Do the recently modified pacemaker guidelines for neurocardiogenic syncope also apply to young patients? Analysis based on five-year follow-up of Israeli soldiers with syncope and a positive tilt test

To assess the classification of neurocardiogenic syncope (NCS) as a IIA indication for pacemaker implantation in the recent American College of Cardiology/American Heart Association Task Force on Practice Guidelines/North American Society for Pacing and Electrophysiology guidelines, we performed chart reviews and followup interviews in a cohort of 45 consecutive young Israeli soldiers (age 18-24 years) with a history of syncope (mean of 9 prior syncopal episodes) and a positive tilt test treated with drug therapy. Asystole longer than 5 s during tilt testing occurred in 11 patients. Five years later, we found that only 2 patients were still taking medications, only 1 patient (2%) still reported frequent syncopal or near-syncopal episodes and 3 patients (7%) had rare symptoms (no more than one syncopal episode during the past 2 years), while the remaining 40 (89%) were symptom free off medications. Thus, NCS in young patients, even with prolonged asystole during tilt testing, a history of frequent syncopal episodes and other high-risk factors described in the guidelines, is often a self-limiting disorder, perhaps stress related or situational in nature; an overwhelming number of patients become asymptomatic and stop taking medications within 1-2 years. These patients do not require long-term therapy; thus, our data would suggest that the IIA pacing indication for NCS should be restricted to older patients.