Importance and indications of tilt-table testing in patients with unexplained syncope

    Authors

    Abstract

    Aim: To investigate the importance and indications of head-up tilt-testing (HUTT) in patients with unexplained syncope. Patients and Methods: We retrospectively analyzed 235 patients who underwent HUTT, between February 2012 and September 2014, at the Department of Cardiology, University Hospital Centre “Sestre milosrdnice” Zagreb. They were divided in three groups according to the HUTT indications as follows: Group A (convulsive syncope, n=30), Group B (suspected vasovagal syncope, n=180) and Group C (paroxysmal vertigo, n=25). The groups were analyzed by their baseline parameters (age, gender, referral specialists (cardiologists, neurologists, others)), HUTT results (positive/negative) and specific responses (cardioinhibitory, vasodepressor, or mixed). Results: Groups A and B were referred most frequently to the HUTT by neurologists and cardiologists (p<0.05) (**Figure 1**). It was positive in 34 (14.5%) patients (5 in Group A and 29 in Group B), i.e. 13 (38.2%) patients had cardioinhibitory, 11 (32.4%) mixed and 10 (29.4%) vasodepressor response (**Figure 2**). In cardioinhibitory subgroup, there were 3 patients (23.1%, 2 males/1 female, mean age 28.5 years) with normal EEG and on antiepileptic drugs. During HUTT, they had typical convulsions with cardioinhibition and bradycardia (heart rate (HR) 30.0±5.0 beats/min) followed by asystole (13.7±11.0 seconds). These three subjects got a permanent DDDR pacemaker (atrial/ventricular stimulation, HR control) and anticonvulsive therapy was slowly withdrawn. They had no syncope recurrences during 24 months of follow-up. Figure 1. Comparison of specialists’ referral to tilt-table testing in patients with convulsive syncope (A), suspected vasovagal syncope (B) and paroxysmal vertigo (C). Figure 2. Electroencephalographic findings in patients with convulsive syncope: 12 patients with antiepileptic drugs (A) and in 18 patients with no medication (B). Conclusion: HUTT has an important role in evaluation of the patients with unexplained syncope. It is indicated in differential diagnosis of vasovagal syncope, especially in patients with syncope accompanied with convulsive elements. (1-3) Finally, pacemaker implantation is effective in preventing syncope relapses in patients with cardioinhibitory convulsive syncope.

    Keywords

    cardioinhibitory syncope, seizures, tilt-up table-test, permanent pacemaker, epilepsy

    DOI

    https://doi.org/10.15836/ccar.2015.241

    Literature

    1. Zaidi A, Clough P, Cooper P, Scheepers B, Fitzpatrick AP. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. J Am Coll Cardiol. 2000;36:181–4. https://doi.org/10.1016/S0735-1097(00)00700-2
    2. Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), Heart Rhythm Society (HRS), Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version 2009). Task Force for the Diagnosis and Management of Syncope. Eur Heart J. 2009;30(21):2631–71. https://doi.org/10.1093/eurheartj/ehp298
    3. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34(29):2281–329. https://doi.org/10.1093/eurheartj/eht150
    Cardiologia Croatica
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    Importance and indications of tilt-table testing in patients with unexplained syncope

    Abstract
    Issue9-10
    Published
    Pages241
    PDF via DOIhttps://doi.org/10.15836/ccar.2015.241
    cardioinhibitory syncope
    seizures
    tilt-up table-test
    permanent pacemaker
    epilepsy

    Authors

    Marko Mornar JelavicORCIDHealth Centre Zagreb - East, Zagreb, Croatia
    Zdravko BabicORCIDUniversity Hospital Centre “Sestre milosrdnice”, Zagreb, Croatia
    Hrvoje HecimovicORCIDUniversity Hospital Centre “Sestre milosrdnice”, Zagreb, Croatia
    Vesna ErcegORCIDUniversity Hospital Centre “Sestre milosrdnice”, Zagreb, Croatia
    Hrvoje PintaricORCIDUniversity Hospital Centre “Sestre milosrdnice”, Zagreb, Croatia

    Abstract

    Aim: To investigate the importance and indications of head-up tilt-testing (HUTT) in patients with unexplained syncope. Patients and Methods: We retrospectively analyzed 235 patients who underwent HUTT, between February 2012 and September 2014, at the Department of Cardiology, University Hospital Centre “Sestre milosrdnice” Zagreb. They were divided in three groups according to the HUTT indications as follows: Group A (convulsive syncope, n=30), Group B (suspected vasovagal syncope, n=180) and Group C (paroxysmal vertigo, n=25). The groups were analyzed by their baseline parameters (age, gender, referral specialists (cardiologists, neurologists, others)), HUTT results (positive/negative) and specific responses (cardioinhibitory, vasodepressor, or mixed). Results: Groups A and B were referred most frequently to the HUTT by neurologists and cardiologists (p<0.05) (**Figure 1**). It was positive in 34 (14.5%) patients (5 in Group A and 29 in Group B), i.e. 13 (38.2%) patients had cardioinhibitory, 11 (32.4%) mixed and 10 (29.4%) vasodepressor response (**Figure 2**). In cardioinhibitory subgroup, there were 3 patients (23.1%, 2 males/1 female, mean age 28.5 years) with normal EEG and on antiepileptic drugs. During HUTT, they had typical convulsions with cardioinhibition and bradycardia (heart rate (HR) 30.0±5.0 beats/min) followed by asystole (13.7±11.0 seconds). These three subjects got a permanent DDDR pacemaker (atrial/ventricular stimulation, HR control) and anticonvulsive therapy was slowly withdrawn. They had no syncope recurrences during 24 months of follow-up. Figure 1. Comparison of specialists’ referral to tilt-table testing in patients with convulsive syncope (A), suspected vasovagal syncope (B) and paroxysmal vertigo (C). Figure 2. Electroencephalographic findings in patients with convulsive syncope: 12 patients with antiepileptic drugs (A) and in 18 patients with no medication (B). Conclusion: HUTT has an important role in evaluation of the patients with unexplained syncope. It is indicated in differential diagnosis of vasovagal syncope, especially in patients with syncope accompanied with convulsive elements. (1-3) Finally, pacemaker implantation is effective in preventing syncope relapses in patients with cardioinhibitory convulsive syncope.

    Literature

    1. 1.
      Zaidi A, Clough P, Cooper P, Scheepers B, Fitzpatrick AP. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. J Am Coll Cardiol. 2000;36:181–4.DOI
    2. 2.
      Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), Heart Rhythm Society (HRS), Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version 2009). Task Force for the Diagnosis and Management of Syncope. Eur Heart J. 2009;30(21):2631–71.DOI
    3. 3.
      Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34(29):2281–329.DOI