Parks 3-step test

Background: The Parks 3-step test is an important test in the diagnosis of a single cyclovertical muscle palsy. Purpose: This video is presented to provide a simplified and easy understanding of the Parks 3-step test for post-graduate residents. Synopsis: The video contains a description of the steps to perform a 3-step test, the results of the test in a case of superior oblique palsy, the conditions that mimic a positive 3-step test, and how to identify these mimicking conditions. Highlights: This is a simple demonstration of a classic clinical diagnostic procedure.

Pediatric patients head-up-tilt-test with pharmacological challenge, it is safe? / Mesa inclinada en pacientes pediátricos con reto farmacológico, ¿es seguro?

Abstract Syncope in pediatrics represents an important cause of visits to the emergency units. For this reason, excluding a cardiac or malignant origin is essential at the time of the initial approach to determine what is the next step in management, or if they need to be referred to a pediatric cardiologist and/or electrophysiologist. Vasovagal syncope is the most frequent cause of syncope in pediatrics, in which a detailed clinical history is enough to make the diagnosis. If no diagnosis is concluded by the history, or if it is necessary to define the hemodynamic response of the patients, the head-up-tilt-test is indicated; this will trigger syncope due to an orthostatic stress caused by the angulated table (passive phase). If a negative response remains, it can be followed by a pharmacologic challenge to trigger the hemodynamic response, which is still controversial in pediatrics. The pharmacologic challenge increases the sensitivity with a slight reduction in test specificity. Although there is not a specific drug for the challenge in pediatric patients yet, the most commonly drugs used are nitrates and isoproterenol, the latter related to a great number of adverse effects. Sublingual administration of nitrates in the challenge has been proven to be ideal, effective, and safe in this specific age group. The aim of this article is to make a literature search to demonstrate the effectiveness and safety of the pharmacologic challenge during the head-up-tilt-test in pediatrics, emphasizing a study conducted at the National Institute of Cardiology with isosorbide dinitrate.

Resumen El síncope en edades pediátricas representa una causa importante en las visitas a unidades de urgencias, por lo que excluir un origen cardíaco o maligno es fundamental al momento del abordaje inicial para determinar la conducta a seguir o la necesidad de derivar al cardiólogo pediatra o electrofisiólogo. El síncope vasovagal (SVV) es la causa más frecuente de síncope en pediatría, para cuyo diagnóstico basta una historia clínica detallada. Cuando ésta no es suficiente para determinar el diagnóstico de síncope reflejo o es necesario definir el tipo de respuesta que lo origina, está indicada una prueba de mesa inclinada que produce un estrés ortostático por la angulación y ello desencadena un síncope (fase pasiva). En pruebas no concluyentes está indicado un reto farmacológico para precipitar la respuesta hemodinámica, pero aún es un tema de controversia en edades pediátricas. El reto farmacológico incrementa la sensibilidad de la prueba, con una ligera reducción de la especificidad. Si bien no existe todavía un medicamento específico para la población pediátrica, los más empleados son los nitratos y el isoproterenol, este último relacionado con un mayor número de efectos adversos. La administración sublingual de los nitratos utilizados ha demostrado ser ideal, efectiva y segura en los pacientes pediátricos. El objetivo del artículo es realizar una revisión de las publicaciones médicas que demuestran la efectividad y seguridad del reto farmacológico durante la prueba de mesa inclinada en pacientes pediátricos, con énfasis en un estudio conducido en el Instituto Nacional de Cardiología con dinitrato de isosorbida (DNIS).

Síncope / Syncope

El síncope es una pérdida transitoria de conciencia y tono postural debido a hipoflujo sanguíneo cerebral que se recupera espontáneamente sin maniobras de RCP. En esta actualización se plantea el síncope vasovagal con sus diagnósticos diferenciales y posibles etiologías, fisiopatología y métodos de estudios. También se presenta la experiencia sobre este tema en nuestro hospital su estudio, tratamiento y diagnostico (tilt test) (AU)

Syncope is a transient loss of consciousness and postural tone due to cerebral blood hypoflow that recovers spontaneously without CPR maneuvers. This update discusses vasovagal syncope with its differential diagnoses and possible etiologies, pathophysiology, and diagnostic methods. Additionally, the experience on this topic of our hospital regarding investigations, treatment, and diagnosis is presented. (AU)

Changes in ventricular late potentials in children and adolescents with postural tachycardia syndrome / 中华实用儿科临床杂志

Objective To investigate the changes in ventricular late potentials (VLP) in children and adolescents with postural tachycardia syndrome (POTS).Methods One hundred and forty-four children and adolescents diagnosed as POTS by using the head-up tilt test (HUTT) in Second Xiangya Hospital of Central South University from January 2012 to March 2019 were selected as POTS group,their age ranged 4 to 16 years old [(11.03 ± 2.34) years old],there were 65 boys and 79 girls.Ninety-one healthy children and adolescents matched by age and gender [aged 4-16 (11.22 ± 1.68) years old,there were 50 boys and 41 girls] were selected as the healthy control group.VLP was measured by SR-1000A ECG automatic analyzer (Boai,Guangdong,China).Results Compared with the healthy control group,the prevalence of positive VLP in the POTS group increased [11.1％ (16/144 cases)vs.1.1％ (1/91 cases)],and the difference was statistically significant(x2=6.904,P ＜ 0.01);the heart rate in the POTS group increased compared with that in the healthy control group [82.0 (74.0-95.0) times/min vs.78.0 (71.0-86.0) times/min],and the difference was statistically significant (Z =-2.265,P ＜ 0.05);the low-amplitude signal (LAS40) in the POTS group prolonged compared with that in the healthy control group[23.0 (17.0-31.0) μV vs.19.0 (13.0-25.0) μV],and the difference was statistically significant (Z =-4.114,P ＜ 0.01);root mean square amplitude(RMS40) increased compared with that in the healthy control group [61.3 (34.4-79.1) ms vs.52.0 (38.8-64.5) ms],and the difference was statistically significant (Z =-2.469,P ＜ 0.05).There was no statistically significant difference in total QRS time (TQRS) between 2 groups [86.0 (76.0-97.5) ms vs.87.0 (81.0-94.0) ms,Z =-0.007,P ＞ 0.05].Conclusions The positive rate of VLP is increased of children and adolescents with POTS.It suggests that there is an abnormal cardiac electrical activity in children and adolescents with POTS.

Changes in ventricular late potentials in children and adolescents with postural tachycardia syndrome / 中华实用儿科临床杂志

Objective@#To investigate the changes in ventricular late potentials (VLP) in children and adolescents with postural tachycardia syndrome (POTS).@*Methods@#One hundred and forty-four children and adolescents diagnosed as POTS by using the head-up tilt test (HUTT) in Second Xiangya Hospital of Central South University from January 2012 to March 2019 were selected as POTS group, their age ranged 4 to 16 years old[(11.03±2.34)years old], there were 65 boys and 79 girls.Ninety-one healthy children and adolescents matched by age and gender[aged 4-16 (11.22±1.68) years old, there were 50 boys and 41 girls]were selected as the healthy control group.VLP was measured by SR-1000A ECG automatic analyzer (Boai, Guangdong, China).@*Results@#Compared with the healthy control group, the prevalence of positive VLP in the POTS group increased [ 11.1%(16/144 cases)vs.1.1%(1/91cases)], and the difference was statistically significant(χ2= 6.904, P<0.01); the heart rate in the POTS group increased compared with that in the healthy control group[82.0 (74.0-95.0) times/min vs.78.0 (71.0-86.0) times/min], and the difference was statistically significant(Z=-2.265, P<0.05); the low-amplitude signal(LAS40) in the POTS group prolonged compared with that in the healthy control group[23.0 (17.0-31.0) μV vs.19.0 (13.0-25.0) μV], and the difference was statistically significant(Z=-4.114, P<0.01); root mean square amplitude(RMS40) increased compared with that in the healthy control group[61.3 (34.4-79.1) ms vs.52.0 (38.8-64.5) ms], and the difference was statistically significant (Z=-2.469, P<0.05). There was no statistically significant difference in total QRS time (TQRS) between 2 groups [86.0 (76.0-97.5) ms vs.87.0 (81.0-94.0) ms, Z=-0.007, P>0.05].@*Conclusions@#The positive rate of VLP is increased of children and adolescents with POTS.It suggests that there is an abnormal cardiac electrical activity in children and adolescents with POTS.

La prueba de inclinación (Tilt Test). 20 años de experiencia en el diagnóstico del Síncope neurocardiogénico Tilt Test: 20 years of experience in the diagnosis of the neurocardiogenic syncope / Tilt Test: 20 years of experience in the diagnosis of the neurocardiogenic syncope

Objetivo: Valorar los resultados de las pruebas de inclinación realizadas en un lapso de 2 décadas. Métodos: Este es un estudio observacional, descriptivo y retrospectivo. Se analizaron los resultados de las Pruebas de Inclinación (PI) realizadas entre 1997 y 2018 en forma consecutiva por una sola persona, inicialmente en el Hospital Clínica Bíblica, posteriormente en el Instituto del Corazón y finalmente en los últimos 17 años en el Centro Cardiológico Integral. Resultados: Se realizaron un total de 2705 pruebas entre los años de 1997 y el 2018. El 60% fue del sexo femenino. Se hicieron 245 pruebas a menores de 20 años (17.3%), 996 pruebas a personas entre 20 y 40 años (36.8%), 969 pruebas a pa cientes entre los 40 y 60 años (35.8%) y a 271 pacientes mayores de 60 años (10%). Del total de la muestra evaluada, 2316 pacientes presentaron un resultado positivo para alguna de los diferentes tipos de respuesta en la prueba de inclinación, equivalente al 85.6%, mientras que 389 pacientes obtuvieron un resultado negativo (respuesta normal), equivalente al 14.4%. En la mayor cantidad de pacientes la positividad de la prueba se presentó en la fase II, 72.7% (1683 pacientes), el 27.3% (633 pacientes) la manifestaron en la fase I. Se presentó una respuesta vasodepresora en 1120 pacientes (48.2%), respuesta mixta en 727 pacientes (31.3%), respuesta cardioinhibidora en 304 casos (13.1%). Además, 69 pacientes pre sentaron una respuesta sugestiva (2.9%) y 104 pacientes tuvieron otros tipos de respuestas (4.5%). De estos últimos, 48% correspondió al síndrome de taquicardia postural ortostática (POTS), 17% a incompetencia cronotrópica, 19% a hipoten sión ortostática y 16% a disautonomía. Un total de 43 pacientes (1,6%) presentaron hipersensibilidad del seno carotídeo. Conclusiones: La PI en nuestro medio tiene una adecuada sensibilidad en el diagnóstico del Síncope Neurocardiológico (SNCG) en los diferentes grupos de edad, es un método seguro, fácil de realizar y accesible a la mayoría de las personas que la requieran

Tilt Test: 20 years of experience in the diagnosis of the neurocardiogenic syncope Objective: To evaluate the results of the tilt tests carried out during 2 decades. Methods: This is an observational, descriptive and retrospective study. We analyzed the results of the tilt tests conducted between 1997 and 2018 consecutively by a single person, initially at the "Hospital Clínica Bíblica", later at the "Instituto del Corazón" and finally in the last 17 years at the "Centro Cardiológico Integral". Results: A total of 2705 tests were carried out between 1997 and 2018. Sixty percent were female. There were 245 tests for people under 20 years (17.3%), 996 tests for people between 20 and 40 years (36.8%), 969 tests for patients between 40 and 60 years (35.8%) and 271 patients older than 60 years (10%). Of the total sample evaluated, 2316 patients presented a positive result for some of the different types of response in the tilt test, equivalent to 85.6%, while 389 patients obtained a negative result (normal response), equivalent to 14.4%. In the largest number of patients, the positivity of the test was presented in phase II, 72.7% (1683 patients), and 27.3% (633 patients) manifested it in phase I. A vasodepressant response was presented in 1120 patients (48.2%), mixed response in 727 patients (31.3%), cardioinhibitory response in 304 cases(13.1%). In addition, 69 patients presented a suggestive response (2.9%) and 104 patients had other types of responses (4.5%). Of the latter, 48% corresponded to orthostatic postural tachycardia syndrome (POTS), 17% to chronotropic incompetence, 19% to orthostatic hypotension and 16% to dysautonomia. A total of 43 patients (1.6%) presented hypersensitivity of the carotid sinus. Conclusions: Tilt test in our environment has an adequate sensitivity in the diagnosis of the neurocardiogenic syncope in different age groups, it is a safe method, easy to perform and accessible to most people who require it.

Síncope único o muy poco frecuente en 104 casos / Single or very isolated syncope in 104 cases

Resumen Introducción: Es frecuente de encontrar personas enviadas para realizar la prueba de Tilt Test (TT), que sufrieron un solo síncope aislado o que ocurre muy ocasionalmente durante su vida. En este trabajo nos preguntamos en qué se diferencian estas personas de las que nunca tienen síncopes. Métodos: Realizamos el examen de TT en 104 pacientes que sufrieron sólo uno o como máximo 5 síncopes por cualquier causa durante su vida. Intentamos explicar cómo actúan los diferentes factores predisponentes para provocar el síncope. Resultados: Encontramos diferencias en factores predisponentes del síncope, entre nuestros pacientes y los controles en factores como: la herencia, la hipermovilidad articular, el encharcamiento venoso durante el TT, la ingesta de alimentos, el uso de fármacos, el estrés y la emoción. Conclusiones: En el síncope único o muy ocasional, deben conjugarse en la persona dos factores. Lo explicamos: Estos pacientes tienen una predisposición orgánica (herencia -hipermovilidad articular- falla en los baroreflejos, algunas enfermedades neurológicas, etc.) a presentar síncopes. Pero los síncopes no ocurrirán a menos que se agregue simultáneamente un factor ambiental, que actúa como un desencadenante (estadía larga de pie, estrés, dolor y emoción, deshidratación, drogas, comida abundante, etc.), es por eso que en estos pacientes los síncopes son tan raros.

Introduction: It is frequent meeting people sent to perform a tilt test suffering from a single or such isolated syncope that occur very occasionally during the patient's life. We ask ourselves how these people differ from those who never have syncopes. Methods: We performed tilt test in 104 patients who suffer a single or maximum 5 syncopes from any cause during their lifetimes. We try to explain how different predisposing factors act to provoke syncope. Results: We found differences between cases and controls in inheritance of syncopes, joint hypermobility, venous pooling during tilt test, food intake, use of drugs, stress and emotion as a trigger for syncope. Conclusions: Patients with single or occasional syncope have an organic predisposition (inheritance - joint hypermobility - failure in the baroreflexes, some neurological diseases, etc.) to present syncopes, but syncopes do not occur unless it is added simultaneously an environmental factor, which acts as a trigger (prolonged standing up - stress, pain and emotion - dehydration - drugs - abundant food, etc.) that is why these episodes are so rare.

Comparison of curative effect and serum electrolytes between different oral rehydration salts in treatment of neurally mediated syncope children / 中南大学学报(医学版)

Objective:To compare the curative effect and the changes of serum electrolytes between oral rehydration salts (ORS) Ⅰ and ORS Ⅲ treatment in neurally mediated syncope children.Methods:The children with the symptom of unexplained syncope and pre-syncope were collected in Second Xiangya Hospital from May 2014 to May 2017.After head-up tilt test (HUTT),their serum electrolytes levels were examined.Children who were positive in the HUTT received ORS (ORS Ⅰ or ORS Ⅲ) and health education.Subjects were randomly divided into an ORS Ⅰ group (n=27) and an ORS Ⅲ group (n=49).Results:There was no statistical significance in sex,age,height,body mass,initial diagnosis and re-diagnosis interval between the 2 groups (P＞0.05);the total efficiency after ORS Ⅲ and ORS Ⅰ treatment were 79.59％ and 62.96％,respectively,with no statistical significance (x2=2.483,P＞0.05);the HUTT negative conversion rate after ORS Ⅲ and ORS Ⅰ treatment were 51.02％ and 48.16％,respectively,with no statistical significance (x2=0.058,P＞0.05);before treatment,the serum sodium [(140.20±2.26) mmol/L vs (138.39±2.72) mmol/L;t=2.856,P＜0.05] in the ORS Ⅲ group was higher than that in the ORS Ⅰ group,the serum phosphorus [(1.46±0.19) mmol/L vs (1.65±0.29) mmol/L;t=3.146,P＜0.05] in the ORS Ⅲ group was lower than that in the ORS Ⅰ group;after treatment,the serum sodium [(140.31±2.01) mmol/L vs (138.88±2.08) mmol/L;t=2.692,P＜0.05] and serum calcium [(2.31±0.09) mmol/L vs (2.24±0.11) mmol/L;t=2.696,P＜0.05] in the ORS Ⅲ group were higher than those in the ORS Ⅰ group,the serum phosphorus [(1.45±0.16) mmol/L vs (1.61±0.25) mmol/L;t=3.128,P＜0.05] in the ORS Ⅲ group was lower than that in the ORS Ⅰ group;after ORS Ⅲ treatment,there was no statistical significance in serum electrolytes between HUTT positive group and HUTT negative group (P＞0.05);after ORS Ⅰ treatment,the serum calcium [(2.29±0.10) mmol/L vs (2.19±0.10) mmol/L;t=2.501,P＜0.05]and serum phosphorus [(1.71±0.24) mmol/L vs (1.50±0.21) mmol/L;t=2.392,P＜0.05] in HUTT positive group were higher than those in HUTT negative group.There was no statistical significance in serum sodium,potassium,magnesium,and chloride (P＞0.05);there was no statistical significance in serum electrolytes between pre-treatment and post-treatment in the ORS Ⅰ group and the ORS Ⅲ group (P＞0.05);there was no statistical significance in serum electrolytes between vasovagal syncope and postural orthostatic tachycardia syndrome in the ORS Ⅰ group and the ORS Ⅲ group before ORS treatment (P＞0.05).Conclusion:The ORS Ⅲ and ORS Ⅰ have the similar efficacy in the treatment of children with neurally mediated syncope.ORS Ⅲ is easier to be accepted by children than ORS Ⅰ,with better compliance.

Relationship between unexplained palpitation in children and head-up tilt test / 中南大学学报(医学版)

Objective:To explore the relationship between unexplained palpitation in children and head-up tilt test (HUTT).Methods:A total of 142 children with the main symptom of unexplained palpitation were admitted to the Specialist Out-Patient Clinic of Children's Cardiovascular Disease from Sept.2008 to Feb.2017 in the Second Xiangya Hospital,Central South University.Among them,63 cases were male,79 cases were female,with the mean age of (10.12±2.88) years old.The detailed history,physical examinations,conventional 12 electrocardiogram,chest X-ray,echocardiography,myocardial enzymes and thyroid function were all examined.The disorders of heart disease,systemic disease and drug effect were ruled out.The HUTT inspection was then given to them.Results:Among the 142 palpitation cases,79 cases were HUTT positive (55.6％) and 63 cases were HUTT negative (44.4％).The age in HUTT positive patients was older than that in HUTT negative patients (P＜0.05),with no significant difference in gender (P＞0.05).There were three types of hemodynamic changes in HUTT positive patients.Among them,38 cases were postural orthostatic tachycardia syndrome (48.1％),36 cases were the vasovagal syncope vasodepressive type (45.6％) and 5 cases were the vasovagal syncope mixed type (6.3％).There were no hemodynamic types for vasovagal syncope cardioinhibitory type,orthostatic hypotension and orthostatic hypertension.Conclusion:Among the clinically unexplained palpitations children,more than half are caused by unbalanced autonomic nervous function.HUTT can help clear the cause of unexplained palpitations.

The etiological distribution and clinical features of autonomic neuromediated syncope in children and adolescents:single center 15 years retrospective analysis / 中国小儿急救医学

Objective To retrospectively analyze the etiological distribution and clinical features of autonomic neuromediated syncope ( NMS) in children and adolescents in single center for 15 years. Methods There were 3182 cases of children and adolescents[aged from 2 to 18 years,the average age(10. 75 ± 3. 13) years] with unexplained syncope or symptoms of presyncope ( including unexplained dizziness,headache,chest tightness,chest pain,sigh,heart palpitations,etc),who came from children syncope outpatient department or inpatient department in the Second Xiangya Hospital,Central South University from September 2000 to October 2015. Of all 3182 cases,1649 cases were male,1533 cases were female. All subjects underwent detailed history collection,careful physical examination,12-lead electrocardiogram,Holter ECG,chest X-ray,echocardiography, EEG and head CT or MRI,blood biochemical examination (including fasting glucose,myocardial enzymes) and were eliminated organic disease of heart,lung,brain and so on,the cause of syncope was not still clear. The head-up tilt test ( HUTT ) was performed after the patient or / and the guardian written informed consent obtained. Results (1)HUTT positive rate was 47. 05％ (1497/3182). Causes for vasovagal syncope in turn was 42. 99％ ( 1368/3182 ) , postural orthostatic tachycardia syndrome was 2. 55％ ( 81/3182 ) , orthostatic hypertension was 0. 79％ (25/3182),orthostatic hypotension was 0. 06％ (2/3182). (2)The clinical symp-toms in NMS of different etiologies were mainly syncope,dizziness,chest tightness,chest pain,headache,heart pal-pitations. Conclusion The causes of NMS in children are vasovagal syncope and postural orthostatic tachycardia syndrome,and the clinical features are syncope,dizziness,chest tightness,chest pain,headache,heart palpitations.

The value of orthostatic intolerance symptom scores on the diagnosis of orthostatic intolerance in children and adolescents / 中华实用儿科临床杂志

Objective To design an effective,inexpensive and handy scoring system of preliminary screening for the diagnosis of orthostatic intolerance (OI)in children and adolescents. Methods Two hundred and seventy -four children or adolescents diagnosed or hospitalized in Children′s Syncope Specialist Clinic or Inpatient Department of the Second Xiangya Hospital of Central South University from July 2016 to March 2017,who were complaining about the following symptoms like unexplained syncope,dizziness,headache,chest tightness,chest pain,etc. The 274 cases in-cluded 141 males and 133 females aging from 5 to 18 years old with a mean age of (11. 8 ± 2. 7)years. Each patient was asked to finish OI questionnaire and head - up tilt test (HUTT). The scores of the eight symptoms,including palpi-tation,headache,profuse perspiration,blurred vision or amaurosis,chest tightness,dizziness,gastrointestinal symptoms and syncope,were added as OI symptom scores. The data were analyzed by SPSS 18. 0 software. Results All the pa-tients were divided into HUTT negative group (n = 151)and positive group (n = 123). The positive group was com-posed of vasovagal syncope (VVS)(n = 88),postural orthostatic tachycardia syndrome (POTS)(n = 33)and ortho-static hypertension (OHT)(n = 2). Among them,31 cases were positive in baseline HUTT (BHUT)and 92 cases were negative in sublingual nitroglycerin - provocated HUTT (SNHUT). The mean OI symptom scores of HUTT positive group were distinctly higher than those of negative group [(6. 4 ± 4. 6)scores vs. (3. 5 ± 3. 4)scores,P = 0. 000]with significant difference. Taking score ≥2. 5 as the borderline,the sensitivity and specificity of HUTT result prediction were 79. 2％ and 50. 3％,respectively. Since the score was supposed to be integer number,HUTT result should be con-sidered as positive when the score was ≥3. In the HUTT positive group,the scores of POTS children group were signifi-cantly higher than those of VVS group [(8. 8 ± 5. 2)scores vs. (5. 5 ± 4. 1)scores,P < 0. 01]and the mixed syncope had the lowest score in the VVS group;The scores of BHUT positive group were obviously higher than those of SNHUT positive group [(7. 8 ± 4. 6)scores vs. (5. 6 ± 4. 4)scores,P < 0. 05]and all the difference were significant. Conclusions OI symptom score has some predictive value on the results of HUTT and can be served as a preliminary screening of OI in children and adolescents.

Several questions of head-up tilt test in the Children with neurally mediated syncope / 国际儿科学杂志

Neurally mediated syncope (NMS)is common in pediatric emergency and intensive care unit.Head-up tilt test(HUTT)has been widely used as an valuable diagnostic tools for NMS,while the results would be affected by multiple factors.Controversies still exist on issues such as the influence factors of positive rate,complication and clinical predictions of the HUTT.In this review,several problems in the application of HUTT in NMS of children are reviewed.

Diagnostic value of head-up tilt test in patients with cough syncope / 重庆医学

Objective To investigate the diagnostic value of head-up tilt test (HUT) in cough syncope (CS).Methods Forty-seven outpatients or inpatients with CS and 79 patients with suspected vasovagal syncope(SVVS) due to syncope history in our hospital from January 2011 to May 2015 served as the observation group and control group respectively.HUT was performed in the two groups.The cough response during HUT,changes of systolic pressure and diastolic pressure caused by cough,HUT positive results and hemodynamic type were observed,Results In the observation group,4 cases(8.51％) were cough caused syncope,26 cases (55.32 ％) were presyncope and 17 cases (36.17 ％) had no symptoms,while 79 cases in the control group had no symptoms,the differences were statistically significant (P＜ 0.05).The total positive rate of cough response in the observation group was 63.83％,and the specificity was 100.00％.The systolic blood pressure had statistical difference between the two groups(.P＜0.05).The diastolic pressure had statistical difference between the cases of non-symptoms with the cases of syncope and cases of presyncope in the observation group (P＜0.05),but had no statistical difference compared with the cases of non-symptoms in the control group(P＞0.05).The heart rate(HR) had no statistical difference among various groups(P＞0.05).The HUT positive rate in the observation group was lower than that in the control group(P＜0.05).The hemodynamic type had no statistical difference between the two groups(P＞0.05).Conclusion Severe coughing during HUT may cause the blood pressure decrease,induces syncope or presyncope,can increase the diagnostic sensitivity of CS patients,which is very useful in the suspected diagnosis of CS patients,especially for CS patients with a unclear history.

Electrocardiogram Characteristics of Suspected Vasovagal Syncope Patients With Positive Head-Up Tilt Test / 中国循环杂志

Objective: To investigate the dynamic electrocardiogram (ECG) changes of head-up tilt test in patients with suspected vasovagal syncope. Methods: A total of 502 outpatients of our hospital with suspicious vasovagal syncope from 2015-08 to 2016-12 were enrolled. All patients received head-up tilt test with synchronization of 12 lead ECG. Based on head-up tilt test result, the patients were divided into 2 groups: Positive group,n=244 and Negative group,n=258. The P wave duration, corrective QT (QTc) duration and P wave axis in ECG were compared between 2 groups. Results: Compared with Negative group, Positive group had the longer P wave duration (95.65±38.50) ms vs (88.61±17.09) ms,P<0.05; P wave axis was right shifted before syncope (69.87±18.18)° vs (66.82±16.51)° , while left shifted during syncope (62.87±25.39)° vs (68.47±15.30)° and after syncope (56.87±22.45)° vs (68.49±16.35)°, allP<0.05; the shorter QTc duration before syncope (418.69±92.35) ms vs (435.76±59.29) ms,P<0.05. Conclusion: The patients with vasovagal syncope had some speciifc ECG features during head-up tilt test including P wave duration, P wave axis and QTc duration, those may play certain forewarning function for vasovagal syncope onset.

Head-up tilt test induced shortened QT interval:a case report and literature review / 临床儿科杂志

Objective To explore the cause of secondary QT interval shortening. Method The data of a child with vasovagal syncope and cardiac depression in whom shortened QT interval was induced in head-up tilt test (HUTT) was analyzed retrospectively, and the related literatures were reviewed. Result A 12-year-old boy visited for fainting when brushing his teeth in the morning. ECG showed sinus bradycardia, heart rate at 55 times /min and normal QT and QTc interval. Dynamic electrocardiogram showed sinus rhythm, mean heart rate at 70 times/min, atrial anterior contraction 3 times, normal mean QT and mean QTc. UCG showed approximately normal heart structure and the left ventricular systolic function. There was no abnormality in EEG and cranial CT. His fasting blood glucose was 5.2 mmol/L. The basal tilt test was positive with vasovagal syncope and cardiac depression. During the tilt table test, Holter monitoring showed that sinus arrest occurred in the child when upright tilt for16 min, and then fainted. Time of sinus arrest was 2.9 s and 11.4 s, respectively, and artificial chest compressions were performed. The QT interval was shortened (QT=330 ms), and so was QTc interval (QTc=320 ms). The ratio of QT/QTp was 78% (the lower limit of normal QT interval was 88% of QTp) before sinus arrest occurred. Conclusion Increased vagal tone may induce QT interval shortening.

The predictive value of orthostatic intolerance symptoms in children and adolescents to the head-up tilt test results / 中国小儿急救医学

Objective To explore the predictive value of orthostatic intolerance( OI) symptoms in children and adolescents to the head-up tilt test( HUTT) results. Methods A total of 274 children or adoles-cents complaining with the following symptoms were chosen:unexplained syncope,dizziness,headache,chest tightness,chest pain,sigh,and so on. The 274 cases included 141 males and 133 females aging from 5 to 18 years old with a mean age of (11. 8 ± 2. 7) years. All the cases in this study came from the syncope special-ized clinic or inpatient department of the Second Xiangya Hospital,Central South University,from July 2016 to March 2017. All the patients had been asked in detail about the history, physical examination, routine 12-lead electrocardiogram,chest X-ray,echocardiogram,electroencephalogram,head computer tomography or magnetic resonance imaging,blood and a series of checks to exclude organic heart,brain,lung diseases. Each patient was asked to finish OI questionnaire and HUTT. Results All 274 patients were divided into HUTT negative group(n=151) and HUTT positive group(n=123). Dizziness(65. 3％) was the most common OI symptom,followed by syncope(50. 7％),blurred vision or amaurosis(45. 6％) and fatigue(43. 4％). There were significant differences in the prevalence of palpitation,headache,profuse perspiration,blurred vision or amaurosis,chest tightness,dizziness,gastrointestinal symptoms( nausea,vomiting,abdominal pain,abdominal distension) and syncope between HUTT positive and HUTT negative groups ( P<0. 05 ) . According to the multivariate Logistic regression analysis,these eight OI symptoms could affect the results of HUTT to some extent(odds ratio>1). Conclusion The symptoms of palpitation,headache,profuse perspiration,blurred vi-sion,chest discomfort,dizziness,gastrointestinal symptoms( nausea,vomiting,abdominal pain,abdominal dis-tension) and syncope can impact the positive results of HUTT.

Diagnostic value of head-up tilt test in patients with cough syncope / 重庆医学

Objective To investigate the diagnostic value of head-up tilt test (HUT) in cough syncope (CS).Methods Forty-seven outpatients or inpatients with CS and 79 patients with suspected vasovagal syncope(SVVS) due to syncope history in our hospital from January 2011 to May 2015 served as the observation group and control group respectively.HUT was performed in the two groups.The cough response during HUT,changes of systolic pressure and diastolic pressure caused by cough,HUT positive results and hemodynamic type were observed,Results In the observation group,4 cases(8.51％) were cough caused syncope,26 cases (55.32 ％) were presyncope and 17 cases (36.17 ％) had no symptoms,while 79 cases in the control group had no symptoms,the differences were statistically significant (P＜ 0.05).The total positive rate of cough response in the observation group was 63.83％,and the specificity was 100.00％.The systolic blood pressure had statistical difference between the two groups(.P＜0.05).The diastolic pressure had statistical difference between the cases of non-symptoms with the cases of syncope and cases of presyncope in the observation group (P＜0.05),but had no statistical difference compared with the cases of non-symptoms in the control group(P＞0.05).The heart rate(HR) had no statistical difference among various groups(P＞0.05).The HUT positive rate in the observation group was lower than that in the control group(P＜0.05).The hemodynamic type had no statistical difference between the two groups(P＞0.05).Conclusion Severe coughing during HUT may cause the blood pressure decrease,induces syncope or presyncope,can increase the diagnostic sensitivity of CS patients,which is very useful in the suspected diagnosis of CS patients,especially for CS patients with a unclear history.

Utilidad del Tilt test en el diagnostico de sincope en pediatria: experiencia de 345 casos / Head-up tilt table test in pediatrics syncope diagnose: 345 cases report

El síncope es la pérdida transitoria del estado de conciencia y del tono postural, representa alrededor de 2-5% de todas las consultas de emergencias. Los pacientes pediátricos, al momento de su evaluación, suelen encontrarse asintomàticos, el diagnóstico se fundamenta en la obtención de un correcto interrogatorio y un minucioso examen clínico. El TILT TEST (TT) puede ser un método efectivo para obtener un diagnóstico etiológico en pacientes con síncope de origen vasovagal (SVV) y en aquellos pacientes en quienes se plantea diagnóstico diferencial de epilepsia y que reciben tratamiento anticonvulsivante. Objetivo: Categorizar los resultados de los TT realizados en pacientes pediátricos, evaluados en la consulta de cardiología entre enero 2013 - enero 2015. Métodos: Estudio retrospectivo y descriptivo de 345 pacientes referidos para realizar TT con sospecha diagnóstica de síncope. Resultados: El sexo predominante fue el femenino (59,7%), el grupo etario predominante: niños de 2-9 años (n: 196; 56,8 %), el restante fueron adolescentes. El TT fue positivo en 183 pacientes (53,04%) para diagnóstico de síncope, aumentó a 76,2 % anexando otras formas de disautonomía, el síncope más frecuente fue el vasodepresor (59 %), con predominio estadísticamente significativo (Z = 3,35; p < 0,001), seguido del sincope mixto. Discusión: El síncope es un motivo de consulta frecuente en pediatría y causa de preocupación para los padres; los resultados coinciden con la literatura, siendo el síncope vasodepresor el más frecuente. Conclusiones: El TT es una herramienta útil para diagnosticar síncope y otros tipos de disautonomía, sobre todo en pacientes que reciben tratamiento anticonvulsivante con sospecha de síncope.

Syncope is defined as complete transient loss of conscious with complete and spontaneous recovery, is a frequent disease, represents 2- 5 % total emergency visits. Most pediatric patients´ evaluation is completely normal, that makes interrogation and clinical examination crucial for diagnose. Head up Tilt test (HUTT) is a valuable diagnose tool in vasovagal or neurally mediated syncope especially in patients who have epilepsy and are receiving seizure treatment. Objective: Head up Tilt test results are described and categorized in patients evaluated in cardiology or referred by another pediatric cardiologist to perform HUTT from january 2013 to january 2015. Methods: Retrospective, descriptive study in 345 children in whom HUTT was performed. Results: Predominant sex was Female 59.7%, the predominant age group includes children 2-9 years (196 ) represents 56.8%, the remainder were adolescents. HUTT was positive for syncope in 183 patients (53.04 %) and increase to 76.2 % if other diasutonomic disorders are added. Vasodepresor syncope was the most frequent (59 %) with statistically significant predominance, followed by mix response. Discussion: Syncope is a frequent medical atenndance cause and it causes parents anxiety. Our results are similar to other authors being vasodepresor syncope the most frequent. Conclusions: HUTT is a valuable tool for syncope diagnose especially in patients who are receiving seizures treatment.

Analysis of the results of head-up tilt test in syncope children / 中华实用儿科临床杂志

Objective To explore the familial genetic characteristics of twins syncope in children.Methods Four pairs of twins with unexplained dizziness,headache,chest tightness,chest pain,pre-syncope and syncope were received head-up tilt test (HUTT) and family history of syncope were inquired.The age,gender,clinical manifestations were analyzed and the HUTT hemodynamic response were performed,and interviewed via telephone.Results The onset age of 4 pairs of twins ranged from 7 to 12 years old,less than 15 years,the median age of the first syncope episodes.Cause of syncope was primarily standing(4/5 cases),2 pairs had syncope positive family history.HUTT hemodynamic response type was mainly vasodepressor syncope (4/5 cases).HUTT result and hemodynamic response type were not completely consistent in the same twins.One case of the first twins was vasodepressor syncope and postural orthostatic tachycardia syndrome.One case of the second twins was vasodepressor syncope,while the other was negative.The third twins were vasodepressor syncope.The fourth twins were negative.HUTT results of the 4 twins were diverse,indicating that environment,psychological factors may get involved in syncope episodes.Conclusions The familial genetic factors of the children with syncope may play an important role in the young age group.Environment and psychological factors may be induce syncope attack.HUTT results of twins are diverse.HUTT result and hemodynamic response type can be inconsistent in the same twin.