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ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction

ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease
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J Am Coll Cardiol, 2008; 51:2372-2373, doi:10.1016/j.jacc.2008.03.024
© 2008 by the American College of Cardiology Foundation
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CORRESPONDENCE: LETTER TO THE EDITOR

Reply

Maw Pin Tan, BMedSci, BMBS, MRCP* and Steve W. Parry, MBBS, PhD, FRCP

* Institute for Ageing and Health, Newcastle University, Westgate Road, Newcastle upon Tyne, Tyne and Wear NE4 6BE, United Kingdom (Email: m.p.tan{at}ncl.ac.uk).

We thank Dr. Kapoor for his interest in our recent paper (1). As mentioned by Dr. Kapoor, beta-blockers had indeed found widespread usage in the treatment of vasovagal syncope in the past. Earlier uncontrolled studies (2,3) and 1 small randomized-controlled study (4) had demonstrated encouraging results, fueling this practice. However, recent randomized controlled trials (5,6), as well as the only multicenter, randomized, placebo-controlled trial published to date (7), have failed to demonstrate any beneficial effects with beta-blockers. There was a statistically nonsignificant trend to benefit in the subgroup of subjects ≥42 years of age, suggesting that further evaluation of the use of beta-blockers in older subjects may be warranted (8).

The studies cited by Dr. Kapoor were uncontrolled studies evaluating the role of intravenous beta-blockers in predicting treatment response to long-term oral beta-blocker therapy. Following the positive diagnosis of vasovagal syncope with a head-up tilt (HUT) test, a second HUT was performed to assess response to intravenous esmolol or propanolol (9–11). However, there has been a reasonable body of evidence demonstrating that the reproducibility of a positive HUT is low (12–15). The role of HUT as an instrument to evaluate treatment benefit is therefore limited, and can only be used in this context if a comparison is made with placebo (16).


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 References
 

  1. Tan MP, Parry SW. Vasovagal syncope in the older patient J Am Coll Cardiol 2008;51:599-606.[Abstract/Free Full Text]
  2. Cohen MB, Snow JS, Grasso V, et al. Efficacy of pindolol for treatment of vasovagal syncope Am Heart J 1995;130:786-790.[CrossRef][ISI][Medline]
  3. Jhamb DK, Singh B, Sharda B, et al. Comparative study of the efficacy of metoprolol and verapamil in patients with syncope and positive head-up tilt test response Am Heart J 1996;132:608-611.[CrossRef][ISI][Medline]
  4. Mahanonda N, Bhuripanyo K, Kangkagate C, et al. Randomized double-blind, placebo-controlled trial of oral atenolol in patients with unexplained syncope and positive upright tilt table test results Am Heart J 1995;130:1250-1253.[CrossRef][ISI][Medline]
  5. Alegria JR, Gersh BJ, Scott CG, Hodge DO, Hammill SC, Shen WK. Comparison of frequency of recurrent syncope after beta-blocker therapy versus conservative management for patients with vasovagal syncope Am J Cardiol 2003;92:82-84.[CrossRef][ISI][Medline]
  6. Madrid AH, Ortega J, Rebollo JG, et al. Lack of efficacy of atenolol for the prevention of neurally mediated syncope in a highly symptomatic population: a prospective, double-blind, randomized and placebo-controlled study J Am Coll Cardiol 2001;37:554-559.[Abstract/Free Full Text]
  7. Sheldon R, Connolly S, Rose S, et al. Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope Circulation 2006;113:1164-1170.[Abstract/Free Full Text]
  8. Cox MM, Perlman BA, Mayor MR, et al. Acute and long-term beta-adrenergic blockade for patients with neurocardiogenic syncope[see comment] J Am Coll Cardiol 1995;26:1293-1298.[Abstract]
  9. Gielerak G, Makowski K, Cholewa M. Prognostic value of head-up tilt test with intravenous beta-blocker administration in assessing the efficacy of therapy in patients with vasovagal syncope Ann Noninvasive Electrocardiol 2005;10:65-72.[CrossRef][ISI][Medline]
  10. Natale A, Newby KH, Dhala A, Akhtar M, Sra J. Response to beta blockers in patients with neurocardiogenic syncope: how to predict beneficial effects J Cardiovasc Electrophysiol 1996;7:1154-1158.[ISI][Medline]
  11. Sra JS, Murthy VS, Jazayeri MR, et al. Use of intravenous esmolol to predict efficacy of oral beta-adrenergic blocker therapy in patients with neurocardiogenic syncope J Am Coll Cardiol 1992;19:402-408.[Abstract]
  12. Brooks R, Ruskin JN, Powell AC, Newell J, Garan H, McGovern BA. Prospective evaluation of day-to-day reproducibility of upright tilt-table testing in unexplained syncope Am J Cardiol 1993;71:1289-1292.[CrossRef][ISI][Medline]
  13. Chen XC, Chen MY, Remole S, et al. Reproducibility of head-up tilt-table testing for eliciting susceptibility to neurally mediated syncope in patients without structural heart disease Am J Cardiol 1992;69:755-760.[CrossRef][ISI][Medline]
  14. de Buitleir M, Grogan Jr. EW, Picone MF, Casteen JA. Immediate reproducibility of the tilt-table test in adults with unexplained syncope Am J Cardiol 1993;71:304-307.[CrossRef][ISI][Medline]
  15. Fish FA, Strasburger JF, Benson Jr DW. Reproducibility of a symptomatic response to upright tilt in young patients with unexplained syncope Am J Cardiol 1992;70:605-609.[CrossRef][ISI][Medline]
  16. Moya A, Permanyer-Miralda G, Sagrista-Sauleda J, et al. Limitations of head-up tilt test for evaluating the efficacy of therapeutic interventions in patients with vasovagal syncope: results of a controlled study of etilefrine versus placebo J Am Coll Cardiol 1995;25:65-69.[Abstract]

Related Article

Predicting the Effectiveness of Beta-Blocker Therapy in Vasovagal Syncope
John R. Kapoor
J. Am. Coll. Cardiol. 2008 51: 2372. [Full Text] [PDF]




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