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Open Access 24-10-2023 | Vasovagal Syncope | Research Article

Variability of cardioinhibition in vasovagal syncope: differences between subgroups during cardioinhibition and beyond

Authors: Ineke A. van Rossum, Frederik J. de Lange, David G. Benditt, Erik W. van Zwet, Marc van Houwelingen, Roland D. Thijs, J. Gert van Dijk

Published in: Clinical Autonomic Research | Issue 6/2023

Abstract

Purpose

We compared hemodynamic parameters between subjects with marked, intermediate and minimal cardioinhibition during vasovagal syncope.

Methods

The study included subjects with a decrease in heart rate while experiencing a complete vasovagal syncope during tilt-table testing. The subjects were classified as having marked, intermediate or minimal cardioinhibition, based on tertile values of the decrease in heart rate. Hemodynamic parameters between these groups were compared before tilt in the supine position, shortly after tilt and during cardioinhibition.

Results

A total of 149 subjects with a median age of 43 (interquartile range 24–60) years were included in the study. Among the three groups with different levels of cardioinhibition, the highest heart rate was observed in subjects with marked cardioinhibition both before and shortly after tilt and at the start of cardioinhibition. The heart rate decrease in these subjects was both larger and faster compared to subjects with minimal and intermediate cardioinhibition.

Conclusion

Subjects with marked cardioinhibition have both a larger and faster decrease in heart rate compared to subjects with intermediate and minimal cardioinhibition, as early as from the start of cardioinhibition. Marked cardioinhibition is related to differences in hemodynamic profiles already present well before the start of cardioinhibition.

Brignole M, Menozzi C, Del Rosso A, Costa S, Gaggioli G, Bottoni N, Bartoli P, Sutton R (2000) New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification. Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope Int Study Europace 2:66–76

Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martin A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG (2018) 2018 ESC guidelines for the diagnosis and management of syncope. Eur Heart J 39:1883–1948CrossRefPubMed

Critchley LA, Lee A, Ho AM (2010) A critical review of the ability of continuous cardiac output monitors to measure trends in cardiac output. Anesth Analg 111:1180–1192CrossRefPubMed

de Jong JSY, Jardine DL, Lenders JWM, Wieling W (2020) Pacing in vasovagal syncope: a physiological paradox? Heart Rhythm 17:813–820CrossRefPubMed

Diaz-Canestro C, Sehgal A, Pentz B, Montero D (2022) Sex specificity in orthostatic tolerance: the integration of haematological, cardiac, and endocrine factors. Eur J Prev Cardiol 29:e246–e248CrossRefPubMed

Dyson KS, Shoemaker JK, Arbeille P, Hughson RL (2010) Modelflow estimates of cardiac output compared with Doppler ultrasound during acute changes in vascular resistance in women. Exp Physiol 95:561–568CrossRefPubMed

Fedorowski A, Rivasi G, Torabi P, Johansson M, Rafanelli M, Marozzi I, Ceccofiglio A, Casini N, Hamrefors V, Ungar A, Olshansky B, Sutton R, Brignole M, Parati G (2021) Underlying hemodynamic differences are associated with responses to tilt testing. Sci Rep 11:17894CrossRefPubMedPubMedCentral

Fenton AM, Hammill SC, Rea RF, Low PA, Shen WK (2000) Vasovagal syncope. Ann Intern Med 133:714–725CrossRefPubMed

Fu Q, Verheyden B, Wieling W, Levine BD (2012) Cardiac output and sympathetic vasoconstrictor responses during upright tilt to presyncope in healthy humans. J Physiol 590:1839–1848CrossRefPubMedPubMedCentral

10.

Fuca G, Dinelli M, Suzzani P, Scarfo S, Tassinari F, Alboni P (2006) The venous system is the main determinant of hypotension in patients with vasovagal syncope. Europace 8:839–845CrossRefPubMed

11.

Ganzeboom KS, Mairuhu G, Reitsma JB, Linzer M, Wieling W, van Dijk N (2006) Lifetime cumulative incidence of syncope in the general population: a study of 549 Dutch subjects aged 35–60 years. J Cardiovasc Electrophysiol 17:1172–1176CrossRefPubMed

12.

Ghariq M, Thijs RD, Bek LM, van Zwet EW, Benditt DG, van Dijk JG (2020) A higher proportion of men than of women fainted in the phase without nitroglycerin in tilt-induced vasovagal syncope. Clin Auton Res 30:441–447CrossRefPubMedPubMedCentral

13.

Guyenet PG (2006) The sympathetic control of blood pressure. Nat Rev Neurosci 7:335–346CrossRefPubMed

14.

Jardine DL, Wieling W, Brignole M, Lenders JWM, Sutton R, Stewart J (2018) The pathophysiology of the vasovagal response. Heart Rhythm 15:921–929CrossRefPubMed

15.

Kaufmann H, Norcliffe-Kaufmann L, Palma JA (2020) Baroreflex dysfunction. N Engl J Med 382:163–178CrossRefPubMed

16.

Kurbaan AS, Bowker TJ, Wijesekera N, Franzen AC, Heaven D, Itty S, Sutton R (2003) Age and hemodynamic responses to tilt testing in those with syncope of unknown origin. J Am Coll Cardiol 41:1004–1007CrossRefPubMed

17.

Moya A, Brignole M, Menozzi C, Garcia-Civera R, Tognarini S, Mont L, Botto G, Giada F, Cornacchia D, International Study on Syncope of Uncertain Etiology I (2001) Mechanism of syncope in patients with isolated syncope and in patients with tilt-positive syncope. Circulation 104:1261–1267CrossRefPubMed

18.

Novak V, Honos G, Schondorf R (1996) Is the heart ‘empty’ at syncope? J Auton Nerv Syst 60:83–92CrossRefPubMed

19.

Rivasi G, Torabi P, Secco G, Ungar A, Sutton R, Brignole M, Fedorowski A (2021) Age-related tilt test responses in patients with suspected reflex syncope. Europace 23:1100–1105CrossRefPubMed

20.

Russo V, Parente E, Groppelli A, Rivasi G, Tomaino M, Gargaro A, Giacopelli D, Ungar A, Parati G, Fedorowski A, Sutton R, van Dijk JG, Brignole M (2022) Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology. EP Europace 25:263–269CrossRef

21.

Schloglhofer T, Gilly H, Schima H (2014) Semi-invasive measurement of cardiac output based on pulse contour: a review and analysis. Can J Anaesth 61:452–479CrossRefPubMed

22.

Schroeder C, Tank J, Heusser K, Diedrich A, Luft FC, Jordan J (2011) Physiological phenomenology of neurally-mediated syncope with management implications. PLoS ONE 6:e26489CrossRefPubMedPubMedCentral

23.

Stewart JM, Medow MS, Sutton R, Visintainer P, Jardine DL, Wieling W (2017) Mechanisms of vasovagal syncope in the young: reduced systemic vascular resistance versus reduced cardiac output. J Am Heart Assoc 6(1):e004417 https://doi.org/10.1161/JAHA.116.004417

24.

Thijs RD, Brignole M, Falup-Pecurariu C, Fanciulli A, Freeman R, Guaraldi P, Jordan J, Habek M, Hilz M, Traon AP, Stankovic I, Struhal W, Sutton R, Wenning G, Van Dijk JG (2021) Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness: consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN). Clin Auton Res 233:102792

25.

van Dijk JG, Ghariq M, Kerkhof FI, Reijntjes R, van Houwelingen MJ, van Rossum IA, Saal DP, van Zwet EW, van Lieshout JJ, Thijs RD, Benditt DG (2020) Novel methods for quantification of vasodepression and cardioinhibition during tilt-induced vasovagal syncope. Circ Res 127:e126–e138PubMed

26.

van Dijk JG, van Rossum IA, Thijs RD (2020) Timing of circulatory and neurological events in syncope. Front Cardiovasc Med 7:36CrossRefPubMedPubMedCentral

27.

van Dijk JG, van Rossum IA, Thijs RD (2021) The pathophysiology of vasovagal syncope: novel insights. Auton Neurosci 236:102899CrossRefPubMed

28.

van Dijk JG, van Rossum IA, van Houwelingen M, Ghariq M, Saal DP, de Lange FJ, Thijs RD, Sutton R, Benditt DG (2022) Influence of age on magnitude and timing of vasodepression and cardioinhibition in tilt-induced vasovagal syncope. JACC Clin Electrophysiol 8:997–1009CrossRefPubMed

29.

Verheyden B, Liu J, van Dijk N, Westerhof BE, Reybrouck T, Aubert AE, Wieling W (2008) Steep fall in cardiac output is main determinant of hypotension during drug-free and nitroglycerine-induced orthostatic vasovagal syncope. Heart Rhythm 5:1695–1701CrossRefPubMed

30.

Wieling W, Jardine DL, de Lange FJ, Brignole M, Nielsen HB, Stewart J, Sutton R (2016) Cardiac output and vasodilation in the vasovagal response: an analysis of the classic papers. Heart Rhythm 13:798–805CrossRefPubMed

Title: Variability of cardioinhibition in vasovagal syncope: differences between subgroups during cardioinhibition and beyond
Authors: Ineke A. van Rossum
Frederik J. de Lange
David G. Benditt
Erik W. van Zwet
Marc van Houwelingen
Roland D. Thijs
J. Gert van Dijk
Publication date: 24-10-2023
Publisher: Springer Berlin Heidelberg
Keyword: Vasovagal Syncope
Published in: Clinical Autonomic Research / Issue 6/2023
Print ISSN: 0959-9851
Electronic ISSN: 1619-1560
DOI: https://doi.org/10.1007/s10286-023-00991-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Variability of cardioinhibition in vasovagal syncope: differences between subgroups during cardioinhibition and beyond

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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