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Pharmacological washout for the correct evaluation of the head-up tilt testing
International Journal of Cardiology 127 (2008) e31 – e32 www.elsevier.com/locate/ijcard
Letter to the Editor
Pharmacological washout for the correct evaluation of the head-up tilt testing Pietro Pugliatti a , Salvatore Patanè b,⁎, Antonino Recupero a , Sebastiano Coglitore a , Gianluca Di Bella a a b
Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy Cardiologia Nuovo Presidio Ospedaliero Cutroni Zodda-Barcellona P.d.G(Me) AUSL5 Messina, Via Cattafi, 98051 Barcellona Pozzo di Gotto, Messina, Italy Received 1 December 2006; accepted 2 January 2007 Available online 6 April 2007
Abstract Head-up tilt testing is an important tool in the diagnosis of syncope. Several different protocols are in use. We describe the case of a 70-yearold Italian woman admitted to our observation. The patient was in antihypertensive treatment with carvedilol and with a combination of lisinopril and hydrochlorothiazide. A simplified Italian protocol head-up tilt testing was performed. A 4.10 s pause with syncope and a profound hypotension (blood pressure values were 65/50 mm Hg) were observed after 3 min in the provocation phase. Second-degree atrioventricular Block of the 2:1 form, advanced second-degree atrioventricular block and junctional escape rhythm (28 bpm) were observed. A simplified Italian protocol head-up tilt testing was performed after 40 days of withdrawal of carvedilol. A 2 s pause with presyncope and a hypotension (blood pressure values were 80/70 mm Hg) were observed after 2 min in the provocation phase. ECG revealed a bradycardic sinusal rhythm with heart rate of 42 bpm. This case assesses the importance of a pharmacological washout for the correct evaluation of the head-up tilt testing. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Head-up tilt testing; Syncope; Blood pressure values
Head-up tilt testing is an important tool in the diagnosis of syncope. Several different protocols are in use [1]. Carvedilol is a beta(1)-, beta(2)-, and alpha(1)-adrenergic blocker without intrinsic sympathomimetic activity, that is approved for the treatment of hypertension. The efficiency and safety of carvedilol in the high risk hypertensive patients is same as in the primary hypertensive patients [2]. Carvedilol has also efficacy in patients with stable angina pectoris and there is evidence that carvedilol has a beneficial haemodynamic effect in patients with congestive heart failure [3]. It has also been reported that the addition of carvedilol to an existing heart failure treatment incites the reverse remodeling of cardiac sympathetic nervous system function [4]. ⁎ Corresponding author. E-mail address: [email protected] (S. Patanè). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.01.028
1. Case report A 70-year-old Italian woman was admitted to our observation. The patient was in an antihypertensive treatment with carvedilol and with a combination of lisinopril and hydrochlorothiazide. A history of two recent
Fig. 1.
e32
P. Pugliatti et al. / International Journal of Cardiology 127 (2008) e31–e32
Fig. 2.
episodes of syncope with consequent chest traumas was also present. Blood pressure values in clinostatism were 150/80 mm Hg, blood pressure values in orthostatism were 140/75 mm Hg, the heart rate was 53 bpm, and the oxygen saturation was normal. A meso-tele-systolic murmur was present. The ECG showed a bradycardic sinusal rhythm with a right bundle branch block. Echocardiographic evaluation revealed an ejection fraction of 60%. No pericardial effusion was observed. An interventricular septal hypertrophy, mild left atrial dilatation, mild mitral regurgitation and mild tricuspidal regurgitation were observed. Echocardiographic evaluation revealed an ejection fraction of 60%. A mild interventricular septal hypertrophy, an early left ventricular diastolic dysfunction without systolic dysfunction and a mild aortic regurgitation was observed. A Holter ECG revealed a bradycardic sinusal rhythm with minimal heart rate of 45 bpm and maximal heart rate of 90 bpm, 430 premature atrial beats, 32 ventricular ectopic beats. A simplified Italian protocol head-up tilt testing [5] was performed (stabilization phase of 5 min in the supine position; passive phase of 20 min at a tilt angle of 60°; provocation phase of further 15 min after 400 g NTG sublingual spray. Test interruption is made when the protocol is completed in the absence of symptoms, or
there is occurrence of syncope or, occurrence of progressive (> 5 min) orthostatic hypotension) (Fig. 2-1). A 4.10 s pause (Fig. 1) with syncope and a profound hypotension (blood pressure values were 65/50 mm Hg) were observed after 3 min in the provocation phase. Second-degree atrioventricular Block of the 2:1 form, advanced seconddegree atrioventricular block and junctional escape rhythm (28 bpm) were observed. Sinusal rhythm and normal blood pressure values were observed after Trendelenburg position. A simplified Italian protocol head-up tilt testing was performed after 40 days of withdrawal of carvedilol (Fig. 2-2). Blood pressure values in clinostatism were 150/ 80 mm Hg, blood pressure values in orthostatism were 160/90 mm Hg, the heart rate was 70 bpm, and the oxygen saturation was normal. A 2 s pause with presyncope and a hypotension (blood pressure values were 80/70 mm Hg) were observed after 2 min in the provocation phase. ECG revealed a bradycardic sinusal rhythm with heart rate of 42 bpm. Sinusal rhythm and normal blood pressure values were observed after Trendelenburg position. An antihypertensive treatment with a nonantiarrhythmic drug was added to the treatment with the combination of lisinopril and hydrochlorothiazide. This case assesses the importance of a pharmacological washout for the correct evaluation of the head-up tilt testing. References [1] Farwell DJ, Sulke AN. A randomised prospective comparison of three protocols for head-up tilt testing and carotid sinus massage. Int J Cardiol Dec 7 2005;105(3):241–9 [Electronic publication 2005 Jul 12]. [2] Zhao XL, Hu DY, Carvedilol Multicenter Clinical Study Group. Efficiency and safety of carvedilol treatment in high risk hypertensive patients. Zhonghua Nei Ke Za Zhi Jan 2006;45(1): 25–8. [3] McTavish D, Campoli-Richards D, Sorkin EM. Carvedilol. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy. Drugs Feb 1993;45(2):232–58. [4] Chizzola PR, Goncalves de Freitas HF, Marinho NV, Mansur JA, Meneghetti JC, Bocchi EA. The effect of beta-adrenergic receptor antagonism in cardiac sympathetic neuronal remodeling in patients with heart failure. Int J Cardiol Jan 4 2006;106(1):29–34. [5] Brignole M, Menozzi C, Del Rosso A, et al. New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification. Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study. Europace Jan 2000;2(1):66–76.
Letter to the Editor
Pharmacological washout for the correct evaluation of the head-up tilt testing Pietro Pugliatti a , Salvatore Patanè b,⁎, Antonino Recupero a , Sebastiano Coglitore a , Gianluca Di Bella a a b
Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy Cardiologia Nuovo Presidio Ospedaliero Cutroni Zodda-Barcellona P.d.G(Me) AUSL5 Messina, Via Cattafi, 98051 Barcellona Pozzo di Gotto, Messina, Italy Received 1 December 2006; accepted 2 January 2007 Available online 6 April 2007
Abstract Head-up tilt testing is an important tool in the diagnosis of syncope. Several different protocols are in use. We describe the case of a 70-yearold Italian woman admitted to our observation. The patient was in antihypertensive treatment with carvedilol and with a combination of lisinopril and hydrochlorothiazide. A simplified Italian protocol head-up tilt testing was performed. A 4.10 s pause with syncope and a profound hypotension (blood pressure values were 65/50 mm Hg) were observed after 3 min in the provocation phase. Second-degree atrioventricular Block of the 2:1 form, advanced second-degree atrioventricular block and junctional escape rhythm (28 bpm) were observed. A simplified Italian protocol head-up tilt testing was performed after 40 days of withdrawal of carvedilol. A 2 s pause with presyncope and a hypotension (blood pressure values were 80/70 mm Hg) were observed after 2 min in the provocation phase. ECG revealed a bradycardic sinusal rhythm with heart rate of 42 bpm. This case assesses the importance of a pharmacological washout for the correct evaluation of the head-up tilt testing. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Head-up tilt testing; Syncope; Blood pressure values
Head-up tilt testing is an important tool in the diagnosis of syncope. Several different protocols are in use [1]. Carvedilol is a beta(1)-, beta(2)-, and alpha(1)-adrenergic blocker without intrinsic sympathomimetic activity, that is approved for the treatment of hypertension. The efficiency and safety of carvedilol in the high risk hypertensive patients is same as in the primary hypertensive patients [2]. Carvedilol has also efficacy in patients with stable angina pectoris and there is evidence that carvedilol has a beneficial haemodynamic effect in patients with congestive heart failure [3]. It has also been reported that the addition of carvedilol to an existing heart failure treatment incites the reverse remodeling of cardiac sympathetic nervous system function [4]. ⁎ Corresponding author. E-mail address: [email protected] (S. Patanè). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.01.028
1. Case report A 70-year-old Italian woman was admitted to our observation. The patient was in an antihypertensive treatment with carvedilol and with a combination of lisinopril and hydrochlorothiazide. A history of two recent
Fig. 1.
e32
P. Pugliatti et al. / International Journal of Cardiology 127 (2008) e31–e32
Fig. 2.
episodes of syncope with consequent chest traumas was also present. Blood pressure values in clinostatism were 150/80 mm Hg, blood pressure values in orthostatism were 140/75 mm Hg, the heart rate was 53 bpm, and the oxygen saturation was normal. A meso-tele-systolic murmur was present. The ECG showed a bradycardic sinusal rhythm with a right bundle branch block. Echocardiographic evaluation revealed an ejection fraction of 60%. No pericardial effusion was observed. An interventricular septal hypertrophy, mild left atrial dilatation, mild mitral regurgitation and mild tricuspidal regurgitation were observed. Echocardiographic evaluation revealed an ejection fraction of 60%. A mild interventricular septal hypertrophy, an early left ventricular diastolic dysfunction without systolic dysfunction and a mild aortic regurgitation was observed. A Holter ECG revealed a bradycardic sinusal rhythm with minimal heart rate of 45 bpm and maximal heart rate of 90 bpm, 430 premature atrial beats, 32 ventricular ectopic beats. A simplified Italian protocol head-up tilt testing [5] was performed (stabilization phase of 5 min in the supine position; passive phase of 20 min at a tilt angle of 60°; provocation phase of further 15 min after 400 g NTG sublingual spray. Test interruption is made when the protocol is completed in the absence of symptoms, or
there is occurrence of syncope or, occurrence of progressive (> 5 min) orthostatic hypotension) (Fig. 2-1). A 4.10 s pause (Fig. 1) with syncope and a profound hypotension (blood pressure values were 65/50 mm Hg) were observed after 3 min in the provocation phase. Second-degree atrioventricular Block of the 2:1 form, advanced seconddegree atrioventricular block and junctional escape rhythm (28 bpm) were observed. Sinusal rhythm and normal blood pressure values were observed after Trendelenburg position. A simplified Italian protocol head-up tilt testing was performed after 40 days of withdrawal of carvedilol (Fig. 2-2). Blood pressure values in clinostatism were 150/ 80 mm Hg, blood pressure values in orthostatism were 160/90 mm Hg, the heart rate was 70 bpm, and the oxygen saturation was normal. A 2 s pause with presyncope and a hypotension (blood pressure values were 80/70 mm Hg) were observed after 2 min in the provocation phase. ECG revealed a bradycardic sinusal rhythm with heart rate of 42 bpm. Sinusal rhythm and normal blood pressure values were observed after Trendelenburg position. An antihypertensive treatment with a nonantiarrhythmic drug was added to the treatment with the combination of lisinopril and hydrochlorothiazide. This case assesses the importance of a pharmacological washout for the correct evaluation of the head-up tilt testing. References [1] Farwell DJ, Sulke AN. A randomised prospective comparison of three protocols for head-up tilt testing and carotid sinus massage. Int J Cardiol Dec 7 2005;105(3):241–9 [Electronic publication 2005 Jul 12]. [2] Zhao XL, Hu DY, Carvedilol Multicenter Clinical Study Group. Efficiency and safety of carvedilol treatment in high risk hypertensive patients. Zhonghua Nei Ke Za Zhi Jan 2006;45(1): 25–8. [3] McTavish D, Campoli-Richards D, Sorkin EM. Carvedilol. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy. Drugs Feb 1993;45(2):232–58. [4] Chizzola PR, Goncalves de Freitas HF, Marinho NV, Mansur JA, Meneghetti JC, Bocchi EA. The effect of beta-adrenergic receptor antagonism in cardiac sympathetic neuronal remodeling in patients with heart failure. Int J Cardiol Jan 4 2006;106(1):29–34. [5] Brignole M, Menozzi C, Del Rosso A, et al. New classification of haemodynamics of vasovagal syncope: beyond the VASIS classification. Analysis of the pre-syncopal phase of the tilt test without and with nitroglycerin challenge. Vasovagal Syncope International Study. Europace Jan 2000;2(1):66–76.