A randomized controlled trial of a tablet-based intervention to address predonation fears among high school donors.

BACKGROUND: Prior studies have shown donation-related fear to be associated with decreased donor confidence and an increased risk for vasovagal reactions. This study examined the effects of a predonation intervention that provided fearful donors with suggestions for coping. STUDY DESIGN AND METHODS: Using a tablet-based application, high school donors (49.4% female) answered a question regarding their fear of having blood drawn. Those who reported fear were randomly assigned to either a control (n = 930) or an intervention (n = 911) group. Donors in the control group rated their confidence in dealing with their fear and then donated as usual. Donors in the intervention group received a brief audiovisual presentation on coping strategies, rated their confidence, and then donated as usual. RESULTS: A higher proportion of fearful versus nonfearful donors experienced a vasovagal reaction, even after controlling for other demographic and health predictors (OR, 2.3; 95% CI, 1.655-3.185, p < 0.001). Fearful donors who received the intervention reported greater confidence than controls, but the proportion of vasovagal reactions did not differ significantly between the intervention (6.1%) and control (6.8%) groups. CONCLUSION: Although the current tablet-based intervention may have some psychological benefit in that it was associated with greater donor confidence, the observed effect was small and did not translate into a lower risk for vasovagal reactions. However, greater confidence among young donors may lead to an increased willingness to donate again-a potential outcome that we will revisit among these donors as part of a planned 2-year follow-up.

Reduced quality of life and greater psychological distress in vasovagal syncope patients compared to healthy individuals.

BACKGROUND: Vasovagal syncope (VVS) patients have a reduced health-related quality of life (HRQoL). There are limited data comparing HRQoL and psychological profile in VVS patients and healthy individuals. We tested the hypothesis that VVS patients have greater impairment in both HRQoL and psychological profile compared to healthy nonfainting individuals, and that both outcome measures are negatively correlated for VVS patients. METHODS: The RAND 36-Item Health Survey (RAND36), global health visual analogue scale (VAS), Hospital Anxiety and Depression Scale, Anxiety Sensitivity Index, and Positive and Negative Affect Schedule - Expanded Form were completed by healthy individuals and at baseline by VVS patients enrolled in the Second Prevention of Syncope Trial, a randomized, placebo-controlled trial of fludrocortisone for VVS. RESULTS: Data were available on 76 VVS patients (34 ± 14 years; 68% F) and 85 healthy participants (35 ± 11 years; 80% F). Compared to healthy participants, VVS patients reported poorer HRQoL on all scales of the RAND36 and the VAS. VVS patients had significantly greater anxiety, depression, and anxiety sensitivity (each P < 0.001). VVS patients had more negative affect (P < 0.001) and less positive affect (P = 0.003) compared to healthy participants. Anxiety, depression, and anxiety sensitivity were negatively correlated with HRQoL for VVS patients, but not for healthy participants. CONCLUSION: In this first direct comparison, VVS patients have a significantly reduced HRQoL and more anxiety and depression compared to healthy nonfainting individuals. For VVS patients, there is a relationship between psychological distress and HRQoL, suggesting a potential benefit from more comprehensive assessment and treatment.

Fear of donation-related stimuli is reported across different levels of donation experience.

BACKGROUND: This study aimed to characterize the extent of donation-related fears among donors with different levels of donation experience. STUDY DESIGN AND METHODS: A sample of 1054 recent donors (48.3% female; mean ± SD age 33.1 ± 9.8 years) completed an anonymous, online survey of their fear of donation-related stimuli, including blood, needles, pain, and fainting. Respondents also provided information regarding demographics, pain, and vasovagal symptoms associated with their recent donation and confidence and intention with respect to a future donation. RESULTS: The sample was divided into four donation history subgroups, including one, two or three, four or five, or six or more prior donations. A significant negative relationship was observed between donation history and each of the assessed fears, indicating less fear with more experience. However, at least one-third of even the most experienced donors reported some fear for each of the stimuli. Further, greater fear was associated with more pain (r = 0.35-0.56, all p < 0.001) and more intense vasovagal symptom reports (r = 0.41-0.61, all p < 0.001). Finally, greater fear was associated with less donor confidence (r = -0.24 to -0.33, all p < 0.001) and lower intentions of donating again (r = -0.14 to -0.20, all p < 0.001). CONCLUSION: These data provide novel evidence that fear persists for many donors, despite increasing experience, and suggest that a greater appreciation of individual differences in fear is needed to address these concerns and promote long-term donor motivation.

Respiratory and hemodynamic contributions to emotion-related pre-syncopal vasovagal symptoms.

Vasovagal reactions are conventionally understood as resulting from systemic changes in cardiovascular activity; however, there exists a complementary perspective focused on specific changes in cerebral vasoconstriction associated with hyperventilation-induced hypocapnia. The present study investigated the role of cardiovascular and respiratory activity in self-reported pre-syncopal vasovagal reactions to a surgery video in a sample of 49 healthy women. Participants who indicated more previous real-life episodes of dizziness reported experiencing significantly more symptoms in the laboratory consistent with a vasovagal response. They also showed lower total peripheral resistance and higher pre-ejection period in general, suggesting lower sympathetic nervous system activity. Significant decreases in end-tidal carbon dioxide (PETCO2) occurred during the surgery video among susceptible participants, without significant increases in respiration rate. Further, participants who experienced reductions from the neutral video in PETCO2, systolic blood pressure, or both, reported vasovagal symptoms during the surgery video. The results suggest that patterns of respiration associated with decreases in PETCO2 may contribute to vasovagal symptoms reported in non-clinical groups as well as those with blood-injection-injury phobia and are associated with susceptibility to dizziness.

Influence of the recurrent syncope episodes on neurocognitive functions in patients with vasovagal syncope.

The aim of study was to evaluate an influence of recurrent syncope episodes on the neurocognitive functions (NCF) in patients with suspected VVS. AIM: The aim of study was to evaluate an influence of recurrent syncope episodes on the neurocognitive functions (NCF) in patients with suspected VVS. MATERIALS AND METHODS: Study population: 24 pts. (16 women) aged 17-70 yrs (mean age 40 years), with suspected VVS, referred to HUTT (head-up tilt test). All pts. underwent initial evaluation regarding to the number and circumstances of the syncopal and/or presyncopal spells. All pts performed HUTT with Westminster protocol. Basing on the syncope history and HUTT results, two groups of pts were distinguished: gr. I - 18 pts with at least 2 syncopal spells and positive HUTT, and gr. II 6 pts with only presyncopal status without complete loss of consciousness and negative HUTT. All pts underwent the evaluation of NCF with computer-assisted Vienna Test System battery, consisted of the following tests: DAUF - evaluation of long-term selective attention and concentration; COG - assessment of attention and concentration; STROOP - registration of the color-word interference tendency, CORSI - estimation of visual short-term memory capacity and implicite visuo-spatial learning. Values of the measured parameters were compared between both groups of pts. RESULTS: Patients without syncope (gr. II) had higher number of correctly reproduced sequences (11,0 vs 8,38 p<0,01) and Reliable Spatial Span score (5,50 vs 4,46,p<0,02) in CORSI test, in relation to pts with syncope history (gr. I). This suggests possible influence of the recurrent syncope episodes on the short-term memory capacity in pts with VVS. There were no significant differences between groups, comparing results of the other tests. CONCLUSIONS: Repeated syncope episodes may lead to impairment of short-term memory capacity in patients with vasovagal syndrome. Syncope episodes may have potentially negative influence on neurocognitive functions in patients with vasovagal syndrome.

Temperament and character personality dimensions in nitrate-tilt-induced vasovagal syncope patients.

OBJECTIVE: Vasovagal syncope (VVS) is a clinical syndrome that is characterized by a transient loss of consciousness and postural tone that are due to a temporary, spontaneously self-terminating global cerebral hypoperfusion. It is known that personality modulates the individual's sensitivity to stressors and that emotional arousal and psychologic uncertainty are conditions that contribute to vasodepressor syncope. Therefore, it is postulated that the personality characteristics of VVS patients could play a role in the pathophysiology of VVS. The aim of our study was to evaluate the temperament and character personality dimensions in patients with VVS as confirmed by nitrate-induced tilt testing. METHODS: From the 450 consecutive patients referred to our Syncope Unit for transient loss of consciousness, we enrolled 162 patients who had positive results from the head up tilt test for VVS and 162 healthy subjects matched for age and sex. All patients underwent a structured clinical interview with a psychologist to exclude the presence of current psychiatric comorbidities and were asked to complete the Cloninger's Temperament and Character Inventory-Revised (TCI-R) questionnaire for psychological assessment. RESULTS: Compared to healthy subjects, both male and female patients with VVS were found to have higher scores of the persistence temperament and self-transcendence character traits. Moreover, male VVS patients had lower scores in "novelty seeking", while female VVS patients scored significantly higher in "reward dependence". CONCLUSION: Our data show that VVS patients significantly differ from matched healthy controls in some temperament and character personality dimensions. Cardiologists should consider referral for psychological assessment when treating patients with refractory VVS.

Fluoxetine vs. placebo for the treatment of recurrent vasovagal syncope with anxiety sensitivity.

AIMS: The optimal medical therapy of patients with vasovagal syncope (VVS) remains controversial. Fluoxetine is effective against anxiety and panic disorders, while its use has shown promising results for VVS. Anxiety sensitivity is a personality trait observed in a considerable proportion of patients with VVS, associated with predisposition to anxiety and panic disorders. Our aim was to examine whether fluoxetine exerts beneficial effects regarding VVS prevention in the subset of patients with anxiety sensitivity. METHODS AND RESULTS: We assessed 106 patients with typical history of recurrent VVS, without other comorbidities, and a diagnostic, positive head-up tilt test. A psychiatric examination ruled out clinical psychiatric disease. Their psychological, stress-related profile was assessed by the Anxiety Sensitivity Index (ASI) questionnaire, a 16-item questionnaire, assessing fear of anxiety-related sensations, previously studied in VVS. Patients scoring positive for ASI (n = 60, 57% of the population) were randomized in a 2:1 fashion to receive either 10-40 mg fluoxetine daily (n = 40) or placebo (n = 20), and were followed-up for 1 year. A significant difference was observed between patients receiving fluoxetine and those with placebo, regarding the distribution of syncope-free time during the study (P < 0.05). A significant difference was also observed between the two groups regarding presyncopal events and the total number of patients who experienced syncope or presyncope during follow-up. CONCLUSION: Sensitivity to anxiety is a common personality trait in recurrent VVS. Fluoxetine is superior to placebo against syncope in these patients. This drug may be a first-line pharmacological treatment for this difficult-to-treat group.

Head-up tilt test results in child twins with nervous mediated syncope.

OBJECTIVE: To investigate the familial genetic characteristics of syncope in children. METHODS: A detailed medical history was taken from four twin pairs of children complaining of dizziness, headache, chest tightness, chest pain, prodromal symptoms of syncope or syncope, meanwhile, these patients were given routine physical examination, 12-lead ECG, echocardiography, Holter ECG, EEG, MRI of the head and other tests to exclude cardio-cerebrovascular and pulmonary diseases, with those with unknown origin for syncope undergoing head-up tilt test (HUTT) and inquiry of detailed family history. RESULTS: The four pairs of twins with syncope beginning at 7-12years and induced mostly by standing position (4/5), and positive family history was noted in two pairs. Vasovagal syncope (VVS)-vasoinhibitory response pattern was predominant in HUTT (4/5). The results and the response pattern in HUTT might diversify between two members within same twin pair: one appeared as vasoinhibitory response pattern and one postural orthostatic tachycardia syndrome (POTS) pattern in the first pair, one vasoinhibitory response pattern and one negative response pattern in the second pair, vasoinhibitory response pattern in the third pair and negative response pattern in the fourth pair. CONCLUSIONS: The hereditary factors may play a more important role in younger children with syncope. Environment and psychological factors may induced syncope attack. The results and the response pattern in HUTT are diversified and which might different between two members within twin pair.

What factors influence parents' perception of the quality of life of children and adolescents with neurocardiogenic syncope?

BACKGROUND: Health-related quality of life, which can be investigated using self-reports or parental reports, could help healthcare providers understand the subjective perception of well-being of children suffering from recurrent syncopal episodes. Quality of life is not only a measure of health but is also a reflection of patients' and parents' perceptions and expectations of health. This study assessed: 1) the consistency and agreement between pediatric patients' self-reports and parents' proxy-reports of their child's quality of life; 2) whether this patient-parent agreement is dependent on additional demographic and clinical or distress factors; 3) whether the parents' psychological distress influences children's and parents' responses to questionnaires on quality of life. METHODS: One hundred and twenty-five Italian children aged 6-18 years old (Mean age 12.75, SD 2.73, 48 % female) and their parents completed the Pediatric Quality of Life inventory with self-reports and parent-proxy reports, the Parenting Stress Index - Short Form questionnaire and the Child Behavior Checklist for ages 6-18. Patients' and parents' scores on quality of life were analyzed via an intra-class correlation coefficient, Spearman's correlation coefficient, Wilcoxon signed-rank test, and Bland-Altman plot. RESULTS: Child-rated quality of life was lower than parent-rated quality of life. However, there were no statistically significant differences between pediatric patients' self-reports and their parents' proxy-reports of on quality of life. Clinically significant patient-parent variation in pediatric health-related quality of life was observed. Differences in patient-parent proxy Pediatric Quality of Life inventory Total Scale Score scores were significantly associated with patient age. CONCLUSION: Concerning parents' proxy-ratings of their children's quality of life on the Pediatric Quality of Life inventory, parental stress was found to be negatively associated with their perceptions of their child's psychological quality of life. Indeed, childhood illness is a source of stress for the whole family, and exposes family members to a greater risk of developing psychosocial difficulties. In conclusion, this study invites reflection on the use of cross-informants in investigating the quality of life of young patients with neurocardiogenic syncope and the psychological factors that influence how quality of life is perceived.

Rationale for the Assessment of Metoprolol in the Prevention of Vasovagal Syncope in Aging Subjects Trial (POST5).

BACKGROUND: Vasovagal syncope (VVS) is a common problem associated with a poor quality of life, which improves when syncope frequency is reduced. Effective pharmacological therapies for VVS are lacking. Metoprolol is a ß-adrenergic receptor antagonist that is ineffective in younger patients, but may benefit older (≥40 years) VVS patients. Given the limited therapeutic options, a placebo-controlled clinical trial of metoprolol for the prevention of VVS in older patients is needed. STRUCTURE OF STUDY: The POST5 is a multicenter, international, randomized, placebo-controlled study of metoprolol in the prevention of VVS in patients ≥40 years old. The primary endpoint is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive metoprolol 25 to 100 mg BID or matching placebo, and followed up for 1 year. Secondary end points include syncope frequency, presyncope, quality of life, and cost analysis. Primary analysis will be intention to treat, with a secondary on-treatment analysis. POWER CALCULATIONS: A sample size of 222, split equally between the groups achieves 85% power to detect a hazard rate of 0.3561 when the event rates are 50% and 30% in the placebo and metoprolol arms. Allowing for 10% dropout, we propose to enroll 248 patients. IMPLICATIONS: This study will be the first adequately powered trial to determine whether metoprolol is effective in preventing VVS in patients ≥40 years. If effective, metoprolol may become the first line pharmacological therapy for these patients.

Disgust stimuli reduce heart rate but do not contribute to vasovagal symptoms.

BACKGROUND AND OBJECTIVES: The vasovagal response demonstrates a unique form of stress response, common in medical settings yet provoked by a variety of blood-injury-injection stimuli. This study aimed to better understand the psychophysiological mechanisms of the vasovagal response.. METHODS: 16 undergraduates with and 42 without a self-reported history of fainting watched five 3-5 min videos with different emotional content. One documentary clip (Neutral condition) described a campus environmental project while another (Blood/Injury) depicted portions of an open heart surgery. Three additional clips were also used, including Medical, Threat, and Contamination stimuli. Vasovagal symptoms and physiological variables were assessed during each video. RESULTS: As predicted, while the disgust-related stimuli (Blood/Injury, Medical, Contamination) were associated with generally lower heart rate, the Blood/Injury video produced the highest symptoms and the only significant difference between previous fainters and non-fainters. The physiological measures also revealed that participants with a fainting history experienced higher stroke volume and lower systolic blood pressure throughout, as well as several main effects of video. LIMITATIONS: An additional decrease in systolic blood pressure and respiration produced by watching the Blood/Injury video may have been sufficient to trigger symptoms in some, though results also suggest that systemic variables do not entirely explain susceptibility to symptoms. More careful evaluation of regional blood flow may be required. CONCLUSIONS: Participants who had previously experienced strong vasovagal responses displayed what appeared to be an anticipatory response to the Blood/Injury video. Finally, disgust stimuli may reduce heart rate but do not appear to contribute to vasovagal symptoms.

Fear of blood draw and total draw time combine to predict vasovagal reactions among whole blood donors.

BACKGROUND: Fear of blood draws is a predictor of vasovagal reaction risk among whole blood donors, and this relationship is particularly evident among less experienced donors. This study examines the combined effect of donor fear and total blood draw time on vasovagal reactions. STUDY DESIGN AND METHODS: After successfully completing the blood donor health screening, 2730 whole blood donors attending high school drives were asked about their fear of having blood drawn. Donor reports of fear versus no fear were combined with total blood draw time to predict phlebotomist ratings of donor vasovagal reactions. RESULTS: Both fear and draw time were significant predictors of vasovagal reactions, with observed reaction rates of 31.2% for fearful donors whose blood draw lasted 10 minutes or more versus 5.0% for nonfearful donors whose draw lasted less than 6 minutes. Binomial regression analyses revealed that fear remained a significant predictor of reaction rates across all blood draw intervals examined (odds ratio, 2.8-4.1; all p < 0.001) and that these effects were maintained after controlling for donor sex, weight, estimated blood volume, pulse rate, and donation status. CONCLUSION: This report shows that both fear and blood draw time increase vasovagal reaction rates, and the two are additive. These findings suggest that fearful donors should be the focus of special attention to reduce their distress before donation as well as careful observation throughout the draw.

Tilt-induced vasovagal syncope and psychogenic pseudosyncope: Overlapping clinical entities.

OBJECTIVE: To describe the combination of tilt-induced vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) and aid its clinical recognition. METHODS: We identified people with tilt-induced VVS/PPS from 2 tertiary syncope referral centers. For each case, 3 controls with tilt-induced VVS were selected at random from the same center. Clinical characteristics were compared between both groups adjusting for multiple comparisons. RESULTS: Of 1,164 tilt-table tests, 23 (2%) resulted in VVS/PPS; these 23 cases were compared with 69 VVS controls. VVS and PPS coincided more often than chance would predict: 2% vs 0.6%, p < 0.001. Typical VVS prodromes and triggers were reported in all people with VVS/PPS and in controls with VVS. Attack frequency was significantly higher in the VVS/PPS (2 per month, range 0.1-60) than in the VVS group (0.25 per month, range 0.02-4; p < 0.001). Delayed recovery of consciousness was more frequently reported in the VVS/PPS group (likelihood ratio [+LR] 8.14, 95% confidence interval [CI] 3.94-16.84), as well as episodes without prodromes (+LR 5.57, 95% CI 2.53-12.26), atypical triggers (+LR 5.00, 95% CI 2.04-12.24), eye closure (+LR 3.75, 95% CI 1.68-8.35), and apparent loss of consciousness >1 minute (+LR 2.86, 95% CI 1.98-4.13). CONCLUSIONS: VVS/PPS presents with a complex phenotype. High attack frequency, delayed recovery of consciousness, apparent loss of consciousness >1 minute, ictal eye closure, atypical triggers, and the absence of prodromes may serve as indicators that PPS coincides with VVS.

[Unexplained loss of consciousness: the diagnosis is never based on one symptom]. / Onverklaarde wegrakingen: de diagnose berust nooit op één symptoom.

Patients with transient loss of consciousness are often seen by a variety of specialists. Even if typical signs occur, it can be difficult to identify specific causes. We discuss two patients with complex presentations. The first patient was diagnosed with sleep syncope, a relatively unknown type of reflex syncope. The prodromal symptoms of discomfort and the subsequent loss of consciousness occurred while the patient was in bed or got up to go to the toilet due to abdominal symptoms. The onset in supine position was misleading, since this is a well-known alarm symptom of a possible cardiac cause. The second patient had vasovagal syncope followed by a psychogenic pseudosyncope. This resulted in frequent loss of consciousness of long duration with typical and atypical triggers and uncommon syncopal signs, including eye closure. These conflicting symptoms can be a pitfall and clinical expertise is required to identify the type of syncope.

The vasovagal response during confrontation with blood-injury-injection stimuli: the role of perceived control.

The vasovagal response (VVR) is a common medical problem, complicating and deterring people from various procedures. It is an unusual stress response given the widespread decreases in physiological activity. Nevertheless, VVR involves processes similar to those observed during episodes of strong emotions and pain. We hypothesized that heightened perceived control would reduce symptoms of VVR. Eighty-two young adults were randomly assigned to perceived control or no perceived control conditions during exposure to a stimulus video of a mitral valve surgery, known to trigger VVR in non-medical personnel. Perceived control was manipulated by allowing some participants to specify a break time, though all received equivalent breaks. Outcomes included subjective symptoms of VVR, anxiety, blood pressure, heart rate, and other measures derived from impedance cardiography. Compared to participants with perceived control, participants with no perceived control reported significantly more vasovagal symptoms and anxiety, and experienced lower stroke volume, cardiac output, and diastolic blood pressure. Participants who were more fearful of blood were more likely to benefit from perceived control in several measures. Perceived control appears to reduce vasovagal symptoms. Results are discussed in terms of cognition and emotion in VVR.

[Episodes of apparent transient loss of consciousness: disorders a cardiologist should not ignore]. / Le perdite transitorie di coscienza solo apparenti: affezioni che il cardiologo non dovrebbe ignorare.

Affections such as psychogenic (functional) pseudosyncope and cataplexy are characterized by transient attacks without impairment of consciousness, but with loss of postural control and unresponsiveness. Therefore, these disorders should be differentiated from syncope and should not be ignored by the cardiologist, who is usually a reference point for patients with syncope or suspected syncope. Clinical findings that suggest psychogenic pseudosyncope include frequent attacks always in the presence of audience, a fall to the ground that may develop slowly enough to allow the patient to stagger and break the fall before hitting the floor, prolonged attacks (>10 min), many psychosomatic symptoms as the clinical context. In most cases, the differential diagnosis should be made with neurally mediated syncope; to this end, tilt test appears to be very useful. Cataplexy is a relevant symptom of narcolepsy; the differential diagnosis between cataplexy and syncope should be made only when symptoms of narcolepsy are mild. Clinical findings that suggest cataplexy include an emotional trigger - above all if the emotion is positive -, an "unreal" fall similar to that observed in patients with psychogenic pseudosyncope, repeated attacks in a daytime, symptoms of narcolepsy as the clinical context. Since cataleptic attacks are triggered by emotion, in most cases the differential diagnosis should be made with vasovagal syncope; a positive emotion as a trigger suggests a cataleptic attack.

Reflex syncope, anxiety level, and family history of cardiovascular disease in young women: case-control study.

AIMS: Anxiety is an emotion, which stimulates sympathetic nervous outflow potentially facilitating vasovagal reflex syncope (VVS) but reports on anxiety levels in patients with VVS are sparse. METHODS AND RESULTS: We studied anxiety levels in young women (21-40 years) referred for unexplained transient loss of consciousness (TLOC), and age-matched female controls with or without past history of TLOC (≈probable VVS). Referred patients underwent head-up tilt (HUT) according to current ESC Guidelines. State and Trait Anxiety Inventory questionnaire evaluated anxiety levels plus a questionnaire explored risk factors for cardiovascular disease (CVD). Sixty-five of 91 women were diagnosed with VVS on HUT. Among 549 controls, 223 (40.6%) reported at least one episode of TLOC. State-anxiety level in patients with VVS undergoing HUT (42.4 ± 9.3) was higher compared with both controls with (38.3 ± 10.2; P < 0.01) and without past TLOC history (35.9 ± 9.8; P < 0.001). Trait anxiety in patients with VVS (42.7 ± 8.4), and controls with TLOC history (42.4 ± 8.4) was higher compared with controls without TLOC history (39.7 ± 8.5; P < 0.01). In the logistic regression using controls without TLOC as reference, both VVS diagnosis and past history of TLOC were associated with family history of CVD [odds ratio (OR) 2.4, 95% confidence interval (CI), 1.3-4.4; P = 0.007, and 2.3, 1.4-3.6; P = 0.001, respectively], and this association was independent of anxiety level. CONCLUSIONS: Trait anxiety and family history of CVD are increased in both young women with VVS and controls with history of TLOC. However, the height of anxiety level does not explain CVD heredity and other mechanisms may link syncope with CVD.