of 39
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
1/39
HEART RHYTHM OBSERVED DURING
POSITIVE HEAD-UP
TILT TESTIN VASOVAGAL SYNCOPE (VVS)
Radu Rosu, MD
ISHNE 2013, Timisoara
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
2/39
BACKGROUND
Syncopeis a T-LOC due to transient globalcerebral hypoperfusion characterized by rapidonset, short duration, and spontaneous
complete recovery. Reflex syncope- cardiovascular reflexes
become intermittently inapropriate, in responseto a trigger, resulting in vasodilatation and/orbradycardia
Vasovagal syncope (VVS)- is mediated byemotion or by orthostatic stress.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
3/39
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
4/39
Vasovagal syncope
Vasovagal syncope is a common disorder
which accounts for 8% to 37% of syncopes.
Most patients experience infrequent faints
and seldom require more than counseling
and reassurance.
Patients with frequent and/or unpredictable
syncope, however, can be severely disabledand require therapy.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
5/39
Reflex syncope is the most frequent cause of
syncope in any setting
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
6/39
Head-Up Tilt Test (HUT)
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
7/39
Tilt Test indications
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
8/39
Tilt testing positive responses
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
9/39
OBJECTIVES:
Heart rhythm obtained during provocative
condition is often used to guide therapy in
vasovagal syncope (VVS).
The aim of this study was to analyze the
heart rhythm during positive head-up tilt test(HUT) in VVS.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
10/39
METHODS:
Retrospective observational study
32 consecutive patients presenting witha history VVS performed HUT in our
cardiology department.
December 2011 - May 2012.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
11/39
Inclusion/Exclusion Criteria
Characteristics Included
Clinical history consistent with VVS YES
Low risk patients with severe simptoms or
their occurrence in high-risk settings
YES
1 syncope YES
Age 18 years YES
Non-syncopal loss of consciousness NO
Symptomatic orthostatic hypotension NO
Cardiac abnormalities which suggested
cardiac syncope
NO
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
12/39
Tilt Test protocol
pre-tiltphase
5 minutes or 20 minutes if venouscannulation was undertaken
pasivephase
40 minutes
activephase
400 mcg of sublingual nitroglycerine
20 minutes
Continuous ECG and intermitent bloodpressure monitoring during the phases
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
13/39
Tilt table test
The HUT was considered positive when
the patient developed syncope or
intolerable presyncope.
All patients were in sinus rhythm, free of
antiarrhythmic drug therapy.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
14/39
RESULTS:
Patients Characteristics
Characteristics
Age, yrs 49,36,8
Gender ratio (male/female) 16/16
History of syncope
Number of syncopes 20,16
Prodrome(%) 80
History of trauma(%) 33,3
ECG 1 patient with RBB without
Brugada pattern
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
15/39
RESULTS:
32 patients
Junctionalrhythm
8
Sinus rhythm
10
Asystole
6
Tachycardia
2
6 negtive Tilt
testexcluded
26 patients
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
16/39
RESULTS:Tilt Test events
Total end-points: 26
Asystole23%
Junctionalrhythm>40/min
15%Junctional
rhythm
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
17/39
Gender-Rhythm types
no significant difference
p-value=0,62
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Male Female
Asytole
Tachycardia
Jonctional rhythm
Synus rhythm
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
18/39
Age-rhythm
no significant difference
rhythm Total
Asystole Junctionalrhythm Sinusrhythm Tachycardia
Age 40 Count 5 4 8 1 18
Total 6 8 10 2 26
p-value=0,41
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
19/39
Gender-active phase vs pasive phase
no significant difference
p-value=0,23
0
12
3
4
5
6
7
8
9
Pasive phase Active phase
Female
Male
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
20/39
Tilt test responses:
Type of response Number of patients
1 Mixt 13 (50%)
2A Cardioinhibition without asystole 4 (15,3%)
2B Cardioinhibition with asystole 6 (23%)
3 Vasodepressor 3 (11,7%)
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
21/39
Gender-type of response
Type of
response
Gender Total
Male Female
1 9 4 13
2A 1 3 4
2B 2 4 6
3 1 2 3
Total 13 13 26
p-value=0,27
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
22/39
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
23/39
Gender-Syncope/Presyncope
Gender Total
Male Female
Presyncope 1 2 3
Syncope 12 11 23
Total 13 13 26
p-value=0,539
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
24/39
Age-Syncope/Presyncope
Age Total40
Presyncope 0 3 3
Syncope 8 15 23
Total 8 18 26
p-value=0,22
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
25/39
Jonctional bradicardia 47 beats/min
in a 23 year old female,
SBP
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
26/39
Sinus rhythm 67/min in a 56 year old male
SBP
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
27/39
Sinus tachycardia 114 beats/min
in a 18 year old male
SBP
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
28/39
Asystole
mean age Male- 504 yrs
Female- 485,3yrs
Prolonged asystole in men (mean=13,47,8s)
vs female (5,50,8s)
2 patients with asystole of 18s and respectively
45s beneficiated from pacemaker implantation.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
29/39
Asystole of 5,7s in 49 year old female
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
30/39
Asystole of 45s
in 58 year old male
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
31/39
Test-related incidents:
1 patient with 45s asystole was placed inthe supine position and cardiac massage
was started, 2 mg atropine has been given.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
32/39
Discussion
A weak correlation
was found between the responses
to Tilt testing and the
mechanism of spontaneous
neurally mediated syncope .
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
33/39
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
34/39
Asystolic syncope 3 s, or
Non-syncopal asystole 6 s
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
35/39
We know from ILR experience that about half ofspontaneous neurally mediated episodes are
asystolic in nature.
The induction of an asystolic NMS during tilt tabletesting can predict the efficacy of pacemaker
therapy albeit to a lesser extent than thatexpected (ISSUE-3).
The vasovagal syncope and pacing trial(SyNPACE) had shown that the time to firstsyncope recurrence was longer in an asystolicventricular pause of 13 8 s response during tilttable testing in paced patients.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
36/39
Cardiac pacing should be the last choice in
highly selected patients affected by severe
NMS.
Other therapies, eg, physical counterpres-sure maneuvers, are more desirable in young
patients.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
37/39
CONCLUSIONS:
The heart rhythm observed during positiveHUT is sinus rhythm and in induced syncopeis most of the time junctional rhytm.
Some patients still present syncope with sinustachycardia and severe blood pressurediminuation.
Prolonged asystole can be the rhythmresponsible for syncope.In this case thepatient can beneficiate from pacemakerimplantation.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
38/39
Tilt Test is:
noninvasive
providing an immediate diagnosis
hampered by a significant risk of misdiagnosis
some patients can beneficiate from pacemaker
implantation
others can be reassured.
8/13/2019 Heart Rhythm Observed During Positive Head-Up Final
39/39
Thank you for your attention!