Cardioinhibitory variant of syncope induced during a long-term passive orthostatic test

In patients suffering from recurrent syncope and after excluding other possible causes, it is recommended to conduct a longterm passive orthostatic test (tilt test) to document vasovagal disorders. The cardioinhibitory variant is confirmed if fainting occurs when there is a pause on the electrocardiogram. The article contains two clinical examples of the development of syncope with prolonged orthostasis. Patients reported a history of episodes of syncopal states. A long-term passive orthostatic test is a diagnostic method that allows differential diagnosis of syncopal conditions in patients. At the stage of diagnostic examination, both patients underwent computed tomography of the head, echocardiography, daily monitoring of ECG and blood pressure, electroencephalography. All indicators of laboratory and instrumental diagnostic methods in patients were within the normal range. In order to further verify the diagnosis, a long-term passive orthostatic test (tilt test) was prescribed in the department of functional diagnostics of the medical diagnostic center. In both cases, the samples were conducted according to the Westminster Protocol. As a result, syncopal conditions were induced with the development of neuroreflective syncope of the cardioinhibitory type with asystole (1 clinical case) and the development of a cardioinhibitory variant of syncope without asystole (2 clinical case), which were accompanied by convulsive syndrome. Thus, tilt test is used to create prolonged passive stress, which allows to identify the presence of autonomous factors that cause neuroreflective fainting in patients. The demonstrated clinical examples show variants of the development of a cardioinhibitory type of syncope during a tilt test. A positive result is determined by the appearance of clinical signs of presyncope or the development of syncope caused by a decrease in blood pressure and / or heart rate. This technique is indicated in patients with a high probability of a positive tilt test result.

1. Brignole M, Moya A, Lange F, Deharo J, Elliott PM, Fanciulli A et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883–1948. https://doi.org/10.1093/eurheartj/ehy037.

2. Zhienbayeva BS, Mazhirova TB. Paroxysmal states in adults (Literature review). Vestnik KazNMU. 2021;(3):269–272. (In Russ.) Available at: https://cyberleninka.ru/article/n/paroksizmalnye-sostoyaniya-u-vzroslyhliteraturnyy-obzor.

3. Shen W-K, Sheldon RS, Benditt DG, Cohen MI, Forman DE et al. 2017 ACC/ AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2017;70(5):e39–e110. https://doi.org/10.1016/j.jacc.2017.03.003.

4. Salari N, Karimi Z, Hemmati M, Mohammadi А, Shohaimi S. Global prevalence of vasovagal syncope: A systematic review and meta-analysis. Global Epidemiol. 2024;(7):100–136. https//doi.org/10.1016/j.gloepi.2024.100136.

5. Chun KJ, Yim Hr, Park J, Park SJ, Park KM, On YK, Kim JS. Role of baroreflex sensitivity in predicting tilt training response in patients with neurally mediated syncope. Yonsei Med J. 2016;2(57):313–320. https://doi.org/10.3349/ymj.2016.57.2.313.

6. Kuchinskaya EA, Pevsner AV. Lifestyle modification as a method of treatment of vasovagal syncope. Cardiology. 2020;60(1):93–98. (In Russ.) https://doi.org/10.18087/cardio.2020.1.n776.

7. Shibao C, Lipsitz LA, Biaggioni I. ASH position paper: evaluation and treatment of orthostatic hypotension. J Clin Hypertens. 2013;15(3):147–153. https://doi.org/10.1111/jch.12062.

8. Shinohara T, Ebata Y, Ayabe R, Fukui A, Okada N, Yufu K et al. Cardiac autonomic dysfunction in patients with head -up tilt test -induced vasovagal syncope. Pacing Clin Electrophysiol. 2014;37(12):1694–1701. https://doi.org/10.1111/pace.12484.

9. Martone AM, Parrini I, Ciciarello F, Galluzzo V, Cacciatore S, Massaro C et al. Recent advances and future directions in syncope management: A comprehensive narrative review. J Clin Med. 2024;13(3):727. https://doi.org/10.3390/jcm13030727.

10. Serodio FJ, Oliveira MM, Laranjo SM, Tavares C, Cunha PS, Abreu A et al. The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy. Rev Port Cardiol. 2016;35(6):343–350. https://doi.org/10.1016/j.repc.2015.11.021.

11. Ардашев АВ. Клиническая аритмология. М: Медпрактиа; 2009. 1220 с. Режим доступа: https://ardashev-arrhythmia.ru/publications/books/klinicheskaya-aritmologiya/.

12. Brignole M, Moya A, Lange FJ, Deharo J-С, Elliott PM, Fanciulli A et al. Practical Instructions for the 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):e43–e80. https://doi.org/10.1093/eurheartj/ehy071.

13. Brignole M, Moya A, de Lange FJ, Deharo J, Elliott P, Fanciulli A et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Russian Journal of Cardiology. 2019;(7):130–194. (In Russ.) https://doi.org/10.15829/1560-4071-2019-7-130-194.

14. Fu Q, D Levine B. Pathophysiology of neurally mediated syncope: Role of cardiac output and total peripheral resistance. Auton Neurosci. 2014;184:24–26. https://doi.org/10.1016/j.autneu.2014.07.004.

15. Moya A, Sutton R, Ammirati F, Blanc J, Brignole M, Dahm J et al. Guidelines for the diagnosis and management of syncope (2009). Rational Pharmacotherapy in Cardiology. 2010;6(1):108–116. (In Russ.) https://doi.org/10.20996/1819-6446-2010-6-1-108-116.

16. Leung AKC, Leung AA, Wong AH, Hon KL. Breath-Holding Spells in Pediatrics: A Narrative Review of the Current Evidence. Curr Pediatr Rev. 2019;15(1):22–29. https://doi.org/10.2174/1573396314666181113094047.

17. Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74(7):932–987. https://doi.org/10.1016/j.jacc.2018.10.043.

18. Pevzner AV, Zyuzina NE, Kheimets GI, Rogoza AN. Differential diagnosis of vasovagal fainting, orthostatic hypotension and baroreflex failure in a patient with syncope. Kardiologiya. 2018;58(5):91–96. (In Russ.) https://doi.org/10.18087/cardio.2018.5.10126.

19. Lebedev DS, Mikhailov EN, Neminushchiy NM, Golukhova EZ, Babokin VE, Bereznitskaya VV et al. Ventricular arrhythmias. Ventricular tachycardia and sudden cardiac death. 2020 Clinical guidelines. Russian Journal of Cardiology. 2021;26(7):4600. (In Russ.) https://doi.org/10.15829/1560-4071-2021-4600.

20. Petrova NN, Semenova NV. Transitional loss of consciousness as an interdisciplinary problem of diagnosis. V.M. Bekhterev Review of Psychiatry and Medical Psychology. 2023;57(3):30–40. (In Russ.) https//doi.org/10.31363/2313-7053-2023-812.