Comparison of a shortened isosorbide dinitrate-potentiated head-up tilt testing with the conventional protocol: tolerance and diagnostic accuracy.

BACKGROUND: The head-up tilt test (HUT) is widely used to investigate unexplained syncope; however, in clinical practice, it is long and sometimes not well tolerated. OBJECTIVES: To compare the sensitivity, specificity, accuracy, and patients' tolerance of a conventional and shortened HUT. METHODS: Patients with a history of vasovagal syndrome (VVS) were randomized to a conventional HUT (group I) consisting of 20-minute passive tilt followed by 25 minutes after administration of sublingual isosorbide dinitrate (ISDN), or a shortened HUT (group II) where ISDN was given immediately after tilt and observed for 25 minutes. The control group consisted of age- and gender-matched subjects without VVS symptoms. A specific questionnaire to evaluate tolerance was applied. RESULTS: Sixty patients (29 ± 10 years, 82% female) were included. In group I, 22/30 patients had a positive HUT compared to 21/30 in group II (73% vs 70%, P = 0.77). There was also no difference in the accuracy between the two protocols (63% vs 73%, P = 0.24). The time to positivity was shorter in group II (13.2 minutes vs 30 minutes, P < 0.001). Within the control group (n = 60), the frequency of false-positives was 47% and 23% for the conventional and shortened HUT, respectively (P = 0.058). After conventional HUT, 65.2% subjects reported that the test was too long compared to 25% subjects after the shortened HUT (P = 0.002). CONCLUSION: In this study, the HUT without passive phase was not inferior to the conventional HUT regarding sensitivity, specificity, and accuracy. Furthermore, the shortened ISDN-potentiated protocol allowed faster diagnosis and was better tolerated.

Incidence and characteristics of transient St-segment elevation during transseptal puncture.

PURPOSE: Delineate retrospectively and prospectively the incidence and characteristics of transient ST-segment elevation during transseptal puncture. METHODS: The study retrospectively evaluated 307 patients from January 1, 2015, to December 31, 2017, and prospectively evaluated 231 patients from January 1, 2018, to July 31, 2019. RESULTS: The presence of ST-segment elevation was significantly higher in the prospective sample than in the retrospective sample (5.2% vs. 1.3%, p < 0.05). Between the two groups, there was no significant difference in age, sex, comorbidities, left atrial volume index, and the etiology of atrial fibrillation among patients with ST-segment alteration. In all patients, the ST-segment elevation was observed in the inferior wall derivations, except for one patient with ST elevation in lead I, AVL, V1-V4 during the septal puncture, associated with sinus bradycardia and reversed hypotension with intravenous fluids. Comparative analysis of the systolic and diastolic arterial pressure and the minimum heart rate during the phenomenon demonstrated more severity in the retrospectively evaluated population than in the prospective population. There was a significant association between the occurrence of ST-segment elevation > 2 mm and the presence of symptoms. In these patients, coronary angiography showed no alterations. Atropine was administered to one patient who presented with junctional bradycardia after the puncture. This medication reversed the situation. CONCLUSION: ST-segment elevation is a short-term phenomenon that can occur during transseptal catheterization without clinically evident symptoms. The catheter ablation procedure can be safely concluded despite the occurrence of the phenomenon.