Article

PDF
Access to the PDF text
Advertising


Free Article !

Archives of cardiovascular diseases
Volume 109, n° 3
pages 199-206 (mars 2016)
Doi : 10.1016/j.acvd.2015.11.009
Received : 17 Mars 2015 ;  accepted : 5 November 2015
Syncope unit in the paediatric population: A single-centre experience
Unité de prise en charge des syncopes dédiée à la population pédiatrique : expérience monocentrique
 

Mathieu Courtheix 1, , Zakaria Jalal 1, Pierre Bordachar, Xavier Iriart, Xavier Pillois, Cécile Escobedo, Catherine Rabot, Laetitia Tribout, Jean-Benoit Thambo
 Hôpital cardiologique Haut-Lévêque, CHU de Bordeaux, université de Bordeaux, 4, avenue de Magellan, 33604 Bordeaux-Pessac, France 

Corresponding author.
Summary
Background

Syncopes are frequent in the paediatric population. Most are benign, but rare cases are caused by cardiac life-threatening diseases. Syncope units developed in the adult population have demonstrated improvement in evaluation and treatment, with a reduction in hospitalization.

Aims

We report our experience of paediatric syncope management in a dedicated unit, and analyse the value of different elements in the identification of cardiac causes.

Methods

This prospective study included 97 consecutive patients (mean age: 12.1±3.3 years) referred between January 2011 and June 2013 to a syncope unit with a paediatric cardiologist, a nurse, a physiotherapist and a psychologist. Patients were classified into diagnostic categories after an initial evaluation that included history, physical examination, electrocardiography, echocardiography and Holter monitoring.

Results

The most common diagnosis was neurocardiogenic syncope (n =69, 70.4%). Fifty-two cases (81.3%) had no or less recurrence after specific management that included physiotherapy and psychological support (follow-up: 11.5±5.4 months). Psychogenic pseudosyncopes affected 20 children (20.6%). Two patients had epileptic seizures. There were five cases of cardiac syncope (5.1%): two long QT syndromes and a catecholaminergic polymorphic ventricular tachycardia received beta-blockers; two atrioventricular complete blocks required pacemakers. One case was of indeterminate cause and received an insertable loop recorder after exhaustive investigations. Exercise-induced syncopes were significantly associated with cardiac origins (P =0.003), such as electrocardiographic abnormalities (P <0.001), whereas echocardiography was not contributive.

Conclusion

Syncope units in the paediatric population may be useful in the diagnostic process, to help identify rare cardiac aetiologies, and could decrease recurrence through specific management.

The full text of this article is available in PDF format.
Résumé
Contexte

Les syncopes sont un problème fréquent en pédiatrie ; la plupart sont bénignes mais quelques cas sont dus à des pathologies cardiaques potentiellement menaçantes. Les unités syncope développées chez l’adulte ont montré un bénéfice dans la prise en charge diagnostique et thérapeutique en réduisant les hospitalisations.

Objectifs

Nous rapportons notre expérience de prise en charge des syncopes en pédiatrie par une unité spécialisée en analysant la valeur de différents éléments pour discriminer les causes cardiaques.

Méthodes

Cette étude prospective a inclus 97 patients (âge moyen : 12,1±3,3ans) consécutivement adressés entre janvier 2011 et juin 2013 à une unité impliquant cardiologue pédiatrique, infirmière, kinésithérapeute et psychologue. Les patients étaient classés en catégories de diagnostic après évaluation initiale comprenant histoire médicale, examen physique, électrocardiogramme, échocardiographie et holter rythmique.

Résultats

Le diagnostic le plus fréquent était les syncopes neurocardiogéniques : 69 patients (70,4 %). Cinquante-deux cas (81,3 %) présentaient moins de récidives après prise en charge spécifique comprenant kinésithérapie et support psychologique (suivi de 11,5±5,4 mois). Les pseudosyncopes psychogéniques représentaient 20 enfants (20,6 %). Deux patients présentaient une épilepsie. Les syncopes cardiaques comprenaient 5 cas (5,1 %) : 2 syndromes du QT long et une tachycardie ventriculaire catécholergique traités par bêtabloquants, 2 blocs atrio-ventriculaires complets nécessitant un pacemaker. Un cas de syncope inexpliquée fut appareillé d’un holter implantable. Les syncopes à l’effort étaient significativement associées à une origine cardiaque (p =0,003), comme les anomalies électrocardiographiques (p <0,001) alors que l’échocardiographie s’avérait non contributive.

Conclusion

Une unité syncope pédiatrique apparaît intéressante dans la démarche diagnostique pour identifier les rares étiologies cardiaques et pourrait réduire les récidives via une prise en charge spécifique.

The full text of this article is available in PDF format.

Keywords : Syncope, Children, Adolescents, Channelopathies, Tilt test

Mots clés : Syncope, Enfants, Adolescents, Canalopathies, Tilt test

Abbreviations : CT, LOC, MRI, NCS, PPS


Background

Syncope is defined as a “transient loss of consciousness (LOC) due to transient global cerebral hypoperfusion characterized by rapid onset, short duration and spontaneous complete recovery”. Presyncope is “a state that resembles the prodrome of syncope, but which is not followed by LOC” [1].

Syncope is a common problem in children and adolescents; nearly 15% of this population will have at least one syncopal event before the age of 18 years, with a female predominance and an incidence peak in those aged 15–19 years [2, 3]. The recurrence rate ranged from 33% to 51% in a 5-year follow-up [4]. While most cases of syncope are benign, around 5% are the initial manifestation of a life-threatening cardiac disease [5, 6]. Thus, diagnostic evaluation has to fulfil two nearly opposite objectives: to reassure large numbers of patients and anxious parents, without missing rare cardiac causes that have to be recognized promptly as they can be fatal.

Issues are similar in the adult population, and led to the development of specific syncope units, which have demonstrated improvement in the diagnostic and management processes, with reductions in duration of hospitalization and favourable long-term outcomes [7, 8].

In this article, we aim to report our experience of syncope evaluation and treatment in children and adolescents in a dedicated syncope unit, with a focus on the specific management of reflex neurocardiogenic syncope (NCS), and the effect on recurrence rates.

Methods

This prospective study included patients aged from 4 to 18 years who were consecutively referred, between 01 January 2011 and 30 June 2013, for syncope evaluation to a paediatric syncope unit in our department of paediatric cardiology, after clinical assessment by general practitioners or within the paediatric emergency unit of our university hospital. This dedicated unit has experienced and trained personnel, including a paediatric cardiologist, a nurse, a physiotherapist and a psychologist. Children and adolescents with a history of structural heart disease, channelopathy or arrhythmia were excluded from the sample. The execution of the study conformed to the principles outlined in the Declaration of Helsinki on research in human subjects. Children were included after informed consent was obtained from their parents. The study was approved by the institutional ethics committee.

Initial assessment

All patients underwent an initial evaluation, which included medical history, physical examination, 12-lead electrocardiogram, echocardiography and 24-hour Holter monitoring. Standardized exercise stress testing and tilt testing (stabilization phase of 15minutes in supine position, passive phase of 20minutes at a tilt angle of 60 degrees and, if no symptom occurred, provocation phase of a further 15minutes after 400μg nitroglycerin delivered sublingually [9]; test was considered positive when symptoms were reproduced in association with hypotension and/or bradycardia) were very often proposed as systematic complementary investigations. In rare cases, other targeted specific tests were carried out according to suspected underlying cause: blood tests, genetic investigations, drug tests, such as isoproterenol infusion (45μg/min in 3min) and epinephrine infusion (0.05μg/kg per min to 0.3μg/kg per min in 20min), and imaging, including computed tomography (CT) and resonance magnetic imaging (MRI).

Data systematically collected regarding medical history included family history of syncope or cardiac disease, previous episodes of fainting, prodomes, associated symptoms (such as palpitations or chest pain) and triggers (effort, stress, pain, etc.).

After initial assessment, patients were classified into five diagnostic categories, according to published data [7]: NCS, cardiac syncope, psychogenic pseudosyncope (PPS), neurological disorder and indeterminate cause (Table 1). A diagnosis of PPS was made after the exclusion of other causes, and was confirmed by the psychologist after clinical evaluation. The distribution of associated circumstances or signs and test results were examined in the different diagnostic categories, especially in order to compare cardiac syncopes versus other causes.

Management of NCS

Patients with a diagnosis of NCS underwent specific management in the syncope unit, consisting of information, reassurance, general recommendations (hydration, increasing salt intake, avoiding hot conditions and situations inducing syncope), physiotherapy training (isometric pressure movements) and consultation with the psychologist.

Individual physiotherapy sessions focused on education about recognizing early symptoms and preventive measures. Physical training included exercise and manoeuvres consisting of isometric muscle contractions, such as leg crossing and arm gripping [10]. Manoeuvres were explained, demonstrated and then practised under supervision. Patients were instructed to maintain the manoeuvre as long as possible, and to move on to a second manoeuvre in the absence of complete disappearance of symptoms; they were encouraged to practise these manoeuvres and exercise regularly.

Patients and their parents were contacted in order to document recurrence of syncope and presyncope, and were asked to assess if there was a significant improvement in the situation in case of recurrent events.

Statistical analysis

Data are expressed as means±standard deviations for continuous variables or as numbers and percentages for categorical variables. The paired t -test, Fisher's test, the χ2 test and linear regression were used to assess differences between subgroups, as appropriate. Statistical significance was set at P <0.05. Data analysis was performed using STATA® software (StataCorp LP, College Station, TX, USA).

Results
Population characteristics

Between 01 January 2011 and 30 June 2013, 97 patients were prospectively enrolled (mean age 12.1±3.3 years; 47.4% males). The 13–15 age group was predominant (Figure 1). Seventy-eight patients (80.4%) had typical syncopes, most of the other 19 patients presented only symptoms of presyncope, and the few remaining cases had another clinical presentation. Medical history revealed at least one previous episode for 80 patients (82.5%). Prodomes concerned 67 children (69.1%), and consisted of lightheadedness, blurred vision, sweating, nausea, abdominal pain and/or tinnitus. LOC caused trauma in nine cases, and symptoms were exercise-induced in eight cases. Other variables are reported in Table 2.



Figure 1


Figure 1. 

Distribution of patients assessed in the syncope unit by age group (4–6 means patients aged from 4 to 6 years; 7–9 means patients aged from 7 to 9 years, etc.).

Zoom

Effort tests were done in 76 cases (78.0%), as well as tilt tests in a similar number of patients (n =74; 76.3%). Other examinations were rarely performed (Table 3).

After complete assessment, we were able to establish an aetiological diagnosis of syncope in 96 patients, as depicted in Figure 2.



Figure 2


Figure 2. 

Distribution of aetiological diagnosis for patients assessed in the syncope unit. NCS: neurocardiogenic syncope; PPS: psychogenic pseudosyncope.

Zoom

Syncope aetiologies

The most common diagnosis was NCS (n =69, 70.4%), with a significant female preponderance (59.4%; P =0.02) and a mean age of 12.3±3.0 years; 59 patients (85.5%) had recurrent episodes and eight patients (11.6%) presented only presyncopal symptoms. Tilt testing was performed in 62 patients in this group, and was positive in 37 cases (59.6%). Management consisted of physiotherapy training for 65 patients (94.2%), associated with a consultation with our psychologist in 33 cases (47.8%).

After a mean follow-up of 11.5±5.4 months, excluding five dropout cases, recurrences occurred in 21 of the 64 patients (32.8%); 52 (81.3%) declared a significant improvement in the situation comparing after versus before specific management by the syncope unit. This included nine patients with recurrence who experienced a substantial decrease in the number and/or severity of episodes. In case of recurrences, patients had the opportunity to benefit from additional training sessions with the physiotherapist, and psychological consultations. Univariate analysis was performed to determine possible predictors of recurrence of NCS among different variables: sex, age, body mass index, previous syncope episodes, traumatic syncopes, effort-related episodes, head-up tilt test results, physiotherapy training and psychological consultation. None of these items was significantly associated with the recurrence rate.

In 20 cases, the cause was considered to be psychogenic, with a masculine predominance (65%) and a mean age of 11.7±3.6 years; nine of these patients did not experience LOC – they represented around half of the presyncope cases in our cohort. Sixteen patients (80.0%) had psychological support and seven patients (35.0%) had a physiotherapy session.

Two children were initially admitted to our unit for syncope, but careful clinical assessment revealed that they had had epileptic seizures; they were referred to the neurological department for specific investigations that confirmed the neurological disorder diagnosis.

Finally, five patients (5.1%) had cardiac syncopes: two had complete atrioventricular block without structural heart disease, which required surgical epigastric pacemaker implantation. The first case was an immunological block (anti-SSA antibodies from the mother) diagnosed in a 4-year-old boy; the second case involved a 15-year-old adolescent who presented a syncope during sports activities, with neither immunological abnormalities nor documented infection following biological investigations. Two adolescents had a type 1 long QT syndrome confirmed by genetic testing (pathogenic mutation of the KNCQ1 gene): a 17-year-old boy presented a long corrected QT interval of 495ms on standard electrocardiogram, whereas the diagnosis was less obvious for a 16-year-old girl with recurrent effort syncopes, but no significant abnormality at initial evaluation and no arrhythmia during effort testing. Complementary explorations included a CT showing normal coronary vessels, an isoproterenol test without malignant arrhythmia and a pathological epinephrine test with important paradoxical extension of the QT interval. Both patients received beta-blocker therapy without recurrence at the follow-up stage.

Catecholaminergic polymorphic ventricular tachycardia was diagnosed in a 5-year-old girl after an LOC at school during playtime. Electrocardiography and echocardiography (including coronary anatomy) were normal, but an effort test revealed monomorphic premature ventricular contractions increasing with and disappearing after exercise. Cardiac MRI was performed and did not show any structural abnormality, whereas an isoproterenol test triggered repetitive polymorphic premature ventricular contractions. Genetic investigations found compound heterozygous mutations of the triadine gene, with an autosomal recessive transmission, as each parent had one of the mutations. Treatment was also based on beta-blockers, with a favourable outcome.

In addition, a case of recurrent traumatic brief LOC in a 12-year-old boy was classified as syncope of indeterminate origin after exhaustive investigations, including tilt test, effort test, isoproterenol test and cardiac MRI. An insertable loop recorder (Reveal® XT; Medtronic, Dublin Ireland) was recently implanted after recurrence to document or eliminate a cardiac arrhythmia.

Statistical analysis revealed that exercise-related episodes were significantly associated with cardiac syncopes (P =0.003), whereas trauma or symptoms (such as chest pain and palpitations) were not. Absence of prodomes was also more frequent in this category (P =0.04) than in non-cardiac syncopes. Electrocardiographic abnormalities appeared significantly more frequently in the cardiogenic syncope group (P <0.001). Conversely, echocardiography was normal for all patients and was not contributive (Table 4).

All causes included, mean hospitalization duration was 1.1±1.0 days, with a minimum of 0 days for 13 patients who only underwent ambulatory management, and a maximum of 8 days for an adolescent hospitalized after a cardiac syncope. Distribution of specific management and therapies by number of patients is shown in Figure 3.



Figure 3


Figure 3. 

Distribution of specific management and therapy by number of patients. ILR: implantable loop recorder.

Zoom

Discussion

Assessment and management of syncope in the paediatric population remains a challenge for physicians, as guidelines focus principally on adults. In this study, we sought to report our experience of syncope evaluation and treatment in children and adolescents in a dedicated syncope unit.

Epidemiological data

This cohort included patients aged from 4 to 18 years, with a predominance of females and of the 13–15 years age group. Our population demography is consistent with previous published data [2, 3, 11]. However, patients were slightly younger than the age incidence peak, mainly because patients aged16years are usually referred to the adult emergency care unit in our hospital. Another specificity was the high rate of syncope recurrence, which underlines that a large number of isolated episodes do not lead to medical evaluation in a specific centre.

NCS was the most frequent aetiology of syncope (70%) in our population; this is in line with the reported literature (incidence of NCS ranging from 61% to 80%) as is the significant female preponderance [11, 12]. PPS is not rare and probably involves 20–30% of patients presenting syncope, although the reported prevalence is often lower because it is insufficiently recognized [13, 14]. Neurological LOC is a classic differential diagnosis of syncope, and has to be considered in the management of syncope. Therefore, evaluation must first confirm diagnosis of authentic syncope, which finally involved around 80% of the patients referred to our unit.

Cardiac aetiologies represented 5.1% of all cases; similar proportions from 2% to 6% have been described by other authors, with a majority of electric heart diseases [5, 6]. One of the main challenges for physicians in caring for children presenting with syncope is not to misdiagnose cardiac causes, which are potentially life-threatening for index patients as well as for their relatives in case of inherited disorders. Most cardiac aetiologies of syncope have specific and effective treatments, emphasizing that the diagnostic process must be perfectly efficient. Some aspects of patient history can suggest a cardiac cause of paediatric syncope: heart disease or premature sudden death in the family, known or suspected heart disease, absence of prodrome, injury during syncope, syncope associated with exercise or specific triggers (loud noise or fright) and syncope preceded by chest pain or palpitations [1, 5]. Recurrent episodes are also suspected, but can be the result of benign causes, such as NCS [15]. In our cohort, effort-induced events and absence of prodromal symptoms were highly associated with cardiac origins (P =0.003 and P =0.04), whereas other variables were not, potentially because of a lack of statistical power due to the small cardiac causes group (n =5).

Contribution of diagnostic tests

The electrocardiogram was the most effective examination for detecting cardiac syncopes, with particular attention paid to the QT interval, given that long QT syndrome is a major cause of cardiac syncope in children and adolescents [5]. Ritter et al. suggested that history, physical examination and electrocardiography allow the identification of a cardiac cause with a sensitivity of 96% [6]. In our cohort, electrocardiography revealed abnormalities for three in five cases, whereas other systematic additional tests were not contributive.

Holter monitoring was not more powerful than standard electrocardiography, as symptoms almost never occur in the short period while the monitor is worn. Hegazy et al. and Ayabakan et al. showed that Holter monitoring has a valuable role in the assessment of high-risk patients (postoperative and cardiomyopathy), but has a low yield in children with syncope [16, 17].

Transthoracic echocardiography was systematically performed after physical examination in our congenital heart disease department, and this strategy was also initially applied in our syncope unit. Ultimately, it turned out to be unnecessary, as none of cardiac syncopes was caused by structural heart disease. In a review of 322 routine echocardiograms performed in paediatric syncope cases, only two revealed consistent abnormalities (i.e. cardiomyopathies) that were considered to be potential causes of the syncope, but the diagnosis was already suspected on the electrocardiogram, which was abnormal in both cases [6]. Since then, echocardiography is considered if clinical suspicion of cardiac cause remains after clinical examination and electrocardiogram, but it is still not systematically performed in patients with syncope.

Exercise testing appeared important for patients who experienced syncopes during or shortly after exertion: it showed a significant abnormality in only one of 97 patients, but led to the diagnosis of a life-threatening channelopathy, and helped in monitoring the effectiveness of beta-blocker therapy. By comparison, episodes occurring after exercise are usually benign vasovagal syncopes.

Head-up tilt testing can be useful in the evaluation of frequent or severe syncope, reproducing symptoms associated with cardioinhibitory, vasodepressor or mixed patterns; its yield in children remains debatable given the high rates of false negatives and their greater susceptibility to orthostatic stress than adults. The few paediatric studies that included a control group showed that sensitivity varies from 43% to 49%, and that specificity varies from 93% to 100% [18]. Although intravenous isoproterenol was classically used in order to increase sensibility, tilt testing potentiated with sublingual nitroglycerin demonstrated a close positive impact on diagnosis, despite a small decrease in specificity, with safety and simplicity [9]. In our cohort, a tilt test positive response was considered to suggest NCS, inducing similar symptoms with haemodynamic changes; it implied a positive predictive value and a specificity of 100%. False positives cannot be excluded, because tilt testing could cause NCS in a patient who had another prior cause of LOC. The best specificity may be obtained by performing the tilt test at 60° or 70° for no longer than 10minutes [19]. Tilt testing is also interesting for diagnosing PPS when symptoms are not related to cardiocirculatory abnormalities causing cerebral hypoperfusion, particularly if associated with eye closure (97% in PPS versus 7% in NCS) [20].

Other investigations are unnecessary in routine practice, but are interesting in management when a cardiac origin is highly suspected: morphological examinations, such as CT to eliminate an anomalous origin of a coronary artery or MRI to search for structural heart disease (right ventricular arrhythmogenic cardiomyopathy, myocarditis, etc.); drug tests, such as epinephrine infusion in suspected long QT syndrome [21] and isoproterenol in catecholaminergic polymorphic ventricular tachycardia [22]; and genetic investigations to confirm the diagnosis of channelopathies and then guide family screening. The implantable loop recorder plays a key role in the management of rare cases of unexplained frequent syncopes, with a high diagnosis yield. Indeed, this device has enabled the unmasking of cause-related symptoms (arrhythmias or not) in around 65% of patients in various series [23, 24, 25].

Management strategy

The therapeutic approach is guided by the underlying cause, but can face different difficulties, from problematic recurrent benign syncopes to questions related to cardiac pacing or defibrillation features in young patients. Drug therapy (fludrocortisone, beta-blockers, etc.) and pacemakers remain unsatisfactory and controversial in NCS [26, 27, 28, 29]. Management principally consists of explanation, reassurance, increasing salt and water intake, avoiding known triggers and different manoeuvres at the onset of prodromes (leg crossing and muscle tensing) [10, 30]. Physical training may reduce syncope recurrences [31]. Psychological rehabilitation is also essential, as patients with NCS show more anxiety and depressive symptoms than control subjects [32]. The rate of recurrent episodes varies from 19% to 59% after 21 months [33, 34]. Kouakam et al. followed 97 children and adolescents, and syncope recurred in 31 cases (32%) during a mean follow-up of 46±28 months, without correlation with the tilt test result [35]. The same proportion was found in our cohort, but with a shorter follow-up, possibly because patient recruitment included many highly recurrent syncopes. Statistical analysis did not identify predictors of NCS recurrence. However, Kouakam et al. asserted a significant relationship between the number of historical syncope episodes and the risk of recurrent syncopes [35], which implies a need to have special consideration for patients with several prior syncopes. A controlled study should be performed to define whether education, physical and psychological rehabilitation improve prognosis. In addition, spontaneous reduction of symptoms occurs in time in paediatric patients with NCS (probably because of restoration of the disturbed autonomic reflex activity), and recurrences seem unlikely after 2 years from first diagnosis [36].

Clinical implications of the paediatric syncope unit

A cohesive structured care pathway generally appears optimal for quality service delivery. A prospective randomized study showed that a designated syncope unit improves diagnostic yield and reduces hospital admissions as well as length of hospital stay, without affecting syncope recurrence and all-cause mortality in adults [37]. No comparable data are available for children and young people. Assessment of syncope in this population remains controversial and without uniform practice, as parental and physician anxiety may lead to multiple investigations. To our knowledge, this study constitutes the first report on a paediatric dedicated syncope unit offering standardized management with appropriate resources and multidisciplinary collaboration (cardiologists, paediatricians, nurses, psychologists and physiotherapists). The aims of the unit are to identify and treat cardiac aetiologies, reassure in case of benign causes and propose adapted therapies and follow-up for recurrent syncopes. This strategy may reduce hospitalization time and could decrease symptoms with continuity of care. Further studies should be conducted to attest its benefits and cost-effectiveness.

Study limitations

As mentioned above, our cohort appeared slightly different to patients presenting to an emergency department because of a selection bias, and this limits extrapolation of the findings across the general paediatric population. Aetiological diagnosis often remained presumptive as certain diagnosis is rarely possible in syncope. Moreover, management was quite heterogeneous and potentially could have affected outcomes: for example, half of the patients with NCS did not have a psychological consultation because of medical choice or patient refusal. Results must be interpreted as obtained in an observational uncontrolled study with the limitations inherent to this approach. Improvement of the situation after management in NCS can be seen as a subjective endpoint, but it really reflects better quality of life from the perspective of patients, which is our first objective. Last, mean follow-up was about 1 year, and a longer follow-up duration is needed to better assess the long-term effects of our specific management strategy.

Conclusions

History, physical examination and electrocardiography are sufficient in routine practice to evaluate paediatric syncopes, most of which have benign reflex causes. In case of abnormalities or particular elements, such as exercise-induced events, further investigations are needed to diagnose a minority of life-threatening heart diseases. Assessment in a dedicated paediatric syncope unit may be useful in the diagnostic process, and should improve clinical outcomes for young patients. We suggest the value of specific and global management for NCS, which will have to be investigated in a controlled study to demonstrate its positive impact on recurrence rates.

Disclosure of interest

The authors declare that they have no competing interest.

References

Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology, European Heart Rhythm Association, and al. Guidelines for the diagnosis and management of syncope (version 2009) Eur Heart J 2009 ;  30 : 2631-2671
Driscoll D.J., Jacobsen S.J., Porter C.J., Wollan P.C. Syncope in children and adolescents J Am Coll Cardiol 1997 ;  29 : 1039-1045 [cross-ref]
Lewis D.A., Dhala A. Syncope in the pediatric patient. The cardiologist's perspective Pediatr Clin North Am 1999 ;  46 : 205-219 [inter-ref]
Friedman N.R., Ghosh D., Moodley M. Syncope and paroxysmal disorders other than epilepsy Swaiman's Textbook of Pediatric Neurology China: Elsevier (2012).  905-925
Black K.D., Seslar S.P., Woodward G.A. Cardiogenic causes of pediatric syncope Clin Pediatr Emerg Med 2011 ;  12 : 266-277 [inter-ref]
Ritter S., Tani L.Y., Etheridge S.P., Williams R.V., Craig J.E., Minich L.L. What is the yield of screening echocardiography in pediatric syncope? Pediatrics 2000 ;  105 : E58
Shen W.K., Traub S.J., Decker W.W. Syncope management unit: evolution of the concept and practice implementation Prog Cardiovasc Dis 2013 ;  55 : 382-389 [cross-ref]
Viqar-Syed M., Bradley D.J., Shen W.K. Syncope units: impact on patient care and health-related costs Cardiol Clin 2013 ;  31 : 39-49 [inter-ref]
Foglia-Manzillo G., Giada F., Fteita N., Nessi I., Santarone M., Raviele A. Tilt testing potentiated with sublingual nitroglycerin in children with unexplained syncope Eur Heart J 2007 ;  28 : 2605-2609 [cross-ref]
van Dijk N., Quartieri F., Blanc J.J., and al. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the Physical Counterpressure Manoeuvres Trial (PC-Trial) J Am Coll Cardiol 2006 ;  48 : 1652-1657 [cross-ref]
Massin M.M., Bourguignont A., Coremans C., Comte L., Lepage P., Gerard P. Syncope in pediatric patients presenting to an emergency department J Pediatr 2004 ;  145 : 223-228 [inter-ref]
Moodley M. Clinical approach to syncope in children Semin Pediatr Neurol 2013 ;  20 : 12-17 [cross-ref]
Benbadis S.R., Chichkova R. Psychogenic pseudosyncope: an underestimated and provable diagnosis Epilepsy Behav 2006 ;  9 : 106-110 [cross-ref]
Luzza F., Di Rosa S., Pugliatti P., Ando G., Carerj S., Rizzo F. Syncope of psychiatric origin Clin Auton Res 2004 ;  14 : 26-29 [cross-ref]
Vlahos A.P., Kolettis T.M. Family history of children and adolescents with neurocardiogenic syncope Pediatr Cardiol 2008 ;  29 : 227
Ayabakan C., Ozer S., Celiker A., Ozme S. Analysis of 2017 Holter records in pediatric patients Turk J Pediatr 2000 ;  42 : 286-293
Hegazy R.A., Lotfy W.N. The value of Holter monitoring in the assessment of Pediatric patients Indian Pacing Electrophysiol J 2007 ;  7 : 204-214
Seifer C.M., Kenny R.A. Head-up tilt testing in children Eur Heart J 2001 ;  22 : 1968-1971 [cross-ref]
Lewis D.A., Zlotocha J., Henke L., Dhala A. Specificity of head-up tilt testing in adolescents: effect of various degrees of tilt challenge in normal control subjects J Am Coll Cardiol 1997 ;  30 : 1057-1060 [cross-ref]
Tannemaat M.R., van Niekerk J., Reijntjes R.H., Thijs R.D., Sutton R., van Dijk J.G. The semiology of tilt-induced psychogenic pseudosyncope Neurology 2013 ;  81 : 752-758 [cross-ref]
Vyas H., Hejlik J., Ackerman M.J. Epinephrine QT stress testing in the evaluation of congenital long-QT syndrome: diagnostic accuracy of the paradoxical QT response Circulation 2006 ;  113 : 1385-1392 [cross-ref]
Celiker A., Erdogan I., Karagoz T., Ozer S. Clinical experiences of patients with catecholaminergic polymorphic ventricular tachycardia Cardiol Young 2009 ;  19 : 45-52 [cross-ref]
Al Dhahri K.N., Potts J.E., Chiu C.C., Hamilton R.M., Sanatani S. Are implantable loop recorders useful in detecting arrhythmias in children with unexplained syncope? Pacing Clin Electrophysiol 2009 ;  32 : 1422-1427 [cross-ref]
Babikar A., Hynes B., Ward N., Oslizok P., Walsh K., Keane D. A retrospective study of the clinical experience of the implantable loop recorder in a paediatric setting Int J Clin Pract 2008 ;  62 : 1520-1525
Sreeram N., Gass M., Apitz C., and al. The diagnostic yield from implantable loop recorders in children and young adults Clin Res Cardiol 2008 ;  97 : 327-333 [cross-ref]
Madrid A.H., Ortega J., Rebollo J.G., and 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 [cross-ref]
McLeod K.A., Wilson N., Hewitt J., Norrie J., Stephenson J.B. Cardiac pacing for severe childhood neurally mediated syncope with reflex anoxic seizures Heart 1999 ;  82 : 721-725 [cross-ref]
Scott W.A., Pongiglione G., Bromberg B.I., and al. Randomized comparison of atenolol and fludrocortisone acetate in the treatment of pediatric neurally mediated syncope Am J Cardiol 1995 ;  76 : 400-402 [inter-ref]
Sheldon R., Connolly S., Rose S., and al. Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope Circulation 2006 ;  113 : 1164-1170 [cross-ref]
Krediet C.T., van Dijk N., Linzer M., van Lieshout J.J., Wieling W. Management of vasovagal syncope: controlling or aborting faints by leg crossing and muscle tensing Circulation 2002 ;  106 : 1684-1689 [cross-ref]
Reybrouck T., Heidbuchel H., Van De Werf F., Ector H. Long-term follow-up results of tilt training therapy in patients with recurrent neurocardiogenic syncope Pacing Clin Electrophysiol 2002 ;  25 : 1441-1446
Hyphantis T.N., Pappas A.I., Vlahos A.P., Carvalho A.F., Levenson J.L., Kolettis T.M. Depressive symptoms and neurocardiogenic syncope in children: a 2-year prospective study Pediatrics 2012 ;  130 : 906-913 [cross-ref]
Bastos S., Scanavacca M., Darrieux F., Ludovice A.C., Sosa E., Hachul D.T. [Clinical outcome of patients with neurocardiogenic syncope (NCS) after therapy interruption] Arq Bras Cardiol 2006 ;  86 : 256-260 [cross-ref]
Diaz J.F., Tercedor L., Moreno E., and al. [Vasovagal syncope in pediatric patients: a medium-term follow-up analysis] Rev Esp Cardiol 2002 ;  55 : 487-492 [cross-ref]
Kouakam C., Vaksmann G., Pachy E., Lacroix D., Rey C., Kacet S. Long-term follow-up of children and adolescents with syncope; predictor of syncope recurrence Eur Heart J 2001 ;  22 : 1618-1625 [cross-ref]
Biffi M., Boriani G., Bronzetti G., Frabetti L., Picchio F.M., Branzi A. Neurocardiogenic syncope in selected pediatric patients – natural history during long-term follow-up and effect of prophylactic pharmacological therapy Cardiovasc Drugs Ther 2001 ;  15 : 161-167 [cross-ref]
Shen W.K., Decker W.W., Smars P.A., and al. Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management Circulation 2004 ;  110 : 3636-3645 [cross-ref]

1  M. Courtheix and Z. Jalal contributed equally to this work.


© 2015  Elsevier Masson SAS. All Rights Reserved.
EM-CONSULTE.COM is registrered at the CNIL, déclaration n° 1286925.
As per the Law relating to information storage and personal integrity, you have the right to oppose (art 26 of that law), access (art 34 of that law) and rectify (art 36 of that law) your personal data. You may thus request that your data, should it be inaccurate, incomplete, unclear, outdated, not be used or stored, be corrected, clarified, updated or deleted.
Personal information regarding our website's visitors, including their identity, is confidential.
The owners of this website hereby guarantee to respect the legal confidentiality conditions, applicable in France, and not to disclose this data to third parties.
Close
Article Outline