La sincope riflessa neuromediata:

condizione patologica o parafisiologica ?

Prof. Gianfranco Piccirillo MD, PhD

Dipartimento di Scienze Cardiovascolari, Respiratorie,

Neurologiche, Anestesiologiche e Geriatriche

Neurally-

mediated

syncope

Orthostatic

hypotension

syncope

Arrhitmics

syncope

Cardiopulmonary

syncope Neurological

syncope

• Vasovagal

• Carotid sinus

hypersensitivity

• Situational

• Pure autonomic

failure (PAF, MSA,

m. Parkinson, Lewy

body

dementia

• Secondary

autonomic failure(

diabetes, kidney

failure,…)

• Drugs

• Bradycardia

syndrome (sick

sinus

syndrome)

• Tachicardia

syndrome

• Aortic stenosis

• AMI

• Pulmonary heart failure

• Pulmonary hypertension

• Vascular thievery

• TIA

56% 2% 20% 3% 1%

18% unknown causes JACC 2001; 37: 1921-1928

Kinsella SM Br J Anaesth. 2001;86(6):859-868

Brignole M, Menozzi C. Carotid sinus syndrome: diagnosis, natural history and

treatment. Eur J Card Pacing Electrophysiol. 1992;2:247–254.

Franke H. On the hyperactive carotid sinus syndrome. Acta Neuroveg (Wien) 1963; 25:187–203.

The frequency of carotid sinus hypersensitivity (CSH) is shown for different age groups.

A M Humm, and C J Mathias J Neurol Neurosurg Psychiatry 2006;77:1267-1270

©2006 by BMJ Publishing Group Ltd

G.Piccirillo Clinical Science (2001) 100, 267-274

Meccanismi Fisiopatologici

ESTRINSECI

INTRINSECI

Meccanismi Fisiopatologici

ESTRINSECI

Piccirillo G Int J Cardiol, 176, (2014) 1041-1043

Piccirillo G Int J Cardiol, 176, (2014) 1041-1043

Piccirillo G Int J Cardiol, 176, (2014) 1041-1043

The three main biological pathways linking particulate matter (PM) and cardiovascular diseases (CVD). Both coarse and fine PM can

induce oxidative stress and inflammation at lung level, with inflammatory response spreading to systemic level and promoti...

N. Martinelli et al European Journal of Internal Medicine, Volume 24, Issue 4, 2013, 295–302

Ozone was an indipendent predictor of cardioihibitory response (odd ratio 1.012, 95% CI 1.001-1.023, p<0.05)

Electrical stimulation of the vagus nerves (1–25 Hz, 10 V, 0.2 ms, 5-s train, left) or intravenous

methacholine (1–10 μg/kg iv, right) produced frequency- or dose-dependent bronchoconstriction

measured as increases in pulmonary inflation pressure in control...

Bethany L. Yost et al. Am J Physiol Lung Cell Mol Physiol 2005;289:L627-L635

©2005 by American Physiological Society

Solari D., Brignole M Stop vasodepressor drugs in reflex syncope: a

randomised controlled trial Heart 2016 Sep 23

Meccanismi Fisiopatologici

INTRINSECI

HF LF

LF

LF +HF

Neurally-

mediated

syncope

Orthostatic

hypotension

syncope

Arrhitmics

syncope

Cardiopulmonary

syncope Neurological

syncope

• Vasovagal

• Carotid sinus

hypersensitivity

• Situational

• Pure autonomic

failure (PAF, MSA,

m. Parkinson, Lewy

body

dementia

• Secondary

autonomic failure(

diabetes, kidney

failure,…)

• Drugs

• Bradycardia

syndrome (sick

sinus

syndrome)

• Tachicardia

syndrome

• Aortic stenosis

• AMI

• Acute Cor Pulmonale,

• Pulmonary hypertension

• Vascular thievery

• TIA

TILT-TABLE

Upright tilt Peripheral

venous

pooling

Venous

return

Left ventricular

volume

Left ventricular

contractility

Mechanoreceptor stimulation

Vasomotor center

Vagal tone Sympathetic tone

Peripheral vasodilatation

Hypotension

Bradycardia or

asystole

Syncope

Piccirillo G et al Physiol Meas. 2016 Nov;37(11):1910-1924

Piccirillo G et al Physiol Meas. 2016 Nov;37(11):1910-1924

Piccirillo G et al Physiol Meas. 2016 Nov;37(11):1910-1924

CONCLUSIONI