Tilt-induced vasovagal syncope and psychogenic pseudosyncope

Abstract

Objective: To describe the combination of tilt-induced vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) and aid its clinical recognition. Methods:We identified people with tilt-induced VVS/PPS from 2 tertiary syncope referral centers.For each case, 3 controls with tilt-induced VVS were selected at random from the same center. Clinical characteristics were compared between both groups adjusting for multiple comparisons. Conclusions: VVS/PPS presents with a complex phenotype. High attack frequency, delayed recovery of consciousness, apparent loss of consciousness .1 minute, ictal eye closure, atypical triggers, and the absence of prodromes may serve as indicators that PPS coincides with VVS. Transient loss of consciousness (TLOC) is a frequent presentation, with vasovagal syncope (VVS) as the most common cause.1 Establishing the cause of TLOC can be difficult, especially when individuals present with 2 conditions simultaneously. The most reliable diagnosis of TLOC is obtained if appropriate pathophysiologic data are recorded during an attack recognized as typical by the individual. Blood pressure (BP), heart rate (HR), or both are low during VVS, but tend to be high during psychogenic pseudosyncope (PPS). 2 We previously noted that PPS either preceded or followed VVS in 12 out of 800 tilt-table tests, a pattern we label here as VVS/ PPS.2 This parallels the situation of psychogenic epileptic seizures (PNESs), which are also found more often in people with epileptic seizures. [3][4][5] Our previous study demonstrated that individuals with PPS had longer periods of apparent TLOC and were more likely to have their eyes closed during apparent TLOC than those with VVS.2 A sudden head drop or sliding down the tilt table was more frequent in individuals with PPS, whereas those with VVS were more likely to exhibit jerking movements. People with VVS/PPS may present with a mixture of the 2 sets of features, but this has not yet been described. Early recognition of VVS/PPS is important to avoid excessive testing. VVS features are probably better known than those of PPS. This

The heart of epilepsy: Current views and future concepts

“…ictal recording of video, heart rate, blood pressure and EEG) [65]. Two large scale surveys of up to 2000 tilt-table tests failed to identify any adult case with syncopal-induced seizures [66,67]. In children, however, a few cases have been reported with a cardioinhibitory reflex syncope followed by video-EEG documented clonic seizures [68][69][70].…”

Use of Biotronik closed loop pacemaker to treat recurrent syncope in pediatric patient with dysautonomia

“…There are often overlapping phenotypes of neurocardiogenic syncope, POTS, and dysautonomia. Psychosomatic symptoms also are common and can either be the main cause of syncope at presentation or develop over time if appropriate psychological support is not readily available 1 . Our patient demonstrated features of POTS on the tilt test, yet some of the collapses documented on loop recorder tracings showed a normal heart rate.…”

2018 ESC Guidelines for the diagnosis and management of syncope

“…In suspected PPS, the tilt test should preferably be performed together with EEG monitoring; a normal EEG helps to confirm the diagnosis. 116,117 In the absence of an EEG, a video recording will be helpful in confirming the diagnosis.…”

“…114 Tilt testing may be helpful in separating syncope from PPS. [115][116][117] Tilt testing has limited value in assessing treatment efficacy. 118 However, tilt testing is widely accepted as a useful tool to demonstrate susceptibility of the patient to reflex syncope, especially a hypotensive (vasodepressive) tendency, and thereby to initiate treatment (e.g.…”

“…Adding video recording to tilt testing may be considered in order to increase the reliability of clinical observation of induced events. 9,116,117,205 IIb C…”