원인 불명의 실신 환자의 진단에 있어서 Head - up tilt Test 의 유용성과 혈관미주신경성 실신 환자의 임상적 특징

윤호중(Ho Joong Youn),정욱성(Wook Sung Chung),백상홍(Sang Hong Baek),김철민(Chul Min Kim),박인수(In Soo Park),김재형(Jae Hyung Kim),최규보(Kyu Bo Choi),홍순조(Soon Jo Hong) 대한내과학회 1994 대한내과학회지 Vol.47 No.2

N/A Background: Syncope, defined as a transient loss of consciousness, is a frequently encountered symptom, but despite thorough clinical and invasive diagnostic investigation, the cause of syncope remains unexplained. In recent years, head-up tilt test has been of increasing interest as a diagnostic aids in patients with unexplained syncope. We studied to define the usefulness of various diagnostic test in the evaluation of patients with recurrent syncope, to assess the usefulness of head-up tilt test in the working of syncope of unknown origin and to evaluate the clinical characteristics of subgroups of patients with syncope induced by head-up tilt test. Methods: Between June, 1991 and November, 1992 at St. Mary`s hospital, 21 patients with history of syncope and 24 control subjects without history of syncope underwent 60° head-up tild test for 60 min. Results: 1) The definite cause for recurrent syncope were diagnosed in 10 of patients (47,6%) after clinical and invasive tests. 2) During head-up tilt test, vasovagal responses were provoked in 5 of 21 patients (23.8%) with recurrent syncope and 1 of 24 patients (4.2%) without syncope (p<0,05). 3) The head-up tilt test induced symptomatic bradycardia or hypotension in 3 of 10 patients (30%.) with negative electrophysiologic results. 4) During tilt induced vasovagal response, a) mean heart rate decreased to 42±24 beat/min from supine control of 70±12 beat/min (p<0. 05), b) mean systolic blood pressure decreased to 95±12 mmHg from supine control of 120±S mmHg (p<0,05), c) mean diastolic blood pressure decreased to 60±21mmHg from supine control of 72±13 mmHg (p<0.05), d) the time interval to onset of vasovagal response was 22±12 min. Conclusions: 1) In a large proportion of patients with recurrent syncope, the diagnosis remains unexplained despite a neurologic and cardiologic investigation including an electrophysiologic study. 2) Vasovagal responses are frequent cause in patients with recurrent unexplained syncope. 3) The head-up tilt test may be a simple, safe and highly yielding provocative test in the investigation of syncope of unknown origin.

원인 불명 실신에서 기립경사검사 결과의 예측

정은아(Eun A Chung),이승현(Seung Hyun Lee),홍영준(Young Joon Hong),박옥영(Ok Young Park),정우곤(Woo Kon Jeong),이상록(Sang Rok Lee),이상현(Sang Hyun Lee),강경태(Kyung Tae Kang),류제영(Jay Young Rhew),박종철(Jong Cheol Park),안영근(Yo 대한내과학회 2001 대한내과학회지 Vol.61 No.2

N/A Background : Vasovagal syncope has been believed to account for the majority of syncope of unknown origin (SUO). Head-up tilt test (HUT) has been well recognized as a useful test in the evaluation of SUO. The purpose of this study was to determine the predictors of HUT to develop a less time-consuming test protocol and get an information on the pathophysiology of vasovagal syncope. Methods : Eighty five patients (mean age, 43±18 years: 47 men, 38 women) underwent a 80 degree HUT without or with isoproterenol infusion (2 μg/min and 5 μg/min, each for 6 minutes) for unexplained syncope or pre-syncope. Positive HUT was defined as symptomatic hypotension (systolic blood pressure ≤80 mm Hg) and/or symptomatic bradycardia (≤45/min for ≥10 seconds) or asystole ≥3 seconds. The patients were divided into two groups according to the result of the HUT: Group I included 47 patients (M:F=25:22) with positive result, Group II, 38 patients (M:F=22:16) with negative result. Results : Group I patients had more episodes of syncope than Group II (3.1±2.5/year vs. 2.0±2.1/year, p<0.05). There were no significant differences between the 2 groups in the heart rate (HR), systolic and diastolic blood pressure (BP) at the baseline supine position. BP after tilt was not significantly different between 2 groups except for systolic BP at 6 minutes after tilt, which was significantly lower in Group I than Group II (109.5±17.5 mm Hg vs. 118.1±18.2 mm Hg, p<0.05). However, HR after tilt was significantly faster in Group I than Group II (81.1±15.1/min vs. 74.2±14.9/min, p<0.05 at 2 minutes after tilt; 83.7±14.4/min vs. 74.6±14.7/min, p<0.01 at 4 minutes after tilt). The increase in HR was greater in Group I than Group II (19.9±12.6/min vs. 12.8±10.6/min, p<0.001). In the prediction of positive HUT with HR rise above 14/min during the early 6 minutes of baseline head-up tilting, the specificity, sensitivity, and positive predictive value were 63.2%, 70.2%, and 70.2%, respectively. Conclusion : In patients with SUO, positive HUT can be predicted with the early HR response during head-up tilt. This result shows that vasovagal syncope is triggered by exaggerated HR response to the decreased venous return and allow us to develop a less time-consuming HUT protocol.(Korean J Med 61:133-140, 2001)

소아청소년 실신 환자에서 기립 경사 검사의 유용성

유가영,최지혜,유춘자,이경석,주찬웅 대한소아청소년과학회 2009 Clinical and Experimental Pediatrics (CEP) Vol.52 No.7

Purpose : We aimed to examine the effectiveness of the head-up tilt test (HUT) for the diagnosis of syncope or presyncope in children and adolescents. Methods : HUT results and clinical features of 160 children and adolescents with syncope or presyncope were studied from May 2003 through March 2008 at the Chonbuk National University Hospital. The children and adolescents were subjected to 70° HUT for 45 minutes. The testees were divided into 2 groups: group I (children) comprising 39 children in the age range 7-12 years (mean, 10.59±1.60 years) and group II (adolescents) comprising 121 adolescents in the age range 13-20 years (mean, 15.93±2.28 years). Positive result rates of the HUT and types of hemodynamic response to the test in the 2 groups were compared. Results : Of the 160 testees, 92 (57.5%) showed positive HUT results; they showed 3 patterns of response to tilting. Twelve patients showed a predominantly vasodepressor response; 10 patients showed a cardioinhibitory response; and 70 patients showed a mixed response. The positive result rates were 43.6% (17/39) and 62.0% (75/121) in groups I and II, respectively. Mixed response was the predominant positive hemodynamic response in both the groups. Conclusion : The HUT is a useful diagnostic tool for evaluating the condition of pediatric patients, including adolescents, with syncope. Further, it may be considered as the first step for evaluating the condition of such patients. 목 적 : 실신은 소아와 청소년들에게 흔히 발생되는 증상으로 혈관 미주신경성 실신이 가장 흔한 형태다. 이 연구의 목적은 원인불명의 실신 및 그와 유사한 증상으로 내원한 소아청소년기 환자들에게 기립 경사 검사(head-up tilt test, HUT)의 반응과 진단적 가치를 검토해 보고자 하였다. 방 법 : 2003년 5월부터 2008년 3월까지 전북대학교병원에 실신 및 실신 전 증상을 주소로 HUT를 하고 임상적으로 혈관 미주신경성 실신이 의심되는 160명(남 82명, 여 78명, 7-20세)을 대상으로 임상 양상 및 HUT 결과와 그 반응에 대해 의무기록을 통하여 후향적 조사를 시행하였다. HUT는 70도 경사에서 45분간 시행하였으며 일부는 isoproterenol 0.5-1.0 ug/min 주사를 이용하였으며 이 환아들을 소아군(7-12세, 39명, 10.59±1.60세), 청소년군(13-20세, 121명, 15.93±2.28세)으로 분류하여 두 군 간의 HUT 양성률과 그 반응유형을 비교해 보았다. 결 과 : 대상 환아 160명 중에서 양성반응인 환아는 92명(57.5 %)이었고, 남녀 비는 차이가 없었다. 양성 반응은 혼합형이 70례로 제일 흔한 반응이었고, 혈관억제형이 12례, 무수축을 동반하지 않은 심장억제형이 6례, 무수축을 동반한 심장억제형이 4례이었다. 실신의 원인을 규명하는데 HUT를 비롯하여 혈액흉부 방사선 촬영, 심전도와 24시간 holter 검사 및 운동부하검사, 뇌파 검사, 뇌 단층촬영과 뇌 자기공명검사, 심초음파 검사 등이 시행되었다. 또한 연령대에 따른 HUT의 양성 반응률 비교는 소아군 43.6% (17/39), 청소년군 62% (75/121)이었고, 혼합형 반응이 소아 군에서 15명(38.4%)에서 청소년군 55명(45.0%)으로 청소년군이 더 높은 양성률을 보였으나 두 그룹간의 통계학적으로 의미 있는 차이는 없었다. 결 론 : HUT는 혈관 미주신경성 실신이 의심되는 병력과 진찰 소견이 정상인 소아에서 여러 다른 검사 방법에 우선하여 시행함으로써 실신의 원인을 규명하는데 유용하다.

Comparison of the Head-up Tilt Test in the Children and Adult

류나리 ( Na Li Yu ),이나미 ( Na Mi Lee ),이대용 ( Dae Yong Yi ),윤신원 ( Sin Weon Yun ),채수안 ( Soo Ahn Chae ),임인석 ( In Seok Lim ) 중앙대학교 의학연구소 2017 中央醫大誌 Vol.42 No.1

Objective: To compare the difference of children (under 18 year-old) and adult (over 40 year-old) in head-up tilt test (HUTT) positive patients. Methods: All patients diagnosed as vasovagal syncope in HUTT from January 2005 to December 2015 in Chung-Ang university hospital. Any patients with underline disease excluded. Results: The mean age was 13.5 years (from 7 to 17 years) and 59.3 years (from 40 to 85 years) in children and adult respectively in HUTT positive patients. There was no sex differences in children and adult [male: 57 (35.4%) vs 65 (43%) (p =0.167)]. The positive rate of passive test was statistically different in two groups [54 patients (33.5%) vs 23 patients (15.2%) (p <0.001)]. The highest heart rate (HR) and delta HR in Type I positive in passive test was statistically different in two groups [highest HR: 107.8 bpm vs 91.0 bpm (p <0.05); increase delta HR: 35.8 bpm vs 22.5 bpm (p <0.001); decrease delta HR 38.0bpm vs 25.6 bpm (p <0.05)]. The HR values except at baseline in Type I positive in provocation test were statistically different in two group [highest HR: 138.4 bpm vs 113.5 bpm (p <0.001); lowest HR: 88.7 bpm vs 77.3 bpm (p <0.05); increase delta HR: 64.5 bpm vs 44.4 bpm (p <0.001), decrease delta HR: 49.7 bpm vs 36.1 bpm (p <0.001)]. Conclusion: The positive rate of passive test and HR differences in HUTT were statically different in two groups. Chung-Ang J Med 2017; 42(1): 17-23

기립경사검사 동안 발생하는 기립 증상들과 자율신경지표들 간의 상관관계

김현아 대한신경과학회 2014 대한신경과학회지 Vol.32 No.3

Background: The aims of the present study were to identify the orthostatic symptoms occurring during the head-up tilt(HUT) test and to compare the autonomic parameters in patients with and without symptoms during the HUT test. Methods: We retrospectively collected autonomic data from patients presenting with autonomic symptoms includingorthostatic dizziness over a 1-year period. A standardized battery of autonomic tests was performed, including the HUTtest, Valsalva maneuver (VM), heart rate (HR) deep breathing test, and quantitative sudomotor axon reflex test (QSART)using Finometer devices to record the beat-to-beat blood pressure (BP) and HR response. We also investigated thepatients’ symptoms during the HUT test and compared the autonomic parameters between patients with and withoutorthostatic symptoms. Results: In total, 898 patients who submitted to autonomic function tests were included in this study. Of these, 17%(157/898) complained of various kinds of symptoms during tilting, while the remainder denied any symptoms. Patientscomplained of atypical symptoms, such as leg or back pain, tingling sensation in the leg, and difficulty breathing or chesttightness, as well as typical orthostatic symptoms. The BP decrease and the HR increase during the HUT test were greaterin the symptomatic group. A prolonged pressure recovery time during VM, a lower sweat output during QSART, and ahigher composite autonomic severity score were observed in the symptomatic group. Conclusions: Approximately one-fifth of the patients complained of symptoms during the HUT test, and thosesymptoms were strongly correlated with the autonomic parameters suggestive of impaired compensative mechanismsin response to a BP fall.

QT연장 증후군 환자에서 Head-Up Tilt Test에 의해 유발된 Torsades De Pointes 1례

전익수,차태준,김길수,김동완,김규종,김찬욱,김성만,주승재,이재우 대한순환기학회 2000 Korean Circulation Journal Vol.30 No.8

소아에서의 실신에 관한 임상적 고찰 및 안구압박검사의 진단적 유용성

김기성(Ki Sung Kim),이은별(Eun Byul Lee),정희정(Hee Jung Chung) 대한소아신경학회 2006 대한소아신경학회지 Vol.14 No.2

Purpose : Nevertheless that syncope of children is a relatively common disease which occurs during adolescence, diagnostic yield rate of syncope of children is far below than that of adults. Some reports indicate that the diagnostic rate could be increased up to 70% by using the head-up tilt test(HUT). However, HUT is relatively invasive and harmful to be used for children. The purpose of this study is to analyze the etiology of syncope in children and investigate whether the ocular compression test(OCT), which is not invasive and relatively safe, could substitute the HUT for vasovagal syncope. Methods : Children who visited NHIC Ilsan Hospital for syncope from January 2004 to July 2006 were retrospectively analyzed. We examined the medical records of the patients and performed the basic diagnostic tests including EEG as well as HUT. OCT was performed during EEG to find check out the presence and the duration of asystole. We classified the patients into 3 groups according to the etiology, such as neurally-mediated(vasovagal), cardiovascular and noncardiovascular syncopes and comparatively analyzed the clinical characteristics of each group. In addition, in case the asystole duration of OCT is prolonged, we performed cross-table analysis to know whether it matches the positive result of HUT in order to confirm the availability of OCT. Results : 55 patients were included in the study and the rate of males to female was 1: 2.4. The causes of syncope were identified in 43 cases(78.2%) and half of which was neurallymediated type. In detail, 24(43.6%) patients were neurally-mediated, 5(9.1%) were cardiovascular, 14(25.5%) non-cardiovascular and 12(21.8%) unidentified. There was no significant difference regarding the clinical characteristics among diagnostic groups. However, the neurallymediated syncope group showed statistically significant difference in the duration of asystole. Therefore, when we make a point over 3 seconds of asystole in OCT, it will produce the most similar result with the HUT in neurally-mediated(vasovagal) syncope(specificity 94.4%). Conclusion : Generally, syncope in children peaks during adolescence and it is more common among girls than boys. The etiologic diagnostic rate was 78.2% and the neurally-mediated syncope was the most common type. The cardiovascular syncope of children was much less in contrast to that of adults. There was no statistically significant difference in the clinical characteristics among the three diagnostic groups. It is concluded that OCT, a non-invasive and relatively safe test, could substitute the invasive, and harmful HUT for vasovagal syncope of children. 목 적 : 소아에서의 실신은 청소년기에 발생하는 비교적 흔한 질환임에도 불구하고 어른과는 달리 아직까지 우리나라에서는 임상양상에 대한 연구가 거의 없는 실태이며, 특히 소아에서는 전통적인 검사만으로는 원인 진단율이 어른에서보다 훨씬 낮다고 한다. 기립경사(head up tilt) 검사를 실시할 경우 진단율을 70%까지 높일 수 있다는 보고가 있으나 소아에서는 시행하기 힘든 침습적 검사이다. 이에 저자들은 실신을 주소로 내원한 환자들의 원인을 분석하고, 뇌파검사 시 시행하는 비침습적 검사인 안구압박(ocular compression) 검사가 혈관미주신경성 실신의 진단에 기립경사 검사를 대신할 수 있는지 여부를 알아보고자 본 연구를 실시하였다. 방 법: 2004년 1월부터 2006년 7월까지 일산병원 소아과에 실신을 주소로 내원한 환자 55례를 대상으로 혈액검사, 뇌파검사(안구압박검사 포함), 24시간 심전도검사, 기립경사 검사를 실시하여 발생 원인에 따라 신경인성, 심혈관계 및 비심혈관계의 세 군으로 크게 나누고 각 군의 임상적 특징을 비교 분석하였다. 또한 안구압박 검사에서 나타난 심정지(asystole) 시간에 따라 기립경사 검사 결과 중 혈관미주신경성 반응과 일치하는지를 교차 분석하여 알아봄으로써 비교적 쉽고 상대적으로 안전한 안구압박 검사의 유용성을 확인하여 보았다. 결 과: 실신을 주소로 내원한 총 환자 수는 55명이었으며 이중 남아 16명, 여아 39명으로 성비는 1:2.4이었고 평균 연령은 11.4세이었다. 실신의 원인은 신경인성 원인이 24명(43.6%), 심혈관계 원인 5명(9.1%), 비심혈관계 원인 14명(25.5%), 미상 12명(21.8%)이었다. 각 질환 군에서 전구증상, 증상이 나타날 때의 자세, 의식소실 시간, 실신이후 동 반되는 증상에는 세 군 간에 통계적인 차이가 없었다. 안구압박 검사 후의 심정지 시간은 신경인성환자 군에서 다른 군과 유의한 차이를 보였으며, 심정지 시간 3초 이상인 경우는 기립경사 검사 결과 혈관미주신경성 실신과 94.4% 특이도로 일치하는 것으로 보아 안구압박 검사의 유용성을 확인할 수 있었다. 결 론 : 소아에서 실신은 주로 청소년기에 발생하였으며 남아 보다 여아에서 더 흔하게 나타났다. 원인 발견률은 78.2%이었으며 이중 신경인성 원인이 약 1/2 정도로 가장 많았고, 어른에서와는 달리 심혈관계 원인이 훨씬 적었다. 실신의 임상양상은 세 군 간에 큰 차이가 없었다. 소아에서의 신경인성 실신 중 혈관미주신경성 실신의 진단에는 시행하기 쉽고 비교적 안전한 안구압박 검사가 상대적으로 위험하고 침습적인 기립경사 검사를 대신할 수 있을 것으로 사료된다.

Clinical utility of heart rate variability during Head-up tilt test in subjects with chronic posttraumatic stress disorder

Park, Joo Eon,Kang, Suk-Hoon,Lee, Ji Yeon,Won, Sung-Doo,So, Hyung Seok,Choi, Jin Hee,Kim, Chan-Hyung,Yoon, In Young Elsevier 2019 Psychiatry Research Vol.272 No.-

<P><B>Abstract</B></P> <P>Posttraumatic stress disorder (PTSD) is characterized by psychophysiological abnormalities, such as an altered baseline heart rate and hyperarousal, implying dysfunctional arousal regulation. Heart rate variabilities (HRVs) is known to reflect autonomic nervous system activity. We examined the changes of HRVs in PTSD patients with head-up tilt position to closely investigate disease-specific changes in autonomic function in PTSD patients. Sixty-seven patients with PTSD and 72 patients without PTSD were assessed using the PTSD Checklist for DSM-5 (PCL-5) and psychiatric interview. Heart rate data including standard deviation of the NN intervals, the square root of the mean squared differences of successive NN intervals, log low-frequency and log high-frequency were collected for 10 min before and after tilting. Considering interactions between groups and head-up tilting, the head-up tilting induced reduction of the high-frequency component of HRVs was significantly greater in the PTSD group [<I>F</I> (1, 272) = 4.718, <I>p</I> = 0.031]. The change of HRVs in PTSD patients suggested the presence of autonomic dysfunction in despite of the posture.</P>

반복적인 실신 및 실신전환자의 기립경사 검사시 뇌혈류 변화

조수진,김준수,이광호,정진상,송희정,이상철,서정돈,이원로 대한신경과학회 1999 대한신경과학회지 Vol.17 No.3

Head-up Tilt Test with Isoproterenol Provocation in Syncope of Unknown Origin

( Moon Hee Ryu ),( Jeong Gwan Cho ),( Youl Bae ),( Jay Young Rhew ),( You Jeong Chung ),( Sug Kee Youn ),( Myung Ho Jeong ),( Jong Chun Park ),( Jung Chaee Kang ) 대한내과학회 1996 The Korean Journal of Internal Medicine Vol.11 No.2