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(Circulation. 2002;105:2741.)
© 2002 American Heart Association, Inc.

Clinical Investigation and Reports

Mechanism of Syncope in Patients With Heart Disease and Negative Electrophysiologic Test

Carlo Menozzi, MD; Michele Brignole, MD; Roberto Garcia-Civera, MD; Angel Moya, MD; Gianluca Botto, MD; Luis Tercedor, MD; Roberta Migliorini, BSc; Xavier Navarro, BSc, on behalf of the International Study on Syncope of Uncertain Etiology (ISSUE) Investigators^*

From the Department of Cardiology, Ospedale S. Maria Nuova (C.M.), Reggio Emilia; Ospedali del Tigullio (M.B.), Lavagna; Ospedale S. Anna (G.B.), Como; and Medtronic Italy (R.M.), Milan, Italy; and Hospital General Vall d’Hebron (A.M.), Barcelona; Hospital Clinico Universitario (R.G.C.), Valencia; Hospital Virgen de las Nieves (L.T.), Granada; and Medtronic Iberica (X.N.), Madrid, Spain.

Correspondence to Michele Brignole, MD, Department of Cardiology, Ospedali del Tigullio, I-16032 Lavagna, Italy. E-mail mbrignole{at}ASL4.liguria.it

Background— In patients with syncope and structural heart disease, syncope is suspected to be attributable to a primary cardiac arrhythmia, but little is known of its mechanism when electrophysiologic study is unremarkable.

Methods and Results— We applied an implantable loop recorder in 35 patients with overt heart disease at risk of ventricular arrhythmia, because these were patients with previous myocardial infarction or cardiomyopathy with depressed ejection fraction or nonsustained ventricular tachycardia in whom an electrophysiologic study was unremarkable. During a follow-up of 3 to 15 months, syncope recurred in 6 patients (17%) after a mean of 6±5 months; in 3 patients, the mechanism of syncope was bradycardia with long pauses (sudden-onset AV block in 2 cases and sinus arrest in 1 case); in 1 patient, there was stable sinus tachycardia; and in 2 patients, who had chronic atrial fibrillation, there was an increase in ventricular rate. A total of 23 episodes of presyncope were documented in 8 patients (23%): no rhythm variation or mild tachycardia in 12 cases, paroxysmal atrial fibrillation or atrial tachycardia in 10 cases, and sustained ventricular tachycardia in 1 case. No patient died during the study period nor suffered from injury attributable to syncopal relapse.

Conclusions— The patients with unexplained syncope, structural heart disease, and negative electrophysiologic study had a favorable medium-term outcome with no case of death and a low recurrence rate of syncope without related injury. The mechanism of syncope was heterogeneous, and ventricular tachyarrhythmia was unlikely.

Key Words: syncope • electrophysiology • arrhythmia • heart diseases • electrocardiography

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