头高位倾斜时自发性与硝酸甘油诱发的血管迷走反射：是否存在神经内分泌差异？

Spontaneous vs nitroglycerin-induced vasovagal reflex on head-up tilt: Are there neuroendocrine differences?

作者信息

Nilsson David, Sutton Richard, Melander Olle, Fedorowski Artur

机构信息

Department of Clinical Sciences, Lund University, Clinical Physiology and Nuclear Medicine Unit, Skåne University Hospital, Malmö, Sweden.

National Heart and Lung Institute, Imperial College, St. Mary's Hospital Campus, London, United Kingdom.

出版信息

Heart Rhythm. 2016 Aug;13(8):1674-8. doi: 10.1016/j.hrthm.2016.03.018.

DOI:10.1016/j.hrthm.2016.03.018

PMID:27450157

Abstract

BACKGROUND

Head-up tilt test (HUT) has been used for nearly 30 years for diagnosing vasovagal syncope (VVS) and was enhanced by sublingual nitroglycerin (glyceryl trinitrate [GTN]) challenge in the 1990s.

OBJECTIVE

The purpose of this study was to explore neuroendocrine differences between spontaneous and drug-induced HUT positivity.

METHODS

Two hundred eighty-eight patients (41.3% male, age 49 ± 21 years) with either positive passive (n = 60 [20.8%], age 38 ± 17 years) or GTN-enhanced HUT (n = 228, age 51 ± 21 years) were assessed. Beat-to-beat hemodynamic data, plasma epinephrine, plasma norepinephrine, plasma renin, C-terminal pro-arginine vasopressin (CT-proAVP), C-terminal endothelin-1, and mid-regional fragment of pro-atrial natriuretic peptide were measured resting supine and after 3 minutes of HUT. In multivariate-adjusted regression analyses controlling for age and gender, clinical, neuroendocrine, and hemodynamic parameters were compared between spontaneous and GTN-mediated positive tests.

RESULTS

Patients with spontaneous VVS reported more syncope compared to those with GTN-mediated VVS (median interquartile range 6 [17] vs 4 [6], P = .002). There was no difference in resting concentrations of neurohormones between the 2 groups. However, after 3 minutes of HUT, those who later developed spontaneous VVS demonstrated higher levels of CT-proAVP (59.5 ± 137 vs 6.9 ± 4.6, P <0.001) and epinephrine (0.57 ± 1.43 vs 0.23 ± 0.19, P = .003), and lower blood pressure (119/73 vs 139/81 mm Hg, P <.001). Asystole during VVS was more common in the spontaneous VVS group (35% vs 17.5%, P = .016).

CONCLUSION

Patients with spontaneous VVS on HUT reported more syncopal events than those with drug-potentiated positive HUT, but both groups shared similar supine neuroendocrine profiles. However, spontaneous VVS during HUT is characterized by lower blood pressure, pronounced increases in epinephrine and vasopressin during early HUT phase, and higher frequency of reflex asystole.

摘要

背景

头高位倾斜试验（HUT）用于诊断血管迷走性晕厥（VVS）已有近30年历史，20世纪90年代通过舌下含服硝酸甘油（三硝酸甘油酯[GTN]）激发试验得到了改进。

目的

本研究旨在探讨自发性和药物诱发的HUT阳性之间的神经内分泌差异。

方法

对288例患者（男性占41.3%，年龄49±21岁）进行评估，其中被动HUT阳性者60例（20.8%，年龄38±17岁），GTN激发的HUT阳性者228例（年龄51±21岁）。测量静息仰卧位及HUT 3分钟后的逐搏血流动力学数据、血浆肾上腺素、血浆去甲肾上腺素、血浆肾素、C末端前体精氨酸加压素（CT-proAVP）、C末端内皮素-1和心房钠尿肽前体中段片段。在控制年龄和性别的多变量调整回归分析中，比较自发性和GTN介导的阳性试验之间的临床、神经内分泌和血流动力学参数。

结果

与GTN介导的VVS患者相比，自发性VVS患者报告的晕厥发作更多（中位数四分位间距6[17]对4[6]，P = 0.002）。两组静息时神经激素浓度无差异。然而，HUT 3分钟后，后来发生自发性VVS的患者CT-proAVP水平更高（59.5±137对6.9±4.6，P<0.001），肾上腺素水平更高（0.57±1.43对0.23±0.19，P = 0.003），血压更低（119/73对139/81 mmHg，P<0.001）。VVS期间心脏停搏在自发性VVS组中更常见（35%对17.5%，P = 0.016）。