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Pacing for Vasovagal Syncope After the Second Vasovagal Pacemaker Study (VPS II): A Matter of Judgement

  • Published:
Cardiac Electrophysiology Review

Abstract

Vasovagal or neurocardiogenic syncope is a common benign condition. In the majority of patients it regresses naturally, or can be controlled by conservative therapy. However there is a group of patients who remain severely affected despite lifestyle measures, counselling and medication. Pacing has been considered in these patients as a result of logic, observational studies, and three randomised but unblinded studies, VPS, VASIS and SYDIT. A randomised and blinded study, VPS II, was recently published, the results of which undermined the results of these preceding studies: despite a 30% trend towards reduced syncope in patients with active pacing, the result was not statistically significant. This left clinicians with a dilemma, whether or not to pace in patients with disabling syncope despite conservative therapy. We believe, based on a review of all currently available evidence, that there remains a role for pacing in the patient with evidence of significant cardioinhibition, particularly severe bradycardia or asystole, and ongoing disabling syncope in spite of conservative measures. When to pace in these patients is a matter of clinical judgement. The threshold for pacing should remain high, however, with extensive attempts of conservative and pharmacological measures and with appropriate discussions with patients prior to instituting pacing, regarding the risks and long-term implications of a pacemaker. More needs to be learned about optimal pacing modalities.

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References

  1. Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D. Incidence and prognosis of syncope. N Engl J Med 2002;347:878–885.

    Google Scholar 

  2. von Bezold A, Hirt L. Uber die physiologischen Wirkungen des essigsauren veratrins. Untersuchungen aus dem physiologischen laboratorium. Wurzburg 1867;1:75–156.

    Google Scholar 

  3. Abboud FM. Neurocardiogenic syncope. N Engl J Med 1993;328:1117–1120.

    Google Scholar 

  4. Fenton AM, Hammill SC, Rea RF, Low PA, Win-Kuang Shen. Vasovagal Syncope. Ann Int Med 2000;133:714–725.

    Google Scholar 

  5. Kenny RA, Ingram A, Bayliss J, Sutton R. Head-up tilt: A useful test for investigating unexplained syncope. Lancet 1986;1:1352–1355.

    Google Scholar 

  6. Almquist A, Goldenberg IF, Milstein S, Chen MY, Chen XC, Hansen R, Gornick CC, Benditt DG. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med 1989;320:346–351.

    Google Scholar 

  7. Strasberg B, Rechavia E, Sagie A, Kusniec J, Mager A, Sclarovsky S, Agmon J. The head-up tilt table test in patients with syncope of unknown origin. Am Heart J 1989;118(5 Pt1):923–927.

    Google Scholar 

  8. Fitzpatrick A, Sutton R. Tilting towards a diagnosis in recurrent unexplained syncope. Lancet 1989;1:658–660.

    Google Scholar 

  9. Waxman MB, Yao L, Cameron DA, Wald RW, Roseman J. Isoproterenol induction of vasodepressor-type reaction in vasodepressor-prone persons. Am J Cardiol 1989;63:58–65.

    Google Scholar 

  10. Raviele A, Gasparini G, Di Pede F, Menozzi C, Brignole M, Dinelli M, Alboni P, Piccolo E. Nitroglycerin infusion during upright tilt: A new test for the diagnosis of vasovagal syncope. Am Heart J 1994;127:103–111.

    Google Scholar 

  11. Moya A, Brignole M, Menozzi C, Garcia-Civera R, Tognarini S, Mont L, Botto G, Giada F, Cornacchia D. Mechanism of syncope in patients with isolated syncope and in patients with tilt-positive syncope. Circulation 2001;104:1261–1267.

    Google Scholar 

  12. Sutton R, Petersen M, Brignole M, et al. Proposed classi-fication for tilt induced vasovagal syncope. Eur J Cardiac Pacing Electrophysiol 1992;2:180–183.

    Google Scholar 

  13. KredietC, van Dijk N, Linzer M, van Lieshout J, WielingW. Management of vasovagal syncope: Controlling or aborting fainting by leg crossing and muscle tensing. Circulation 2002;106:1684–1689

    Google Scholar 

  14. Krediet C, Wieling W. Manouevres to combat vasovagal syncope. Europace 2003;5:303.

    Google Scholar 

  15. Sheldon R, Rose S, Flanagan P, Koshman ML, Killam S. Risk factors for syncope recurrence after a positive tilt-table test in patients with syncope. Circulation 1996;93; 973–981.

    Google Scholar 

  16. Di Girolamo E, Di Iorio C, Sabatini P, Leonzio L, Barbone C, Barsotti A. Effects of paroxetine hydrochloride, a selective serotonin reuptake inhibitor, on refractory vasovagal syncope: A randomised, double-blind, placebo-controlled study. J AmColl Cardiol 1999;33:1227–1230.

    Google Scholar 

  17. Raviele A, Brignole M, Sutton R, Alboni P, Giani P, Menozzi C, Moya A. Effect of etilefrine in preventing syncopal recurrence in patients with vasovagal syncope: A double-blind, randomized, placebo-controlled trial. The Vasovagal Syncope International Study. Circulation 1999;99:1452–1457.

    Google Scholar 

  18. Ward CR, Gray JC, Gilroy JJ, Kenny RA. Midodrine: A role in the management of neurocardiogenic syncope. Heart 1998;79:45–49.

    Google Scholar 

  19. Cox MM, Perlman BA, Mayor MR, Silberstein TA, Levin A, Pringle L, Castellanos A, Myerburg RJ. Acute and long-term β-adrenergic blockade for patients with neurocardiogenic syncope. J Am Coll Cardiol 1995;26:1293–1298.

    Google Scholar 

  20. Petersen ME, Chamberlain-Webber R, Fitzpatrick AP, Ingram A, Williams T, Sutton R. Permanent pacing for cardioinhibitory malignant vasovagal syndrome. Br Heart J 1994;71:274–281.

    Google Scholar 

  21. Benditt DG, Sutton R, Gammage M, Fetter J, Markowitz T, Gorski J, Nygaard GA, Fetter J. Clinical experience with Thera DR rate drop response pacing algorithm in carotid sinus syndrome and vasovagal syncope. Pacing Clin Electrophysiol 1997;20:832–839.

    Google Scholar 

  22. Sra JS, Jazayeri MR, Avitall B, Dhala A, Deshpande S, Blanck Z, Akhtar M. Comparison of cardiac pacing with drug therapy in the treatment of neurocardiogenic (vasovagal) syncope with bradycardia or asystole. N Engl JMed 1993;328:1085–1090.

    Google Scholar 

  23. Sheldon RS, Koshman ML, Wilson W, Kieser T, Rose S. Effect of dual-chamber pacing with automatic rate-drop sensing on recurrent neurally mediated syncope. Am J Cardiol 1998;81:158–162.

    Google Scholar 

  24. Connolly SJ, Sheldon R, Roberts RS, Gent M. The North American Vasovagal Pacemaker Study: A randomised trial of permanent cardiac pacing for the prevention of vasovagal syncope. J AmColl Cardiol 1999;33:16–20.

    Google Scholar 

  25. Sutton R, Brignole M, Menozzi C, Raviele A, Alboni P, Giani P, Moya A. Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope. Pacemaker versus no therapy: A multicenter randomised study. Circulation. 2000;102:294–299.

    Google Scholar 

  26. Ammirati F, Colivicchi F, Santini M. Permanent cardiac pacing versus medical treatment for the prevention of recurrent vasovagal syncope. A multicenter, randomised, controlled trial. Circulation 2001: 104:52–57.

    Google Scholar 

  27. Beecher H. Surgery as placebo. JAMA 1961;176:1102–1107.

    Google Scholar 

  28. Kaptchuk T, Goldman P, Stone D, StasonW. Do medical devices have placebo effects? J Clin Epidemiol 2000;53:786–792.

    Google Scholar 

  29. Connolly SJ, Sheldon R, Thorpe KE, Roberts RS, Ellenbogen KA, Wilkoff BL, Morillo C, Gent M. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope. Second vasovagal pacemaker study (VPS II): A randomised trial. JAMA 2003;289:2224–2229.

    Google Scholar 

  30. Malik P, Koshman ML, Sheldon RS. Timing of first syncope recurrence predicts syncope frequency following a positive tilt table test. J Am Coll Cardiol 1997;29:1284–1289.

    Google Scholar 

  31. Brignole M. Randomized clinical trials of neurallymediated syncope. J Cardiovasc Electrophysiol 2003;14:S64–S69.

    Google Scholar 

  32. Julian DG. What is right and what is wrong about evidence-based medicine? J Cardiovasc Electrophysiol. 2003;14:S2–S5.

    Google Scholar 

  33. Krahn AD, Klein GJ, Yee R, Takle-Newhouse T, Norris C. Use of an extended monitoring strategy in patients with problematic syncope. Circulation 1999;99:406–410.

    Google Scholar 

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Authors and Affiliations

  1. Division of Cardiology, University of Western Ontario, London, Ontario, Canada

    Geoffrey M. Trim, Andrew D. Krahn, George J. Klein, Allan C. Skanes & Raymond Yee

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  1. Geoffrey M. Trim
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  2. Andrew D. Krahn
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  3. George J. Klein
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  4. Allan C. Skanes
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  5. Raymond Yee
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Trim, G.M., Krahn, A.D., Klein, G.J. et al. Pacing for Vasovagal Syncope After the Second Vasovagal Pacemaker Study (VPS II): A Matter of Judgement. Card Electrophysiol Rev 7, 416–420 (2003). https://doi.org/10.1023/B:CEPR.0000023168.26698.1e

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  • DOI: https://doi.org/10.1023/B:CEPR.0000023168.26698.1e

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