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Neurocardiogenic Syncope and Associated Conditions: Insight Into Autonomic Nervous System Dysfunction

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Neurocardiogenic Syncope and Associated Conditions: Insight Into Autonomic Nervous System Dysfunction Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol 2013;41(1):75-83 doi: 10.5543/tkda.2013.44420 75 Neurocardiogenic syncope and associated conditions: insight into autonomic nervous system dysfunction Nörokardiyojenik senkop ve ilişkili durumlar: Otonomik sinir sistemi işlev bozukluğuna bir bakış Antoine Kossaify, M.D., Kamal Kallab, M.D. Department of Syncope and Electrophysiology, ND Secours/USEK University Hospital, Byblos, Lebanon Summary– Neurocardiogenic syncope is known to be asso- Özet– Nörokardiyojenik senkopun mekanizması hala tam ola- ciated with autonomic nervous system dysfunction, although rak aydınlatılamamasına ragmen otonom sinir sistemi işlev the mechanism has not been entirely elucidated. In this study, bozukluğu ile ilişkili olduğu bilinmektedir. Bu yazıda nörokardi- we sought to highlight the pathogenic role of the autonomic yojenik senkop patogenezinde otonom sinir sisteminin rolünü nervous system in neurocardiogenic syncope and to review destekleyen en göze çarpıcı konuları araştırırken, temelinde the associated co-morbidities known to have a dysautonomic otonom sinir sistemi bozukluğunun olduğu bilinen komorbid basis. Herein we discuss migraine, orthostatic hypotension, durumları da gözden geçidik. Bu amaçla otonom sinir siste- postural orthostatic tachycardia syndrome, endothelial dys- minin patogenezdeki rolü ve klinik çıkarımları üzerine odak- function, chronic fatigue syndrome, and carotid sinus hyper- lanarak migren, ortostatik hipotansiyon, postüral ortostatik sensitivity with a focus on the pathogenic role of the autonom- taşikardi sendromu, endotel işlev bozukluğu, kronik yorgunluk ic nervous system and any consecutive clinical implications. sendromu ve karotis sinüs hipersensitivitesi tartışıldı. Tilt testi Other conditions, such as pre-syncopal heart rate acceleration sırasında ortaya çıkabilen senkop öncesi kalp atımlarında hız- and/or instability and pre-syncopal breathing instability, which lanma ve/veya instabilite ve senkop öncesi instabil solunum occur during a tilt test, are discussed in the same perspective. gibi durumlar da aynı perspektif içinde tartışıldı. atients presenting with syncope are often diffi- perfusion. A clinically sig- Abbreviations: cult to manage, especially if the episode was not nificant deficiency in one P ANS Autonomic nervous system witnessed. Neurocardiogenic syncope (NCS) is the or more of these processes NCS Neurocardiogenic syncope most frequent cause of syncope, and treatment strate- may lead to syncope.[1] gies are based on an incomplete understanding of its Current knowledge about the pathophysiology of pathophysiology, although autonomic nervous system NCS is still limited, although there are often common (ANS) dysfunction is known to be a major determi- triggering factors such as excessive pain, heat, or fear, nant.[1] which are known to initiate an intense sympathetic re- During a sustained upright posture under normal action. In addition, orthostatis has been suggested as conditions, the decrease in venous return triggers a re- a main triggering factor, which leads to a reduction in flex sympathetic reaction that is counteracted by a bal- venous return and activates the mechanoreceptors of anced vagal reaction. Complex interactive processes the heart, resulting in vigorous myocardial contrac- involving cardiac output, peripheral vascular resis- tion in relatively underfilled cardiac chambers. This tance, mean arterial pressure, metabolic factors, intra- process leads to a sudden reduction in the sympathetic vascular blood volume, and cerebrovascular resistance tone as well as to parasympathetic overdrive, which (with its intrinsic auto-regulation) maintain cerebral precipitates the Bezold-Jarisch reflex, resulting in Received: July 22, 2012 Accepted: November 28, 2012 Correspondence: Antoine Kossaify, M.D. Chu-Nds-HND Secours Hospital, Jbeil PoB 3, Byblos, Lebanon. Tel: +00 961 323 20 46 e-mail: [email protected] © 2013 Turkish Society of Cardiology 76 Türk Kardiyol Dern Arş severe hypotension and/or bradycardia.[2,3] Vaddadi minster Protocol, which favors prolonged passive tilt- et al.[4] reported that there are many sympathetic ner- ing,[20] and the Minneapolis[21] and Italian protocols, vous system phenotypes at the electrical, neurochemi- which use Nitroglycerin.[22,23] There is substantial evi- cal, and cellular level in patients with recurrent NCS. dence that the Italian protocol considerably increases Interestingly, they found a subnormal norepinephrine the yield of tilt testing without significantly increasing spillover during tilt testing in patients with low supine false positive rates,[23] while isoproterenol provoca- systolic blood pressure (<100 mmHg). tion (Minneapolis) significantly increases the yield of false positive results, making its use on a routine basis Many medical conditions have a physiopatho- questionable.[24] logical basis related to autonomic dysfunction. Some forms of NCS are known to be correlated with ortho- Three types of hemodynamic responses during static hypotension and postural orthostatic tachycar- tilt tests have been described:[25] type 1, the classic dia syndrome,[5] while some forms of migraine are vasovagal syncope pattern, which happens when an also known to be associated with NCS.[6] The occur- initial rapid and compensatory reflex adaptation to an rence of pre-syncopal breathing instability[7] and heart upright position occurs (reflex tachycardia) followed rate acceleration during a tilt test have been associated by a steady-state condition with minimal decrease of with test positivity.[8,9] Fatigue is frequently encoun- tachycardia, until the abrupt onset of syncope; type tered in patients experiencing syncope and postural 2, the dysautonomic vasovagal pattern, which occurs orthostatic tachycardia syndrome.[10] In light of this, when the reflex tachycardia and adaptation to an up- we hypothesize that ANS dysfunction represents a right position are absent, with a progressive fall in common etiopathogenic mechanism for many con- blood pressure until the occurrence of syncope; and ditions, and accordingly, we sought to review and type 3, the orthostatic intolerance pattern, which hap- discuss autonomic dysfunction in the setting of NCS pens when a minimal progressive fall in blood pressure when associated with each of these conditions. occurs similar to type 2, but without the occurrence of syncope. The clinical relevance of pre-syncope with- Autonomic dysfunction and NCS out bradyarrhythmias during tilt tests is still question- able, especially after nitroglycerin provocation.[26] NCS is defined as a syndrome in which the triggering Similarly, when a cardioinhibitory reaction occurs, of a neural reflex typically results in a self-limited epi- different types of arrhythmias may be observed (sinus sode of systemic hypotension characterized by both bradycardia, sinus arrest, junctional rhythm, or vari- bradycardia (asystole or relative bradycardia) and able degree of atrioventricular block) and therefore peripheral vasodilation.[11,12] Knowing the patient’s the relevance of these arrhythmias is questionable medical history remains a key diagnostic issue in the when they are not associated with syncope.[27] All of clinical approach to patients presenting with syncope these phenomena explain the substantial variations in of unknown origin,[13] and can also be used to identify the diagnostic yield of the head-up tilt test,[28] which is associated conditions (e.g., migraine, orthostatic hy- mainly related to the functional and dynamic pattern potension, depression) that may help in the assess- of the ANS, which may modulate each individual’s ment of NCS. Many tests (e.g., handgrip test, ortho- susceptibility to exhibit NCS.[29] static presser response, Valsalva test, deep breathing test, postural test, heart rate variability) are available NCS and associated conditions to assess autonomic function,[14,15] although head-up tilt testing remains the most clinically useful test for a) Orthostatic hypotension evaluating patients suspected to have NCS. Orthostatic hypotension is defined as a decrease in Head-up tilt testing is simple to perform, but has systolic blood pressure of at least 20 mm hg or a de- many limitations and lacks a uniform standardized crease in diastolic blood pressure of at least 10 mm protocol.[16,17] By triggering syncopal episodes in hg within 3 minutes of standing or a head-up tilt of at a controlled atmosphere, this test has allowed for a least 60 degrees.[11] It has been well established that greater understanding of the mechanism of NCS and orthostatic hypotension is correlated with ANS dys- associated ANS dysfunction.[18] Many protocols for function (functional or organic), and when prolonged the tilt test have been proposed,[19] including the West- and severe, may lead to syncope.[30] The decrease in Neurocardiogenic syncope and associated conditions 77 blood pressure results from the inability of the ANS tachycardia syndrome, most of the patients were re- to achieve appropriate reflex vasoconstriction and ported to have a positive tilt test, orthostatic tachy- tachycardia during orthostatism. Orthostatic hypoten- cardia, and ANS dysfunction (characterized by de- sion is more prevalent in the elderly because of the creased vagal baroreflex and potentiated sympathetic frequent decrease in physiological functions such as vasomotion). baroreceptor sensitivity, accordingly when orthostasis In subjects suffering from NCS, an increase in is prolonged and non compensated, it may lead
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