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Comparison of trinitroglycerin and adenosine as provocative agents for head-up tilt test in patients with unexplained syncope: a semi-crossover randomized clinical trial with prospective follow-up

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Abstract

Purpose

Head-up tilt test (HUTT) is a reasonable diagnostic evaluation for patients with suspected vasovagal syncope; however, its lengthy duration is a remarkable limitation. Although adenosine (AD), as an alternative provocative agent, is a promising option for tackling this shortcoming, it received little appreciation in the literature. We aimed to compare the efficacy and the time to elicit a positive response to HUTT for sublingual trinitroglycerin (TNG) and intravenous AD. Furthermore, we evaluated patients’ outcomes in the follow-up.

Methods

Patients with a chief complaint of transient loss of consciousness (TLOC) were evaluated. We randomized patients with the diagnosis of unexplained syncope after diagnostic evaluations, to undergo TNG-augmented HUTT or AD-augmented HUTT. They were crossed over to receive the other medication in case of negative response to the test. In the follow-up, we evaluated traumatic and non-traumatic TLOCs, hospitalization due to syncope, and death in patients.

Results

We randomized 132 patients (41.70 ± 19.37 years, 52.3% female) to receive TNG (n = 66) or AD (n = 66). Respectively, the positivity rate of TNG and AD for the first and the crossover-HUTT was 31.1% and 26.7%, and 20.5% and 26.2% with no statistically significant differences in both tests (P ˃ 0.50). The time to positive response was significantly shorter for AD than TNG (P < 0.001). In the follow-up, re-admission was significantly more prevalent in HUTT-negative patients compared to HUTT-positive patients (P = 0.04).

Conclusions

We found that diagnostic yield of TNG and AD in HUTT is comparable, while AD acts 4 times faster than TNG in evoking a vasovagal response.

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Acknowledgments

We also acknowledge the dedicated staff of Tehran Heart Center for their invaluable supports.

Funding

This study was funded by Tehran University of Medical Sciences.

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Authors and Affiliations

  1. Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran

    Masih Tajdini, Seyedeh Hamideh Mortazavi, Ali Vasheghani Farahani, Saeed Sadeghian, Mehdi Easapour Moghadam, Danesh Soltani & Ali Bozorgi

  2. Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran

    Arya Aminorroaya

  3. Universal Scientific Education and Research Network, Tehran, Iran

    Arya Aminorroaya

  4. Department of Cardiology, Urmia University of Medical Sciences, Urmia, Iran

    Behzad Rahimi

Authors
  1. Masih Tajdini
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  5. Ali Vasheghani Farahani
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Correspondence to Ali Bozorgi.

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The authors declare that they have no conflict of interest.

Ethical approval

The protocol of the study conforms to the 1964 Helsinki declaration and has been approved by the ethics committee of Tehran University of Medical Sciences with the approval ID of IR.TUMS.MEDICINE.REC.1397.272.

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We obtained written informed consents from all of the participants or their parents if their age was less than 18.

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Tajdini, M., Aminorroaya, A., Rahimi, B. et al. Comparison of trinitroglycerin and adenosine as provocative agents for head-up tilt test in patients with unexplained syncope: a semi-crossover randomized clinical trial with prospective follow-up. J Interv Card Electrophysiol 60, 31–39 (2021). https://doi.org/10.1007/s10840-019-00652-6

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  • DOI: https://doi.org/10.1007/s10840-019-00652-6

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