Abstract
Recent reports suggest that cardiac pacing incorporating a rate-drop response algorithm is associated with a reduction in the frequency of syncopal episodes in patients with apparent cardioinhibitory vasovagal syncope. The detection portion of the algorithm employs a programmable heart rate change-time duration “window” to both identify abrupt cardiac slowing suggestive of an imminent vasovagal event and trigger “high rate” pacing. The purpose of this study was to develop recommendations for programming the rate-drop response algorithm. Pacemaker programming, symptom status, and drug therapy were assessed retrospectively in 24 patients with recurrent vasovagal syncope of sufficient severity to warrant consideration of pacemaker treatment. In the 53±19 months prior to pacing, patients had experienced an approximate syncope burden of 1.2 events/month. During follow-up of 192±160 days, syncope recurred in 4 patients (approximate syncope burden, 0.3 events / month, p < 0.05 vs. pre-pacing), and pre-syncope in 5 patients. In these patients, rate-drop response parameters were initially set based on electrocardiographic and/or tilt-table recordings, and were re-programmed at least once in 14 (58%) individuals. A 20 beat/min window height (top rate minus bottom rate), a window width of 10 beats (61% of patients), and 2 or 3 confirmation beats (79% of patients) appeared to be appropriate in most patients. Treatment intervention rate was set to >100 beats/min 89% of patients, with a duration of 1 to 2 min in 79%. In conclusion, a narrow range of rate-drop response parameter settings appeared to be effective for most individuals in this group of highly symptomatic patients.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Benditt DG, Lurie KG. Treatment of neurally mediated syncopal syndromes. In: Smith TW, ed. Cardiovascular Therapeutics. Philadelophia: WB Saunders, 1996;368–377.
Fitzpatrick AP, Ahmed R, Williams S, et al. A randomized trial of medical therapy in “malignant vasovagal syndrome” or “neurally-mediated bradycardia hypotension syndrome”. Eur J Cardiac Pacing Electrophysiol 1991;1:99–102.
Brignole M, Menozzi C, Gianfranchi L, et al. A controlled trial of acute and long-term medical therapy in tilt-induced neurally-mediated syncope. Am J Cardiol 1992;70:339–342.
Kosinski DJ, Grubb BP. Neurally mediated syncope with an update on indications and usefulness of head-up tilt table testing and pharmacologic therapy. Curr Opinion Cardiol 1994;9:53–64.
Morillo C, Leitch JW, Yee R, Klein GJ. A placebo-controlled trial of intravenous and oral disopyramide for prevention of neurally mediated syncope induced by head-up tilt. J Am Coll Cardiol 1993;22:1843–1848.
Grubb BP, Wolfe D, Samoil D, Temesy-Armos P, Hahn H, Elliott L. Usefulness of fluoxetine hydrochloride for prevention of resistant upright tilt induced syncope. PACE 1993;16:458–464.
Mahanonda N, Bhuripanyo K, Kangkagate C, Wansanit K, Kulchot B, Nademanee K, Chaithiraphan S. Randomized double-blind placebo-controlled trial of oral atenolol in patients with unexplained syncope and positive upright tilt table results. Am Heart J 1995;130(6):1250–1253.
Fitzpatrick A, Theodorakis G, Ahmed R, et al. Dual chamber pacing aborts vasovagal syncope induced by head-up 60 degree tilt. PACE 1991;14:13–19.
Petersen MEV, Chamberlain-Webber R, Fitzpatrick AP, et al. Permanent pacing for cardio-inhibitory malignant vasovagal syndrome. Br Heart J 1994;71:274–281.
Benditt DG, Petersen M, Lurie KG, et al. Cardiac pacing for prevention of recurrent vasovagal syncope. Ann Int Med 1995;122:204–209.
Gammage MD, Hess M, Markowitz T. Initial experience with a rate drop algorithm in malignant vasovagal syndrome. Eur J Cardiac Pacing Electrophys 1995;5:45–--.
Samoil D, Grubb BP, Brewster P, et al. Comparison of single and dual chamber pacing techniques in prevention of upright tilt induced vasovagal syncope. Eur J Cardiac Pacing Electrophysiol 1993;1:36–41.
Sra J, Jazayeri MR, Avitall B, et al. Comparison of cardiac pacing with drug therapy in the treatment of neurocardiogenic (vasovagal) syncope with bradycardia or asystole. N Engl J Med 1993:328”85-1090.
Sheldon RS, Gent M, Roberts RS, Connolly SJ, on behalf of the NAVPAC Investigators. North American. Vasovagal Pacemaker Study: Study design and organization. PACE 1997;20:844–848.
Sheldon R, Koshman ML, Wilson W, Kieser T, Rose S. Effect of dual-chamber pacing with automatic rate-drop sensing on recurrent neurally-mediated syncope. Am J Cardiol 1998;81:158–162.
Benditt DG, Ferguson DW, Grubb BP, Kapoor WN, Kugler J, Lerman BB, Maloney JD, Raviele A, Ross B, Sutton R, Wolk MJ, Wood DL. Tilt-table testing for assessing syncope. An American College of Cardiology expert consensus document. J Am Coll Cardiol 1996;28:263–275.
Fish FA, Strasburger JF, Benson DW Jr. Reproducibility of a symptomatic response to upright tilt in young patients with unexplained syncope. Am J Cardiol 1992;70:605–609.
Dreifus LS, Fisch C, Griffin JC, et al. Guidelines for implantation of cardiac pacemaker and antiarrhythmic devices. American Heart Association/American College of Cardiology Task Force report. J Am Coll Cardiol 1991;18:1–13.
British Pacing and Electrophysiology GroupWorking Party. Recommendations for pacemaker prescription for symptomatic bradycardia. Br Heart J 1991;66:185–191.
Author information
Authors and Affiliations
Additional information
and the Rate-Drop Response Investigators Group
Rights and permissions
About this article
Cite this article
Benditt, D.G., Sutton, R., Gammage, M. et al. 'Rate-Drop Response' Cardiac Pacing for Vasovagal Syncope. J Interv Card Electrophysiol 3, 27–33 (1999). https://doi.org/10.1023/A:1009815304770
Issue Date:
DOI: https://doi.org/10.1023/A:1009815304770