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Pacing in neurocardiogenic/vasovagal syncope

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Abstract

Pacing for neurocardiogenic or vasovagal syncope (VVS) has been practised for five decades, but the 1986 advent of tilt testing provided a means of diagnosis frequently revealing, in the early days, asystole caused by VVS. This was the basis for pacing these patients and the first studies created enthusiasm followed by randomised controlled trials, which were imperfectly designed, “confirming” benefit. When better trial design was employed, there was no obvious benefit. However, some cardiologists had seen patients experience a huge positive difference with pacing, so they set out to identify them. Two studies using ECG loop recorders to document heart rhythm during spontaneous attacks allowed better patient selection for pacing and appeared to achieve the aim. Further, it was noted in the second study, a randomised controlled trial (RCT) with good design, that tilt testing added a further dimension to the identification of the patient who would benefit. Thus, loop recorders are used to show asystole in spontaneous attacks and when tilt testing is negative, implying a lesser vasodepressor component, the patient will have the best outcome. From the available evidence, pacing should be dual-chamber in older patients (>40 years) with severe symptoms and in whom standard measures have demonstrably failed. The method of triggering pacing and its timing of introduction have not yet been resolved. Today’s method is rate-hysteresis but there is another sensed event as an alternative: right ventricular impedance, which is now in RCT with substantial pilot evidence in its favour.

Keywords

Dual-chamber pacing Rate-hysteresis Cardioinhibition Vasodepression Right ventricular impedance 

Abbreviations

CLS

Closed loop system

HRS

Heart Rhythm Society

ILR

Implantable/insertable loop recorder

ISSUE

International study of syncope of unknown etiology

SUP

Syncope unit project

SYDIT

Syncope diagnosis and treatment

SYNPACE

Syncope and pacing

VASIS

Vasovagal international study

VPS

Vasovagal pacemaker study

VVS

Vasovagal syncope

Schrittmachertherapie bei neurokardiogener/vasovagaler Synkope

Zusammenfassung

Die Schrittmachertherapie bei neurokardiogener oder vasovagaler Synkope (VVS) wird schon seit fünfzig Jahren angewendet. Mit Einführung der Kipptischuntersuchung ab 1986 stand ein diagnostisches Mittel zur Verfügung, das – in der Anfangszeit – häufig eine VVS-bedingte Asystolie zeigte. Das war Grundlage für die Schrittmachertherapie bei diesen Patienten. Die ersten Studien stimmten enthusiastisch, es folgten fehlerhaft konzipierte randomisierte, kontrollierte Studien (RCT), die den Nutzen „bestätigten“. In besser designten Studien fand sich dagegen kein offensichtlicher Nutzen. Einige Kardiologen waren allerdings auf Patienten gestoßen, die unter der Schrittmachertherapie eine immense positive Veränderung erfahren hatten und sie begannen, diese Patienten zu identifizieren. Zwei Studien, in denen EKG-Loop-Rekorder zur Aufzeichnung des Herzrhythmus während spontaner Anfälle verwendet wurden, ermöglichten eine bessere Patientenselektion für die Schrittmachertherapie und schienen zielführend. In der zweiten Arbeit, einer RCT mit gutem Design, wurde zudem beobachtet, dass die Kipptischuntersuchung der Identifikation profitierender Patienten eine weitere Dimension hinzufügte. Daher werden Loop-Rekorder eingesetzt, um die Asystolie bei spontanen Anfällen zu zeigen, und wenn die Kipptischuntersuchung negativ ausfällt, was auf eine geringere vasodepressorische Komponente hindeutet, hat der Patient das beste Outcome. Auf Basis der verfügbaren Evidenz sollte die Schrittmachertherapie mit einem Zweikammerverfahren erfolgen, wenn die Patienten älter sind (>40 Jahre), schwere Symptome haben und mit Standardmaßnahmen nachweislich erfolglos behandelt wurden. Das Verfahren zur Auslösung der Stimulation und das Timing ihrer Einleitung sind noch nicht geklärt. Gegenwärtig wird die Frequenzhysterese genutzt, es gibt aber ein anderes wahrgenommenes Ereignis als Alternative: die rechtsventrikuläre Impedanz. Aktuell wird sie in RCT geprüft, wobei solide erste Studiendaten für sie sprechen.

Schlüsselwörter

Zweikammerstimulation Frequenzhysterese Kardioinhibitorische Wirkung Vasodepressorische Wirkung Rechtsventrikuläre Impedanz 

Notes

Compliance with ethical guidelines

Conflict of interest

R. Sutton is a consultant to Medtronic Inc., a member of the speakers’ bureau of St Jude Medical Inc. (Abbott Laboratories Inc.), a stockholder in the following companies: Boston Scientific Inc., Edwards Lifesciences Inc., and AstraZeneca PLC.

This article does not contain any new studies with human participants or animals performed by any of the authors. For the cited studies, the ethical guidelines applied as stated in the respective papers.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.National Heart and Lung Institute, Hammersmith Hospital Campus, B block South, 2nd floor, NHLI—Cardiovascular ScienceImperial CollegeLondonUK

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