![Page 1: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/1.jpg)
Vasovagal Syncope: Vasovagal Syncope: Current Management and Role of Current Management and Role of Cardiac PacingCardiac PacingAntonio Raviele, MD, FESC, FHRSAntonio Raviele, MD, FESC, FHRS
ALFA – Alliance to Fight Atrial fibrillation, Mestre – Venice, ItalyALFA – Alliance to Fight Atrial fibrillation, Mestre – Venice, Italy
Curso de Actualizaciòn en Arritmias, Mexico City, Mexico - 16-18 November, 2016
![Page 2: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/2.jpg)
Treatment of VVS
Only rarely necessary
![Page 3: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/3.jpg)
Vasovagal Syncope
•Is a begnin condition
•Is not a threat to life
•Does not impair quality of life
Majority of casesMajority of cases
![Page 4: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/4.jpg)
Patient Reassurance
• Benign nature of VVS
Patient Counseling
• Recognition premonitory symptoms
• Avoidance of precipitating conditions
![Page 5: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/5.jpg)
• Prolonged Sitting - Standing
• Crowded - Hot Places
• Strenuous Exercise in Warm Enviroment
• Dehydration - Volume Depletion
• Potentially Hypotensive Drugs
• Venipuncture – Emotional/Stressful Situations
VVS - Triggering factors
![Page 6: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/6.jpg)
Treatment - VVS
• Frequent syncopal episodes
• No predictable circumst. / warning sympt.
• Important physical injury
• Potential occupational hazard
IndicatedIndicated
![Page 7: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/7.jpg)
Therapeutical Options
NON PHARMACOLOGICAL
• alpha-agonists• betablockers• fludrocortisone • serotonin inhibitors• disopyramide• scopolamine• teophylline/clonidine• ACE-I
PHARMACOLOGICAL ELECTRICAL
• pacemaker• ablation
• reassurance • counseling • high salt diet• water intake• support stockings• counter-maneuvers• tilt training
![Page 8: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/8.jpg)
Therapeutical Options
NON PHARMACOLOGICAL
• reassurance • counseling • high salt diet• water intake• support stockings• counter-maneuvers• tilt training
![Page 9: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/9.jpg)
Leg Crossing Leg Crossing & &
Muscle Muscle TensingTensing
HandgripHandgrip Arm muscle Arm muscle tensingtensing
Counter-Pressure Maneuvers
SquattingSquatting Bending Bending forwardforward
Crash Crash positionposition
![Page 10: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/10.jpg)
Mechanism of action
• Venous Return
• Cardiac Output
• Blood Pressure
• Interruption of VV Reaction
![Page 11: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/11.jpg)
J Am Coll Cardiol 2006; 48: 1652-7
![Page 12: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/12.jpg)
Van Dijk N et al.J Am Coll Cardiol. 2006;48:1652-1657
Kaplan-Meier syncope-free survival curve of time to first syncopal recurrence
31.6%31.6%
50.9%50.9%
FU = 14 mthsFU = 14 mths
![Page 13: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/13.jpg)
Comparison between Kaplan–Meier curves of freedom from syncope recurrence in patients who performed PCM training and control untreated group of patients.
Tomaino M et al. Europace 2014;16:1515-1520
PCM
No Therapy
ISSUE-3 trial subanalysis
![Page 14: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/14.jpg)
PACE 1998;21:193-196PACE 1998;21:193-196
![Page 15: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/15.jpg)
HUTT / Tilt Training
• 5 in-hospital head-up tilt sessions for a planned duration of 10-50 minutes at 60° (once a day for 5 days)
• daily tilt training at home by standing against a wall for a planned duration of up to 40 minutes (twice a day)
![Page 16: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/16.jpg)
Tilt TrainingTilt Training
In the literature there are discordant results
regarding the real efficacy of this measure
![Page 17: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/17.jpg)
Vyas A, et al. Int J Cardiol 2012; 167: 1906-1911
• However, the effect is lost if only randomized studies are included.• Moreover, tilt training is hampered by the low compliance of the patients to
continue the treatment for a long period of time.
A recent metanalysis of all studies performed with tilt training has shown that this therapy is effective in preventing recurrences of VVS with 70% decrease
![Page 18: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/18.jpg)
HUTT / HUTT / Tilt TrainingTilt Training
• Tilt training, at best, and if really effective,
may be recommended only in a very selected
group of highly motivated patients.
![Page 19: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/19.jpg)
Therapeutical Options
• alpha-agonists• betablockers• fludrocortisone • serotonin inhibitors• disopyramide• scopolamine• teophylline/clonidine• ACE-I
PHARMACOLOGICAL
![Page 20: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/20.jpg)
VVS Open Studies – Drug EfficacyVVS Open Studies – Drug Efficacy
• alpha-agonists 73% 86% 12
• betablockers 74% 81% 15
• fludrocortisone 47% 68% 13
• serotonin inhibitors 55% 92% 13
• disopyramide 87% 91% 24
• scopolamine 44% 93% 14
• teophylline 33% 50% 11
Drug Acute Chronic FU
![Page 21: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/21.jpg)
In all these studies, with only few exceptions, no difference was found in the recurrence rate of syncope during follow-up between pts treated with drugs and those treated with placebo
Placebo – Controlled Trials
Ammirati F et al. In: Alboni P, Furlan R (eds), Vasovagal Syncope, Springer 2015; 237-245
![Page 22: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/22.jpg)
Liao Y, et al. Acta Paediatrica 2009; 98: 1194-1200
Midodrine
This drug has given positive results in 4 studies, with a consistent risk reduction of syncopal recurrences of more than 60%,
![Page 23: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/23.jpg)
• These studies are not placebo-controlled
• Studied children or extraordinarily symptomatic pts
• Used tilt test outcomes as the main measure
• Regarded a limited number of patients
• Had a short period of follow-up
Midodrine & VVS / Positive results
![Page 24: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/24.jpg)
Europace 2011; 13: 1639-1647
![Page 25: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/25.jpg)
Metanalysis of prespecified, prestratified substudy of POST I and a large earlier observational study showed evidence of benefit of metoprolol in pts older than 42
yearsSheldon RS et al. Circ Arrhythm Electrophysiol. 2012;5:920-926
(Metoprolol) (Metoprolol)
Metoprolol
![Page 26: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/26.jpg)
• However, these data need to be confirmed by an ongoing prospective, multicenter, randomized trial (POST 5) with results expected in 2017, before they can be largely applied in daily clinical practice.
Metoprolol & VVS / Positive results
![Page 27: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/27.jpg)
Sheldon R. et al.J Am Coll Cardiol. 2016; 68: 1-9
49%
Fludrocortisone
Fludrocortisone, at a dose of 0.2 mg daily, significantly reduced by 49% the syncopal recurrence rate after the initial 2 weeks of dose stabilization.
![Page 28: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/28.jpg)
However, the study did not meet its primary objective of demonstrating that fludrocortisone reduces the likelihood of vasovagal syncope by the specified risk reduction of 40%. Indeed the reduction was more modest, only 31%
31%
![Page 29: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/29.jpg)
Drug Therapy for Vasovagal SyncopeDrug Therapy for Vasovagal Syncope
“To date there are not sufficient data to
support the use of any pharmacological
therapy for vasovagal syncope”
ESC Guidelines on Management of SyncopeBrignole et al. Eur Heart J 2001; 22: 1256-1306
![Page 30: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/30.jpg)
Therapeutical OptionsTherapeutical Options
ELECTRICAL
• pacemaker• ablation
![Page 31: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/31.jpg)
VVS / Rationale for pacingVVS / Rationale for pacing
To counteract
the cardioinhibitory component
of the pathological reflex
![Page 32: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/32.jpg)
Pacing for VVS / StudiesPacing for VVS / Studies
• Randomized open-label controlled
• Randomized double-blind placebo-controlled
![Page 33: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/33.jpg)
VPS VASIS SYDIT Pts no. 54 42 93 Mean age 43 60 58 Median no. of syncopes 14-35 5.5 7-8 Tilt test + + +
Control arm no pm no pm atenol
Recurrence (Pm arm) 22% 5% 4%
Recurrence (control arm) 70% 61% 25%
p value 0.000 0.000 0.004
Pacemaker RDR DDI 45-80
RDR
Randomized open-label controlled studies
VPS. J Am Coll Cardiol 1999; 33: 16-20VASIS. Circulation 2000; 102: 294-299 SYDIT. Circulation 2001;104:52-57
Risk Risk
83%83%
92%92%
Mean FU: few mo – 3.7 yrs
![Page 34: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/34.jpg)
VPS II SYNPACE
Pts no. 100 29 Mean age 49 53 Median no. of syncopes 16 14-10 Tilt test + / - +
Control arm pm off pm off
Recurrence (Pm arm) 33% 50%
Recurrence (control arm) 42% 38%
p value ns ns
Pacemaker RDR RDR
Randomized double-blind placebo-controlled trials
Risk Risk
-21%-21%
+32%+32%
VPS II. JAMA 2003; 289: 2224-2229 SYNPACE. Eur Heart J 2004; 25: 1741-8
![Page 35: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/35.jpg)
a substantial placebo effect
of pacemaker implantation
Randomized double-blind placebo-controlled trials
![Page 36: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/36.jpg)
VVS / Limitation of pacingVVS / Limitation of pacing
The vasodepressor component
is not affected by pacing and may be
responsible for the LoC at the time
the pathological reflex develops
![Page 37: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/37.jpg)
It has been suggested that selecting patients
with vasovagal syncope for PM implantation
on the basis of the results of implantable loop
recorder may give better results
Pacing for VVSPacing for VVS
![Page 38: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/38.jpg)
Eur Heart J 2006; 27: 1085-92
![Page 39: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/39.jpg)
Brignole M et al. Eur Heart J 2006; 27: 1085-92
90%
59%1 year
Patients with documentation of asystole by ILR at the time of
spontaneous syncope
PM
![Page 40: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/40.jpg)
Time to first recurrence of syncope according to the intention-to-treat analysis (ISSUE III)
Brignole M et al. Circulation. 2012;125:2566-2571
75%
43%
PM
2 years
![Page 41: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/41.jpg)
Patients who seem to benefit mostly from pacemaker implantation are those with tilt test negative.
Brignole M et al. Circ Arrhythm Electrophysiol. 2014;7:10-16
This is because a positive tilt test might identify patients who are likely to also have a vasodepressor response during VVS, and therefore not respond as well to permanent pacing
![Page 42: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/42.jpg)
Eur Heart J 2009; 30: 2631-2671
![Page 43: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/43.jpg)
VVS / Pacing indication
Class IIa recommendation
Cardiac pacing is recommended in patients 40 years of
age or older, with frequently recurrent and unpredictable
syncope, and with documented spontaneous pauses during
electrocardiographic monitoring (≥3 sec if symptomatic
and ≥6 sec if asymptomatic).
Moya A et al. Eur Heart J 2009; 30: 2631-2671
![Page 44: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/44.jpg)
VVS / Pacing indication
However, owing to the risk of complications following
pacemaker implantation and the fact that electrical
therapy may be ineffective in a significant percentage of
patients considered to be appropriate candidate (25% at 2
years in ISSUE III trial), pacing should be considered
only in highly selected patients, especially those with
repeated injury and limited or absent prodromes.
Sheldon RS et al. Heart Rhythm 2015; 12(6): e41-e63
![Page 45: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/45.jpg)
Therapeutical OptionsTherapeutical Options
ELECTRICAL
• pacemaker• ablation
![Page 46: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/46.jpg)
Europace 2005; 7: 1-13
![Page 47: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/47.jpg)
J Cardiovasc Electropysiol 2009; 20: 558-563
![Page 48: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/48.jpg)
It consists in performing a transcatheter endocardial ablation of the parasympathetic post-ganglionic neurons located inside the atrial wall that allows selective vagal denervation and elimination or
attenuation of the cardioinhibitory reflex of the vasovagal syncope
Pachon JCM et al. Europace 2011;13:1231-1242
![Page 49: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/49.jpg)
Pachon JCM et al. Europace 2011;13:1231-1242
Cardioneuroablation was performed in 43 patients with recurrent VVS and important cardioinhibition at tilt testing
93% of syncopal recurrence during a mean follow-up of 41 months
![Page 50: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/50.jpg)
Considerations
• It is clear that these results, although interesting, need to
be confirmed by future randomized, multicenter trials
before considering cardioneuroablation a consolidated
therapy for vasovagal syncope
![Page 51: Vasovagal syncope management Mexico City 2016](https://reader033.vdocument.in/reader033/viewer/2022051503/5875bc4d1a28ab33128b4911/html5/thumbnails/51.jpg)