Sex and age differences in clinical presentation and head-up tilt test results in patients with vasovagal syncope
Authors: Tavolinejad H , Masoudi M , Sadeghian S , Vasheghani-Farahani A , Yadangi S , Bozorgi A , Masoudkabir F , Tajdini M 
Published: November 2023

Abstract

Background
Previous evidence indicates important sex- and age-specific characteristics of vasovagal syncope (VVS), which may be relevant to diagnostic and therapeutic approaches.

Purpose
To investigate differences in presentation, symptoms, and head-up tilt test (HUTT) response in patients with VVS based on biological sex and age groups.

Methods
This study analyzed data from the HUTT registry at a tertiary syncope unit between 2017 and 2022, including adults aged 18 years or older who were diagnosed with VVS. The diagnosis was based on clinical criteria, and conformed with the latest syncope guidelines. Clinical features and head-up tilt test results were recorded and analyzed to understand the sex and age-specific characteristics of VVS. HUTT was performed using an electrically-controlled tilt table, with continuous hemodynamic monitoring, according to the Italian protocol. The type of response to HUTT was decided according to the Vasovagal Syncope International Study (VASIS) criteria, and HUTT was only considered positive if syncope occurred during the test.

Results
Among 1,914 eligible patients, 49% were female, and the mean age was 46.43 ± 17.77. Male participants were significantly older (44 vs 49 years of age, P&lt;0.001), and had higher rates of diabetes mellitus (10% vs 7%) and hypertension (25% vs 19%), while female patients had a higher prevalence of anemia (24% vs 11%). There was a non-significant trend for more emergency department visits among males (7% vs 5%). Females were more likely to experience prodromal symptoms such as nausea and abdominal discomfort, typical cutaneous symptoms, and less typical prodromes like aura. Compared to males, female patients were also more likely to report specific triggers, which helps establish the diagnosis of VVS and makes avoidance of triggers possible. On the other hand, females were more likely to experience seizure-like movements, and experienced more post-syncopal symptoms. The head-up tilt test results were not significantly different based on sex (Figure 1). Younger patients were more likely to experience specific triggers and manifest prodromal symptoms, compared to older individuals, which highlights the challenges for diagnosis of VVS in older age. In contrast, younger patients with VVS were more likely to present with seizure-like movements and abnormal gaze during the VVS episode. There was a non-significant trend for higher rates of urinary incontinence during VVS among older patients. Older patients were less likely to have a cardioinhibitory response during HUTT, which confirms findings from previous studies (Figure 2).

Conclusion
The present study highlights the differences in the clinical presentation of VVS based on sex and age, providing valuable information for diagnosis and management of this condition. Further studies are needed to understand the mechanisms behind these differences and to develop tailored treatment plans for VVS.