Ventricular standstill despite normal electrophysiology study: a further possible indication for pacing

Permanent pacing has usually been indicated for the treatment of organic disease of the sinus node or specific cardiac conducting tissue. We report three patients in whom profound syncope was apparently related to intense, transient autonomic dysfunction. Although ventricular standstill was documented in all three, detailed electrophysiology study, responses to graded Valsalva manoeuvres and carotid sinus massage, and repeated observations after cardiac autonomic blockade by IV atropine (0.03 mg/Kg) and propranolol (0.15 mg/Kg) were essentially normal. Permanent ventricular (VVI) pacing has controlled symptoms in all three, over follow-up period of 20 to 26 months. These observations suggest that transient autonomic imbalance may be a cause of undiagnosed cardiac syncope. This is neither excluded by normal electrophysiology study nor by normal responses to usual provocative autonomic interventions.