Seizure-like activities in patients with head-up tilt test-induced syncope.

The purpose of this study was to assess the prevalence and the characteristics of seizure-like activities during head-up tilt test (HUT)-induced syncope, in patients with suspected vasovagal syncope (VVS). We also evaluated the differences in hemodynamic parameters between patients with and without seizure-like activities.A total of 71 patients with suspected VVS, who showed syncope during HUT between October 2010 and May 2013, were analyzed. Electrocardiogram and hemodynamic parameters were continuously monitored during HUT. We also performed video recording of patients during HUT to identify eyeball deviation or seizure-like limb movements.In all, 47 patients (66.2%) showed seizure-like activities at the time of syncope during HUT, 14 patients presented eyeball deviation, without abnormal limb movements, and 33 patients showed abnormal limb movements, such as myoclonic or tonic-clonic activities, as well as eyeball deviation. Upon comparison of the 2 groups with or without seizure-like activities, patients showing seizure-like activities presented a significantly lower heart rate at the time of syncope in HUT (38.51 ±â€Š16.81 vs 49.67 ±â€Š20.12, P < .05). Also, upon comparison within patients showing seizure-like activities, the patients who showed abnormal limb movements with eyeball deviation demonstrated a significantly lower systolic blood pressure and cardiac output at the time of syncope (34.30 ±â€Š12.24 vs 49.00 ±â€Š14.14, P < .05; 0.58 ±â€Š0.40 vs 1.32 ±â€Š0.97, P < .05).Seizure-like activities were observed in high percentage in about 66% of patients during HUT-induced syncope. The occurrence of seizure-like activities was associated with more severe transient hemodynamic changes, such as lower heart rate, systolic blood pressure, and cardiac output at the time of the HUT-induced syncope.

Hemodynamic parameters and baroreflex sensitivity during head-up tilt test in patients with neurally mediated syncope.

BACKGROUND: We aimed to investigate differences in hemodynamic parameters and the role of baroreflex sensitivity (BRS) in patients with a history of neurally mediated syncope (NMS) compared with a control group. METHODS: Hemodynamic parameters and BRS were continuously measured noninvasively using a Finometer at rest and during passive head-up tilt test (HUT) in patients with a history of NMS (n = 55) and a control group (n = 77). The tilting period was divided into pretest (resting supine position), initial (first 3 minutes of tilting), last (last 3 minutes of tilting), and recovery (3 minutes after tilting was complete) periods. RESULTS: Decrease in systolic blood pressure (- 14.7 ± 15.7 mm Hg vs - 7.6 ± 14.3 mm Hg, P < 0.01) was more prominent and increase in total systemic peripheral resistance was significantly smaller (67.6 ± 418.7 dyn.s/cm5 vs 189.4 ± 261.0 dyn.s/cm5 , P = 0.04) from the initial to the last period of HUT in the patient group compared with the control group. BRS was significantly higher during the pretest period (20.1 ± 10.9 ms/mm Hg vs 13.0 ± 8.1 ms/mm Hg, P < 0.01) in the patient group, while the decrease in BRS from the pretest to the initial period was greater (-8.5 ± 6.0 ms/mm Hg vs - 3.2 ± 4.1 ms/mm Hg, P = 0.01). CONCLUSIONS: Dysfunctional BRS in response to orthostatic stress might be involved in pathological autonomic cardiac modulation of NMS.

Role of Baroreflex Sensitivity in Predicting Tilt Training Response in Patients with Neurally Mediated Syncope.

PURPOSE: An association between baroreflex sensitivity (BRS) and the response to tilt training has not been reported in patients with neurally mediated syncope (NMS). This study sought to investigate the role of BRS in predicting the response to tilt training in patients with NMS. MATERIALS AND METHODS: We analyzed 57 patients who underwent tilt training at our hospital. A responder to tilt training was defined as a patient with three consecutive negative responses to the head-up tilt test (HUT) during tilt training. RESULTS: After tilt training, 52 patients (91.2%) achieved three consecutive negative responses to the HUT. In the supine position before upright posture during the first session of tilt training for responders and non-responders, the mean BRS was 18.17 ± 10.09 ms/mm Hg and 7.99 ± 5.84 ms/mm Hg (p=0.008), respectively, and the frequency of BRS ≥ 8.945 ms/mm Hg was 45 (86.5%) and 1 (20.0%; p=0.004), respectively. Age, male gender, frequency of syncopal events before HUT, type of NMS, phase of positive HUT, total number of tilt training sessions, and mean time of tilt training did not differ between the study groups. In the multivariate analysis, BRS <8.945 ms/mm Hg in the supine position (odds ratio 23.10; 95% CI 1.20-443.59; p=0.037) was significantly and independently associated with non-response to tilt training. CONCLUSION: The BRS value in the supine position could be a predictor for determining the response to tilt training in patients with NMS who are being considered for inpatient tilt training.

Comparison of recurrence rate based on the frequency of preceding symptoms in patients with neurocardiogenic syncope or presyncope.

BACKGROUND AND OBJECTIVES: In patients with neurocardiogenic syncope or presyncope, symptoms developed unpredictably and intermittently. The purpose of this study was to determine whether there was any significant difference in the recurrence rate of symptoms during the follow-up period between patients with many episodes of symptoms and those with fewer episodes of symptoms before diagnosis, as well as to assess the clinical significance of previous episodes of symptoms during treatment. SUBJECTS AND METHODS: A total of 100 patients with neurocardiogenic syncope or presyncope were divided in two groups (high episode group, n=54; low episode group, n=46) according to the frequency of symptoms before the head-up tilt test. We retrospectively analyzed the recurrence of symptoms using telephone interviews and medical record reviews. RESULTS: The clinical characteristics were not significantly different between the two groups. However, the recurrence rate was significantly lower in the high episode group than in the low episode group (5.6% vs. 19.6%, p=0.001). In the high episode group, patients treated with medication showed higher recurrence of symptoms than those without medication. In the lower episode group, a similar result was observed. CONCLUSION: The frequency of previous symptoms at the diagnosis of neurocardiogenic syncope or presyncope did not predict the occurrence of symptoms during the follow-up period. Therefore, to continue drug treatment based on the frequency of symptoms in patients with neurocardiogenic syncope or presyncope may not be the best option.

Gender difference in patients with recurrent neurally mediated syncope.

PURPOSE: The gender difference of neurally mediated syncope is not well defined in a large patient population. The aim of this study was to evaluate the gender difference of clinical manifestations in patients with neurally mediated syncope who underwent head-up tilt test. MATERIALS AND METHODS: The medical records of 1,051 consecutive patients with two or more episodes of syncope, who were diagnosed as having neurally mediated syncope by head-up tilt test, were retrospectively reviewed. RESULTS: Of 1,051 patients, 497 (47.3%) patients were male and 554 (52.7%) patients were female. Female patients were experiencing syncopal episodes for longer periods of their lives (8.2 +/- 9.5 years vs. 6.8 +/- 9.2 years, p = 0.002) and more episodes of syncope prior to head-up tilt test (HUT) (7.2 +/- 9.4 vs. 5.0 +/- 6.4, p = 0.001) than male patients. Micturition syncope (20.0 % vs. 5.2 %, p < 0.001) was observed more frequently in male patients than in female patients. To the contrary, however, defecation syncope (16.3 % vs. 9.3 %, p < 0.001) was observed more frequently in female patients than in male patients. CONCLUSION: Female patients were experiencing syncopal episodes for longer periods of their lives and more episodes of syncope than male patients. Gender difference was also noted with regard to frequency of situational syncope.

Seizure-like activities during head-up tilt test-induced syncope.

PURPOSE: Some patients with neurally mediated reflex syncope may be misdiagnosed as epilepsy because myoclonic jerky movements are observed during syncope. The seizure-like activities during the head-up tilt test (HUT) have been rarely reported. The purpose of this study was to assess the characteristics of these seizure-like activities and evaluate whether there are differences in the clinical characteristics and hemodynamic parameters of patients with neurally mediated reflex syncope with and without seizure-like activities during HUT-induced syncope. MATERIALS AND METHODS: The medical records of 1,383 consecutive patients with a positive HUT were retrospectively reviewed, and 226 patients were included in this study. RESULTS: Of 226 patients, 13 (5.75%) showed seizure-like activities, with 5 of these (2.21%) having multifocal myoclonic jerky movements, 5 (2.21%) having focal seizure-like activity involving one extremity, and 3 (1.33%) having upward deviation of eye ball. Comparison of patients with and without seizure-like activities revealed no significant differences in terms of clinical variables and hemodynamic parameters during HUT. CONCLUSION: Seizure-like activities occurred occasionally during HUT-induced syncope in patients with neurally mediated reflex syncope. The seizure-like activities during HUT might not be related to the severity of the syncopal episodes or hemodynamic changes during HUT.

Is home orthostatic self-training effective in preventing neurally mediated syncope?

BACKGROUND: Repeated orthostatic stress may prove to be of benefit in the regulation of neurally mediated syncope. But the role of home orthostatic self-training is not established to prevent symptoms in patients with neurally mediated syncope. We performed a prospective and randomized study to evaluate the effectiveness of repeated home orthostatic self-training in preventing tilt-induced neurally mediated syncope. METHODS AND RESULTS: Fourty-two consecutive patients (24 males and 18 females, mean age 39 years, 16-68 years) with recurrent neurally mediated syncope were randomized into the tilt training and control groups. The home orthostatic self-training program consisted of daily sessions for 7 days a week for 4 weeks. In order to determine the effects of home orthostatic self-training, we repeated the head-up tilt test in both groups 4 weeks later. Among the tilt-training group, 9 of 16 patients (56%) had a positive response on follow-up head-up tilt test. Among the untreated control group, 9 of 17 patients (53%) had a positive response on follow-up head-up tilt test. In subgroup analyses according to the number of tilt-training sessions or the classified type, we found no differences in the follow-up head-up tilt test responses. Spontaneous syncope or presyncope over mean follow-up of 16.9 months were observed in 42.9% versus 47.1% in the tilt-training and control group, respectively. CONCLUSIONS: Home orthostatic self-training was ineffective in reducing the positive response rate of head-up tilt test in patients with recurrent neurally mediated syncope.