · JAMA · doi:10.1001/jama.289.17.2224 · Cited by 500 · see citing works
Brignole, M. (2000) · Europace · doi:10.1053/eupc.1999.0064 · Cited by 451 · see citing works
Self-citationSutton, R., Brignole, M., Menozzi, C., Raviele, A., Alboni, P., Giani, P., & Moya, A. (2000) · Circulation · doi:10.1161/01.cir.102.3.294 · Cited by 407 · see citing works
Self-citationKrahn, A. D., Klein, G. J., Yee, R., & Skanes, A. C. (2001) · Circulation · doi:10.1161/01.cir.104.1.46 · Cited by 405 · see citing works
Mechanism of Syncope in Patients With Isolated Syncope and in Patients With Tilt-Positive Syncope
Moya, A., Brignole, M., Menozzi, C., Garcia-Civera, R., Tognarini, S., Mont, L., Botto, G., Giada, F., Cornacchia, D., & on behalf of the International Study on Syncope of Uncertain Etiology (ISSUE) Investigators (2001) · Circulation · doi:10.1161/hc3601.095708 · Cited by 378 · see citing works
Self-citationBrignole, M., Sutton, R., Menozzi, C., Garcia-Civera, R., Moya, A., Wieling, W., Andresen, D., Benditt, D. G., & Vardas, P. (2006) · European Heart Journal · doi:10.1093/eurheartj/ehi842 · Cited by 376 · see citing works
Self-citationUse of an Extended Monitoring Strategy in Patients With Problematic Syncope
Krahn, A. D., Klein, G. J., Yee, R., Takle-Newhouse, T., & Norris, C. (1999) · Circulation · doi:10.1161/01.cir.99.3.406 · Cited by 360 · see citing works
RAVIELE, A., GIADA, F., MENOZZI, C., SPECA, G., ORAZI, S., GASPARINI, G., SUTTON, R., & BRIGNOLE, M. (2004) · European Heart Journal · doi:10.1016/j.ehj.2004.06.031 · Cited by 323 · see citing works
Self-citationAmmirati, F., Colivicchi, F., & Santini, M. (2001) · Circulation · doi:10.1161/hc2601.091708 · Cited by 299 · see citing works
Use of implantable loop recorders in the diagnosis and management of syncope*1
FARWELL, D. (2004) · European Heart Journal · doi:10.1016/j.ehj.2004.03.010 · Cited by 132 · see citing works
An Implantable Loop Recorder Study of Highly Symptomatic Vasovagal Patients
Deharo, J.-C., Jego, C., Lanteaume, A., & Djiane, P. (2006) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2005.09.043 · Cited by 110 · see citing works
Brignole, M., Moya‐Mitjans, À., Menozzi, C., García–Civera, R., & Sutton, R. (2005) · EP Europace · doi:10.1016/j.eupc.2004.11.001 · Cited by 106 · see citing works
Self-citationFindings on ambulatory electrocardiographic monitoring in subjects older than 80 years
Kantelip, J., Sage, É., & Duchene-Marullaz, P. (1986) · The American Journal of Cardiology · doi:10.1016/0002-9149(86)90760-5 · Cited by 106 · see citing works
Brignole, M., Gaggioli, G., Menozzi, C., Gianfranchi, L., Bartoletti, A., Bottoni, N., Lolli, G., Oddone, D., Rosso, A. D., & Pellinghelli, G. (1997) · Circulation · doi:10.1161/01.cir.96.11.3921 · Cited by 98 · see citing works
Self-citationGrimm, W., Degenhardt, M., Hoffmann, J., Menz, V., Wirths, A., & Maisch, B. (1997) · European Heart Journal · doi:10.1093/oxfordjournals.eurheartj.a015473 · Cited by 73 · see citing works
Mechanism of syncope in patients with positive adenosine triphosphate tests
Donateo, P., Brignole, M., Menozzi, C., Bottoni, N., Alboni, P., Dinelli, M., Del Rosso, A., Croci, F., Oddone, D., Solano, A., et al. (2003) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(02)02621-9 · Cited by 68 · see citing works
Self-citationComparison of Patients With Syncope of Unknown Cause Having Negative or Positive Tilt-Table Tests
Sheldon, R. S., Rose, S., & Koshman, M. L. (1997) · The American Journal of Cardiology · doi:10.1016/s0002-9149(97)00425-6 · Cited by 56 · see citing works
Permanent cardiac pacing vs. medical treatment for the prevention of recurrent vasovagal syncope
Ammirati, F., Colivicchi, F., & Santini, M. (2001) · ACC Current Journal Review · doi:10.1016/s1062-1458(01)00501-3 · Cited by 45 · see citing works
Frequency and significance of cardiac rhythm disturbances in healthy elderly individuals
Wajngarten, M., Grupi, C., Bellotti, G. M. V., da Luz, P. L., Azul, L. G. D. S., & Pileggi, F. (1990) · Journal of Electrocardiology · doi:10.1016/0022-0736(90)90138-r · Cited by 27 · see citing works
Perennes, A., Fatemi, M., Borel, M. L., Lebras, Y., L'Her, C., & Blanc, J. (2006) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2005.09.044 · Cited by 21 · see citing works
Minimal heart rates and longest pauses in healthy adult subjects on two occasions eight years apart
Mølgaard, H., Sørensen, K. E., & Bjerregaard, P. (1989) · European Heart Journal · doi:10.1093/oxfordjournals.eurheartj.a059561 · Cited by 19 · see citing works
The Steering Committee of the ISSUE 2 study (2003) · EP Europace · doi:10.1016/s1099-5129(03)00048-5 · Cited by 19 · see citing works
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Developed in collaboration with, European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS), societies, E. B. T. F., European Society of Emergency Medicine (EuSEM), European Federation of Internal Medicine (EFIM), European Union Geriatric Medicine Society (EUGMS), American Geriatrics Society (AGS), European Neurological Society (ENS), et al. (2009) · European Heart Journal · doi:10.1093/eurheartj/ehp298 · Cited by 2,040 · see citing works
Self-citation2018 ESC Guidelines for the diagnosis and management of syncope
Brignole, M., Moya, A., de Lange, F. J., Deharo, J.-C., Elliott, P. M., Fanciulli, A., Fedorowski, A., Furlan, R., Kenny, R. A., Martín, A., et al. (2018) · European Heart Journal · doi:10.1093/eurheartj/ehy037 · Cited by 1,951 · see citing works
Self-citationIndications for the use of diagnostic implantable and external ECG loop recorders
Task Force members, Brignole, M., Vardas, P., Hoffman, E., Huikuri, H., Moya, A., Ricci, R., Sulke, N., Wieling, W., EHRA Scientific Documents Committee, et al. (2009) · Europace · doi:10.1093/europace/eup097 · Cited by 362 · see citing works
Self-citationSyncope Due to Idiopathic Paroxysmal Atrioventricular Block
Brignole, M., Deharo, J.-C., De Roy, L., Menozzi, C., Blommaert, D., Dabiri, L., Ruf, J., & Guieu, R. (2011) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2010.12.045 · Cited by 147 · see citing works
Self-citationAmnesia for loss of consciousness is common in vasovagal syncope
O'Dwyer, C., Bennett, K., Langan, Y., Fan, C. W., & Kenny, R. A. (2011) · Europace · doi:10.1093/europace/eur069 · Cited by 109 · see citing works
Flammang, D., Church, T. R., De Roy, L., Blanc, J.-J., Leroy, J., Mairesse, G. H., Otmani, A., Graux, P. J., Frank, R., Purnode, P., et al. (2012) · Circulation · doi:10.1161/circulationaha.111.022855 · Cited by 93 · see citing works
Priorities for Emergency Department Syncope Research
Sun, B. C., Costantino, G., Barbic, F., Bossi, I., Casazza, G., Dipaola, F., McDermott, D., Quinn, J., Reed, M., Sheldon, R. S., et al. (2014) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2014.04.014 · Cited by 86 · see citing works
Self-citationMaggi, R., Menozzi, C., Brignole, M., Podoleanu, C., Iori, M., Sutton, R., Moya, A., Giada, F., Orazi, S., & Grovale, N. (2007) · EP Europace · doi:10.1093/europace/eum092 · Cited by 79 · see citing works
Self-citationNovel cardiovascular biomarkers in unexplained syncopal attacks: the <scp>SYSTEMA</scp> cohort
Fedorowski, A., Burri, P., Struck, J., Juul‐Möller, S., & Melander, O. (2013) · Journal of Internal Medicine · doi:10.1111/joim.12043 · Cited by 62 · see citing works
Verheyden, B., Gisolf, J., Beckers, F., Karemaker, J. M., Wesseling, K. H., Aubert, A. E., & Wieling, W. (2007) · Clinical Science · doi:10.1042/cs20070042 · Cited by 58 · see citing works
Ungar, A., Sgobino, P., Russo, V., Vitale, E., Sutton, R., Melissano, D., Beiras, X., Bottoni, N., Ebert, H. H., Gulizia, M., et al. (2013) · Heart · doi:10.1136/heartjnl-2013-304399 · Cited by 58 · see citing works
Self-citationMoya, A., Brignole, M., Sutton, R., Menozzi, C., Garcia-Civera, R., Wieling, W., Andresen, D., Benditt, D. G., Garcia-Sacristán, J. F., Beiras, X., et al. (2008) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2008.07.043 · Cited by 38 · see citing works
Self-citationFlevari, P., Leftheriotis, D., Komborozos, C., Fountoulaki, K., Dagres, N., Theodorakis, G., & Kremastinos, D. (2009) · European Heart Journal · doi:10.1093/eurheartj/ehp255 · Cited by 38 · see citing works
Key challenges in the current management of syncope
Sutton, R., Brignole, M., & Benditt, D. G. (2012) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2012.102 · Cited by 33 · see citing works
Self-citationBlanc, J.-J. (2013) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2012.11.002 · Cited by 29 · see citing works
Furukawa, T., Maggi, R., Solano, A., Croci, F., & Brignole, M. (2011) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2011.01.057 · Cited by 28 · see citing works
Self-citationIndikationen Zur Loop-Rekorder-Implantation Bei Synkope
Schuchert, A. (2018) · Herzschrittmachertherapie + Elektrophysiologie · doi:10.1007/s00399-018-0571-1 · Cited by 2 · see citing works
- Authors
- Brignole, M.
- Affiliations
- Presidio Ospedaliero (IT)
- Corresponding author
- Brignole, M.
- ORCID
- Brignole, M.
- Venue
- European Heart Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2006-08-09
- Volume
- 27
- Issue
- 18
- Pages
- 2232-2239
- ISSN
- 0195-668X (ISSN-L)
- 1522-9645
- OpenAlex
- W2128490123
- Cited by
- 145
- References
- 24
- Citations by year
- 2026: 2 · 2025: 5 · 2024: 4 · 2023: 2 · 2022: 1 · 2021: 6 · 2020: 2 · 2019: 5 · 2018: 8 · 2017: 4 · 2016: 6 · 2015: 6 · 2014: 11 · 2013: 14 · 2012: 12
- FWCI
- 11.12
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Heart Journal (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- HighWire Press Open Archive (submittedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Life Sciences › Neuroscience › Neurology › Vestibular and auditory disorders
- Keywords
- neurally mediated syncope, tilt table test, implantable loop recorder, syncope mechanism, syncope recurrence, diagnostic test correlation, orthostatic hypotension
- MeSH terms
- Adenosine Triphosphate, Adult, Aged, Electrodes, Implanted, Female, Humans, Male, Middle Aged, Prospective Studies, Recurrence, Sensitivity and Specificity, Electrocardiography, Ambulatory, Tilt-Table Test, Syncope, Vasovagal
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