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Utility of a single-stage isoproterenol tilt table test in adults - A randomized comparison with passive head-up tilt

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第4期33卷 985-990页

作者： Shen, WK Jahangir, A Beinborn, D Lohse, CM Hodge, DO Rea, RF Hammill, SC Mayo Clin & Mayo Fdn Div Cardiovasc Dis & Internal Med Rochester MN 55905 USA Mayo Clin & Mayo Fdn Biostat Sect Rochester MN 55905 USA

OBJECTIVES This study was conducted to develop a time-efficient tilt table test. BACKGROUND Current protocols of tilt table testing are quite time-consuming. This study was designed to assess the diagnostic value, tolerance and procedural time of a. single-stage isoproterenol tilt table protocol. METHODS A single-stage isoproterenol tilt table test was compared with the passive tilt table test. The study was prospectively designed in a randomized and crossover fashion. RESULTS The study population consisted of 111 patients with a history of syncope (mean age 55 +/- 20 years). Of the total, 62 patients (56%;95% confidence interval, 46% to 65%) had a positive vasovagal response during isoproterenol tilt table testing and 35 (32%;23% to 41%) during passive tilt table testing (p = 0.002). The mean procedural times of the study population were 11.7 +/- 3.6 min and 36.9 +/- 13.3 min for isoproterenol and passive tilt table testing, respectively (p < 0.001). All patients tolerated single-stage isoproterenol testing. In the 23 control subjects (mean age 34 +/- 11 years), the apparent specificities were 91% (72% to 99%) and 83% (61% to 99%) for passive and single-stage tilt table testing, respectively. CONCLUSIONS The single-stage isoproterenol tilt table test was more effective in inducing a positive vasovagal response in an adult population than the standard passive tilt table test, and it significantly reduced the procedural time. The increase in positive yield was associated with a moderate decrease in apparent specificity. These observations support the conclusion that single-stage tilt table testing could be a reasonable diagnostic option in patients undergoing syncope evaluation. (J Am Coil Cardiol 1999;33:985-90) (C) 1999 by the American College of Cardiology.

关键词：交叉研究诊断鉴别异丙肾上腺素敏感性与特异性拟交感神经药晕厥血管迷走神经性/诊断倾斜台试验成年人老年人女(雌)性人类男(雄)性中年人

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Formal analysis of the optimal duration of tilt testing for the diagnosis of neurally mediated syncope

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AMERICAN HEART JOURNAL 2001年第2期141卷 282-288页

作者： Stein, KM Slotwiner, DJ Mittal, S Scheiner, M Markowitz, SM Lerman, BB Cornell Univ Div Cardiol New York Hosp Med CtrDept Med New York NY 10021 USA

Background Although tilt resting has emerged as the test of choice for assessing patients with suspected neurally mediated syncope, the optimum duration of tilt testing is poorly defined. This in pari relates to the absence of a gold standard to assess test performance. Objective Our purpose was to formally estimate the effects of varying duration of drug-free tilt testing an tilt performance in diagnosing neurally mediated syncope. Design If a test's specificity is known, then in the absence of a gold standard an imputed (estimated) sensitivity may be calculated on the basis of the observed diagnostic yield in a given population as a function of assumed population prevalence. We determined the relationship of specificity to drug-free tilt test duration by use of data from 11 previous studies reporting the results of drug-free tilt testing in a total of 435 control subjects (60 to 80 degrees of tilt, footboard support, 15- to 60-minute duration). Data (weighted for study size) were fit to an exponential function relating specificity to tilt duration. Test yield was evaluated as a function of tilt duration in 213 consecutive patients referred to our laboratory For the evaluation of suspected neurally mediated syncope who underwent passive tilt testing for up to 30 to 60 minutes. Results The estimated specificity of tilt testing was 94% at 30 minutes, 92% at 40 minutes, and 88% after 60 minutes of passive tilt. The cumulative yield of tilt testing was only 17% at 30 minutes, 22% at 40 minutes, and 28% after 60 minutes. On the basis of an estimated population prevalence of 25% to 50% in this referral population, imputed sensitivity is 27% to 48% at 30 minutes, 36% to 64% at 40 minutes, and 43% to 74% after 60 minutes of passive tilt. The overall diagnostic accuracy was not strongly influenced by tilt duration beyond 30 minutes and ranged from 60% to 84%. Conclusions Passive tilt testing tie, tilt testing without pharmacologic provocation) for durations of up to 60 minu

关键词：数据说明统计患病率回顾性研究敏感性与特异性疾病严重程度指数晕厥血管迷走神经性/诊断晕厥血管迷走神经性/流行病学倾斜台试验/标准时间因素女(雌)性人类男(雄)性中年人

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Continuous monitoring of an endocardial index of myocardial contractility during head-up tilt test

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AMERICAN HEART JOURNAL 2000年第6期139卷 1022-1030页

作者： Deharo, JC Peyre, JP Chalvidan, T Thirion, X Valli, M Ritter, P Djiane, P Hop St Marguerite Univ Serv Cardiol Dept Cardiol F-13009 Marseille France Hop St Marguerite Univ Dept Stat F-13009 Marseille France La Timone Univ Hosp Pharmacol Lab Marseille France Ctr Chirurg Val Or Dept Cardiol St Cloud France

Background Previous studies suggest that vigorous myocardial contractions stimulate ventricular mechanoreceptors and lead to vasovagal syncope, We studied an endocardial index of myocardial contractility during the head-up tilt test in vasovagal patients and control patients, and we evaluated the effect of negative inotropic drugs on myocardial contractility and tilt test outcome. Methods and Results We investigated 19 patients with recurrent vasovagal syncope and positive tilt test (group 1) and 1 1 patients with no syncope and negative tilt test (group 2). Myocardial contractility was continuously measured during a tilt test (60 degrees) through a microaccelerometer incorporated in the tip of a right ventricular electrode to sense left ventricular contractility, Patients in groups 1 and 2 were evaluated during an unmedicated tilt test and patients in group 1 were reevaluated during a tilt test with infusion of esmolol (n = 10) or disopyramide (n = 9). During the unmedicated test, patients in group exhibited a significant increase in myocardial contractility immediately on postural change (P < .05), unlike patients in group 2, Patients in group also had a further increase in myocardial contractility before the end of tilt (P < .01). With drug administration, the changes in supine myocardial contractility were nonsignificant and were not related with the outcome of the tilt test (P < .05). Conclusions An increase in myocardial contractility is detected by the sensor during the tilt test. The changes induced by the drugs on supine myocardial contractility are minor and not related with the outcome of the head-up tilt test.

关键词：肾上腺素能β受体拮抗剂/投药和剂量肾上腺素能β受体拮抗剂/诊断应用抗心律失常药/投药和剂量抗心律失常药/诊断应用强心药/投药和剂量强心药/诊断应用丙吡胺/投药和剂量丙吡胺/诊断应用多巴酚丁胺/投药和剂量多巴酚丁胺/诊断应用电极植入电生理学/方法心内膜/药物作用心内膜/病理生理学心率/药物作用心率/生理学输注静脉内监测生理学心肌收缩/药物作用心肌收缩/生理学体位/生理学丙醇胺类/投药和剂量丙醇胺类/诊断应用复发回顾性研究敏感性与特异性晕厥血管迷走神经性/诊断晕厥血管迷走神经性/病理生理学遥测术倾斜台试验女(雌)性人类男(雄)性中年人

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Misdiagnosis of epilepsy: Many seizure-like attacks have a cardiovascular cause

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第1期36卷 181-184页

作者： Zaidi, A Clough, P Cooper, P Scheepers, B Fitzpatrick, AP Manchester Royal Infirm Manchester Heart Ctr Manchester M13 9WL Lancs England Hope Hosp Ctr Clin Neurosci Salford M6 8HD Lancs England

OBJECTIVES We sought to investigate the value of cardiovascular tests to diagnose convulsive syncope in patients with apparent treatment-resistant epilepsy. BACKGROUND As many as 20%, to 30% of epileptics may have been misdiagnosed. Many of these patients may have cardiovascular syncope, with abnormal movements due to cerebral hypoxia, which may be difficult to differentiate from epilepsy on clinical grounds. METHODS Seventy-four patients (33 men, mean age 38.9 +/- 18 years [range 16 to 77]) who were previously diagnosed with epilepsy were studied. Inclusion criteria included continued attacks despite adequate anticonvulsant drug treatment (n = 36) or uncertainty about the diagnosis of epilepsy, on the basis of the clinical description of the seizures (n = 38). Each patient underwent a head-up tilt test and carotid sinus massage during continuous electrocardiography, electroencephalography and blood pressure monitoring. Ten patients subsequently underwent long-term electrocardiographic (ECG) monitoring with an implantable loop recorder. RESULTS In total, an alternative diagnosis was found in 31 patients (41.9%), including 13 (36.1%) of 36 patients taking an anticonvulsant medication. Nineteen patients (25.7%) developed profound hypotension or bradycardia during the head-up tilt test, confirming the diagnosis of vasovagal syncope. One other patient had a typical vasovagal reaction during intravenous cannulation. Two patients developed psychogenic symptoms during the head-up tilt test. Seven patients (9.5%) had significant ECG pauses during carotid sinus massage. In two patients, episodes of prolonged bradycardia correlated precisely with seizures according to the insertable ECG recorder. CONCLUSIONS A simple, noninvasive cardiovascular evaluation may identify an alternative diagnosis in many patients with apparent epilepsy and should be considered early in the management of patients with convulsive blackouts. (C) 2000 by the American College of Cardiology.

关键词：血压/生理学血压监测便携式诊断鉴别误诊心电描记术便携式脑电描记术癫痫/并发症癫痫/诊断心率/生理学发作/诊断发作/病因学发作/病理生理学晕厥血管迷走神经性/并发症晕厥血管迷走神经性/诊断晕厥血管迷走神经性/病理生理学倾斜台试验青少年成年人老年人女(雌)性人类男(雄)性中年人

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Provocation of neurocardiogenic syncope by clomipramine administration during the head-up tilt test in vasovagal syndrome

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第1期36卷 174-178页

作者： Theodorakis, GN Markianos, M Zarvalis, E Livanis, EG Flevari, P Kremastinos, DT Onassis Cardiac Surg Ctr Dept Cardiol 2 Athens 17674 Greece Univ Athens Eginit Hosp Sch Med Neurochem Lab GR-11528 Athens Greece

OBJECTIVES We sought to test the hypothesis that activation of the serotonergic system in patients with vasovagal syndrome during the head-up tilt test provokes syncope. BACKGROUNDCentral serotonergic activation participates in the pathogenesis of neurocardiogenic syncope. Drugs increasing serotonin (5-HT) in the central nervous system have not been tested as drug challenges during the head-up tilt test with clomipramine (Clom-HUT). METHODS The serotonergic re-uptake inhibitor clomipramine was infused (5 mg in 5 min) at the start of Clom-HUT in 55 patients (mean age 40 +/- 17 years) with a positive history of recurrent neurocardiogenic syncope and in 22 healthy control subjects (mean age 46 +/- 15 years). Blood samples were taken at 0, 5, 10 and 20 min for estimation of plasma prolactin and cortisol as neuroendocrine indicators of central serotonergic responsitivity. All subjects had been previously tested with a basic 60 degrees head-up tilt test (B-HUT) for 30 min, and if negative, isoproterenol infusion was given at the end of the test. RESULTS Twenty-nine (53%) of the 55 patients and none of the 22 control subjects had a positive result in the B-HUT. With Clom-HUT, the proportion of patients who experienced a positive response increased to 80% (n = 44), although this happened to only one control subject. Prolactin and cortisol plasma levels increased significantly in the positive Clom-HUT patient group only. CONCLUSIONS The results indicate an increased responsitivity of the central serotonergic neural system in subjects with vasovagal syndrome, the activation of which leads to sympathetic withdrawal. The use of clomipramine infusion with the tilt test seems to considerably improve its diagnostic value. (C) 2000 by the American College of Cardiology.

关键词：中枢神经系统/药物作用中枢神经系统/代谢氯米帕明/投药和剂量诊断鉴别心电描记术心率氢化可的松/血液输注静脉内催乳素/血液复发敏感性与特异性血清素/代谢血清素摄取抑制药/投药和剂量晕厥血管迷走神经性/血液晕厥血管迷走神经性/诊断晕厥血管迷走神经性/病理生理学倾斜台试验成年人女(雌)性人类男(雄)性中年人

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Effects of paroxetine hydrochloride, a selective serotonin reuptake inhibitor, on refractory vasovagal syncope: A randomized, double-blind, placebo-controlled study

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第5期33卷 1227-1230页

作者： Di Girolamo, E Di Iorio, C Sabatini, P Leonzio, L Barbone, C Barsotti, A Univ G DAnnunzio SS Annunziata Hosp Cardiovasc Clin Inst Cardiol Div CCU Chieti Italy

OBJECTIVES The purpose of the study was to determine whether the well tolerated serotonin reuptake inhibitor paroxetine hydrochloride could prevent vasovagal syncope in patients resistant to or intolerant of previous traditional therapies. BACKGROUND Serotonergic mechanisms play a major role in the processes leading to neurocardiogenic vasovagal syncope, and serotonin reuptake inhibitors have been reported to be effective in preventing refractory syncope. METHODS Sixty-eight consecutive patients (26 men and 42 women, mean age 44.7 +/- 16.5 years) with recurrent syncope and positive head-up tilt test and in whom standard therapies with beta-adrenergic blocking agents, vagolytic, negative inotropic or mineral corticoid agents were ineffectual or poorly tolerated were referred for study. Patients randomly received either paroxetine at 20 mg once a day or a placebo. A head-up tilt test was then reperformed after one month of treatment, and the clinical effect was noted over a mean follow-up of 25.4 +/- 7.9 months. RESULTS The response rates (negative tilt test) after one month of treatment were 61.8% versus 38.2% (p < 0.001) in the paroxetine and placebo groups, respectively. During follow-up spontaneous syncope was reported in six patients (17.6%) in the paroxetine group as compared to 18 patients (52.9%) in the placebo group (p < 0.0001). Only one patient (2.9%) asked to be discontinued from the drug for severe side effects. CONCLUSIONS Paroxetine was found to significantly improve the symptoms of patients with vasovagal syncope unresponsive to or intolerant of traditional medications and was well tolerated by patients. (C) 1999 by the American College of Cardiology.

关键词：急性病双盲法心电描记术便携式随访研究帕罗西汀/治疗应用不应期电生理学/药物作用二级预防血清素摄取抑制药/治疗应用晕厥血管迷走神经性/诊断晕厥血管迷走神经性/药物疗法晕厥血管迷走神经性/病理生理学倾斜台试验治疗结果成年人女(雌)性人类男(雄)性中年人

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Indications, methodology, and classification of results of tilt-table testing

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第8A期84卷 10Q-19Q页

作者： Sutton, R Bloomfield, DM Royal Brompton Hosp London W1N 1HG England Chelsea Westminster Hosp London W1N 1HG England Columbia Univ Coll Phys & Surg New York NY USA

Tilt-table testing has become an important part of the evaluation of patients with unexplained syncope, although nor every patient with vasovagal syncope requires it. Studies have attested to the effectiveness of the technique for providing direct diagnostic evidence of a patient's susceptibility to vasovagal syncope. This article reviews the need for tilt-table testing and the recommended methods for performing a test, In addition, a detailed classification of the hemodynamic patterns of collapse displayed over the course of a tilt-table study is provided. These distinctive collapse patterns document the evolution of a syncopal event and are particularly important to identify because they can influence the selection of therapy, (C) 1999 by Excerpta Medico, Inc.

关键词：自主神经系统/病理生理学自主神经系统疾病/诊断自主神经系统疾病/病理生理学血压/生理学心率/生理学试验预期值晕厥血管迷走神经性/诊断晕厥血管迷走神经性/病理生理学倾斜台试验人类

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Role of pacing in the treatment of vasovagal syncope

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第8A期84卷 26Q-32Q页

作者： Sheldon, R Univ Calgary Hlth Sci Ctr Cardiovasc Res Grp Calgary AB T2N 4N1 Canada

Patients with frequent vasovagal syncope have a markedly poor quality of life and are often resistant to treatment by standard pharmacologic approaches. Although the evidence is not conclusive, clinical vasovagal syncope is probably associated with some degree of bradycardia, Studies of temporary pacing during tilt-table testing have shown that pacing prevents syncope in more than half of patients who develop a vasovagal response, Three open-label studies of permanent pacing showed that pacing was associated with substantial improvement, and the prospective randomized Vasovagal Pacemaker Study reported an 85% relative risk reduction in patients randomized to pacemaker therapy compared with medical therapy, The roles of specific pacemaker modes in vasovagal syncope have not been determined, although early evidence indicates that rate-drop responsiveness is useful. The second Vasovagal Pacemaker Study may clarify the role of rate-drop responsiveness. (C) 1999 by Excerpta Medico, Inc.

关键词：心脏起搏器人工晕厥血管迷走神经性/诊断晕厥血管迷走神经性/病因学晕厥血管迷走神经性/治疗倾斜台试验治疗结果人类

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Distinct hemodynamic profiles in patients with vasovagal syncope: A heterogeneous population

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第6期35卷 1470-1477页

作者： Shen, WK Low, PA Rea, RF Lohse, CM Hodge, DO Hammill, SC Mayo Clin & Mayo Fdn Div Cardiovasc Dis & Internal Med Rochester MN 55905 USA Mayo Clin & Mayo Fdn Peripheral Neuropathy Res Lab Rochester MN 55905 USA Mayo Clin & Mayo Fdn Biostat Sect Rochester MN 55905 USA

OBJECTIVE The objective was to investigate mechanisms of vasovagal syncope by identifying laboratory techniques that characterize cardiovascular profiles in patients With vasovagal syncope. BACKGROUND The triggering mechanisms of vasovagal syncope are complex. The patient population is likely heterogeneous. We hypothesized that distinct hemodynamic profiles are definable with provocative maneuvers. METHODS Three groups of subjects were matched for age and gender: 16 patients with a history of syncope and an inducible vasovagal response during passive tilt table testing (70 degrees, 45 min, group I), 16 with a history of syncope, negative passive tilt table testing but positive isoproterenol tilt table testing (0.05 mu g/kg per min, 70 degrees, 10 min, group II), and 16 control subjects. Beat-to-beat hemodynamic functions were determined noninvasively by photoplethysmography and impedance cardiography. RESULTS At baseline, hemodynamic functions were not different among the three groups (supine). In response to tilt before any symptoms developed, total peripheral resistance decreased 99% +/- 14%, in group I from baseline supine to tilt position but increased 27% +/- 18% in group II and 28% +/- 17% in controls (p < 0.001). Responses to isoproterenol were not significantly different between group LT and controls in supine position. In response to tilt during isoproterenol infusion before any symptoms developed, total peripheral resistance decreased 24% +/- 20% in group II and increased 20% +/- 48% in controls (p = 0.002). CONCLUSIONS Group I patients may have impaired ability to increase vascular resistance during orthostatic stress. The inability to overcome isoproterenol-induced vasodilatation during tilt is important in triggering a vasovagal response in group II patients. These data suggest that the population with vasovagal response is heterogeneous. Distinct hemodynamic profiles in response to various provocative maneuvers are definable with noninvasive, continuou

关键词：血流动力学/药物作用血流动力学/生理学异丙肾上腺素拟交感神经药晕厥血管迷走神经性/诊断晕厥血管迷走神经性/病理生理学倾斜台试验迷走神经/病理生理学血管阻力/药物作用血管阻力/生理学成年人女(雌)性人类男(雄)性中年人

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Usefulness of tilt test-induced patterns of heart rate and blood pressure using a two-stage protocol with glyceryl trinitrate provocation in patients with syncope of unknown origin

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第6期84卷 665-670页

作者： Kurbaan, AS Franzén, AC Bowker, TJ Williams, TR Kaddoura, S Petersen, MEV Sutton, R Univ London Imperial Coll Sci Technol & Med St Marys Hosp Dept Cardiol London W2 1NY England Univ London Imperial Coll Sci Technol & Med Chelsea & Westminster Hosp London W2 1NY England Gloucestershire Royal Hosp Gloucester GL1 3NN England

This study assesses the vasovagal collapse pattern changes, i.e, heart rate (HR) and arterial blood pressure (BP) with a 2-stage tilt-test protocol using glyceryl trinitrate (GTN) provocation. With use of the 45-minute 60 degrees head-up Westminster protocol, 102 consecutive patients were studied. Sublingual GTN 300 mu g was given to those with a negative passive tilt. Heart rate and BP patterns were classified according to the Vasovagal International Study classification (VASIS)and then compared between those with a positive passive tilt and those with a positive tilt after having been given GTN. Twelve patients did not. tolerate tilt testing, and 16 herd a negative response despite taking GTN. Thirty-five patients (20 women and 15 men, mean age 45 +/- 21 years [mean +/- SD]) did not take GTN and 38 (26 women and 12 men, mean age 53 +/- 22 years) had positive passive test results. When comparing the VASIS classification between the 2 groups, results showed: type 1, mixed BP and HR decreased without severe bradycardia (31% [passive] vs 54% [with GTN], p = NS);type 2A, BP decreased before HR decreased (20% vs 22%, p = NS);type 2B, HR decreased before or coincident with BP (34% vs 8%, p = 0.003);type 3, BP decreased without HR decrease (9% vs 0%, p = NS);exception 1, chronotropic incompetence (0% vs 13%, p = 0.026);and exception 2, excessive HR increase (6% vs 3%, p = NS). Thus, GTN use increases frequency of positive results from 34% to 73%. Older people with chronotropic incompetence, who may benefit from pacing, were identified. In younger people there was an increase in those with cardioinhibition. (C) 1999 by Excerpta Medica, Inc.

关键词：投药舌下年龄因素血压/生理学诊断鉴别心率/生理学硝酸甘油/诊断应用性别因素晕厥血管迷走神经性/诊断晕厥血管迷走神经性/病理生理学倾斜台试验血管舒张药/诊断应用青少年成年人老年人老年人 80以上儿童女(雌)性人类男(雄)性中年人

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