Transcript Vasovagal syncope and long asystole on head tilt table
ISRAELI AIR FORCE AEROMEDICAL CENTER
Vasovagal syncope and long asystole on head-up tilt test in jet pilot
Dan Carter M.D., Bella Azaria M.D., Alon Grossman M.D., Liav Goldstein M.D.,M.ha
Case presentation
• 23 years old otherwise healthy F-15 pilot.
• 2 previous unreported syncope events • An episode of syncope that lasted for a minute on routine E.N.T. exam • Fast and full recovery.
• E.E.G.: Normal.
• Neurological exam: Normal.
• 12 leads ECG,echocardiography, treadmill and holter:normal • Head tilt test:Positive
Diagnosis
Vasovagal syncope- recurrent episodes Should the aviator get a waiver?
Vasovagal Syncope
• Common cause of recurrent syncope • Mechanisms • Malignant vasovagal syncope • Diagnosis
Indications for head tilt table
• Recurrent episodes of syncope.
• A single episode of syncope that ended in a serious injury. ( such as MVA).
• A single episode of syncope in high risk patient.
• Syncope induced by known etiology, in which the choice of treatment can be influenced by the existence of vasovagal syncope.
Asystole during head-up tilt test
• Asystole during head-up tilt test does not imply a malignant outcome, and syncope recurrence is low.
Baron-esquivias et. Al:Long term outcome of patients with asystole induced by head-up tilt test.Eur.Heart J,2002.
• Asystole during head-up tilt testing does not predict either a more malignant outcome…
Dhala et al:Relevance of asystole during head-up tilt testing. Am J Cardiol, 1995.
Treatment for vasovagal syncope
• Conservative management • Pharmacological therapy • Pacemakers
Waivers-military
• Incidence USAF population :12-48%. •
USAF\US Navy :
vasovagal syncope with a known risk factor is waivered.
Waivers-civilian
•
F.A.A.:
waiver in a case of avoidable etiology •
J.A.A
.: Waiver after single vasovagal episode
Risk assessment
• 4% a year with < 5 episodes .
• Mortality :very low.
• No evidence of prior episodes of syncope or presyncope during flights.
Cardiology consults
• Waiver should be granted for two seated high performance platform. • Waiver should be granted for two seated high performance platform, after gradual exposure to stimulants • Waiver should be granted to cargo multicrew platform.
• The aviator should be granted unlimited waiver after exposure to stimulants like centrifuge exercise
Our Decision
• Waiver for high performance platforms was not granted.
• A waiver for multicrew low performance platform was granted.
• Subsequently, the aviator stopped flying