Neurocardiogenic syncope pacemaker therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]
Overview
Neurocardiogenic syncope is usually a self-limited episode of systemic hypotension characterized by both bradycardia (asystole or relative bradycardia) and peripheral vasodilation.[1][2]
Dual chamber pacing (DDD) is indicated only in patients with refractory neurocardiogenic syncope with significant bradycardia or asystole. In addition to cardiac pacing, adjunctive medical therapy may also be required as cardiac pacing alone has shown to be ineffective.
Indications
- Refractory neurocardiogenic syncope with significant bradycardia or asystole.[3][4][5] Among patients with significant bradycardia, despite the successful demonstration of permanent pacers to increase time to first syncopal episode and to reduce recurrent episodes by the VASIS study [3] and the VPS study [5] respectively, the recent VPS-II study, did not demonstrate any reduction in the risk of recurrent syncopal events.[6] Therefore, the use of cardiac pacing in such patient population still remains controversial.
- If cardiac pacing is indicated, dual chamber pacing is preferred following the demonstration of a strong positive tilt table test. Adjunctive medical therapy should be continued as it has shown to be more effective than pacing alone.
ACC/AHA Guidelines- Permanent Pacing in Hypersensitive Carotid Sinus Syndrome and Neurocardiogenic Syncope (DO NOT EDIT)[7]
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Class I1. Permanent pacing is indicated for recurrent syncope caused by spontaneously occurring carotid sinus stimulation and carotid sinus pressure that induces ventricular asystole of more than 3 seconds.[8][9] (Level of Evidence: C) Class IIa1. Permanent pacing is reasonable for syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer.[8] (Level of Evidence: C) Class IIb1. Permanent pacing may be considered for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing.[4][3][6][10] (Level of Evidence: B) Class III1. Permanent pacing is not indicated for a hypersensitive cardioinhibitory response to carotid sinus stimulation without symptoms or with vague symptoms. (Level of Evidence: C) 2. Permanent pacing is not indicated for situational vasovagal syncope in which avoidance behavior is effective and preferred. (Level of Evidence: C) |
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Guideline Resource
The ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities [7]
References
- ↑ Grubb BP (2005). "Neurocardiogenic syncope and related disorders of orthostatic intolerance". Circulation. 111 (22): 2997–3006. doi:10.1161/CIRCULATIONAHA.104.482018. PMID 15939833. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help) - ↑ Benditt DG, Ferguson DW, Grubb BP, Kapoor WN, Kugler J, Lerman BB, Maloney JD, Raviele A, Ross B, Sutton R, Wolk MJ, Wood DL (1996). "Tilt table testing for assessing syncope. American College of Cardiology". Journal of the American College of Cardiology. 28 (1): 263–75. PMID 8752825. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 3.2 Sutton R, Brignole M, Menozzi C, Raviele A, Alboni P, Giani P, Moya A (2000). "Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope : pacemaker versus no therapy: a multicenter randomized study. The Vasovagal Syncope International Study (VASIS) Investigators". Circulation. 102 (3): 294–9. PMID 10899092. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help) - ↑ 4.0 4.1 Ammirati F, Colivicchi F, Santini M (2001). "Permanent cardiac pacing versus medical treatment for the prevention of recurrent vasovagal syncope: a multicenter, randomized, controlled trial". Circulation. 104 (1): 52–7. PMID 11435337. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help) - ↑ 5.0 5.1 Connolly SJ, Sheldon R, Roberts RS, Gent M (1999). "The North American Vasovagal Pacemaker Study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope". Journal of the American College of Cardiology. 33 (1): 16–20. PMID 9935002. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help) - ↑ 6.0 6.1 Connolly SJ, Sheldon R, Thorpe KE, Roberts RS, Ellenbogen KA, Wilkoff BL, Morillo C, Gent M (2003). "Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial". JAMA : the Journal of the American Medical Association. 289 (17): 2224–9. doi:10.1001/jama.289.17.2224. PMID 12734133. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help) - ↑ 7.0 7.1 Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW (2008). "ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons". Circulation. 117 (21): e350–408. doi:10.1161/CIRCUALTIONAHA.108.189742. PMID 18483207. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help) - ↑ 8.0 8.1 Brignole M, Menozzi C, Lolli G, Bottoni N, Gaggioli G (1992). "Long-term outcome of paced and nonpaced patients with severe carotid sinus syndrome". The American Journal of Cardiology. 69 (12): 1039–43. PMID 1561975. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Brignole M, Menozzi C, Gianfranchi L, Oddone D, Lolli G, Bertulla A (1991). "Neurally mediated syncope detected by carotid sinus massage and head-up tilt test in sick sinus syndrome". The American Journal of Cardiology. 68 (10): 1032–6. PMID 1927916. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help) - ↑ Sheldon R, Koshman ML, Wilson W, Kieser T, Rose S (1998). "Effect of dual-chamber pacing with automatic rate-drop sensing on recurrent neurally mediated syncope". The American Journal of Cardiology. 81 (2): 158–62. PMID 9591898. Retrieved 2012-05-17. Unknown parameter
|month=ignored (help)