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We appreciate the interest of Sheldon et al. in our article and the opportunity to respond to his letter. We are aware of his concerns regarding the methodology of our study, considering the diagnosis of vasovagal syncope based on the typical clinical history. We do not question the great clinical value of the tilt test, but in this technified medicine we also need to consider the value of simple things such as the anamnesis and physical examination. We recognize the progress in the knowledge of physiology, which the tilt test has rendered, but nevertheless it is not the gold standard for the diagnosis of vasovagal syncope, with its limited sensitivity and specificity and its dependence on the protocol.
In our study, only those patients with a clear anamnesis of vasovagal syncope were included. In fact, more than 700 patients with unexplained syncope were evaluated, and in the end only 50 patients were eligible for the study, including those patients with clear clinical history of vasovagal syncope who were highly symptomatic. A complete study to discard other possible causes of syncope was carried out in all patients. Moreover, there was no new etiological diagnosis of syncope during the follow-up (1). We want to emphasize that despite the lack of efficacy of atenolol, the median number of syncopal events dropped in both groups during the follow-up (from 3 to 2 and 0), simply after evaluating them, performing the tilt table test and explaining the pathogenesis of the disease. This fact may explain Dr. Sra’s (2)skepticism on the medical capacity to prove the benefit of any treatment for vasovagal syncope. This could also be the reason why almost any treatment that has been tested for the therapy of vasovagal syncope has been considered to be effective (3). But we do not know whether a clinical diagnosis, reassuring the patient and explaining to the patient the postural maneuvers can be enough to provide symptomatic relief in most patients.
We would like to congratulate Sheldon et al. for his efforts in establishing the role of beta-blockers for the treatment of vasovagal syncope. We share his frustrations in the treatment of this disabling and frequent disease. There is no doubt that new randomized and controlled studies are needed to reach a definitive answer. We are happy to have raised doubts on the efficacy of the drugs most commonly used for this pathology.
- American College of Cardiology
- Madrid A.H.,
- Ortega J.,
- Rebollo J.G.,
- et al.
- Sra J.S.