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Cited by 378Cardiovascular Syncope and Autonomic DisordersHeart Rate Variability and Autonomic ControlCardiac electrophysiology and arrhythmias

Mechanism of Syncope in Patients With Isolated Syncope and in Patients With Tilt-Positive Syncope

Moya, Angel, Brignole, Michele, Menozzi, Carlo, Garcia-Civera, Roberto, Tognarini, Stefano, Mont, Luis, Botto, Gianluca, Giada, Franco +2 more·2001·Circulation
DOI 10.1161/hc3601.095708
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Abstract

Background Because of its episodic behavior, the correlation of spontaneous syncope with an abnormal finding can be considered a reference standard. Methods and Results We inserted an implantable loop recorder in 111 patients with syncope, absence of significant structural heart disease, and a normal ECG; tilt-testing was negative in 82 (isolated syncope) and positive in 29 (tilt-positive). The patients had had ≥3 episodes of syncope in the previous 2 years and were followed up for 3 to 15 months. Results were similar in the isolated syncope group and the tilt-positive group: syncope recurred in 28 (34%) and 10 patients (34%), respectively, and electrocardiographic correlation was found in 24 (23%) and 8 (28%) patients, respectively. The most frequent finding, which was recorded in 46% and 62% of patients, respectively, was one or more prolonged asystolic pauses, mainly due to sinus arrest, preceded for a few minutes by progressive bradycardia or progressive tachycardia-bradycardia. Bradycardia without pauses was observed in 8% and 12% of cases, respectively. The remaining patients had normal sinus rhythm or sinus tachycardia, except for one, who had ectopic atrial tachycardia. In the tilt-positive group, an asystolic syncope was also recorded when the type of response to tilt-testing was vasodepressor or mixed. Presyncopal episodes were never characterized by asystolic pauses; normal sinus rhythm was the most frequent finding. Conclusions Homogeneous findings were observed during syncope. In most patients, the likely cause was neurally-mediated, and the most frequent mechanism was a bradycardic reflex. In the other cases, a normal sinus rhythm was frequently recorded. Presyncope was not an accurate surrogate for syncope in establishing a diagnosis.

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Crossref · 10.1161/hc3601.095708

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  • These patients appear to benefit from permanent pacing.

    “These patients appear to benefit from permanent pacing.105–112”

    From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [107]

    The Clinical Events section (page unavailable) reports that 14 patients received permanent pacemakers based on loop-recorder findings. But the Clinical Implications section (page unavailable) says the efficacy of therapy in preventing further syncope remains to be proved; this study does not establish that those patients benefited from pacing. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Implantable loop recorders improve care only in the subset of patients who are older, have asystole documented on the recorder, and had negative tilt test results, probably because many diagnoses are vasovagal syncope.

    “However, the devices have been shown to improve care in only the subset of patients who are older, have asystole documented on the ILR, and whose tilt test results were negative, probably because many of the diagnoses are of vasovagal syncope.”

    From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [107]

    The Abstract reports ILR-documented asystole in both tilt-negative and tilt-positive patients, and Clinical Implications reports ILR-guided therapy in 16 patients. But the paper does not show that care improves only for older, tilt-negative patients; Clinical Implications explicitly says the efficacy of therapy in preventing further syncope remains to be proved. The Discussion also reports asystolic syncope in tilt-positive patients. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

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Research works printed but not linked: 2

  1. [18]18. Nierop P, van Mechelen R, van Elsacker A, et al. Heart rhythm during syncope and presyncope. Pacing Clin Electrophysiol. 2000;23: 1532-1538.
  2. [22]22. Alboni P, Dinelli M, Raviele A, et al. Is a second tilt test useful in patients with unexplained syncope? Eur J Cardiac Pacing Electrophysiol. 1995; 5:292-295.

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Authors
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
Affiliations
  • From the Departments of Cardiology of Hospital Vall d’Hebron, Barcelona, Spain (A.M.); Ospedali Riuniti, Lavagna, Italy (M.B.); Ospedale S Maria Nuova, Reggio Emilia, Italy (C.M.); Hospital Clinico Universitario, Valencia, Spain (R.G.-C.); Ospedale Villa Maria, Piombino, Italy (S.T.); Hospital Clinico, Barcelona, Spain (L.M.); Ospedale Umberto I, Mestre, Italy (F.G.); Ospedale S. Anna, Como, Italy (G.B.); Ospedale per gli Infermi, Faenza, Italy (D.C.).
  • Hospital Clínico Universitario de Valencia (ES)
ORCID
Venue
Circulation
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2001-09-11
Volume
104
Issue
11
Pages
1261-1267
ISSN
  • 0009-7322 (ISSN-L)
  • 1524-4539
DOI
10.1161/hc3601.095708
OpenAlex
W2135058841
Cited by
378
References
13
Citations by year
2026: 2 · 2025: 4 · 2024: 7 · 2023: 4 · 2022: 7 · 2021: 13 · 2020: 8 · 2019: 3 · 2018: 13 · 2017: 21 · 2016: 16 · 2015: 9 · 2014: 22 · 2013: 27 · 2012: 18
FWCI
19.46
Type
journal article
Language
en
Open access
closed
Locations
  • Circulation (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
syncope, implantable loop recorder, sinus arrest, neurally mediated syncope, vasodepressor syncope, presyncope, syncope recurrence, syncope mechanism
MeSH terms
Adult, Aged, Aged, 80 and over, Bradycardia, Cardiac Pacing, Artificial, Electrocardiography, Female, Humans, Male, Middle Aged, Recurrence, Syncope, Tachycardia, Tilt-Table Test

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