Tilt training EM R1 송진우

Transcription

1 Tilt training EM R1 송진우

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3 Introduction North American Vasovagal Pacemaker Study Randomized, controlled trial Reduction in the likelihood of syncope by dual chamber pacing with rate drop response No significant effect of pacing on the occurence of presyncope Repeated diagnostic tilt table test in neurocardiogenic syncope Improvement of tilt tolerance Repeated exposure of cardiovascular system to orthostatic stress could have a therapeutic effect on the regulation of cardiovascular reflex mechanisms Possible therapeutic effect of repeated tilt testing was suggested earlier : Morillo et al., Sheldon et al. Purpose To evaluate the effect of continued tilt training on the orthostatic tolerance in patients with neurocardiogenic syncope

4 Patients and Methods 42 patients With neurocardiogenic syncope Recurrent neurocardiogenic syncope At least one positive head-up tilt test Between 1995~1998 Admitted to hospital for a diagnostic workup for a program of tilt table training

5 Patients and Methods Head-up tilt table test According to the Westminster protocol 15 min. resting period in recumbent position Patients were tilted to the upright position at a standard angle of 60 Continuous ECG monitoring During the procedure Heart rate and blood pressure Measured in recumbent position At the end of resting period 3 min after assuming the upright position Every 5 min during the tilt test Negative If the patient could sustain the tilt procedure for 45 min.

6 Patients and Methods Tilt training The same procedure was adopted as for diagnostic tilt testing Tilted daily to 60 position until syncope or severe orthostatic intolerance occurred Target To obtain 2 consecutive negative tilt table tests After hospital discharge Instructed to continue a program of daily tilt training at home One or two sessions per day for 30 minutes To stand with their feet 15cm away from the wall and lean with the upper back against a wall without moving Follow-up Returned to the hospital for control tilt tests Contact by telephone

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8 Results Diagnostic head-up tilt test Positive tilt test After a mean duration of 21 minutes (SD 13 minutes, minimum 20s) Type of syncope Cardioinhibitory : 14 cases (33%) Vasodepressor : 19 cases (45%) Mixed : 9 cases (22%) Duration of positive tilt test Cardioinhibitory : mean 14.8 min, SD 9 min Vasodepressor : mean 22.9 min, SD 14 min Mixed : 26.5 min, SD 15 min

9 Results Tilt training and Follow-up First negative tilt test result Second session : 18 cases (43%) Third session : 9 cases (21%) Fourth session : 8 cases (19%) Fifth session : 3 cases (7%) Sixth session : 3 cases (7%) Eighth session : 1 cases (2%) Mean 3.24, median 3, SD 1.46 At home, self tilt training Follow-up period : mean 15 months, SD 7.3 months 28 of 42 pt. : continuing tilt training at home 25 of 28 pt. : completely asymptomatic 3 of 28 pt. : still had presyncope 13 of 42 pt. : discontinued tilt training 11 of 13 pt. : completely asymptomatic 1 of 13 pt. : occasional presyncope 1 of 13 pt. : syncope, every 3 months

10 Results Effect of tilt training 36 of 42 pt. (86%) Remained completely free of syncope Mean follow-up 16 months, SD 7.8 months 4 of 42 pt. (9.5% ) Still experienced presyncope 1 of 42 pt. Still experienced syncope 1 of 42 pt. Died from MI At the time of hospital discharge 41 of 42 pt. Could support 45 minutes of head-up tilting 1 of 42 pt. Symptoms persisted though all of eight in hospital tilt training sessions After discharge, with regular tilt training, he became asymptomatic

11 Discussion Morillo et al. In disopyramide study Firstly observe a striking decrease in the incidence of positive tilt tests over time Sheldon et al. Apparent reduction in the risk of a recurrence of syncope after a positive tilt table test The cause might be due to Natural history Reassurance Counseling Coaching on appropriate postural maneuvers

12 Discussion Pharmacological agents to prevent neurocardiogenic syncope No pharmacological agent has proven to be successful overall Cardiac pacing Little effect on the occurrence of presyncope Tilt training method 36 patients (86%) : asymptomatic 4 patients (9.6%) : still with presyncope 1 patients : symptomatic with syncope

13 Discussion Neurally mediated syncope is the result of an imbalance between orthostatic tolerance and gravitational stress Orthostatic intolerance occurs commonly after space flight 9 of 14 crew members could not complete a 10-minute stand test after returning to Earth The lack of gravitational stress can lead to deconditioning of orthostatic tolerance in otherwise healthy subjects Prolonged bed rest experiments for 30 days, daily application of lower body negative pressure prevented orthostatic hypotension and syncope Tilt training Corrects the intolerance for gravitational stress from conditioning of orthostatic reflexes Augments the skeletal pump decreasing peripheral pooling When will stop tilt training?