Trim Geoffrey M, Krahn Andrew D, Klein George J, Skanes Allan C, Yee Raymond
Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
Card Electrophysiol Rev. 2003 Dec;7(4):416-20. doi: 10.1023/B:CEPR.0000023168.26698.1e.
Vasovagal or neurocardiogenic syncope is a common benign condition. In the majority of patients it regresses naturally, or can be controlled by conservative therapy. However there is a group of patients who remain severely affected despite lifestyle measures, counselling and medication. Pacing has been considered in these patients as a result of logic, observational studies, and three randomised but unblinded studies, VPS, VASIS and SYDIT. A randomised and blinded study, VPS II, was recently published, the results of which undermined the results of these preceding studies: despite a 30% trend towards reduced syncope in patients with active pacing, the result was not statistically significant. This left clinicians with a dilemma, whether or not to pace in patients with disabling syncope despite conservative therapy. We believe, based on a review of all currently available evidence, that there remains a role for pacing in the patient with evidence of significant cardioinhibition, particularly severe bradycardia or asystole, and ongoing disabling syncope in spite of conservative measures. When to pace in these patients is a matter of clinical judgement. The threshold for pacing should remain high, however, with extensive attempts of conservative and pharmacological measures and with appropriate discussions with patients prior to instituting pacing, regarding the risks and long-term implications of a pacemaker. More needs to be learned about optimal pacing modalities.
血管迷走性或神经心源性晕厥是一种常见的良性病症。大多数患者的病情会自然缓解，或可通过保守治疗得到控制。然而，有一部分患者尽管采取了生活方式调整、咨询和药物治疗等措施，病情仍严重受影响。基于逻辑推理、观察性研究以及三项随机但未设盲的研究（VPS、VASIS和SYDIT），已考虑对这些患者进行起搏治疗。最近发表了一项随机且设盲的研究VPS II，其结果推翻了之前这些研究的结果：尽管积极起搏的患者晕厥有减少30%的趋势，但结果无统计学意义。这使临床医生陷入两难境地，即在保守治疗后，对于致残性晕厥患者是否进行起搏治疗。基于对所有现有证据的回顾，我们认为，对于有明显心脏抑制证据的患者，尤其是严重心动过缓或心搏停止，且尽管采取了保守措施仍持续存在致残性晕厥的患者，起搏治疗仍有作用。对这些患者何时进行起搏治疗需临床判断。然而，起搏的阈值应保持较高，需广泛尝试保守和药物措施，并在进行起搏治疗前与患者进行适当讨论，告知其起搏器的风险和长期影响。关于最佳起搏方式，还有更多需要了解的地方。
