INCIDENCE AND CHARACTERISTICS OF SLEEP-RELATED SYNCOPE IN PATIENTS WITH VASOVAGAL SYNCOPE
CCC ePoster Library. Tewfik E. 10/26/19; 280514; 279
Dr. Ernest Tewfik
Dr. Ernest Tewfik
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Abstract
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BACKGROUND: Sleep-related syncope (SRS) occurring shortly after waking up from sleep and for which vasovagal syncope (VVS) was found to be the most probable diagnosis is not thought to be rare but there is little literature on the subject. We sought to identify the incidence and characteristics of SRS in a tertiary care center VVS population

METHODS AND RESULTS: All syncope patients who underwent head-up tilt (HUT) between October 2010 and August 2016 and had either a positive HUT for VVS or a Calgary Syncope Symptom Score (CSSS) of ≥-2 suggestive of VVS, as well as no other confounding diagnosis which could explain syncope, were retrospectively included. Medical charts were reviewed and a questionnaire was sent to be completed subsequently over the phone to obtain additional details when needed. Presence or absence of SRS could be determined in 89/133 (67%) patients, from the questionnaires in 79/127 (62%) and in 10 patients from the medical charts alone. SRS was reported in 19/89 (21%). In 8/19 (42%) SRS occurred while recumbent while in 9 (47%) prodrome was felt while still lying but syncope occurred sitting or standing; in 2 patients, SRS occurred after waking in a minimally inclinable airplane seat. Patients with SRS compared to those without SRS had more syncopes in the past 6 months (3 vs.1, p < 0.0005) and year (3.5 vs. 1, p < 0.00005), a higher CSSS (3 vs. 1, p=0.007), and more frequent asystole on HUT (36% vs.13%, p=0.04). On multivariate regression, SRS was associated with blood-injection-injury phobia (p=0.007), more frequent recent syncopes (p=0.02) and self-reported insomnia (p=0.02). Amongst those for whom prodromal symptoms could be verified, the most prevalent were warmth (14/15 (93%)), palpitations (12/14 (86%)) and dizziness (12/14 (86%)); gastrointestinal (GI) symptoms occurred in 8/16 (50%) cases. A definite or probable arousal stimulus before SRS was identified in 7/19 (37%) patients. SRS patients also often reported episodes of syncope immediately on rising from sleep either due to orthostatic hypotension (5/15 (33%)) or post micturition/defecation (5/15 (33%)).

CONCLUSION: SRS is a frequent but under-reported condition in VVS patients which in some cases may be precipitated by sudden arousal from sleep. Prodromal symptoms of vasodilation (palpitations, warmth) are most common though GI symptoms are also frequent. Asystole with HUT provoked VV reaction is more often seen in those reporting SRS raising the question of possible pacemaker therapy especially in those with recurrent syncope while still recumbent.
BACKGROUND: Sleep-related syncope (SRS) occurring shortly after waking up from sleep and for which vasovagal syncope (VVS) was found to be the most probable diagnosis is not thought to be rare but there is little literature on the subject. We sought to identify the incidence and characteristics of SRS in a tertiary care center VVS population

METHODS AND RESULTS: All syncope patients who underwent head-up tilt (HUT) between October 2010 and August 2016 and had either a positive HUT for VVS or a Calgary Syncope Symptom Score (CSSS) of ≥-2 suggestive of VVS, as well as no other confounding diagnosis which could explain syncope, were retrospectively included. Medical charts were reviewed and a questionnaire was sent to be completed subsequently over the phone to obtain additional details when needed. Presence or absence of SRS could be determined in 89/133 (67%) patients, from the questionnaires in 79/127 (62%) and in 10 patients from the medical charts alone. SRS was reported in 19/89 (21%). In 8/19 (42%) SRS occurred while recumbent while in 9 (47%) prodrome was felt while still lying but syncope occurred sitting or standing; in 2 patients, SRS occurred after waking in a minimally inclinable airplane seat. Patients with SRS compared to those without SRS had more syncopes in the past 6 months (3 vs.1, p < 0.0005) and year (3.5 vs. 1, p < 0.00005), a higher CSSS (3 vs. 1, p=0.007), and more frequent asystole on HUT (36% vs.13%, p=0.04). On multivariate regression, SRS was associated with blood-injection-injury phobia (p=0.007), more frequent recent syncopes (p=0.02) and self-reported insomnia (p=0.02). Amongst those for whom prodromal symptoms could be verified, the most prevalent were warmth (14/15 (93%)), palpitations (12/14 (86%)) and dizziness (12/14 (86%)); gastrointestinal (GI) symptoms occurred in 8/16 (50%) cases. A definite or probable arousal stimulus before SRS was identified in 7/19 (37%) patients. SRS patients also often reported episodes of syncope immediately on rising from sleep either due to orthostatic hypotension (5/15 (33%)) or post micturition/defecation (5/15 (33%)).

CONCLUSION: SRS is a frequent but under-reported condition in VVS patients which in some cases may be precipitated by sudden arousal from sleep. Prodromal symptoms of vasodilation (palpitations, warmth) are most common though GI symptoms are also frequent. Asystole with HUT provoked VV reaction is more often seen in those reporting SRS raising the question of possible pacemaker therapy especially in those with recurrent syncope while still recumbent.
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