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