A small percentage of pediatric patients with neurally mediated
syncope will have an asystolic response during upright tilt table testing. The purpose of this study is to evaluate the incidence of
asystole during tilt table testing, and to assess the outcome of medical management of such patients. Of 398 patients undergoing evaluation for recurrent
syncope between January 1989 and 1994, 18 (4.5%) experienced
asystole lasting > or = 5 seconds during baseline tilt test. Patients had experienced a mean of four episodes of
syncope, with a mean age at the time of tilt test of 11.1 +/- 4.0 years. The median duration of
asystole was 10 seconds (range 5-40 s). Treatment was individualized to increased fluids and
salt intake (3 patients),
metoprolol (8 patients),
pseudoephedrine (4 patients),
disopyramide (1 patient), or combination
therapy with fludrohydrocortisone (2 patients). During a median duration of follow-up of 31 months, no additional
syncope was experienced by 78% of patients. Recurrent
syncope in 4 patients was associated with either noncompliance or discontinuation of
therapy in 3 patients; in 1 patient, increasing the dose of
metoprolol was effective in preventing recurrences. We conclude that young patients with recurrent
syncope and
asystole during tilt test may be safely and effectively managed with pharmacological
therapy, without resorting to pacemaker implantation.