Vasovagal Syncope and Bradyarrhythmias Mechanisms, distinguishing cause and effect
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1 Vasovagal Syncope and Bradyarrhythmias Mechanisms, distinguishing cause and effect Walid Saliba, MD, FHRS, FACC Director EP lab Director Atrial Fibrillation Center Department of Cardiovascular Medicine Cleveland Clinic
2 ESC 2018 Eur Heart J Jun 1;39(21):
3 1. Reflex Syncope (aka NMS / NCS) Vasovagal syncope 1. Upright posture or sitting, emotional stress, pain, or medical settings. 2. Features: diaphoresis, warmth, nausea, and pallor; 3. Vasodepressor hypotension and/or inappropriate bradycardia 4. Followed by fatigue Situational syncope Coughing, laughing, swallowing, micturition, or defecation Carotid Sinus Syndrome Tight collar, necktie, carotid massage Eur Heart J Nov;30(21) Heart Rhythm, Vol 12, No 6, June 2015
4 1. Reflex Syncope - Vasovagal Mechanisms Exagerated Cardiovascular reflexes in regulating BP C Fibers Cardio-inhibitory component Vasodpressor component
5 Reflex Vasovagal Syncope
6 EKG Progressive slowing of the SR (may be rapid) +/- Increase in PR Sinus Arrest or AVB Asystole
7 Diagnosis History History History History History History History History History History History - Younger age (CSS more in elderely) - No Known Cardiac disease - Syncope in the standing position - Presence of prodrome : Nausea, vomiting, yawning, feeling warmth, diaphoresis - Presence of specific triggers: pain, distressful stimulus, medical environment - Situational triggers: cough, laugh, micturition, deglutition, defecation, prolonged standing. - Recurrences of syncope with similar characteristics.
8 Management of reflex syncope ACC/AHA Treatment for VVS Lifestyle modification Avoid triggering events Avoid dehydration, vasodilatation (etoh) Physical counterpressure maneuves Leg crossing, thigh muscle contractions, squatting Leg compression support stockings Increased salt (2-4 g daily), fluid hydration Disappointing/ Frustrating Circulation Aug 1;136(5):e25-e59
9 Pacemakers Overall limited role in Vasovagal Syncope Vasovagal syncope usually both vasodepressor as well as cardioinhibitory - Tilt test can be used to help identify patient who may not benefit from PPM (2B)
10 ISSUE 3 77 pts (age >40 yrs) Syncope (with asystole) - >3 sec asystole or - 6 sec asystole without syncope on ILR PPM implanted Rate Drop Response vs Sensing only Recurrence: PPM OFF 57% vs. PPM ON 25% RRR 56% COR LOE Recommendation IIb B-R SR population of patients 40 years of age or older with recurrent VVS and prolonged spontaneous pauses. Dual-chamber pacing might be reasonable in a select Circulation. 2012; 125:
11 2. Bradyarrhythmia Sinus node Dysfunction (SSS) AV block - 2 nd / 3 rd. Degree AVB - High Grade - 2:1 AV block
12 Sinus Node / AV node Dysfunction: Causes Idiopathic degenerative fibrosis Congenital heart disease Musculoskeletal disorder Infiltrative disorders (amyloid..) Infectious diseases (Lyme..) Inflammatory disease (Sarcoid..) Cardiothoracic surgery Pathologic Reversible Physiologic Pharmacologic agents* (BB,CCB,AAD..) Electrolyte disturbances Hypothyroidism Ischemia (including infarction) Hypothermia Sleep apnea Increased vagal tone (athlete.. ) Coughing, Vomiting, Defecation, micturition
13 Case 1 55 year old architect No structural heart disease Athletic, jogs 45 minutes every day Developed recurrent palpitations and 2 episodes of syncope WHAT NEXT? 1. PPM + Beta Blockers 2. PPM + AAD 3. Reassure 4. Other: AF ablation
14 Sinus node dysfunction improved after AF catheter ablation No recurrences of presyncopal events or documented sinus pauses in patients with successful AF ablation without a PPM. Patients with a pacemaker had a 13-fold reduction in atrial pacing (64% vs 5%)
15 Case 2 51 year old male with no significant PMH Admitted for recurrent syncope EKG: 2:1 AV block; does not improve with walking Echo: LVEF 50%, Inf WMA Cath: Normal coronaries? h/o tick bite 1 year ago lime titers negative Thyroid normal / no meds EKG following day; feels better
16 Case 2 FDG-PET - The total Myocardium Perfusion Defect is 6 %. - The total Myocardium with Inflammation is 40 % Bronch: TBNA: Non caseating granuloma Started on Prednisone 30 mg/d Do we have a diagnosis? Now what? PPM? ICD? CRT? CRT-D?
17 Case 3 66 year old male Known to have slow heart beat Refused pacemaker in the past Good exercise tolerance No syncope Echo: Normal size LV. Normal LVEF
18 Case 4 68 year old ; BMI 28kg/m2 HTN on Lisinopril Intermittent Palpitations Given atenolol 100/d Infrequent dizziness upon getting up from a sitting position
19 Case 4 Holter 4:00 AM Holter: Intermittent episodes of. Dizziness at 11: 00am correlated with SR at 95bpm
20 Case 5 19 year old male athlete Asymptomatic Coming for check up: Told he had irregular pulse.
21 Case 6 56 year old Infrequent Parox AF with dizziness ASA and Metoprolol 25 mg bid. Normal LVEF, Normal Stress 90% THR MCOT to evaluate AF burden No syncope/presyncope 1. Should you be concerned? 2. Stop BB? 3. Reassurance AV Block
22 Paroxysmal AV block No PR prolongation Sinus 1:1 Increase in SR Slowing in SR AV Block Increase in SR Junctional Resumption of 1:1
23 Case 7 68 year old female s/p liver transplant, intubated in the ICU, s/p tracheostomy We are called to evaluate recurrent pauses for possible Pacemaker placement 1. Mobitz type I block 2. Post conversion pause 3. Vagal mediated block 4. Sinus node exit block
24 Case 8 70 year old with intermittent dizziness
25 EP STUDY Risk of AVB in patients with conduction diseases HV < 55 ms 4% HV > 70 ms 12% HV > 100 ms 24% Pacing dependent infranodal block High Pharmacologic HV > 120 ms Uncertain Syncope, -ve EPS with ILR implantation One third
26 Baseline Intervals A H V HV
27 Case 8 Where is the site of block on this tracing? 1. AV node 2. Infra His
28 Case 9 45 year old female with several months history of palpitations, bradycardia and exercise intolerance; not feeling well. No syncope. No prior history of heart disease. Diagnosed with Afib and paroxysmal AV block and advised PPM placement and AAD therapy. Echo: Normal Other work up: - CT scan of chest normal. - Cardiac MRI Normal.
29 EKG #1 in the office
30 Feels Terrible 2:1 AV block? 2:1 AV block with?pac s Pailpitations Parox AF?
31 A AV Node V Presence of nodoventricular accessory pathway with retrograde conduction
32 A AV Node V
33 A case of AV block treated with Ablation
34
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