Pediatric Cardiology

, Volume 35, Issue 4, pp 596–600 | Cite as

P-Wave Dispersion: An Indicator of Cardiac Autonomic Dysfunction in Children With Neurocardiogenic Syncope

  • Melis Demir Köse
  • Özlem Bağ
  • Barış Güven
  • Timur Meşe
  • Aysel Öztürk
  • Vedide Tavlı
Original Article


Neurocardiogenic syncope is the most frequent cause of fainting in childhood and adolescence. Although head-up tilt table testing (HUTT) was previously considered as the reference standard in the diagnosis of syncope, in children with a typical history of reflex syncope, normal physical examination, and electrocardiogram (ECG) are sufficient to cease investigation; however, according to recent reports, TT is indicated in patients in whom this diagnosis cannot be proven by initial evaluation. The hypothesis of this study is that P-wave dispersion (PWD) can be a useful electrocardiographic predictor of cardiac autonomic dysfunction in children with vasovagal syncope (VVS). The study was designed prospectively and included 50 children with positive and 50 children with negative HUTT who presented with at least two previous unexplained episodes of syncope as well as 50 sex- and age-matched healthy children as the control group. All standard 12-lead ECGs were obtained in patients and controls, and the difference between maximum and minimum durations of the P wave was defined as the PWD. A total of 100 children with VVS and 50 healthy controls were evaluated for the study. The P maximum values of HUTT-positive (HUTT[+]) patients were significantly greater than those in the HUTT-negative (HUTT[−]) and control groups(p < 0.05). In addition, mean PWD values were 50.2 ± 18.5, 39.6 ± 11.2 and 32.0 ± 11.2 ms in the HUTT(+), HUTT(–), and control groups, respectively. The difference between groups was statistically significant (p < 0.05). We suggest that PWD is an early sign of cardiac autonomic dysfunction in children with neurally mediated syncope and can be used as a noninvasive electrocardiographic test to evaluate orthostatic intolerance syndromes.


Children Syncope Head-up tilt test P-wave dispersion Neurocardiogenic 


  1. 1.
    Babaoglu K, Altun G, Binnetoğlu K (2011) P-wave dispersion and heart rate variability in children with mitral valve prolapse. Pediatr Cardiol 32(4):449–454CrossRefPubMedGoogle Scholar
  2. 2.
    Benditt DG, van Dijk JG, Sutton R et al (2004) Syncope. Curr Probl Cardiol 29:145–229CrossRefGoogle Scholar
  3. 3.
    Bissinger A, Grycewicz T, Grabowicz W, Lubinski A (2011) The effect of diabetic autonomic neuropathy on P-wave duration, dispersion and atrial fibrillation. Arch Med Sci 7(5):806–812PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Blair P, Grubb MD (1999) Pathophysiology and differential diagnosis of neurocardiogenic syncope. Am J Cardiol 84:3–9Google Scholar
  5. 5.
    Brignole M, Alboni P, Benditt D, Bergfeldt L, Blanc JJ, Bloch Thomsen PE (2001) Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J 22:1256–1306CrossRefPubMedGoogle Scholar
  6. 6.
    Brignole M, Menozzi C, Del Rosso A, Costa S, Gaggioli G, Bottoni N et al (2002) New classification of hemodynamics of vasovagal syncope: beyond the VASIS classification. Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study. Europace 2:66–76CrossRefGoogle Scholar
  7. 7.
    Cheema AN, Ahmed MW, Kadish AH, Goldberger JJ (1995) Effects of autonomic stimulation and blockade on signal-averaged P-wave duration. J Am Coll Cardiol 26:497–502CrossRefPubMedGoogle Scholar
  8. 8.
    Chirife R, Feitosa GS, Franki WS (1975) Electrocardiographic detection of left atrial enlargement. Correlation of P wave witch left atrial dimension by echocardiography. Br Heart J 37:1281–1285PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Dilaveris PE, Gialafos EJ, Sideris SK et al (1988) Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J 135:733–738CrossRefGoogle Scholar
  10. 10.
    Dilaveris P, Batchvarov V, Gialafos J, Malik M (1999) Comparison of different methods for manual P wave duration measurement in 12-lead electrocardiograms. Pacing Clin Electrophysiol 22(10):1532–1538CrossRefPubMedGoogle Scholar
  11. 11.
    Freeman R (2006) Assessment of cardiovascular autonomic function. Clin Neurophysiol 117(4):716–730CrossRefPubMedGoogle Scholar
  12. 12.
    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(Pt 8):1839–1848PubMedCentralCrossRefPubMedGoogle Scholar
  13. 13.
    Gisolf J, Westerhof BE, van Dijk N, Wesseling KH, Wieling W, Karemaker JM (2004) Sublingual nitroglycerin used in routine tilt testing provokes a cardiac output-mediated vasovagal response. J Am Coll Cardiol 44(3):588–593CrossRefPubMedGoogle Scholar
  14. 14.
    Grubb BP, Temesy-Armos P, Moore J, Wolfe D, Hahn H, Elliott L (1992) The use of head upright tilt table testing in the evaluation and management of syncope in children and adolescents. Pacing Clin Electrophysiol 15:742–748CrossRefPubMedGoogle Scholar
  15. 15.
    Grubb BP, Kosinski DJ, Boehm K, Kip K (1997) The postural orthostatic tachycardia syndrome: a neurocardiogenic variant identified during head-up tilt table testing. Pacing Clin Electrophysiol 20(9 Pt 1):2205–2212CrossRefPubMedGoogle Scholar
  16. 16.
    Imamoglu EY, Oztunc F, Eroglu AG, Onal H, Guzeltas A (2008) Dispersion of the P wave as a test for cardiac autonomic function in diabetic children. Cardiol Young 18(6):581–585CrossRefPubMedGoogle Scholar
  17. 17.
    Karataş Z, Alp H, Sap F, Altın H, Baysal T, Karaarslan S (2012) Usability of QTc dispersion for the prediction of orthostatic intolerance syndromes. Eur J Paediatr Neurol 16(5):469–474CrossRefPubMedGoogle Scholar
  18. 18.
    Kocer A, Barutcu I, Atakay S, Ozdemirli B, Gul L, Karakaya O (2009) P wave duration changes and dispersion. A risk factor or autonomic dysfunction in stroke? Neurosciences (Riyadh) 14(1):14–18Google Scholar
  19. 19.
    Longin E, Reinhard J, von Buch C, Gerstner T, Lenz T, König S (2008) Autonomic function in children and adolescents with neurocardiogenic syncope. Pediatr Cardiol 29(4):763–770CrossRefPubMedGoogle Scholar
  20. 20.
    Mangru NN, Young ML, Mas MS, Chandar JS, Pearse LA, Wolff GS (1996) Usefulness of tilt table test with normal saline infusion in management of neurocardiac syncope in children. Am Heart J 131:953–955CrossRefPubMedGoogle Scholar
  21. 21.
    McLeod KA (2003) Syncope in childhood. Arch Dis Child 88:350–353PubMedCentralCrossRefPubMedGoogle Scholar
  22. 22.
    Medow MS, Stewart JM, Sanyal S, Mumtaz A, Sica D, Frishman WH (2008) Pathophysiology, diagnosis, and treatment of orthostatic hypotension andvasovagal syncope [review]. Cardiol Rev 16(1):4–20CrossRefPubMedGoogle Scholar
  23. 23.
    Nussinovitch U (2012) Meta-analysis of p-wave dispersion values in healthy individuals: the influence of clinical characteristics. Ann Noninvasive Electrocardiol 17(1):28–35CrossRefPubMedGoogle Scholar
  24. 24.
    Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology, European Heart Rhythm Association, Heart Failure Association, Heart Rhythm Society, Moya A et al (2009) Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 30(21):2631–2671CrossRefGoogle Scholar
  25. 25.
    Topcu B, Akalin F (2010) The autonomic nervous system dysregulation in response to orthostatic stress in children with neurocardiogenic syncope. Cardiol Young 20(2):165–172CrossRefPubMedGoogle Scholar
  26. 26.
    Verheyden B, Liu J, van Dijk N, Westerhof BE, Reybrouck T, Aubert AE et al (2008) Steep fall in cardiac output is main determinant of hypotension during drug-free and nitroglycerine-induced orthostatic vasovagal syncope. Heart Rhythm 5(12):1695–1701CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Melis Demir Köse
    • 1
  • Özlem Bağ
    • 1
  • Barış Güven
    • 2
  • Timur Meşe
    • 2
  • Aysel Öztürk
    • 3
  • Vedide Tavlı
    • 2
  1. 1.Clinic of PediatricsBehçet Uz Children’s HospitalIzmirTurkey
  2. 2.Clinic of Pediatric CardiologyBehçet Uz Children’s HospitalIzmirTurkey
  3. 3.Clinic of Pediatric NeurologyBehçet Uz Children’s HospitalIzmirTurkey

Personalised recommendations