Vasovagal syncope or postural orthostatic tachycardia syndrome in children with neurological symptoms at disease onset: a clinical analysis of 88 cases
WANG Ai-Ping1,2, ZHENG Jing1,2, WANG Cheng1, CAI Hong1, MAO Ding-An1,2, LIN Ping1, LI Fang1, LUO Hai-Yan1,2, XIONG Jia-Jia1,2, LIU Li-Qun1,2
Department of Pediatrics, Second Xiangya Hospital of Central South University, Changsha 410011, China
Abstract:Objective To study the clinical features of vasovagal syncope (VVS) and postural orthostatic tachycardia syndrome (POTS) in children with neurological symptoms at disease onset. Methods A retrospective analysis was performed on the medical data of 88 children with the initial symptoms of the nervous system, such as transient loss of consciousness, dizziness, headache, and convulsion, who were finally diagnosed with VVS or POTS. Results Of the 88 children, there were 35 boys (40%) and 53 girls (60%), with an age of 4-15 years. The peak age of onset was between 10 and 13 years. All the children had the initial symptoms of transient loss of consciousness, dizziness, headache, and convulsion. Nervous system diseases were excluded by electroencephalography, cerebrospinal fluid examination, and cranial MRI. Of the 88 children, 53 (60%) were confirmed with VVS, and 35 (40%) with POTS, according to the results of head-up tilt test (HUTT). Five children with the initial symptom of transient loss of consciousness were misdiagnosed with epilepsy. Predisposing factors were determined for 59 children (67%), and prolonged standing was the most common factor, followed by change in body position and strenuous exercise. Premonitory symptoms were observed in 66 children (75%), among which chest discomfort was the most common symptom, followed by gastrointestinal symptoms (nausea, vomiting, and abdominal pain) and pale complexion. All 88 children received health education and exercise for autonomic nerve function, among whom 53 children with VVS were given oral rehydration salts and 35 children with POTS were given oral rehydration salts and metoprolol. All 88 children were followed up for 18 months, and the response rates to the above treatment at 3, 6, 12, and 18 months of follow-up were 87%, 93%, 93%, and 90% respectively. Conclusions In addition to nervous system diseases, functional cardiovascular diseases including VVS and POTS should be considered for children with the initial symptoms of transient loss of consciousness, dizziness, headache, and convulsion. HUTT can be used to make a confirmed diagnosis, and the early treatment can achieve a good outcome.
WANG Ai-Ping,ZHENG Jing,WANG Cheng et al. Vasovagal syncope or postural orthostatic tachycardia syndrome in children with neurological symptoms at disease onset: a clinical analysis of 88 cases[J]. CJCP, 2020, 22(5): 488-493.
Chen L, Li X, Todd O, et al. A clinical manifestation-based prediction of haemodynamic patterns of orthostatic intolerance in children:a multi-centre study[J]. Cardiol Young, 2014, 24(4):649-653.
[4]
Brignole M. ‘Ten Commandments’ of ESC syncope guidelines 2018:the new European Society of Cardiology (ESC) clinical practice guidelines for the diagnosis and management of syncope were launched 19 March 2018 at EHRA 2018 in Barcelona[J]. Eur Heart J, 2018, 39(21):1870-1871.
[5]
Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus-Report of the ILAE Task Force on Classification of Status Epilepticus[J]. Epilepsia, 2015, 56(10):1515-1523.
[6]
Gowda VK, Amoghimath R, Benakappa N, et al. Spectrum of nonepileptic paroxysmal events in children from Southern India[J]. J Neurosci Rural Pract, 2019, 10(4):608-612.
[7]
Silvani A, Calandra-Buonaura G, Johnson BD, et al. Physiological mechanisms mediating the coupling between heart period and arterial pressure in response to postural changes in humans[J]. Front Physiol, 2017, 8:163.
[8]
Salo LM, Woods RL, Anderson CR, et al. Nonuniformity in the von Bezold-Jarisch reflex[J]. Am J Physiol Regul Integr Comp Physiol, 2007, 293(2):R714-R720.
Jelavić MM, Babić Z, Hećimović H, et al. The role of tilt-table test in differential diagnosis of unexplained syncope[J]. Acta Clin Croat, 2015, 54(4):417-423.
[13]
Eisermann M, Kaminska A, Moutard ML, et al. Normal EEG in childhood:from neonates to adolescents[J]. Neurophysiol Clin, 2013, 43(1):35-65.
[14]
Scraggs TL. EEG maturation:viability through adolescence[J].Neurodiagn J, 2012, 52(2):176-203.
[15]
Stephenson JB. Syncope and electroencephalography[J]. Brain, 2014, 137(Pt7):e284.
[16]
van Dijk JG, Thijs RD, van Zwet E, et al. The semiology of tilt-induced reflex syncope in relation to electroencephalographic changes[J]. Brain, 2014, 137(Pt 2):576-585.
[17]
Mayuga KA, Fouad-Tarazi F. Dynamic changes in T-wave amplitude during tilt table testing:correlation with outcomes[J].Ann Noninvasive Electrocardiol, 2007, 12(3):246-250.
Dauphinot V, Gosse P, Kossovsky MP, et al. Autonomic nervous system activity is independently associated with the risk of shift in the non-dipper blood pressure pattern[J]. Hypertens Res, 2010, 33(10):1032-1037.
[20]
Topcu B, Akalin F. The autonomic nervous system dysregulation in response to orthostatic stress in children with neurocardiogenic syncope[J]. Cardiol Young, 2010, 20(2):165-172.
Wang Y, Zhang C, Chen S, et al. Frequency domain indices of heart rate variability are useful for differentiating vasovagal syncope and postural tachycardia syndrome in children[J]. J Pediatr, 2019, 207:59-63.
[24]
Antiel RM, Caudill JS, Burkhardt BE, et al. Iron insufficiency and hypovitaminosis D in adolescents with chronic fatigue and orthostatic intolerance[J]. South Med J, 2011, 104(8):609-611.
Qingyou Z, Junbao D, Chaoshu T. The efficacy of midodrine hydrochloride in the treatment of children with vasovagal syncope[J]. J Pediatr, 2006, 149(6):777-780.
[28]
Lin J, Jin H, Du J. Assessment of therapeutic biomarkers in the treatment of children with postural tachycardia syndrome and vasovagal syncope[J]. Cardiol Young, 2014, 24(5):792-796.
Zhang Q, Jin H, Wang L, et a1. Randomized comparison of metoprolol versus conventional treatment in preventing recurrence of vasovagal syncope in children and adolescents[J]. Med Sci Monit, 2008, 14(4):CR199-CR203.