Asystolic cardiac arrest during head-up tilt test: incidence and therapeutic implications.
Occasionally, the cardioinhibitory response may be profound during tilt induced syncope. Whether this response is associated with more severe symptoms or predicts a poor response to pharmacotherapy remains controversial. The aim of this study was to characterize patients with vasovagally mediated asystole occurring during head-up tilt test and to evaluate the respective interests of sequential pacing and beta-blockers to treat them. We performed 60 degree tilt testing in 179 consecutive patients with unexplained syncope (91 women and 88 men, age 36.6 +/- 20.1 years). Asystole was defined as a ventricular pause > 5 seconds. All patients with tilt induced asystole received therapy with either beta-blockers or sequential pacing, the efficacy of which was evaluated with serial tilt tests. Of 77 patients with positive tilt test, 10 developed syncope related to asystole (mean duration 11.9 +/- 4.9 s), 2 with spontaneous recovery, and 8 with seizures needing a brief cardiopulmonary resuscitation. When compared with patients without asystole, asystolic patients had more severe symptoms (seizures: 6/10 vs 9/67, P = 0.05, injury 9/10 vs 27/67, P = 0.0048). In the first six patients in whom cardiac pacing was considered, syncope or presyncope still occurred despite atrioventricular pacing at 45 beats/min. Five of these 6 patients, as well as the remaining 4 asystolic patients, were tilted with beta-blockers: 3 patients became tilt-negative; 3 were significantly improved; and 3 did not respond. During follow-up (mean 22.7 +/- 11.7 months) with every patient taking beta-blockers and seven having a permanent pacemaker, no syncopal recurrence was observed. Tilt-induced asystole that may require resuscitative maneuvers occurs especially in patients with a history of seizures or injury. Therapy with beta-blockers in often effective to prevent induction of syncope as well as recurrences.
Lacroix
D
D
Department of Cardiology, Hôpital Cardiologique de Lille, University of Lille, France.
Kouakam
C
C
Klug
D
D
Guédon-Moreau
L
L
Vaksmann
G
G
Kacet
S
S
Lekieffre
J
J
D000293:Adolescent; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D002648:Child; D015716:Electrocardiography, Ambulatory; D005260:Female; D005500:Follow-Up Studies; D006323:Heart Arrest / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D018667:Tilt-Table Test / Q000009:adverse effects*
D000319:Adrenergic beta-Antagonists