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Home , Paroxysmal attack, Syncope (medicine)

Circ J 2002; 66: 866–868

Neurally Mediated Syncope Manifesting During A Case Report

Takeshi Shirayama, MD; Keiji Inoue, MD; Takashi Sakamoto, MD; Midori Yamamura, MD; Hiroki Mani, MD; Akiko Yoshida, MD; Hiroto Imai, MD; Yayoi Matoba, MD; Masao Nakagawa, MD

A 64-year-old male was admitted to hospital because of repeated episodes of syncope and palpitation. Ambulatory monitoring revealed paroxysmal atrial fibrillation (AF) as the cause of palpitation; he did not have structural . The induction of AF by rapid pacing (50Hz for 1s) in an upright position provoked syncope with a vasodepressor response. Atropine sulfate blocked the induction of syncope. The possible etiology was neurally mediated syncope that manifested only during AF, which suggests that the abnormal vagal activity during AF in this case exaggerated the vasodepessor response while upright. (Circ J 2002; 66: 866–868) Key Words: Atrial fibrillation; Head-up tilt; Neurally mediated syncope; Vagal

yncope is often encountered in an emergency room, Laboratory tests revealed hyperlipidemia (triglyceride, but its etiology is not always clear. Neurally medi- 240mg/dl; total cholesterol, 208mg/dl) and hyperuricemia S ated syncope, which is characterized by abnormal (8.6 mg/dl). Liver enzymes (aspartate aminotransferase, vagal reflex, has been recently recognized as a major cause alanine aminotransferase,γ-glutamyl transpeptidase) were of syncopal episodes,1–3 and it can be provoked repeatedly normal. pressure was 132/70mmHg, and heart rate by the head-up tilt test with fairly good sensitivity.2,4 A was regular at 85beats/min. The ECG was normal, as was paroxysmal attack of atrial fibrillation (AF) is another ultrasonic . Ambulatory ECG monitoring pathological entity that can be concomitant with increased revealed occasional episodes of AF concurrent with palpi- vagal tone,5 but because this hardly ever causes tation (Fig1). Paroxysmal AF (heart rate ~150beats/min) collapse while the patient has a structurally normal heart, was recorded during an episode of with collapse. syncope induced by the interaction of these 2 has Neither nor long pause was recorded. The been neglected as a diagnosis.6–8 electroencephalogram was normal, which excluded epilep- We describe a patient who suffered from syncope only sy. Because no episode of syncope was detected during the in the presence of AF. The head-up tilt test was negative, hospital stay, a cardiac electrophysiological study was but the induction of AF caused faintness or syncope in an performed. Maximum sinus node recovery time was upright position. 1,240 ms and corrected sinus node recovery time was 420 ms. Sino-atrial conduction time was 114 ms. Atrio- ventricular conduction was normal (effective refractory Case Report period: 240ms, functional refractory period: 390ms, basic A 64-year-old male was admitted to hospital because of cycle length 500ms). No arrhythmia was induced by the repeated episodes of syncope during palpitation attacks for extrastimulus method, but AF was easily induced by rapid the past 7 months. He would lose abruptly, but recovered within 1min without neurological symp- toms. His history showed that he had had palpitation attacks for 20 years under the diagnosis of ‘arrhythmia’. He had general fatigue, and occasional sweating, with the , but had never had syncope or faintness until recently. Physical examination showed mild hepatomegaly, pos- sibly related to alcohol intake (800–900ml of Japanese sake daily for 40 years), but otherwise normal findings.

(Received June 18, 2001; revised manuscript received August 16, 2001; accepted August 31, 2001) Kyoto Prefectural University of , Second Department of Medicine, Kyoto, Japan Fig1. ECG recording during a palpitation attack shows atrial fibril- Mailing address: Takeshi Shirayama, MD, PhD, Kyoto Prefectural lation. The onset and the offset of the attack are shown. This strip was University of Medicine, Second Department of Medicine, Kawara- recorded in a monitor lead (a bipolar lead between the right upper machi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan chest and the center of the lower chest).

Circulation Journal Vol.66, September 2002 Syncope During AF 867 pacing (50Hz, 1s) at the right atrial appendage (the AF threshold was 3 mA)9,10 and sinus rhythm was restored spontaneously within 10min. the patient’s hemodynamics were stable and no syncope was induced. A head-up tilt test was performed to ascertain if there was an autonomic nerve etiology. Because palpitation always preceded his syncope, a temporary pacing electrode was inserted to induce the arrhythmia. was measured manually by a cuff-method at 1-min intervals and ECG (10-s strip) was recorded at the same time. When AF was induced, the ECG was continuously recorded until the arrhythmia was terminated (Fig2). In the supine posi- tion, the induction of AF increased heart rate, but did not cause any change in blood pressure. At the head-up posi- Fig2. Hemodynamics during a head-up tilt test. Atrial fibrillation tion of 80 degrees for 20min, systolic blood pressure was induced by rapid pacing (50 Hz for 1 s) at the right atrial decreased slightly (152/68mmHg to 120/70mmHg) before appendage in the supine and head-up (80°) positions. In the supine stabilizing and no syncope was observed. After the induc- position, blood pressure did not decrease during atrial fibrillation, but tion of AF, blood pressure decreased to 66/30mmHg with in the head-up position, it decreased to 66/30mmHg and the patient lost consciousness. The decrease in blood pressure during sinus loss of consciousness. Blood pressure recovered when the rhythm while head-up was modest, and the hemodynamics were AF terminated spontaneously. stable before the induction of the arrhythmia. The effects of autonomic drugs were examined during the head-up tilt test (Table1). Isoproterenol infusion at a dose of 0.5μg/min increased sinus heart rate by 20%, and Neurally mediated syncope is a major cause of syncope1–3 facilitated the maintenance of AF, but it did not cause a and is characterized by a sudden onset of syncope that vasodepressor response in the head-up position. Atropine follows some early signs such as blurred vision, but without sulfate (0.05mg/kg body weight) blocked the vasodepres- any neurological sequelae. Careful history taking often sor response during AF, but not the induction of AF. After helps diagnose this syndrome. Recently, the head-up tilt pharmacological denervation with propranolol (0.2mg/kg) test has been used to evaluate the syncope and an abnormal and atropine (0.05mg/kg), neither sustained AF nor vaso- vagal response has been reported.4 However, in the present depressor response was induced. case, the head-up tilt test revealed a modest vasodepressor The patient had severe urinary retention after the oral response, but could not induce his symptoms. disopyramide (300mg/day) that was administered to block Taking into consideration that in most cases AF could the abnormal vagal reflex and AF, so he was given oral occur under the strong influence of vagal tone,5 we sus- pilsicainide (150mg/day) to prevent the AF and has not had pected that the mechanism of this patient’s syncope was the a syncopal episode for 1 year. concurrent emergence of AF and a vasodepressor reaction caused by an abnormal neural response. Indeed, an abnor- mal vasodepressor response during paroxysmal supra- Discussion ventricular has been reported,11 and another Recurrent syncope is a common clinical problem, but its report observed that the arrhythmia occurred more often etiology is sometimes difficult to detect.1,3 When there are during the head-up tilt test in patients who suffered from preceding palpitations, the syncope is usually caused by a tachycardia.12 Thus we tried to induce AF during the head- tachyarrhythmia that disturbs the hemodynamics. The up tilt test to see if the syncope could be reproduced, with a present case always had palpitations before he experienced positive result, but a somewhat complex mechanism. The syncope, but only AF was recorded during ambulatory test revealed that the maintenance of AF was facilitated by monitoring, and his symptoms were reproducible during an adrenergic mechanism, because the arrhythmia was the arrhythmia, which usually does not cause syncope in sustained for longer in the presence of isoproterenol or patients whose cardiac function is normal. No ventricular atropine, but was blocked by propranolol. On the other arrhythmia was induced during the clinical electrophysio- hand, the vasopressor response was induced under the influ- logical test. ence of vagal tone, because atropine blocked the response

Table 1 Heart Rate and Blood Pressure During the Head-up Tilt Test and the Effects of Drugs Atrial fibrillation Sinus rhythm Patient position max HR av HR min BP AF duration av HR BP Supine Control 140 135 146/72 33 s 85 152/68 Isoproterenol 168 154 118/60 2.5 min 103 116/56 Head-up Control 180 163 66/30 2 min 92 120/70 Isoproterenol ––––110106/64 Atropine 180 170 104/56 15 min 102 136/74 Denervation 150 130 144/60 24 s 81 154/84

Doses of drugs: isoproterenol, 0.5μg/ml; atropine, 0.05 mg/kg; propranolol, 0.2 mg/kg. denervation = atropine + propranolol. HR, heart rate; BP, blood pressure; AF, atrial fibrillation.

Circulation Journal Vol.66, September 2002 868 SHIRAYAMA T et al.

(Fig 2, Table 1). The AF possibly influenced vagal tone multicentre prospective trial: The OESIL 2 study (Osservatorio Epidemiologico della Sincope nel Lazio). Eur Heart J 2000; 21: 877– afferently, which exaggerated the vasodepressor response. 880. Atrial rapid pacing induced AF, but the patient did not have 3. Savage DD, Corwin L, McGee DL, Kannel WB, Wolf PA. Epi- an abnormality in either sinus node or atrioventricular node demiologic features of isolated syncope: The Framingham Study. function, so the bradycardia–tachycardia syndrome can be 1985; 16: 626–629. excluded. 4. Linzer M, Yang EH, Estes NA 3rd, Wang P, Vorperian VR, Kapoor WN. Diagnosing syncope. Part 2: Unexplained syncope: Clinical It is possible that AF with a rapid ventricular response Efficacy Assessment Project of the American College of Physicians. could decrease cardiac output, which would lead to a Ann Intern Med 1997; 127: 76–86. significant fall in blood pressure. However, AF in the 5. Coumel P. Autonomic influences in atrial tachyarrhythmias. J supine position did not change blood pressure at all, despite Cardiovasc Electrophysiol 1996; 7: 999–1007. 6. Leitch J, Klein G, Tee R, Murdock C, Teo WS. Neurally mediated a rapid heart rate, and was also the case after injection of syncope and atrial fibrillation. N Engl J Med 1991; 324: 495–496. atropine in the head-up position (Table1). These observa- 7. Kato H, Masutani S, Hoshiyama M, Shibuya K, Isoda T, Hishi T, et tions suggest that the arrhythmia itself did not cause the al. Neurally mediated syncope complicated with paroxysmal atrial deterioration in his hemodynamics, but exaggerated the fibrillation. Acta Paediatr Jpn 1996; 38: 695–698. 8. Brignole M, Gianfranchi L, Menozzi C, Raviele A, Oddone D, Lolli abnormal vasodepressor response of the vagal nerve. G, et al. Role of autonomic reflexes in syncope associated with paroxysmal atrial fibrillation. J Am Coll Cardiol 1993; 22: 1123– 1129. Conclusion 9. Ishibashi K, Inoue D, Sakai R, Inoue M, Shirayama T, Asayama J, et We report here a case of neurally mediated syncope that al. Effects of disopyramide on the atrial fibrillation threshold in the human atrium. Int J Cardiol 1995; 52: 177–184. was exaggerated by AF, which is an unusual but very 10. Inoue K, Shirayama T, Shiraishi H, Matoba Y, Imai H, Inoue D, et important mechanism of syncope. This case is instructive al. Clinical significance of the atrial fibrillation threshold in patients in recognizing the cause of syncope. with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol 2001; 24: 796–805. 11. Leitch JW, Klein GJ, Yee R, Leather RA, Kim YH. Syncope associ- References ated with supraventricular tachycardia. An expression of tachycardia rate or vasomotor response? Circulation 1992; 85: 1064–1071. 1. Hori S. Diagnosis of patients with synope in emergency medicine. 12. Shinohara M, Kobayashi Y, Obara C, Miyata A, Chiyoda K, Keio J Med 1994; 43: 185–191. Nakagawa H, et al. Neurally mediated syncope and : A 2. Ammirati F, Colivicchi F, Santini M. Diagnosing syncope in clinical study of syncopal patients using the head-up tilt test. Jpn Circ J 1999; practice: Implementation of a simplified diagnostic algorithm in a 63: 339–342.

Circulation Journal Vol.66, September 2002