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Previous Volume 328:1085-1090 April 15, 1993 Number 15 Next

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ABSTRACT

Background The efficacy of permanent cardiac pacing in patients with neurocardiogenic (or vasovagal) syncope associated with bradycardia or asystole is not clear. We compared the efficacy of cardiac pacing with that of oral drug therapy in the prevention of hypotension and syncope during head-up tilt testing.

Methods Among 70 patients with a history of syncope in whom hypotension and syncope could be provoked during head-up tilt testing, 22 had bradycardia (a heart rate <60 beats per minute, with a decline in the rate by at least 20 beats per minute) or asystole along with hypotension during testing. There were 9 men and 13 women, with a mean (±SD) age of 41 ±17 years. Head-up tilt testing was repeated during atrioventricular sequential pacing (in 20 patients with sinus rhythm) or ventricular pacing (in 2 patients with atrial fibrillation). Regardless of the results obtained during artificial pacing, all the patients subsequently had upright-tilt testing repeated during therapy with oral metroprolol, theophylline, or disopyramide.

Results During the initial tilt test, 6 patients had asystole and 16 had bradycardia along with hypotension. Despite artificial pacing, the mean arterial pressure during head-up tilt testing still fell significantly, from 97 ±19 to 57 ±19 mm Hg (P<0.001); 5 patients had syncope, and 15 had presyncope. By contrast, 19 patients who later received only medical therapy (metoprolol in 10, theophylline in 3, and disopyramide in 6), 2 patients who received both metoprolol and atrioventricular sequential pacing, and 1 patient who received only atrioventricular sequential pacing had negative head-up tilt tests. After a median follow-up of 16 months, 18 of the 19 patients who were treated with drugs alone (94 percent) remained free of recurrent syncope or presyncope, whereas the patient treated only with a permanent dual-chamber pacemaker had recurrent syncope.

Conclusions In patients with neurocardiogenic syncope associated with bradycardia or asystole, drug therapy is often effective in preventing syncope, whereas artificial pacing is not.

Source Information

Presented in part at the 64th Annual Scientific Sessions of the American Heart Association, November 11-14, 1991.

From the Sinai Samaritan Medical Center, 945 N. 12th St., Milwaukee, WI 53233, where reprint requests should be addressed to Dr. Sra.

Full Text of this Article

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Treatment of Neurocardiogenic Syncope
van Lieshout J. J., Jellema W. T., Wieling W., Fitzpatrick A. P., Papa L. J., Sra J. S.
Extract | Full Text  
N Engl J Med 1993; 329:969-970, Sep 23, 1993. Correspondence

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