Association between hypotension during 24 h ambulatory blood pressure monitoring and reflex syncope: the SynABPM 1 study

Giulia Rivasi, Antonella Groppelli, Michele Brignole, Davide Soranna, Antonella Zambon, Grzegorz Bilo, Martino Pengo, Bashaaer Sharad, Viktor Hamrefors, Martina Rafanelli, Giuseppe Dario Testa, Ciara Rice, Rose Anne Kenny, Richard Sutton, Andrea Ungar, Artur Fedorowski, Gianfranco Parati, Giulia Rivasi, Antonella Groppelli, Michele Brignole, Davide Soranna, Antonella Zambon, Grzegorz Bilo, Martino Pengo, Bashaaer Sharad, Viktor Hamrefors, Martina Rafanelli, Giuseppe Dario Testa, Ciara Rice, Rose Anne Kenny, Richard Sutton, Andrea Ungar, Artur Fedorowski, Gianfranco Parati

Abstract

Aims: Diagnostic criteria for ambulatory blood pressure monitoring (ABPM) in patients with suspected reflex syncope are lacking. The study hypothesis was that patients with reflex syncope have a higher prevalence of systolic blood pressure (SBP) drops on ABPM.

Methods and results: ABPM data from reflex syncope patients and controls, matched by average 24 h SBP, age, sex, and hypertension were compared. Patients with constitutional hypotension, orthostatic hypotension, and predominant cardioinhibition during carotid sinus massage or prolonged electrocardiogram monitoring or competing causes of syncope were excluded. Daytime and nighttime SBP drops (<110, 100, 90, 80 mmHg) were assessed. Findings were validated in an independent sample. In the derivation sample, daytime SBP drops were significantly more common in 158 syncope patients than 329 controls. One or more daytime drops <90 mmHg achieved 91% specificity and 32% sensitivity [odds ratio (OR) 4.6, P < 0.001]. Two or more daytime drops <100 mmHg achieved 84% specificity and 40% sensitivity (OR 3.5, P = 0.001). Results were confirmed in the validation sample of 164 syncope patients and 164 controls: one or more daytime SBP drops <90 mmHg achieved 94% specificity and 29% sensitivity (OR 6.2, P < 0.001), while two or more daytime SBP drops <100 mmHg achieved 83% specificity and 35% sensitivity (OR 2.6, P < 0.001).

Conclusion: SBP drops during ABPM are more common in reflex syncope patients than in controls. Cut-off values that may be applied in clinical practice are defined. This study expands the current indications for ABPM to patients with reflex syncope.

Keywords: Ambulatory blood pressure; Blood pressure cut-off values; Hypotension; Hypotensive episode; Low blood pressure.

Conflict of interest statement

Conflicts of interests: R.S. declares the following potential conflicts of interest: consulting fees from Medtronic Inc (unrelated to present work); payment for expert testimony in medico-legal cases in UK (related to syncope but unrelated to this work); member of clinical events committee for the BioSync study (published in 2021 in European Heart Journal); Secretary to the Executive Board of World Society of Arrhythmias; private shareholder receiving only dividends from Boston Scientific Corp and Edwards Lifesciences Corp. A.F. has received speaker fees from Medtronic Inc., Biotronik, and Bristol-Myers Squibb, and is consultant to Medtronic Inc, and Argenx BV. The other authors declare no conflicts of interest.

© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology.

Figures

Structured Graphical Abstract
Structured Graphical Abstract
ABPM; ambulatory blood pressure monitoring; SBP, systolic blood pressure; HR, heart rate; DBP, diastolic blood pressure; PP, pulse pressure.
Figure 1
Figure 1
Twenty-four hour ambulatory blood pressure monitoring report of a patient with reflex syncope, showing a systolic blood pressure drop (88/46 mmHg) at 8.15 am. Case report from the Hypertension Clinic of Careggi Hospital, Florence, Italy. DBP, diastolic blood pressure; HR, heart rate; PP, pulse pressure; SBP, systolic blood pressure.
Figure 2
Figure 2
Diagnostic yield of ≥1 or ≥2 systolic blood pressure drops according to different cut-off values. For each cut-off value shown in the figure, the standard error of sensitivity (vertical line) and specificity (horizontal line) are given. Vertical dotted lines indicate the threshold of 90% specificity that was considered to provide an acceptably low rate of false positive diagnoses. (A) ≥1 systolic blood pressure drop during daytime or night-time. (B) ≥2 systolic blood pressure drops during daytime or night-time.
Figure 3
Figure 3
Sensitivity and specificity of daytime systolic blood pressure drops A), two or more episodes (B). The dashed horizontal line indicates the 90% specificity.

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