1/4. Paroxysmal atrioventricular block induced during head-up tilt test.A 71-year-old female with vasovagal near-syncope suffered from paroxysmal second-degree AV block during Holter monitoring. AV block was easily reproduced during head-up tilt test. She was successfully treated with a dual chamber pacemaker. This treatment is unusual and the role of cardiac pacing in patients with vasovagal symptoms is reviewed.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
2/4. syncope in pharmacologically unmasked brugada syndrome: indication for an implantable defibrillator or an unresolved dilemma?A 30-year-old Caucasian male was referred for evaluation of a 2-year history of recurrent post-exertion lightheadedness and near syncopal spells in the setting of a family history of unexplained sudden cardiac death. Cardiac evaluation demonstrated normal heart structure, but the 12-lead surface ECG was suggestive of but not diagnostic of brugada syndrome. An exercise stress test reproduced the patient's usual symptoms during the recovery period, and was consistent with a typical vasovagal faint. The same symptoms were observed during a head-up tilt table test. However, given the family history and ECG, pharmacological testing with procainamide, isoprenaline and metoprolol, as well as programmed ventricular stimulation, were undertaken. Pharmacological provocation further supported a diagnosis of brugada syndrome, whereas programmed ventricular stimulation was considered non-diagnostic regarding ventricular tachyarrhythmia susceptibility. Consequently, despite ECG and pharmacological findings suggestive of brugada syndrome, there appeared to be sufficient evidence to believe that this patient's symptoms were the result of neurally mediated syncope and not due to ventricular tachyarrhythmias. The patient was treated with midodrine, and has remained symptom-free for 16 months. Thus, given the frequency with which vasovagal syncope occurs in young patients, its occurrence is not unexpected in individuals with concomitant diagnoses such as brugada syndrome. In as much as current recommendations favour implantable defibrillators in symptomatic brugada syndrome, the identification of other causes of syncope in such patients poses an uncomfortable, and currently unsettled dilemma.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
3/4. syncope during exercise, documented with continuous blood pressure monitoring during ergometer testing.A 27-year old female had one episode of transient loss of consciousness and several of near-unconsciousness during strenuous exercise and sexual activity. Episodes started with abdominal discomfort or nausea and light headedness. unconsciousness never exceeded one minute. When trying to stand up, she felt she would lose consciousness again. We performed a bicycle ergometer exercise test, continuously monitoring blood pressure via non-invasive finger photoplethysmography (Finometer, FMS, The netherlands). Beat-to-beat changes in stroke volume, cardiac output and total peripheral resistance were calculated using Modelflow (FMS, The netherlands). At a power of 140 W, the patient reported being near exhaustion; shortly after this she reported nausea. She stopped cycling 30 s later, then saw "black spots" and felt an oncoming loss of consciousness. Dismounting the ergometer and squatting provided immediate relief from symptoms. Symptoms during the test were similar to those during previous episodes. The diagnosis was exercise-induced vasovagal reactions. This is the first report that documents the beat-to-beat changes in blood pressure, stroke volume and total peripheral resistance during exercise-induced vasovagal syncope. It illustrates the usefulness of combining exercise testing with continuous non-invasive blood pressure monitoring in the diagnostic work-up of exercise-induced syncope, and shows the therapeutic value of squatting to prevent loss of consciousness in exercise-related vasovagal syncope.- - - - - - - - - - ranking = 2keywords = near (Clic here for more details about this article) |
4/4. Outcome of biofeedback-assisted relaxation for neurocardiogenic syncope and headache: a clinical replication series.Preliminary evidence exists through single case reports that psychophysiological interventions may be useful in the treatment of syncope (fainting). To explore this possibility, a case series of ten patients with histories of recurrent unexplained syncope or near syncope, headache, and a poor response to or tolerance for medication was performed. All patients were treated with electromyographic, thermal, biofeedback as well as progressive and autogenic relaxation. Six of the ten patients showed a major decrease in symptoms at the end of treatment. Descriptive comparisons between the improved and unimproved group were made and a detailed case study of one improved patient is presented. The results suggested that biofeedback-assisted relaxation treatment was most effective in younger patients whose syncope was associated with a strong psychophysiological response and whose headaches were intermittent, not daily occurrences.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |