open access

Vol 21, No 6 (2014)
Review paper
Published online: 2014-12-18
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Pacing for neurally-mediated syncope: How to decide?

Michele Brignole
DOI: 10.5603/CJ.2014.0092
·
Cardiol J 2014;21(6):601-605.

open access

Vol 21, No 6 (2014)
Review articles
Published online: 2014-12-18

Abstract

Neurally-mediated syncope has a broad clinical spectrum which ranges from typical vasovagal syncope on one hand, to those situations in which reflex syncope occurs with uncertain, or even apparently absent, triggers or prodromes, on the other hand. Overlap of clinical features is frequent in clinical practice and makes any classification difficult to apply when selecting patients for cardiac pacing. Typically, the reflex is both hypotensive and cardio-inhibitory. The rationale for efficacy of cardiac pacing is that the cardio-inhibitory reflex is dominant, since there is no role for pacing in preventing vasodilatation and hypotension. Establishing a relationship between symptoms and cardio-inhibitory reflex should be the goal of the clinical evaluation before embarking on permanent pacing. Similar efficacy has been observed in patients affected by dominant cardio-inhibitory reflex irrespective of the clinical form. In general, cardiac pacing should be considered last choice applied only in highly selected patients, i.e. those ≥ 40 years of age, affected by severe forms of reflex syncope with recurrences associated with frequent injury, often due to the lack of prodromes. Recurrence of syncope may still occur despite cardiac pacing in a minority of patients.

Abstract

Neurally-mediated syncope has a broad clinical spectrum which ranges from typical vasovagal syncope on one hand, to those situations in which reflex syncope occurs with uncertain, or even apparently absent, triggers or prodromes, on the other hand. Overlap of clinical features is frequent in clinical practice and makes any classification difficult to apply when selecting patients for cardiac pacing. Typically, the reflex is both hypotensive and cardio-inhibitory. The rationale for efficacy of cardiac pacing is that the cardio-inhibitory reflex is dominant, since there is no role for pacing in preventing vasodilatation and hypotension. Establishing a relationship between symptoms and cardio-inhibitory reflex should be the goal of the clinical evaluation before embarking on permanent pacing. Similar efficacy has been observed in patients affected by dominant cardio-inhibitory reflex irrespective of the clinical form. In general, cardiac pacing should be considered last choice applied only in highly selected patients, i.e. those ≥ 40 years of age, affected by severe forms of reflex syncope with recurrences associated with frequent injury, often due to the lack of prodromes. Recurrence of syncope may still occur despite cardiac pacing in a minority of patients.

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Keywords

syncope, carotid sinus syndrome, implantable loop recorder, tilt table test, adenosine, prolonged monitoring

About this article
Title

Pacing for neurally-mediated syncope: How to decide?

Journal

Cardiology Journal

Issue

Vol 21, No 6 (2014)

Article type

Review paper

Pages

601-605

Published online

2014-12-18

DOI

10.5603/CJ.2014.0092

Bibliographic record

Cardiol J 2014;21(6):601-605.

Keywords

syncope
carotid sinus syndrome
implantable loop recorder
tilt table test
adenosine
prolonged monitoring

Authors

Michele Brignole

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