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Pacing for Cardioinhibitory Vasovagal Syncope — EECC MCQ

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HardCardiac DevicesPacing for Cardioinhibitory Vasovagal SyncopeEECC

A 60-year-old man presents with recurrent syncope. Tilt table testing shows a cardioinhibitory response with asystole lasting 12 seconds during the vasovagal reflex. His symptoms are severely debilitating despite conservative measures. Is pacing indicated?

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Correct answer: B — Pacing may be considered (Class IIa) for recurrent severe cardioinhibitory vasovagal syncope (asystole >3 seconds documented on tilt test or implantable loop recorder) refractory to conservative measures, in patients over 40

Yes. This 60-year-old has recurrent, severely debilitating vasovagal/reflex syncope with a documented cardioinhibitory response and a 12-second tilt-induced asystolic pause, despite conservative treatment. In UK exam practice, pacing is reserved for highly selected patients, typically aged over 40, with severe recurrent unpredictable reflex syncope and documented asystole; it is not used for all vasovagal syncope and is not beneficial without a cardioinhibitory/asystolic mechanism. A 12-second pause is well above the usual >3-second threshold for symptomatic/tilt-induced asystole, so option B is correct.

Reference: 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy, section 5.4 Pacing for reflex syncope: https://academic.oup.com/eurheartj/article/42/35/3427/6358547