Mechanisms of Vasovagal Syncope

New York Medical College

Status and phase: Active, not recruiting; Early Phase 1

Conditions: Postural Tachycardia Syndrome; Vasovagal Syncope

Treatments: Drug: L-Ng-monomethyl Arginine (L-NMMA); Drug: Phenylephrine

Study type: Interventional

Funder types: Other

Identifiers

NCT01791816

1R01HL112736-01A1

Details and patient eligibility

About

Vasovagal Syncope (simple postural faint) is the most common cause of acute loss of consciousness. Postural tachycardia syndrome(POTS) is the most common chronic form of postural lightheadedness. Together they afflict many Americans, mostly young women, who are prevented from gainful employ or school attendance. The underlying mechanism is not known. Our past work suggests that a simple molecule, nitric oxide, acts to subvert normal blood flow controls causing blood to pool in the gut when standing. Our proposal will show the mechanism behind this problem and will indicate effective medical treatments. Patients will be compared to healthy control subjects.

Full description

Vasovagal Syncope (VVS,simple faint) is the most common cause of transient loss of consciousness and is the acute episodic form of orthostatic intolerance(OI). Postural tachycardia syndrome (POTS) is the common chronic form of OI. Both are defined by debilitating symptoms and signs while upright relieved by recumbency. Pathophysiological mechanisms have remained elusive although our past work shows that excessive upright central hypovolemia results from splanchnic pooling due to defective splanchnic arterial and venous constriction. Preliminary data support the hypothesis that production of nitric oxide (NO) is enhanced in these patients resulting in reduced sympathetic noradrenergic neurotransmission at pre-junctional and post-junctional sites. Our approach is two-fold: 1) We will use intradermal microdialysis and laser Doppler flowmetry (LDF) to delineate the microvascular mechanisms of NO modulation of noradrenergic neurotransmission free of confounding systemic reflex changes. 2) We will systemically apply this mechanism to a model of orthostatic stress, lower body negative pressure(LBNP), while measuring cardiac output by inert gas rebreathing, regional blood volume, and regional blood flow using plethysmographic techniques focusing on splanchnic changes, and muscle sympathetic nerve activity by peroneal microneurography. We will study synaptic peripheral neurotransmission of Norepinephrine and how it is affected by supplemental NO and by nitric oxide synthase inhibitor.

Enrollment: 90 estimated patients

Sex: All

Ages: 14 to 29 years old

Volunteers: Accepts Healthy Volunteers

Inclusion criteria

1. POTS patients referred for day to day orthostatic intolerance with greater than 3 symptoms for greater than 3 months and will have the diagnosis of symptomatic postural tachycardia made during a screening tilt table test :

   • dizziness
   • nausea and vomiting
   • palpitations
   • fatigue
   • headache
   • exercise intolerance
   • blurred vision
   • abnormal sweating heat.

2. Vasovagal Syncope patients will have at least 3 episodes of fainting episodes in the past year.

3. Healthy control subjects

Cases will be between the ages of 14 and 29 years old Cases will have normal physical examination, and normal electrocardiographic and echocardiographic evaluations.

Only those free from heart disease, and from systemic illness will be eligible to participate.

This excludes patients with illnesses and disease states known to be associated with endothelial cell dysfunction such as diabetes, renal disease, congestive heart failure, systemic hypertension, acute and chronic inflammatory diseases, neoplasm, immune mediated disease, trauma, morbid obesity and peripheral vascular disease.

At the time of testing all patients and control subjects must refrain from vasoactive drugs for two weeks. Please check with us about any medication that you are taking.

Exclusion criteria

• Cardiovascular causes of syncope
• An active medical condition that may explain the diagnosis
• A previous medical condition with undocumented resolution that may explain the diagnosis
• Past or present major psychiatric disorder
• Substance abuse within 2 years before onset of symptoms.

Trial design

Primary purpose: Diagnostic

Allocation: N/A

Interventional model: Single Group Assignment

Masking: None (Open label)

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90 participants in 1 patient group

Phenylephrine and L-Ng-monomethyl Arginine (L-NMMA)

Experimental group

Treatment:

Drug: Phenylephrine

Drug: L-Ng-monomethyl Arginine (L-NMMA)