Petersen M E, Chamberlain-Webber R, Fitzpatrick A P, Ingram A, Williams T, Sutton R
Chelsea and Westminster Hospital, London.
Br Heart J. 1994 Mar;71(3):274-81. doi: 10.1136/hrt.71.3.274.
To evaluate the effect of permanent pacing in cardioinhibitory malignant vasovagal syndrome.
37 patients with permanent pacemakers for cardioinhibitory malignant vasovagal syndrome. All presented with syncope (median six episodes, median frequency two episodes a year) and after conventional investigation and invasive electrophysiological assessment they remained undiagnosed, and without a generally accepted indication for pacemaker implantation. In all vasovagal syncope with cardioinhibition (heart rate at syncope < 60 beats/min) developed during tilt tests performed according to the Westminster protocol (head up tilt at 60 degrees with a footplate support for 45 minutes or until syncope intervenes). Dual chamber pacemakers were implanted in 35 (95%) and VVI pacemakers in the remaining two (5%).
Over a mean (SD) follow up since implantation of 50.2 (23.9) months symptomatic improvement occurred in 89%: 62% remained free of syncope and 27% were completely symptom free. The collective syncopal burden of these 37 patients was reduced from 136 to 11 episodes each year. During follow up three patients died from unrelated causes. Patients who become asystolic during the tilt test (sinus pause of at least four seconds) experienced no greater benefit from pacing than those with less extreme cardioinhibition. Patients who remained free of syncope since implantation were younger than those who continued to experience syncope. Patients who remained completely symptom free after implantation were younger, more likely to be male, and had had fewer syncopal episodes before implantation than those who continued to experience syncope or presyncope. No other demographic, clinical, investigative, or pacing variable suggested a more favourable outcome after implant.
This retrospective and uncontrolled experience suggests a possible role for permanent pacing in selected patients with cardioinhibitory malignant vasovagal syndrome. Improved acquisition of tilt test data may enable better selection of patients who are suitable for permanent pacing. A randomised prospective study to compare permanent pacing with no treatment or with medical treatment in cardioinhibitory malignant vasovagal syndrome is indicated.
评估永久性起搏治疗心脏抑制型恶性血管迷走性晕厥的效果。
37例因心脏抑制型恶性血管迷走性晕厥植入永久性起搏器的患者。所有患者均有晕厥表现（中位数为6次发作，发作频率中位数为每年2次），经传统检查和有创电生理评估后仍未明确诊断，且无普遍认可的起搏器植入指征。在按照威斯敏斯特方案进行的倾斜试验（头高脚倾斜60度，脚踏板支撑45分钟或直至晕厥发作）过程中，所有患者均出现伴有心脏抑制的血管迷走性晕厥（晕厥时心率<60次/分钟）。35例（95%）植入双腔起搏器，其余2例（5%）植入VVI起搏器。
自植入起搏器后的平均（标准差）随访时间为50.2（23.9）个月，89%的患者症状改善：62%的患者未再发生晕厥，27%的患者完全无症状。这37例患者的晕厥总负担从每年136次降至11次。随访期间，3例患者死于无关原因。倾斜试验期间出现心脏停搏（窦性停搏至少4秒）的患者，起搏治疗的获益并不比心脏抑制程度较轻的患者更大。自植入起搏器后未再发生晕厥的患者比仍有晕厥发作的患者年轻。植入后完全无症状的患者比仍有晕厥或先兆晕厥发作的患者年轻、男性比例更高，且植入前晕厥发作次数更少。没有其他人口统计学、临床、检查或起搏变量提示植入后有更良好的预后。
这项回顾性且无对照的研究提示，永久性起搏可能对部分心脏抑制型恶性血管迷走性晕厥患者有效。更好地获取倾斜试验数据可能有助于更准确地选择适合永久性起搏治疗的患者。有必要开展一项随机前瞻性研究，比较永久性起搏与不治疗或药物治疗对心脏抑制型恶性血管迷走性晕厥的疗效。
