Circulation. 2001;104:2045-2050
doi: 10.1161/hc4201.097837
doi: 10.1161/hc4201.097837
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(Circulation. 2001;104:2045.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Mechanism of Syncope in Patients With Bundle Branch Block and Negative Electrophysiological Test
From the Departments of Cardiology, Ospedali Riuniti (M.B., P.D.), Lavagna, Italy; Ospedale S. Maria Nuova (C.M., N.B.), Reggio Emilia, Italy; Hospital Vall d’Hebron (A.M.), Barcelona, Spain; Hospital Clinico Universitario (R.G.-C.), Valencia, Spain; Hospital Clinico (L.M.), Barcelona, Spain; Hospital Virgen de las Nives (M.A.), Granada, Spain; Hospital Virgen del Rocio (F.E.), Sevilla, Spain; and Hospital Xeral de Vigo (J.B.), Vigo, Spain.
Correspondence to Michele Brignole, MD, Department of Cardiology, Ospedali Riuniti, I-16032 Lavagna, Italy. E-mail mbrignole{at}ASL4.liguria.it
Background— In patients with syncope and bundle branch block (BBB), syncope is suspected to be attributable to a paroxysmal atrioventricular (AV) block, but little is known of its mechanism when electrophysiological study is negative.
Methods and Results— We applied an implantable loop recorder in 52 patients with BBB and negative conventional workup. During a follow-up of 3 to 15 months, syncope recurred in 22 patients (42%), the event being documented in 19 patients after a median of 48 days. The most frequent finding, recorded in 17 patients, was one or more prolonged asystolic pause mainly attributable to AV block; the remaining 2 patients had normal sinus rhythm or sinus tachycardia. The onset of the bradycardic episodes was always sudden but was sometimes preceded by ventricular premature beats. The median duration of the arrhythmic event was 47 seconds. An additional 3 patients developed nonsyncopal persistent III-degree AV block, and 2 patients had presyncope attributable to AV block with asystole. No patients suffered injury attributable to syncopal relapse.
Conclusions— In patients with BBB and negative electrophysiological study, most syncopal recurrences have a homogeneous mechanism that is characterized by prolonged asystolic pauses, mainly attributable to sudden-onset paroxysmal AV block.
Key Words: syncope • electrophysiology • arrhythmia • heart block • electrocardiography
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|
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|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|