Tilt training increases vasoconstrictor reserve in patients with neurocardiogenic syncope | Revista Portuguesa de Cardiologia (English edition)

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sessions. Note changes in response leading to improved adaptation." ] ] ] "textoCompleto" => "IntroductionSyncope is defined as a transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery. It is common in the general population, with an estimated incidence of 18.1–39.7events/1000 person-years,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and has serious effects on quality of life, including high morbidity, risk of physical injury and work absenteeism.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>Neurocardiogenic syncope (NCS) is the most common form, with a higher incidence in young adults.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> Its pathophysiology is poorly understood, but it has been demonstrated that alterations in the reactions of the autonomic nervous system to stressful stimuli such as active orthostatism are involved in triggering syncope.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Various treatment options have been proposed over the years for NCS, ranging from behavior modification to cardiac pacing and various types of drug therapy, but none has been shown to be fully effective.Tilt training (TT), a new non-pharmacological treatment for NCS, was proposed in 1998 by Ector et al.,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> who showed that repeated and prolonged exposure of the cardiovascular system to orthostatic stimuli had therapeutic effects in patients with NCS. The effectiveness of tilt training has been evaluated in several non-randomized observational studies,<a class="elsevierStyleCrossRefs" href="#bib0040">8–10</a> but the results have been inconsistent, varying according to the training protocol and particularly patient compliance. The mechanisms of action are largely unknown; it is thought that desensitization of cardiopulmonary receptors to orthostatism may be involved, as well as autonomic remodeling and alterations in baroreflex activity.The aim of this study was to clarify the mechanisms of action of tilt training, specifically to characterize hemodynamic and autonomic responses during a TT program in patients with NCS refractory to conventional measures.Part of this work was awarded the prize for best communication at CPC2010.MethodsPopulationBetween 2007 and 2010 we studied 28 patients (50% male, mean age 41±14 years), each with more than two syncopal episodes in the previous six months. All had NCS refractory to conventional measures (compression stockings and counterpulsation measures, midodrine, and paroxetine) and documented by tilt testing in accordance with our center's standard protocol. Briefly, after a supine resting period, the patient underwent passive tilt testing for 20 min at 70°; if no spontaneous syncope had occurred 375μg sublingual nitrates were administered. The test was terminated either by a positive response or 20 min after nitrate administration.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> A positive test was defined as reproduction of syncope in association with bradycardia (decrease in heart rate >30% of the maximum value in the upright position), hypotension (decrease in heart rate [HR] of >50% of the maximum value in the upright position), or both, and classified according to the VASIS system.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The following exclusion criteria were applied: (1) structural heart disease or cardiac rhythm disturbance; (2) neurologically mediated syncope including classical or delayed orthostatic hypotension; (3) excessive reaction to nitrates; (4) refusal to consent to the test; (5) physical inability to remain standing for 30min; (6) impossibility of suspending cardiovascular medication that could interfere with assessment of the autonomic nervous system; and (7) pregnancy.The study complies with the Declaration of Helsinki and informed consent was obtained from all participants.Tilt training programThe TT protocol has two simultaneous components. The first, in-hospital, component consists of nine tilt training sessions three times a week in the mornings after a light breakfast, without ingestion of caffeine or other xanthines. Training took place in a laboratory specifically designed for autonomic evaluation, in a calm environment and with controlled temperature and humidity. After 15min of supine (0°) rest, the patient was placed on a tilt table with feet supported and with restraining straps to prevent falls in the event of syncope. For the first two weeks the tilt table was at 60° and at 70° for the third week. During training the patient underwent continuous non-invasive monitoring of BP, electrocardiogram (ECG) and thoracic impedance (Task Force Monitor, CNSystems, Graz, Austria), and the test was stopped if symptoms occurred. The hospital sessions were complemented by daily home training, with the patient in orthostatic position at 60° to a flat vertical surface with feet apart about 15cm from the wall for 20min, and 10° head-up during sleep. Patients were instructed to stop the daily orthostatic maneuver whenever they felt the onset of symptoms. All patients were followed clinically at 1 month and every 6 months for a maximum of 36 months.Data acquisition and analysisRR intervals (RRI) and systolic blood pressure (SBP) were recorded continuously, beat-to-beat (Task Force Monitor, CNSystems, Graz, Austria). Other hemodynamic parameters – HR, mean blood pressure (MBP), systolic volume (SV), cardiac output (CO), and peripheral vascular resistance (PVR) – were calculated on the basis of thoracic impedance (Task Force Monitor, CNSystems, Graz, Austria).The data were analyzed using an interface programmed in MATLAB (MathWorks, USA), implementing a routine to detect SBP peaks and the fiducial points of the R waves of each ECG complex, beat-to-beat, in order to construct a time curve of BP (systogram) and of HR (tachogram). The reconstructed signals were used to calculate HR and BP variability and baroreflex sensitivity.Heart rate and systolic blood pressure variabilityAutoregression techniques were used to extract the characteristics of the cardiovascular parameters HR and BP. The total maneuver time was divided into 5-min segments, to facilitate computation and to better visualize the dynamics of cardiovascular alterations taking place during the maneuver. A frequency power spectrum was obtained for each interval and two main bands were isolated: high frequency (HF; 0.15–0.4Hz), an indicator of parasympathetic activity, and low frequency (LF; 0.04–0.15Hz), which indicates sympathetic activity.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Baroreflex sensitivity and effectivenessBaroreflex sensitivity is a measure of overall response to baroreceptor activation that assesses the relationship between simultaneous changes in HR and BP. In the present work baroreflex sensitivity was estimated using the sequence method. Briefly, the SBP signal was analyzed to identify sequences (ramps) of three or more heartbeats with a progressive increase (up-ramp) or decrease (down-ramp) in BP of at least 1mmHg. The algorithm identified spontaneous baroreflex sequences, defined as SBP ramps followed by concomitant and concordant variations of ≥5ms in RRI that were analyzed in three time lags, of −0, −1 and −2 heartbeats. Each sequence was included only once.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> For each spontaneous sequence the slope of the linear relation between the SPB ramps and RRIs was calculated. Only periods with correlation coefficient >0.8 were analyzed.For each period selected for analysis, the baroreflex effectiveness index (BEI) was calculated, defined as the ratio between the total number of baroreflex sequences detected and the total number of SBP ramps.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The higher the BEI the more SBP ramps are followed by alterations in RRI, and hence the more effective the baroreflex in bringing about the necessary cardiovascular adaptations.Statistical analysisFor the statistical analysis, performed using SPSS version 18, each session was divided into seven 5-min periods, the first being the baseline period and the others on the tilt table.Continuous variables are presented as means±standard deviation and were tested for normality by the Kolmogorov–Smirnov test. The results of the first and ninth TT sessions were compared using the Student's t test for paired data. Values of p<0.05 were considered statistically significant.ResultsWe studied 28 patients, 14 male, mean age 41±14 years. The mean number of syncopal episodes before beginning the TT program was 4.0±3.2/patient/year (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Hemodynamic parametersHeart rate: HR tended to decrease between the first and the ninth TT sessions (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Mean blood pressure and systolic volume: MBP and SV showed a non-significant increase between the first and the ninth TT sessions (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).Cardiac output: No changes in CO were seen between the first and the ninth TT sessions (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).Peripheral vascular resistance: A statistically significant increase in PVR (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) was observed between the first and the ninth TT sessions (1485±225 vs. 1591±187dynscm−5, p<0.05), with a decrease in standard deviation (206±60 vs. 150±42, p<0.05). This was reflected in a tendency towards a lower dynamic equilibrium value (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Cardiovascular autonomic functionIn the assessment of cardiac autonomic function over the course of the TT program, analysis of HR and BP variability using autoregression techniques showed an increase in sympathetic tone reflected in a progressive increase in overall autonomic activity during TT (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>) and a significant increase in indices of variability in the LF (sympathetic) and HF (parasympathetic) bands. This increase was also seen, although without statistical significance, in changes in BEI (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Follow-upThere was a significant decrease in the number of episodes of syncope (4.0±3.2/patient in the 12 months before TT vs. 1.4±0.8/patient post-TT, p<0.05). In five patients no change in the pattern of episodes was seen. Although all patients completed all the in-hospital sessions, after one year 11 (39%) had stopped home self-training due to symptomatic improvement.DiscussionTo the best of our knowledge, this is the first study to combine assessment of alterations in cardiocirculatory parameters, cardiovascular autonomic function and baroreflex sensitivity resulting from tilt training in patients with NCS refractory to conventional measures. We demonstrated a significant increase in vasoconstrictor reserve in these patients after nine TT sessions, as well as significant increases in baroreflex sensitivity as determined by the sequence method and in parameters of HR variability (LF and HF) calculated by autoregression techniques. Our results show that TT significantly increases autonomic tone (both sympathetic and parasympathetic), as well as baroreflex sensitivity, after three weeks of training. This response, which in our opinion is due mainly to remodeling of autonomic activity in the periphery, in particular of the cardiovascular system, was beneficial, significantly reducing the number of syncopal episodes, and confirms that TT should be used as a complement to conventional therapeutic measures.NCS is the most common cause of transient loss of conscious. It can be triggered by a variety of stimuli such as emotional stress, heat or prolonged standing. Although prognosis is generally good, it is associated with a marked reduction in quality of life, due to both risk of physical injury and loss of self-confidence induced by fear of further episodes.The therapeutic options for these patients are limited to preventing new episodes and resulting physical injury, and improving their general quality of life. The most widely used measures include advice on avoiding possible triggers, recognition of prodromes and maneuvers that can abort a syncopal episode. In some patients drug therapy can complement these measures, while cardiac pacing is reserved for specific groups.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Studies have indicated certain limitations to tilt training, the main one being patient compliance with the long treatment period.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> Compliance is in fact principally a problem in patients who become asymptomatic after a few sessions, and education and motivation are thus essential.The ESC guidelines on syncope identify the fact that randomized trials have failed to demonstrate the value of tilt training as a reason for the limited use of this therapy. Comparing our study with others<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> reveals differences that could affect the conclusions drawn, particularly the inclusion criteria, the training protocol, and most importantly, the diversity of the endpoints, which would tend to lead to differences in interpretation of the results and hence in evaluation of the efficacy of tilt training. Thus, while we set out to assess the effect of TT complemented with home self-training on reducing the number of syncopal episodes, thereby improving patients’ quality of life, Foglia-Manzillo et al.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> used a positive tilt test one month after tilt training as the endpoint. The question arises as to whether the aim of training is to bring about changes that enable individuals to improve their daily lives, or to prepare the individual to react to intense stimuli such as changes in posture. After assessing our patients, we are of the opinion that the choice of endpoint should incline towards the first, and in this case tilt training was shown to be effective.Studies by Abe et al.<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a> and Reybrouck et al.<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a> have similar conclusions to ours. Abe et al., using a similar protocol to ours, observed no spontaneous or orthostatic stress-induced syncopal episodes after TT, while Reybrouck et al. reported a significantly lower number of episodes after TT complemented by home self-training. They also reported that patients who did not complete the TT program had no episodes of syncope up to a year after dropping out, which suggests that autonomic activity had been restored in these patients.However, although the efficacy of tilt training has been demonstrated, the physiological mechanisms underlying the improvement in these patients’ general condition are not entirely clear. Previous studies have indicated that humoral mechanisms – the renin–angiotensin system<a class="elsevierStyleCrossRef" href="#bib0100">20</a>, baroreflex changes, and overall autonomic alterations – may be involved in the responses observed.<a class="elsevierStyleCrossRefs" href="#bib0105">21–24</a> In particular, Verheyden et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> observed increased vasoconstrictor reserve without changes in baroreflex or autonomic tone, while Tan et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> showed increases in HF and LF indicators of increased autonomic tone. Our study is the first to relate hemodynamic changes to modifications in autonomic tone assessed by changes in BP and HR variability. Our results show a significant increase in PVR and in LF and HF, without significant alterations in other variables. This implies that the increase in PVR is due mainly to increased sympathetic activity in the vascular system that maintains BP without large variations during postural changes. At the same time, a slight rise in mean BP is seen, accompanied as expected by reduced chronotropic response, reflected by increased HF and a slight, non-significant increase in baroreflex sensitivity and its ability to adapt to changes in posture. Besides these changes in PVR, it is also worth noting the decrease in standard deviation, which we take to reflect peripheral and somatic sympathetic remodeling, indicating a reduction in the variations around a mean equilibrium value that enables the individual to adapt better (without large variations) to postural changes. Furthermore, although not analyzed in the present study, TT may also increase muscle tone in the lower limbs, which together with the increase in PVR would improve postural adaptation.In conclusion, in patients with refractory neurocardiogenic syncope, our training protocol may be an effective therapeutic option, with long-term benefits in terms of greater tolerance to orthostatism, through three main mechanisms: an increase in, and lower variability of, vasoconstrictor reserve; overall increase in autonomic tone; and changes in baroreflex sensitivity. This suggests that it improves patients’ quality of life." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres251799" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec239397" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres251798" "titulo" => array:5 [ 0 => "Resumo" 1 => "Objectivo" 2 => "População e métodos" 3 => "Resultados" 4 => "Conclusão" ] ] 3 => array:2 [ "identificador" => "xpalclavsec239396" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Tilt training program" ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Data acquisition and analysis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Heart rate and systolic blood pressure variability" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Baroreflex sensitivity and effectiveness" ] ] ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Hemodynamic parameters" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Cardiovascular autonomic function" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Follow-up" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-07-11" "fechaAceptado" => "2011-12-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec239397" "palabras" => array:3 [ 0 => "Syncope" 1 => "Tilt training" 2 => "Autonomic nervous system" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec239396" "palabras" => array:3 [ 0 => "Síncope" 1 => "Treino de ortostatismo" 2 => "Sistema nervoso autónomo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Neurocardiogenic syncope (NCS) is a common clinical entity resulting from an excessive reflex autonomic response, particularly during orthostatism. Treatment options are controversial and of limited effectiveness. Tilt training (TT) is a promising option to treat these patients. However, its mechanism of action and clinical impact remain unclear. ObjectiveTo characterize hemodynamic and autonomic responses during a TT program in patients with NCS refractory to conventional measures. MethodsWe studied 28 patients (50% male, mean age 41±14 years) without structural heart disease, with NCS documented by tilt testing. The TT program included nine tilt sessions (three times a week, 30min) (60° – 6 sessions, 70° – 3 sessions), under ECG and blood pressure monitoring combined with home orthostatic self-training and 10° head-up during sleep. Systolic volume, cardiac output, total peripheral resistance, baroreflex sensitivity and heart-rate variability were computed. Patients were reassessed at 1 month and every 6 months for a maximum of 36 months (24±12 months). ResultsOver the course of the TT program there was a significant increase in total peripheral resistance (1485±225 vs. 1591±187dynscm−5, p<0.05), with a decrease in standard deviation (206±60 vs. 150±42, p<0.05). During follow-up, syncope recurred in five patients (19%), with a significant reduction in the number of episodes (4.0±3.2/patient in the 12 months before TT vs. 1.4±0.8/patient post-TT, p<0.05). ConclusionIn refractory NCS, TT may be an effective therapeutic option, with long-term benefits. These results appear to be due to an increase in vasoconstrictor reserve combined with a reduction in its variance." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "A síncope neurocardiogénica (SNc) é uma entidade clínica comum, resultante de uma resposta autonómica reflexa excessiva durante o stress ortostático. As diferentes opções terapêuticas são controversas e de eficácia limitada. O treino de ortostatismo (TTr) tem-se mostrado uma alternativa prometedora no tratamento destes doentes (D). No entanto, permanece por esclarecer o seu mecanismo de acção e o impacto clínico numa população com SNc recorrente. ObjectivoCaracterizar a resposta hemodinâmica e autonómica durante um programa de TTr em doentes com SNc refractária às medidas convencionais. População e métodosForam estudados 28D (50% do sexo masculino, 41±14 anos), sem evidência de cardiopatia, com SNc documentada em teste de ortostatismo passivo. O TTr incluiu 9 sessões hospitalares (3×/semana, 30 minutos) com monitorização contínua de pressão arterial e frequência cardíaca (60° – 6 sessões – 70° – 3 sessões), complementadas com treino diário no domicílio e elevação da cabeceira a 10° durante o sono. O volume sistólico, o débito cardíaco, a resistência vascular periférica, a sensibilidade do barorreflexo e a variabilidade da frequência cardíaca foram calculados. Todos os doentes foram reavaliados no fim do 1° mês e no final de cada 6 meses num período máximo de 36 meses (follow-up 24±12 meses). ResultadosAo longo das sessões de TTr verificou-se um aumento significativo e consistente da resistência total periférica (1485±225 vs. 1591±187 dyne*s/cm5, p<0,05) associado a uma diminuição do seu desvio-padrão (206±60 vs. 150±42, p<0,05). Durante o período de follow-up, houve recorrência de síncope em 5D (19%), com redução significativa do numero de síncopes (4.0±3.2/D nos 12 meses pre-TTr vs. 1.4±0.8/D pos-TTr, p<0.05). ConclusãoEm doentes com SNc refractária, o TTr mostrou ser uma opção terapêutica eficaz, com beneficio a longo-prazo. A melhor tolerância ao ortostatismo parece resultar do aumento da reserva vasoconstritora e da sua menor variabilidade." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Laranjo, S. O treino de ortostatismo (tilt training) aumenta a reserva vasoconstritora em doentes com síncope reflexa neurocardiogénica. Rev Port Cardiol. 2012;31(7-8):469-476." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2785 "Ancho" => 2493 "Tamanyo" => 293102 ] ] "descripcion" => array:1 [ "en" => "Changes in hemodynamic variables between the first and the ninth tilt training sessions. Note changes in response leading to improved adaptation." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1458 "Ancho" => 1319 "Tamanyo" => 92143 ] ] "descripcion" => array:1 [ "en" => "Changes in peripheral vascular resistance between the first and the ninth tilt training sessions; the increase is one of the factors involved in absence or reduced number of syncopal episodes." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n=28 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Height (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">166±8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.3±13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41±14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22–71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Syncopal episodes before training (n/year/patient) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.0±3.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab355063.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the study population." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1455.1±287 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1625.5±316 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1553.3±380 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1781.9±330<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1545.8±334 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1790.7±323<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1462.2±334 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1818.7±361<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1455.3±351 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1767.9±270<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1469.8±359 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1759.8±293<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1337.1±365 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1535.7±340<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab355059.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "p<0.05." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "p<0.01." ] ] ] "descripcion" => array:1 [ "en" => "Changes in peripheral vascular resistance (dynscm−5)." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">225.45±83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">184.52±80<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">159.33±63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">132.05±36<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">156.23±48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">134.73±46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">159.27±38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">143.55±41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">151.37±46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">140.76±32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">155.04±49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">138.54±32<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">226.70±93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">193.99±60 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab355062.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "p<0.05." ] ] ] "descripcion" => array:1 [ "en" => "Changes in standard deviation of peripheral vascular resistance." ] ] 5 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">20min</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">25min</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">30min</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RRI (ms2)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">500.87±106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">942.90±280<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">544.08±146 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">914.64±225<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">712.91±288 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1063.4±216<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">217±74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">335.18±103<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">182.06±54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">325.27±100<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">208.17±62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">524.6±120<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SBP (mmHg2)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.11±0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.56±0.9<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.32±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.42±0.8<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.64±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.92±0.7<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.62±0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.58±0.6<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.49±0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.45±0.6<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.05±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.95±0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab355061.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "p<0.05." ] ] ] "descripcion" => array:1 [ "en" => "Changes in autonomic outflow to the cardiovascular system between the first and the ninth tilt training sessions." ] ] 6 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Session 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.971±17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65.13±18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61.06±20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.69±17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.631±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65.14±15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.771±15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.04±20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.21±18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.41±17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62.360±14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67.95±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65.73±14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.95±19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab355060.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Changes in baroreflex sensitivity between the first and the ninth tilt training sessions." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the diagnosis and management of syncope (version 2009). 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Original article

Tilt training increases vasoconstrictor reserve in patients with neurocardiogenic syncope

O treino de ortostatismo (tilt training) aumenta a reserva vasoconstritora em doentes com síncope reflexa neurocardiogénica

Sérgio Laranjoa,b,

Corresponding author

sergiolaranjo@gmail.com

Corresponding author.

, Mário Martins Oliveiraa,b, Cristiano Tavaresa,b, Vera Geraldesa,b, Sofia Santosc, Eunice Oliveirac, Rui Ferreirac, Isabel Rochaa,b

a Instituto de Fisiologia e Unidade de Sistema Nervoso Autónomo, Faculdade de Medicina de Lisboa, Lisboa, Portugal

b Instituto de Medicina Molecular, Lisboa, Portugal

c Serviço de Cardiologia, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, EPE, Lisboa, Portugal

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Syncope is defined as a transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset&#44; short duration&#44; and spontaneous complete recovery&#46; It is common in the general population&#44; with an estimated incidence of 18&#46;1&#8211;39&#46;7<span class="elsevierStyleHsp" style=""></span>events&#47;1000 person-years&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and has serious effects on quality of life&#44; including high morbidity&#44; risk of physical injury and work absenteeism&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Neurocardiogenic syncope &#40;NCS&#41; is the most common form&#44; with a higher incidence in young adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Its pathophysiology is poorly understood&#44; but it has been demonstrated that alterations in the reactions of the autonomic nervous system to stressful stimuli such as active orthostatism are involved in triggering syncope&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Various treatment options have been proposed over the years for NCS&#44; ranging from behavior modification to cardiac pacing and various types of drug therapy&#44; but none has been shown to be fully effective&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Tilt training &#40;TT&#41;&#44; a new non-pharmacological treatment for NCS&#44; was proposed in 1998 by Ector et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> who showed that repeated and prolonged exposure of the cardiovascular system to orthostatic stimuli had therapeutic effects in patients with NCS&#46; The effectiveness of tilt training has been evaluated in several non-randomized observational studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> but the results have been inconsistent&#44; varying according to the training protocol and particularly patient compliance&#46; The mechanisms of action are largely unknown&#59; it is thought that desensitization of cardiopulmonary receptors to orthostatism may be involved&#44; as well as autonomic remodeling and alterations in baroreflex activity&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to clarify the mechanisms of action of tilt training&#44; specifically to characterize hemodynamic and autonomic responses during a TT program in patients with NCS refractory to conventional measures&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Part of this work was awarded the prize for best communication at CPC2010&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Population</span><p id="par0035" class="elsevierStylePara elsevierViewall">Between 2007 and 2010 we studied 28 patients &#40;50&#37; male&#44; mean age 41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years&#41;&#44; each with more than two syncopal episodes in the previous six months&#46; All had NCS refractory to conventional measures &#40;compression stockings and counterpulsation measures&#44; midodrine&#44; and paroxetine&#41; and documented by tilt testing in accordance with our center&#39;s standard protocol&#46; Briefly&#44; after a supine resting period&#44; the patient underwent passive tilt testing for 20 min at 70&#176;&#59; if no spontaneous syncope had occurred 375<span class="elsevierStyleHsp" style=""></span>&#956;g sublingual nitrates were administered&#46; The test was terminated either by a positive response or 20 min after nitrate administration&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> A positive test was defined as reproduction of syncope in association with bradycardia &#40;decrease in heart rate &#62;30&#37; of the maximum value in the upright position&#41;&#44; hypotension &#40;decrease in heart rate &#91;HR&#93; of &#62;50&#37; of the maximum value in the upright position&#41;&#44; or both&#44; and classified according to the VASIS system&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The following exclusion criteria were applied&#58; &#40;1&#41; structural heart disease or cardiac rhythm disturbance&#59; &#40;2&#41; neurologically mediated syncope including classical or delayed orthostatic hypotension&#59; &#40;3&#41; excessive reaction to nitrates&#59; &#40;4&#41; refusal to consent to the test&#59; &#40;5&#41; physical inability to remain standing for 30<span class="elsevierStyleHsp" style=""></span>min&#59; &#40;6&#41; impossibility of suspending cardiovascular medication that could interfere with assessment of the autonomic nervous system&#59; and &#40;7&#41; pregnancy&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study complies with the Declaration of Helsinki and informed consent was obtained from all participants&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Tilt training program</span><p id="par0045" class="elsevierStylePara elsevierViewall">The TT protocol has two simultaneous components&#46; The first&#44; in-hospital&#44; component consists of nine tilt training sessions three times a week in the mornings after a light breakfast&#44; without ingestion of caffeine or other xanthines&#46; Training took place in a laboratory specifically designed for autonomic evaluation&#44; in a calm environment and with controlled temperature and humidity&#46; After 15<span class="elsevierStyleHsp" style=""></span>min of supine &#40;0&#176;&#41; rest&#44; the patient was placed on a tilt table with feet supported and with restraining straps to prevent falls in the event of syncope&#46; For the first two weeks the tilt table was at 60&#176; and at 70&#176; for the third week&#46; During training the patient underwent continuous non-invasive monitoring of BP&#44; electrocardiogram &#40;ECG&#41; and thoracic impedance &#40;Task Force Monitor&#44; CNSystems&#44; Graz&#44; Austria&#41;&#44; and the test was stopped if symptoms occurred&#46; The hospital sessions were complemented by daily home training&#44; with the patient in orthostatic position at 60&#176; to a flat vertical surface with feet apart about 15<span class="elsevierStyleHsp" style=""></span>cm from the wall for 20<span class="elsevierStyleHsp" style=""></span>min&#44; and 10&#176; head-up during sleep&#46; Patients were instructed to stop the daily orthostatic maneuver whenever they felt the onset of symptoms&#46; All patients were followed clinically at 1 month and every 6 months for a maximum of 36 months&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Data acquisition and analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">RR intervals &#40;RRI&#41; and systolic blood pressure &#40;SBP&#41; were recorded continuously&#44; beat-to-beat &#40;Task Force Monitor&#44; CNSystems&#44; Graz&#44; Austria&#41;&#46; Other hemodynamic parameters &#8211; HR&#44; mean blood pressure &#40;MBP&#41;&#44; systolic volume &#40;SV&#41;&#44; cardiac output &#40;CO&#41;&#44; and peripheral vascular resistance &#40;PVR&#41; &#8211; were calculated on the basis of thoracic impedance &#40;Task Force Monitor&#44; CNSystems&#44; Graz&#44; Austria&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The data were analyzed using an interface programmed in MATLAB &#40;MathWorks&#44; USA&#41;&#44; implementing a routine to detect SBP peaks and the fiducial points of the R waves of each ECG complex&#44; beat-to-beat&#44; in order to construct a time curve of BP &#40;systogram&#41; and of HR &#40;tachogram&#41;&#46; The reconstructed signals were used to calculate HR and BP variability and baroreflex sensitivity&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Heart rate and systolic blood pressure variability</span><p id="par0060" class="elsevierStylePara elsevierViewall">Autoregression techniques were used to extract the characteristics of the cardiovascular parameters HR and BP&#46; The total maneuver time was divided into 5-min segments&#44; to facilitate computation and to better visualize the dynamics of cardiovascular alterations taking place during the maneuver&#46; A frequency power spectrum was obtained for each interval and two main bands were isolated&#58; high frequency &#40;HF&#59; 0&#46;15&#8211;0&#46;4<span class="elsevierStyleHsp" style=""></span>Hz&#41;&#44; an indicator of parasympathetic activity&#44; and low frequency &#40;LF&#59; 0&#46;04&#8211;0&#46;15<span class="elsevierStyleHsp" style=""></span>Hz&#41;&#44; which indicates sympathetic activity&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Baroreflex sensitivity and effectiveness</span><p id="par0065" class="elsevierStylePara elsevierViewall">Baroreflex sensitivity is a measure of overall response to baroreceptor activation that assesses the relationship between simultaneous changes in HR and BP&#46; In the present work baroreflex sensitivity was estimated using the sequence method&#46; Briefly&#44; the SBP signal was analyzed to identify sequences &#40;ramps&#41; of three or more heartbeats with a progressive increase &#40;up-ramp&#41; or decrease &#40;down-ramp&#41; in BP of at least 1<span class="elsevierStyleHsp" style=""></span>mmHg&#46; The algorithm identified spontaneous baroreflex sequences&#44; defined as SBP ramps followed by concomitant and concordant variations of &#8805;5<span class="elsevierStyleHsp" style=""></span>ms in RRI that were analyzed in three time lags&#44; of &#8722;0&#44; &#8722;1 and &#8722;2 heartbeats&#46; Each sequence was included only once&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> For each spontaneous sequence the slope of the linear relation between the SPB ramps and RRIs was calculated&#46; Only periods with correlation coefficient &#62;0&#46;8 were analyzed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">For each period selected for analysis&#44; the baroreflex effectiveness index &#40;BEI&#41; was calculated&#44; defined as the ratio between the total number of baroreflex sequences detected and the total number of SBP ramps&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The higher the BEI the more SBP ramps are followed by alterations in RRI&#44; and hence the more effective the baroreflex in bringing about the necessary cardiovascular adaptations&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">For the statistical analysis&#44; performed using SPSS version 18&#44; each session was divided into seven 5-min periods&#44; the first being the baseline period and the others on the tilt table&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Continuous variables are presented as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation and were tested for normality by the Kolmogorov&#8211;Smirnov test&#46; The results of the first and ninth TT sessions were compared using the Student&#39;s t test for paired data&#46; Values of p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 were considered statistically significant&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">We studied 28 patients&#44; 14 male&#44; mean age 41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years&#46; The mean number of syncopal episodes before beginning the TT program was 4&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;2&#47;patient&#47;year &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hemodynamic parameters</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Heart rate</span>&#58; HR tended to decrease between the first and the ninth TT sessions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mean blood pressure and systolic volume</span>&#58; MBP and SV showed a non-significant increase between the first and the ninth TT sessions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cardiac output</span>&#58; No changes in CO were seen between the first and the ninth TT sessions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Peripheral vascular resistance</span>&#58; A statistically significant increase in PVR &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; was observed between the first and the ninth TT sessions &#40;1485<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>225 vs&#46; 1591<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>187<span class="elsevierStyleHsp" style=""></span>dyn<span class="elsevierStyleHsp" style=""></span>s<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">&#8722;5</span>&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; with a decrease in standard deviation &#40;206<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60 vs&#46; 150<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; This was reflected in a tendency towards a lower dynamic equilibrium value &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cardiovascular autonomic function</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the assessment of cardiac autonomic function over the course of the TT program&#44; analysis of HR and BP variability using autoregression techniques showed an increase in sympathetic tone reflected in a progressive increase in overall autonomic activity during TT &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; and a significant increase in indices of variability in the LF &#40;sympathetic&#41; and HF &#40;parasympathetic&#41; bands&#46; This increase was also seen&#44; although without statistical significance&#44; in changes in BEI &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Follow-up</span><p id="par0115" class="elsevierStylePara elsevierViewall">There was a significant decrease in the number of episodes of syncope &#40;4&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;2&#47;patient in the 12 months before TT vs&#46; 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#47;patient post-TT&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; In five patients no change in the pattern of episodes was seen&#46; Although all patients completed all the in-hospital sessions&#44; after one year 11 &#40;39&#37;&#41; had stopped home self-training due to symptomatic improvement&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; this is the first study to combine assessment of alterations in cardiocirculatory parameters&#44; cardiovascular autonomic function and baroreflex sensitivity resulting from tilt training in patients with NCS refractory to conventional measures&#46; We demonstrated a significant increase in vasoconstrictor reserve in these patients after nine TT sessions&#44; as well as significant increases in baroreflex sensitivity as determined by the sequence method and in parameters of HR variability &#40;LF and HF&#41; calculated by autoregression techniques&#46; Our results show that TT significantly increases autonomic tone &#40;both sympathetic and parasympathetic&#41;&#44; as well as baroreflex sensitivity&#44; after three weeks of training&#46; This response&#44; which in our opinion is due mainly to remodeling of autonomic activity in the periphery&#44; in particular of the cardiovascular system&#44; was beneficial&#44; significantly reducing the number of syncopal episodes&#44; and confirms that TT should be used as a complement to conventional therapeutic measures&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">NCS is the most common cause of transient loss of conscious&#46; It can be triggered by a variety of stimuli such as emotional stress&#44; heat or prolonged standing&#46; Although prognosis is generally good&#44; it is associated with a marked reduction in quality of life&#44; due to both risk of physical injury and loss of self-confidence induced by fear of further episodes&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The therapeutic options for these patients are limited to preventing new episodes and resulting physical injury&#44; and improving their general quality of life&#46; The most widely used measures include advice on avoiding possible triggers&#44; recognition of prodromes and maneuvers that can abort a syncopal episode&#46; In some patients drug therapy can complement these measures&#44; while cardiac pacing is reserved for specific groups&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Studies have indicated certain limitations to tilt training&#44; the main one being patient compliance with the long treatment period&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> Compliance is in fact principally a problem in patients who become asymptomatic after a few sessions&#44; and education and motivation are thus essential&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The ESC guidelines on syncope identify the fact that randomized trials have failed to demonstrate the value of tilt training as a reason for the limited use of this therapy&#46; Comparing our study with others<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> reveals differences that could affect the conclusions drawn&#44; particularly the inclusion criteria&#44; the training protocol&#44; and most importantly&#44; the diversity of the endpoints&#44; which would tend to lead to differences in interpretation of the results and hence in evaluation of the efficacy of tilt training&#46; Thus&#44; while we set out to assess the effect of TT complemented with home self-training on reducing the number of syncopal episodes&#44; thereby improving patients&#8217; quality of life&#44; Foglia-Manzillo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> used a positive tilt test one month after tilt training as the endpoint&#46; The question arises as to whether the aim of training is to bring about changes that enable individuals to improve their daily lives&#44; or to prepare the individual to react to intense stimuli such as changes in posture&#46; After assessing our patients&#44; we are of the opinion that the choice of endpoint should incline towards the first&#44; and in this case tilt training was shown to be effective&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Studies by Abe et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> and Reybrouck et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> have similar conclusions to ours&#46; Abe et al&#46;&#44; using a similar protocol to ours&#44; observed no spontaneous or orthostatic stress-induced syncopal episodes after TT&#44; while Reybrouck et al&#46; reported a significantly lower number of episodes after TT complemented by home self-training&#46; They also reported that patients who did not complete the TT program had no episodes of syncope up to a year after dropping out&#44; which suggests that autonomic activity had been restored in these patients&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">However&#44; although the efficacy of tilt training has been demonstrated&#44; the physiological mechanisms underlying the improvement in these patients&#8217; general condition are not entirely clear&#46; Previous studies have indicated that humoral mechanisms &#8211; the renin&#8211;angiotensin system<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#44; baroreflex changes&#44; and overall autonomic alterations &#8211; may be involved in the responses observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;24</span></a> In particular&#44; Verheyden et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> observed increased vasoconstrictor reserve without changes in baroreflex or autonomic tone&#44; while Tan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> showed increases in HF and LF indicators of increased autonomic tone&#46; Our study is the first to relate hemodynamic changes to modifications in autonomic tone assessed by changes in BP and HR variability&#46; Our results show a significant increase in PVR and in LF and HF&#44; without significant alterations in other variables&#46; This implies that the increase in PVR is due mainly to increased sympathetic activity in the vascular system that maintains BP without large variations during postural changes&#46; At the same time&#44; a slight rise in mean BP is seen&#44; accompanied as expected by reduced chronotropic response&#44; reflected by increased HF and a slight&#44; non-significant increase in baroreflex sensitivity and its ability to adapt to changes in posture&#46; Besides these changes in PVR&#44; it is also worth noting the decrease in standard deviation&#44; which we take to reflect peripheral and somatic sympathetic remodeling&#44; indicating a reduction in the variations around a mean equilibrium value that enables the individual to adapt better &#40;without large variations&#41; to postural changes&#46; Furthermore&#44; although not analyzed in the present study&#44; TT may also increase muscle tone in the lower limbs&#44; which together with the increase in PVR would improve postural adaptation&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In conclusion&#44; in patients with refractory neurocardiogenic syncope&#44; our training protocol may be an effective therapeutic option&#44; with long-term benefits in terms of greater tolerance to orthostatism&#44; through three main mechanisms&#58; an increase in&#44; and lower variability of&#44; vasoconstrictor reserve&#59; overall increase in autonomic tone&#59; and changes in baroreflex sensitivity&#46; This suggests that it improves patients&#8217; quality of life&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neurocardiogenic syncope &#40;NCS&#41; is a common clinical entity resulting from an excessive reflex autonomic response&#44; particularly during orthostatism&#46; Treatment options are controversial and of limited effectiveness&#46; Tilt training &#40;TT&#41; is a promising option to treat these patients&#46; However&#44; its mechanism of action and clinical impact remain unclear&#46;</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To characterize hemodynamic and autonomic responses during a TT program in patients with NCS refractory to conventional measures&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We studied 28 patients &#40;50&#37; male&#44; mean age 41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years&#41; without structural heart disease&#44; with NCS documented by tilt testing&#46; The TT program included nine tilt sessions &#40;three times a week&#44; 30<span class="elsevierStyleHsp" style=""></span>min&#41; &#40;60&#176; &#8211; 6 sessions&#44; 70&#176; &#8211; 3 sessions&#41;&#44; under ECG and blood pressure monitoring combined with home orthostatic self-training and 10&#176; head-up during sleep&#46; Systolic volume&#44; cardiac output&#44; total peripheral resistance&#44; baroreflex sensitivity and heart-rate variability were computed&#46; Patients were reassessed at 1 month and every 6 months for a maximum of 36 months &#40;24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 months&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Over the course of the TT program there was a significant increase in total peripheral resistance &#40;1485<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>225 vs&#46; 1591<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>187<span class="elsevierStyleHsp" style=""></span>dyn<span class="elsevierStyleHsp" style=""></span>s<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">&#8722;5</span>&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; with a decrease in standard deviation &#40;206<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60 vs&#46; 150<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; During follow-up&#44; syncope recurred in five patients &#40;19&#37;&#41;&#44; with a significant reduction in the number of episodes &#40;4&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;2&#47;patient in the 12 months before TT vs&#46; 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#47;patient post-TT&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In refractory NCS&#44; TT may be an effective therapeutic option&#44; with long-term benefits&#46; These results appear to be due to an increase in vasoconstrictor reserve combined with a reduction in its variance&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A s&#237;ncope neurocardiog&#233;nica &#40;SNc&#41; &#233; uma entidade cl&#237;nica comum&#44; resultante de uma resposta auton&#243;mica reflexa excessiva durante o <span class="elsevierStyleItalic">stress</span> ortost&#225;tico&#46; As diferentes op&#231;&#245;es terap&#234;uticas s&#227;o controversas e de efic&#225;cia limitada&#46; O treino de ortostatismo &#40;TTr&#41; tem-se mostrado uma alternativa prometedora no tratamento destes doentes &#40;D&#41;&#46; No entanto&#44; permanece por esclarecer o seu mecanismo de ac&#231;&#227;o e o impacto cl&#237;nico numa popula&#231;&#227;o com SNc recorrente&#46;</p> <span class="elsevierStyleSectionTitle">Objectivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Caracterizar a resposta hemodin&#226;mica e auton&#243;mica durante um programa de TTr em doentes com SNc refract&#225;ria &#224;s medidas convencionais&#46;</p> <span class="elsevierStyleSectionTitle">Popula&#231;&#227;o e m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Foram estudados 28D &#40;50&#37; do sexo masculino&#44; 41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 anos&#41;&#44; sem evid&#234;ncia de cardiopatia&#44; com SNc documentada em teste de ortostatismo passivo&#46; O TTr incluiu 9 sess&#245;es hospitalares &#40;3&#215;&#47;semana&#44; 30 minutos&#41; com monitoriza&#231;&#227;o cont&#237;nua de press&#227;o arterial e frequ&#234;ncia card&#237;aca &#40;60&#176; &#8211; 6 sess&#245;es &#8211; 70&#176; &#8211; 3 sess&#245;es&#41;&#44; complementadas com treino di&#225;rio no domic&#237;lio e eleva&#231;&#227;o da cabeceira a 10&#176; durante o sono&#46; O volume sist&#243;lico&#44; o d&#233;bito card&#237;aco&#44; a resist&#234;ncia vascular perif&#233;rica&#44; a sensibilidade do barorreflexo e a variabilidade da frequ&#234;ncia card&#237;aca foram calculados&#46; Todos os doentes foram reavaliados no fim do 1&#176; m&#234;s e no final de cada 6 meses num per&#237;odo m&#225;ximo de 36 meses &#40;<span class="elsevierStyleItalic">follow-up</span> 24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 meses&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ao longo das sess&#245;es de TTr verificou-se um aumento significativo e consistente da resist&#234;ncia total perif&#233;rica &#40;1485<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>225 vs&#46; 1591<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>187 dyne&#42;s&#47;cm5&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; associado a uma diminui&#231;&#227;o do seu desvio-padr&#227;o &#40;206<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60 vs&#46; 150<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Durante o per&#237;odo de <span class="elsevierStyleItalic">follow-up</span>&#44; houve recorr&#234;ncia de s&#237;ncope em 5D &#40;19&#37;&#41;&#44; com redu&#231;&#227;o significativa do numero de s&#237;ncopes &#40;4&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;2&#47;D nos 12 meses pre-TTr vs&#46; 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#47;D pos-TTr&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#227;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Em doentes com SNc refract&#225;ria&#44; o TTr mostrou ser uma op&#231;&#227;o terap&#234;utica eficaz&#44; com beneficio a longo-prazo&#46; A melhor toler&#226;ncia ao ortostatismo parece resultar do aumento da reserva vasoconstritora e da sua menor variabilidade&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Laranjo&#44; S&#46; O treino de ortostatismo &#40;tilt training&#41; aumenta a reserva vasoconstritora em doentes com s&#237;ncope reflexa neurocardiog&#233;nica&#46; Rev Port Cardiol&#46; 2012&#59;<span class="elsevierStyleBold">31&#40;7-8&#41;</span>&#58;469-476&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Changes in hemodynamic variables between the first and the ninth tilt training sessions&#46; Note changes in response leading to improved adaptation&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Changes in peripheral vascular resistance between the first and the ninth tilt training sessions&#59; the increase is one of the factors involved in absence or reduced number of syncopal episodes&#46;</p>"
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                  \t\t\t\t">1818&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>361<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">20<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1455&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>351&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1767&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>270<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1469&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>359&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1759&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>293<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1337&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>365&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1535&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>340<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => "xTab355059.png"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Session 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Rest&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">225&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">184&#46;52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>80<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">5<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">132&#46;05<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">156&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">134&#46;73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">143&#46;55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">151&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">140&#46;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">155&#46;04<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">138&#46;54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">226&#46;70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">193&#46;99<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Changes in standard deviation of peripheral vascular resistance&#46;</p>"
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        "mostrarFloat" => true
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">25<span class="elsevierStyleHsp" style=""></span>min</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">30<span class="elsevierStyleHsp" style=""></span>min</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Session 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Session 9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Session 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Session 9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Session 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Session 9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">RRI &#40;ms</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleItalic">&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">500&#46;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>106&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">942&#46;90<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>280<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">544&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>146&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">914&#46;64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>225<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2011.12.020

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Year/Month	Html	Pdf	Total

2024 November	4	4	8
2024 October	38	30	68
2024 September	52	30	82
2024 August	58	34	92
2024 July	43	29	72
2024 June	50	32	82
2024 May	46	21	67
2024 April	28	30	58
2024 March	34	17	51
2024 February	30	23	53
2024 January	29	34	63
2023 December	20	21	41
2023 November	36	37	73
2023 October	21	18	39
2023 September	26	19	45
2023 August	41	20	61
2023 July	34	16	50
2023 June	26	13	39
2023 May	54	37	91
2023 April	23	6	29
2023 March	37	22	59
2023 February	43	33	76
2023 January	23	13	36
2022 December	43	28	71
2022 November	30	34	64
2022 October	39	20	59
2022 September	39	32	71
2022 August	33	23	56
2022 July	39	31	70
2022 June	32	28	60
2022 May	36	37	73
2022 April	41	29	70
2022 March	39	36	75
2022 February	34	28	62
2022 January	42	21	63
2021 December	26	26	52
2021 November	56	34	90
2021 October	67	41	108
2021 September	33	30	63
2021 August	38	37	75
2021 July	28	21	49
2021 June	26	21	47
2021 May	49	53	102
2021 April	68	36	104
2021 March	86	25	111
2021 February	63	14	77
2021 January	46	12	58
2020 December	41	7	48
2020 November	43	16	59
2020 October	41	17	58
2020 September	80	14	94
2020 August	48	9	57
2020 July	84	11	95
2020 June	54	7	61
2020 May	88	3	91
2020 April	73	7	80
2020 March	83	17	100
2020 February	187	18	205
2020 January	100	9	109
2019 December	90	7	97
2019 November	58	2	60
2019 October	80	7	87
2019 September	44	5	49
2019 August	49	8	57
2019 July	69	10	79
2019 June	67	6	73
2019 May	70	14	84
2019 April	43	15	58
2019 March	111	8	119
2019 February	123	8	131
2019 January	87	3	90
2018 December	87	10	97
2018 November	153	7	160
2018 October	417	14	431
2018 September	118	8	126
2018 August	82	5	87
2018 July	27	4	31
2018 June	40	7	47
2018 May	41	10	51
2018 April	58	4	62
2018 March	70	6	76
2018 February	37	5	42
2018 January	38	9	47
2017 December	71	6	77
2017 November	53	7	60
2017 October	60	15	75
2017 September	65	15	80
2017 August	43	16	59
2017 July	32	13	45
2017 June	57	9	66
2017 May	45	11	56
2017 April	33	31	64
2017 March	19	14	33
2017 February	40	5	45
2017 January	34	2	36
2016 December	50	10	60
2016 November	27	4	31
2016 October	19	10	29
2016 September	20	6	26
2016 August	7	3	10
2016 July	14	5	19
2016 June	7	4	11
2016 May	8	4	12
2016 April	24	6	30
2016 March	29	10	39
2016 February	43	21	64
2016 January	31	10	41
2015 December	31	11	42
2015 November	38	9	47
2015 October	33	15	48
2015 September	38	7	45
2015 August	57	4	61
2015 July	38	6	44
2015 June	35	2	37
2015 May	25	3	28
2015 April	34	9	43
2015 March	14	9	23
2015 February	30	5	35
2015 January	44	4	48
2014 December	43	12	55
2014 November	24	1	25
2014 October	39	2	41
2014 September	28	3	31
2014 August	27	6	33
2014 July	25	6	31
2014 June	38	4	42
2014 May	20	4	24
2014 April	30	4	34
2014 March	43	6	49
2014 February	45	7	52
2014 January	53	7	60
2013 December	42	10	52
2013 November	54	10	64
2013 October	41	10	51
2013 September	46	14	60
2013 August	60	15	75
2013 July	62	17	79
2013 June	55	6	61
2013 May	50	13	63
2013 April	62	18	80
2013 March	47	17	64
2013 February	42	18	60
2013 January	54	14	68
2012 December	36	13	49
2012 November	24	11	35
2012 October	14	5	19
2012 September	10	4	14

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