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Related Experiment Video

Updated: Mar 6, 2026

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Should we treat severe vasovagal syncope with a pacemaker?

R Sutton1

  • 1Imperial College, National Heart & Lung Institute, London, UK.

Journal of Internal Medicine
|March 16, 2017
PubMed
Summary

Cardiac pacing offers limited benefit for vasovagal syncope (VVS), particularly when vasodepression is severe. Pacing may help older patients with less severe symptoms, but optimal delivery methods require further investigation.

Keywords:
cardioinhibitiondual-chamber cardiac pacingpacemaker algorithmspacemaker complicationsregression of symptoms to the meanvasodepressionvasovagal syncope

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Area of Science:

  • Cardiology
  • Neuroscience
  • Medical Devices

Background:

  • Vasovagal syncope (VVS) involves cardioinhibitory and vasodepressor components.
  • Cardiac pacing targets the cardioinhibitory reflex but not vasodepression.
  • Long-term randomized controlled trials (RCTs) have yielded mixed results for pacing in VVS.

Observation:

  • Early studies showed pacing benefits, but later RCTs with switched-off devices revealed no significant advantage.
  • The ISSUE-3 study demonstrated pacing efficacy in preventing syncope recurrence in older patients.
  • A sub-study indicated that patients with negative tilt tests, despite appearing similar to tilt-positives, had significantly lower recurrence rates.

Findings:

  • Pacing benefits VVS patients with less severe vasodepression.
  • Dual-chamber pacing is accepted, but optimal delivery algorithms are debated.
  • Relying solely on heart rate fall for pacing triggers is insufficient due to delayed detection.

Implications:

  • Pacing may be considered for older VVS patients with severe symptoms and negative tilt tests.
  • Future pacing strategies should explore algorithms that detect neuroendocrine changes earlier.
  • Careful patient selection is crucial, considering symptom severity, regression to the mean, and potential hardware complications.