nach oben

Journal of Interventional Cardiac Electrophysiology

Erschienen in:

07.01.2020 | Vasovagal Syncope

Comparison of trinitroglycerin and adenosine as provocative agents for head-up tilt test in patients with unexplained syncope: a semi-crossover randomized clinical trial with prospective follow-up

verfasst von: Masih Tajdini, Arya Aminorroaya, Behzad Rahimi, Seyedeh Hamideh Mortazavi, Ali Vasheghani Farahani, Saeed Sadeghian, Mehdi Easapour Moghadam, Danesh Soltani, Ali Bozorgi

Erschienen in: Journal of Interventional Cardiac Electrophysiology | Ausgabe 1/2021

Einloggen, um Zugang zu erhalten

Abstract

Purpose

Head-up tilt test (HUTT) is a reasonable diagnostic evaluation for patients with suspected vasovagal syncope; however, its lengthy duration is a remarkable limitation. Although adenosine (AD), as an alternative provocative agent, is a promising option for tackling this shortcoming, it received little appreciation in the literature. We aimed to compare the efficacy and the time to elicit a positive response to HUTT for sublingual trinitroglycerin (TNG) and intravenous AD. Furthermore, we evaluated patients’ outcomes in the follow-up.

Methods

Patients with a chief complaint of transient loss of consciousness (TLOC) were evaluated. We randomized patients with the diagnosis of unexplained syncope after diagnostic evaluations, to undergo TNG-augmented HUTT or AD-augmented HUTT. They were crossed over to receive the other medication in case of negative response to the test. In the follow-up, we evaluated traumatic and non-traumatic TLOCs, hospitalization due to syncope, and death in patients.

Results

We randomized 132 patients (41.70 ± 19.37 years, 52.3% female) to receive TNG (n = 66) or AD (n = 66). Respectively, the positivity rate of TNG and AD for the first and the crossover-HUTT was 31.1% and 26.7%, and 20.5% and 26.2% with no statistically significant differences in both tests (P ˃ 0.50). The time to positive response was significantly shorter for AD than TNG (P < 0.001). In the follow-up, re-admission was significantly more prevalent in HUTT-negative patients compared to HUTT-positive patients (P = 0.04).

Conclusions

We found that diagnostic yield of TNG and AD in HUTT is comparable, while AD acts 4 times faster than TNG in evoking a vasovagal response.

Lee TM, Chen MF, Su SF, Chao CL, Liau CS, Lee YT. Excessive myocardial contraction in vasovagal syncope demonstrated by echocardiography during head-up tilt test. Clin Cardiol. 1996;19(2):137–40.CrossRef

Shalev Y, Gal R, Tchou PJ, Anderson AJ, Avitall B, Akhtar M, et al. Echocardiographic demonstration of decreased left ventricular dimensions and vigorous myocardial contraction during syncope induced by head-up tilt. J Am Coll Cardiol. 1991;18(3):746–51.CrossRef

Forleo C, Guida P, Iacoviello M, Resta M, Monitillo F, Sorrentino S, et al. Head-up tilt testing for diagnosing vasovagal syncope: a meta-analysis. Int J Cardiol. 2013;168(1):27–35. https://doi.org/10.1016/j.ijcard.2012.09.023.CrossRefPubMed

Fenton AM, Hammill SC, Rea RF, Low PA, Shen WK. Vasovagal syncope. Ann Intern Med. 2000;133(9):714–25. https://doi.org/10.7326/0003-4819-133-9-200011070-00014.CrossRefPubMed

Layland J, Carrick D, Lee M, Oldroyd K, Berry C. Adenosine: physiology, pharmacology, and clinical applications. J Am Coll Cardiol Intv. 2014;7(6):581–91. https://doi.org/10.1016/j.jcin.2014.02.009.CrossRef

Fragakis N, Antoniadis AP, Saviano M, Vassilikos V, Pappone C. The use of adenosine and adenosine triphosphate testing in the diagnosis, risk stratification and management of patients with syncope: current evidence and future perspectives. Int J Cardiol. 2015;183:267–73. https://doi.org/10.1016/j.ijcard.2015.01.089.CrossRefPubMed

Carrega L, Saadjian AY, Mercier L, Zouher I, Bergé-Lefranc JL, Gerolami V, et al. Increased expression of adenosine A2A receptors in patients with spontaneous and head-up-tilt-induced syncope. Heart Rhythm. 2007;4(7):870–6. https://doi.org/10.1016/j.hrthm.2007.03.002.CrossRefPubMed

Deharo JC, Mechulan A, Giorgi R, Franceschi F, Prevot S, Peyrouse E, et al. Adenosine plasma level and A2A adenosine receptor expression: correlation with laboratory tests in patients with neurally mediated syncope. Heart. 2012;98(11):855–9. https://doi.org/10.1136/heartjnl-2011-301411.CrossRefPubMed

Saadjian AY, Gerolami V, Giorgi R, Mercier L, Berge-Lefranc JL, Paganelli F, et al. Head-up tilt induced syncope and adenosine A(2A) receptor gene polymorphism. Eur Heart J. 2009;30(12):1510–5. https://doi.org/10.1093/eurheartj/ehp126.CrossRefPubMed

10.

Saadjian AY, Levy S, Franceschi F, Zouher I, Paganelli F, Guieu RP. Role of endogenous adenosine as a modulator of syncope induced during tilt testing. Circulation. 2002;106(5):569–74.CrossRef

11.

Deharo J-C, Guieu R, Mechulan A, Peyrouse E, Kipson N, Ruf J, et al. Syncope without prodromes in patients with normal heart and normal electrocardiogram. J Am Coll Cardiol. 2013;62(12):1075. https://doi.org/10.1016/j.jacc.2013.05.060.CrossRefPubMed

12.

Guieu R, Deharo JC, Ruf J, Mottola G, Kipson N, Bruzzese L, et al. Adenosine and clinical forms of neurally-mediated syncope. J Am Coll Cardiol. 2015;66(2):204–5. https://doi.org/10.1016/j.jacc.2015.04.066.CrossRefPubMed

13.

Franceschi F, By Y, Peyrouse E, Fromonot J, Gerolami V, Kipson N, et al. A2A adenosine receptor function in patients with vasovagal syncope. Europace. 2013;15(9):1328–32. https://doi.org/10.1093/europace/eut066.CrossRefPubMed

14.

Mechulan A, Deharo JC, Giorgi R, Prevot S, Montserrat C, Peyrouse E, et al. Expression of adenosine A2A receptors and ATP-test in patients with syncope of unexplained origin. Eur Heart J. 2010;31:888–9. https://doi.org/10.1093/eurheartj/ehq290.CrossRef

15.

Poorhosseini H, Abbasi SH. The Tehran Heart Center. Eur Heart J. 2018;39(29):2695–6. https://doi.org/10.1093/eurheartj/ehy369.CrossRefPubMed

16.

Sutton R, Petersen M, Brignole M, Raviele A, Menozzi C, & Giani P. Proposed classification for vasovagal syncope. European Journal of Cardiac Pacing and Electrophysiology. 1992;2.

17.

Brignole M, Menozzi C, Del Rosso A, Costa S, Gaggioli G, Bottoni N, et al. New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification: Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Europace. 2000;2(1):66–76. https://doi.org/10.1053/eupc.1999.0064.CrossRefPubMed

18.

Shryock JC, Belardinelli L. Adenosine and adenosine receptors in the cardiovascular system: biochemistry, physiology, and pharmacology. Am J Cardiol. 1997;79(12A):2–10.CrossRef

19.

Iwamoto T, Umemura S, Toya Y, Uchibori T, Kogi K, Takagi N, et al. Identification of adenosine A2 receptor-cAMP system in human aortic endothelial cells. Biochem Biophys Res Commun. 1994;199(2):905–10. https://doi.org/10.1006/bbrc.1994.1314.CrossRefPubMed

20.

Biaggioni I, Olafsson B, Robertson RM, Hollister AS, Robertson D. Cardiovascular and respiratory effects of adenosine in conscious man. Evidence for chemoreceptor activation. Circ Res. 1987;61(6):779–86.CrossRef

21.

Biaggioni I, Killian TJ, Mosqueda-Garcia R, Robertson RM, Robertson D. Adenosine increases sympathetic nerve traffic in humans. Circulation. 1991;83(5):1668–75.CrossRef

22.

Jackson EK. Role of adenosine in noradrenergic neurotransmission in spontaneously hypertensive rats. Am J Phys. 1987;253(4 Pt 2):H909–18. https://doi.org/10.1152/ajpheart.1987.253.4.H909.CrossRef

23.

Mittal S, Stein KM, Markowitz SM, Slotwiner DJ, Rohatgi S, Lerman BB. Induction of neurally mediated syncope with adenosine. Circulation. 1999;99(10):1318–24.CrossRef

24.

Berne RM, Rubio R, Curnish RR. Release of adenosine from ischemic brain: effect on cerebral vascular resistance and incorporation into cerebral adenine nucleotides. Circ Res. 1974;35. https://doi.org/10.1161/01.res.35.2.262.

25.

Mitro P, Habalova V, Evin L, Muller E, Simurda M, Slaba E, et al. Gene polymorphism of the adenosine A2a receptor in patients with vasovagal syncope. Pacing Clin Electrophysiol. 2016;39(4):330–7. https://doi.org/10.1111/pace.12806.CrossRefPubMed

26.

Ueeda M, Thompson RD, Arroyo LH, Olsson RA. 2-Alkoxyadenosines: potent and selective agonists at the coronary artery A2 adenosine receptor. J Med Chem. 1991;34(4):1334–9.CrossRef

27.

Brignole M, Gaggioli G, Menozzi C, Del Rosso A, Costa S, Bartoletti A, et al. Clinical features of adenosine sensitive syncope and tilt induced vasovagal syncope. Heart. 2000;83(1):24–8. https://doi.org/10.1136/heart.83.1.24.CrossRefPubMedPubMedCentral

28.

Mittal S, McNulty EJ, Stein KM, Markowitz SM, Slotwiner DJ, Iwai S, et al. Clinical utility of an adenosine-nitroglycerin tilt test protocol. J Am Coll Cardiol. 2002;39(5):115A.CrossRef

29.

Farwell DJ, Sulke AN. A randomised prospective comparison of three protocols for head-up tilt testing and carotid sinus massage. Int J Cardiol. 2005;105(3):241–9. https://doi.org/10.1016/j.ijcard.2004.10.066.CrossRefPubMed

30.

Kirsch P, Mitro P, Mudrakova K, Valocik G. Diagnostic yield of adenosine and nitroglycerine stimulated tilt test in patients with unexplained syncope. Bratisl Lek Listy. 2007;108(6):259–64.PubMed

31.

Mitro P, Kirsch P. The use of adenosine in the diagnosis of suspected vasovagal syncope. J Cardiovasc Electrophysiol. 2009;20:S85. https://doi.org/10.1111/j.1540-8167.2009.01586.x.CrossRef

32.

Mittal S, Stein KM, Markowitz SM, Iwai S, Guttigoli A, Lerman BB. Single-stage adenosine tilt testing in patients with unexplained syncope. J Cardiovasc Electrophysiol. 2004;15(6):637–40. https://doi.org/10.1046/j.1540-8167.2004.03556.x.CrossRefPubMed

33.

Shen WK, Hammill SC, Munger TM, Stanton MS, Packer DL, Osborn MJ, et al. Adenosine: potential modulator for vasovagal syncope. J Am Coll Cardiol. 1996;28(1):146–54.CrossRef

34.

Watanabe N, Kawasaki S, Oonishi Y, Onuma Y, Munetsugu Y, Itou T, et al. Characteristics of head-up tilt testing with additional adenosine compared with head-up tilt testing with isoproterenol and isosorbide dinitrate. Journal of Arrhythmia. 2014;30(6):473–7. https://doi.org/10.1016/j.joa.2014.02.004.CrossRef

Titel: Comparison of trinitroglycerin and adenosine as provocative agents for head-up tilt test in patients with unexplained syncope: a semi-crossover randomized clinical trial with prospective follow-up
verfasst von: Masih Tajdini
Arya Aminorroaya
Behzad Rahimi
Seyedeh Hamideh Mortazavi
Ali Vasheghani Farahani
Saeed Sadeghian
Mehdi Easapour Moghadam
Danesh Soltani
Ali Bozorgi
Publikationsdatum: 07.01.2020
Verlag: Springer US
Schlagwort: Vasovagal Syncope
Erschienen in: Journal of Interventional Cardiac Electrophysiology / Ausgabe 1/2021
Print ISSN: 1383-875X
Elektronische ISSN: 1572-8595
DOI: https://doi.org/10.1007/s10840-019-00652-6

Neu im Fachgebiet Kardiologie

15.04.2024 | ACC 2024 | Kongressbericht | Nachrichten

Update Kardiologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Springer Medizin

Comparison of trinitroglycerin and adenosine as provocative agents for head-up tilt test in patients with unexplained syncope: a semi-crossover randomized clinical trial with prospective follow-up

Abstract

Purpose

Methods

Results

Conclusions

Neu im Fachgebiet Kardiologie

Verbesserung der HDL-Funktion als Lipidtherapie floppt in Mega-Studie

Blutdrucksenkung per Spritze additiv zur Standardtherapie wirksam

Lässt sich die diabetische Kardiomyopathie aufhalten?

Olezarsen halbiert Triglyzeridwerte

Update Kardiologie

Springer Medizin

Abstract

Purpose

Methods

Results

Conclusions

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 1/2021

Impact of re-definition of paroxysmal and persistent atrial fibrillation in the 2012 and 2016 European Society of Cardiology atrial fibrillation guidelines on outcomes after pulmonary vein isolation

Tachycardia cycle length alternans in orthodromic reciprocating tachycardia due to mutually dependent dual AV node physiology and retrograde supernormal conduction

Dynamic changes in the signal-averaged electrocardiogram are associated with the long-term outcomes after ablation of ischemic ventricular tachycardia

Dextrocardia and atrial fibrillation ablation: relevance of anatomy

The in-ear region as a novel anatomical site for ECG signal detection: validation study on healthy volunteers

Merging three-dimensional CT with electroanatomic mapping facilitates ablation of ventricular arrhythmias originating from aortic root and great cardiac vein

Neu im Fachgebiet Kardiologie

Verbesserung der HDL-Funktion als Lipidtherapie floppt in Mega-Studie

Blutdrucksenkung per Spritze additiv zur Standardtherapie wirksam

Lässt sich die diabetische Kardiomyopathie aufhalten?

Olezarsen halbiert Triglyzeridwerte

Update Kardiologie