Medical director: Doc. Cinchini Elisabetta


The Rate of Asystolic Reflex Syncope Is Not Influenced by Age

Michele Brignole, MD, Antonella Groppelli, MD, Vincenzo Russo, MD, Artur Fedorowski, MD, Gert van Dijk, MD, Paolo Alboni, MD


The head-up tilt test (HUT) and other evidence suggest that the vagal effect on the heart decreases with age.


The main aim of the study was to assess whether this age effect also affects the rate of asystole in spontaneous reflex syncope (RS).


We performed an analysis of pooled individual data from 4 studies that recruited patients 40 years of age affected by certain or suspected RS who received an implantable loop recorder (ILR) and reported follow-up data on syncope recurrence. We assessed the presence of asystolic syncope of >3 seconds or nonsyncopal asystole of >6 seconds recorded by ILR and compared the findings to tilt test results on the same patients.


A total of 1,046 patients received ILR because of unexplained syncope. Of these, 201 (19.2%) had a documentation of an asystolic event of 10-second (Q1-Q3: 6- to 15-second) duration. They were subdivided in 3 age tertiles: 60 years (n = 64), 61 to 72 years (n = 72), and 73 years (n = 65). The rate of asystolic events was similar in the 3 subgroups (50.1%, 50.1%, and 49.2%, respectively; P = 0.99). Conversely, the rate of asystolic syncope induced during HUT (performed in 169 of 201) was greatly age dependent (31.0%, 12.1%, and 11.1% in increasing age tertiles, respectively; P = 0.009).


The rate of the spontaneous asystolic form of RS documented by ILR is constant at any age >40 years. Conversely, the rate of asystolic syncope induced by HUT is higher in younger patients and decreases with age. The contrasting results between spontaneous and tilt-induced events cast doubt on the concept that asystole in RS is less common in older patients. (J Am Coll Cardiol EP 2024;10:566–574) © 2024 by the American College of Cardiology Foundation.

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