Materiały źródłowe

• #1 Management and therapy of vasovagal syncope: A review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2998831/

  Vasovagal syncope is a common cause of recurrent syncope. […] This review focuses on the management of vasovagal syncope and discusses the non-pharmacological and pharmacological treatment options, especially the use of midodrine and selective serotonin reuptake inhibitors. […] The cornerstone of therapy for young patients with vasovagal syncope remains education and reassurance, except in rare and isolated cases of patients with a high frequency of recurrent episodes despite nonpharmacological measures. […] However, some drugs such as midodrine and paroxetine showed positive results in patients with recurrent vasovagal syncope. […] The main goal of treatment is to reduce syncope recurrence and physical trauma. […] Patients with a high risk of recurrence or injury can be identified by risk scores and may require tailored treatment.

• #2 Vasovagal syncope – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/symptoms-causes/syc-20350527

  Vasovagal syncope is usually harmless and requires no treatment. […] Your healthcare professional may recommend tests to rule out more-serious causes of fainting, such as heart conditions. […] You may not always be able to avoid a vasovagal syncope episode. If you feel like you might faint, lie down and lift your legs. This allows gravity to keep blood flowing to your brain. If you can’t lie down, sit down and put your head between your knees until you feel better.

• #3 Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7252686/

  Neurocardiogenic syncope is the most frequent cause of syncope in the general population. Many years have been spent on determining an effective treatment for this condition. Conventional treatment usually follows a tiered approach for neurocardiogenic syncope, as follows: first, lifestyle modification, including increased fluid intake and the introduction of physical counterpressure maneuvers, is tried; then the use of targeted pharmacologic therapy, particularly agents that support blood pressure or that drive blood pressure is attempted; and, finally, pacemaker implantation in patients with a predominant cardioinhibitory component to their syncopal episodes is performed. More recently, autonomic modulation with cardiac ganglion ablation has emerged as a promising treatment modality for patients refractory to traditional approaches.

• #4 Textbook | Vasovagal Syncope | Syncopedia

  https://syncopedia.org/vasovagal-syncope/

  In vasovagal syncope, recognizing the diagnosis is the first part of the treatment. As it is an episodal event, most patients dont need more than a few lifestyle measures to learn how to prevent the vasovagal faints. […] By tensing the abdominal muscles and the muscles in the extremities the venous return can be increased almost instantaneously. This can be done by whole body muscle tensing or by leg crossing and tensing the calves. Prodromes have to be present, otherwise the counter pressure manoeuvres can not be applied in time to prevent the faint. This makes this a very useful method under the younger population, as they have prodromes most of the time. In older patients, prodromes are often absent, and physical counterpressure manoeuvres and thus not a good intervention in these patients.

• #5 Update on treatment strategies for vasovagal syncope – Cardiac Rhythm News

  https://cardiacrhythmnews.com/update-treatment-strategies-vasovagal-syncope/

  When speaking on therapy of vasovagal syncope (VVS), it is important to stress that a specific treatment of VVS is only rarely necessary in clinical practice. Indeed, in the majority of patients, VVS is a benign condition that does not represent a threat to life and that does not significantly impair quality of life; writes Antonio Raviele (Venice, Italy) for Cardiac Rhythm News. […] In these patients, syncope may be easily prevented by patient reassurance about the benign nature of his or her condition and other educational measures, in particular recognition of premonitory symptoms, and avoidance of precipitating conditions such as: prolonged sitting or standing in crowded and hot places, strenuous exercise in warm environment, dehydration, volume depletion, potentially hypotensive drugs, venipuncture and emotional stressful situations. Therefore, a specific treatment is only indicated in particular situations, ie. patients with frequent syncopal episodes, absence of predictable circumstances or warning symptoms that allow the patient to assume supine position or other evasive action, important physical injury and potential occupational hazard.

• #6 Management and therapy of vasovagal syncope: A review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2998831/

  An informative and instructive talk with the patient about the benign nature and prognosis is the first step in the treatment of patients with vasovagal syncope. […] Midodrine, an alpha-agonist vasoconstrictor, affects smooth muscle cells both in arteries and veins without effecting heart rhythm or negative inotropy. […] In 3 small randomized, placebo-controlled trials, midodrine had a beneficial effect on symptom frequency, symptoms during head-up tilt, and quality of life. […] Some open-label studies and one randomized, placebo-controlled trial demonstrated that SRI may reduce recurrent vasovagal syncope. […] The role of cardiac pacing is controversial. […] Given a IIa/B classification by the European Society of Cardiology, pacemaker implantation may play a role in special circumstances.

• #7 Vasovagal Syncope | Cedars-Sinai

  https://www.cedars-sinai.org/health-library/diseases-and-conditions/v/vasovagal-syncope.html

  Watch for the warning signs of vasovagal syncope, like dizziness, nausea, or sweaty palms. If you have a history of vasovagal syncope and think you are about to faint, lie down right away. Tensing your arms or crossing your legs can help prevent fainting. Passively raising or propping up your legs in the air can also help. […] To immediately treat someone who has fainted from vasovagal syncope, help the person lie down and lift their legs up in the air. This will restore blood flow to the brain, and the person should quickly regain consciousness. The person should lie down for a little while afterwards. […] If you have had episodes of vasovagal syncope, your healthcare provider might make some suggestions on how to help prevent fainting. These might include: Avoiding triggers, such as standing for a long time or the sight of blood, Moderate exercise training, Discontinuing medicines that lower blood pressure, like diuretics, Eating a higher salt diet, to help keep up blood volume, Drinking plenty of fluids, to maintain blood volume, Wearing compression stockings or abdominal binders.

• #8 Vasovagal Syncope: A Review of Current and Future Strategies – touchCARDIOLOGY

  https://touchcardio.com/syncope/journal-articles/vasovagal-syncope-a-review-of-current-and-future-strategies/

  Education about physical counter-manoeuvres, and exercise training. […] Physical counter-manoeuvres: At the onset of pre-syncopal symptoms, lower body tensing (clenching of leg, buttock and abdominal muscles together with concomitant leg crossing, plus linking of the fingers and pulling apart vigorously without letting go) results in an almost instantaneous increase in mean arterial pressure, stroke volume and cardiac output, raising the BP and reducing syncope frequency. […] Water and salt supplementation: A single 500 mL bolus of water can increase BP, total peripheral resistance and orthostatic tolerance. […] Midodrine is a peripherally acting alpha2 adrenoceptor agonist, which increases BP by venous and arterial vasoconstriction. […] Cardioneuroablation may help patients with severely symptomatic recurrent VVS with a pronounced asystolic component.

• #9 Textbook | Vasovagal Syncope | Syncopedia

  https://syncopedia.org/vasovagal-syncope/

  The goal of drinking enough water and eating salt is to increase the central blood volume and prevent a vasovagal reaction. When building a history with the patient, be sure to ask about their water and salt intake. Patients with frequent episodes of (pre)syncope should at least drink 3 L of water every day and they should always have clear urine. Eating more salt increases central blood volume but also increases the overall blood pressure. When advising a patient to increase their salt intake, be sure to take notice of the blood pressure of the patient.

• #10 Vasovagal Syncope: Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/23325-vasovagal-syncope

  Most people who have vasovagal syncope will recover on their own. For others, treatment may include: […] Medications. Some medications for heart rhythm disorders or blood pressure may help. These include fludrocortisone and midodrine. […] Compression stockings. Waist-high stockings (medical grade) work best. If you find these too uncomfortable, you can wear compression clothing made for athletes. […] Counter-pressure maneuvers. These include crossing your legs and squeezing your leg muscles tightly for several seconds, as well as interlocking your fists and pulling your arms apart. These maneuvers can help increase your blood pressure and prevent you from fainting. […] Pacing devices. In rare cases, you may need a pacemaker or another device that can help you avoid passing out because of pauses in your heartbeat. […] Catheter ablation. Healthcare providers are using cardioneuroablation to treat rare cases. This targets nerves in your heart.

• #11 Neurocardiogenic Syncope: A Focus on the Management of Vasovagal Episodes

  https://www.uspharmacist.com/article/neurocardiogenic-syncope-a-focus-on-the-management-of-vasovagal-episodes

  Vasovagal syncope is responsible for the majority of neurocardiogenic cases; therefore, it is commonly used synonymously with the term neurocardiogenic syncope. […] The management of neurocardiogenic syncope, particularly recurrent episodes of the vasovagal type, may be difficult due its unclear etiology. Several nonpharmacologic and pharmacologic treatment options have been proposed to decrease the incidence of syncope and potential consequences (i.e., falls, injuries, and other trauma). […] Prior to the utilization of pharmacologic agents, nonpharmacologic interventions should be considered for all patients who experience vasovagal syncope. […] Increasing fluid and salt intake has also been shown to prevent and decrease the number of syncopal episodes. […] In addition, the use of waist-high support stockings with a minimum of 30 mmHg ankle counterpressure may help decrease and prevent syncopal episodes.

• #12 Patient education: Syncope (fainting) (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/syncope-fainting-beyond-the-basics

  Vasovagal syncope treatment — Vasovagal syncope can usually be treated by learning to take precautions to avoid potential triggers and minimize the potential risk of harm. For example, if you faint while blood is being drawn, you may be instructed to lie down during the procedure. If you have a feeling that you will pass out during any activity, you should immediately lie down and elevate your legs. Staying well hydrated is one of the basics of treatment to prevent vasovagal syncope. […] Counter-pressure maneuvers — Counter-pressure maneuvers such as tensing your arms with clenched fists, leg pumping, and leg-crossing may stop a vasovagal syncopal episode, or at least delay it long enough that you can lie down with the feet elevated. Such maneuvers include: […] Orthostatic training — In people with orthostatic hypotension and vasovagal syncope, orthostatic training (sometimes called standing training) may be useful to reduce susceptibility to future syncope. Techniques are designed to decrease pooling of blood in the extremities, which can allow the blood pressure to drop when you stand.

• #13 What can I do when first-line measures are not enough for vasovagal syncope? | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/85/12/920

  Orthostatic training, with repetitive tilt-table testing until a test is negative, or with daily standing quietly against a wall for prolonged periods of time, has not been shown to have sustained benefit in reducing the recurrence of syncopal episodes (class IIb recommendation). Dual-chamber pacing can be considered in carefully selected patients age 40 or older with syncope and documented asystole of at least 3 seconds or spontaneous pauses of at least 6 seconds without syncope on implantable loop recorder monitoring (class IIb recommendation). Strict patient selection increases the likelihood that pacing will be effective. Compression garments carry a class IIa recommendation for orthostatic hypotension, but they have not been adequately studied in vasovagal syncope.

• #14 Update on treatment strategies for vasovagal syncope – Cardiac Rhythm News

  https://cardiacrhythmnews.com/update-treatment-strategies-vasovagal-syncope/

  Therapy for VVS patients The main therapeutic measures, that are currently available for the treatment of VVS, include non-pharmacological, pharmacological, and electrical options. […] Amongst the non-pharmacological options—besides patient reassurance and counselling—we have to mention high salt diet, increased water intake, support stockings, counter-pressure manoeuvres, and tilt training. […] The effectiveness of these manoeuvres has been confirmed in a multicentre prospective trial, the PC trial in 2006. […] Tilt training was initially proposed by Ector and colleagues in 1998. […] A recent meta-analysis of all studies performed with tilt training showed that this therapy is effective in preventing recurrences of VVS. […] Amongst the pharmacological options, several drugs with different effects have been proposed for the prevention of VVS.

• #15

  https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=abr0578

  You can usually get relief by lying down with your legs raised (elevated). This helps more blood to flow to your brain and may help relieve symptoms like feeling dizzy. […] An episode of vasovagal syncope usually responds well to self-care. Other treatment often isn’t needed. But if the fainting keeps happening, your doctor may suggest further treatments. […] Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse advice line if you are having problems. It’s also a good idea to know your test results and keep a list of the medicines you take.

• #16 Vasovagal syncope | UM Health-Sparrow

  https://www.uofmhealthsparrow.org/departments-conditions/conditions/vasovagal-syncope

  In most cases of vasovagal syncope, treatment is unnecessary. Your healthcare professional may help you understand your fainting triggers and discuss ways you might avoid them. […] If vasovagal syncope interferes with your quality of life, your healthcare professional may suggest trying one or more of the following remedies: […] Medicines. A drug called fludrocortisone acetate that’s usually used to treat low blood pressure may be helpful in preventing vasovagal syncope. Selective serotonin reuptake inhibitors also may be used. […] Therapies. Your healthcare professional may recommend ways to lessen the pooling of blood in your legs. These may include foot exercises, wearing compression stockings or tensing your leg muscles when standing. You may need to increase salt in your diet if you don’t usually have high blood pressure. Avoid prolonged standing especially in hot, crowded places and drink plenty of fluids. […] Surgery. Very rarely, inserting an electrical pacemaker to regulate the heartbeat helps some people with vasovagal syncope who haven’t been helped by other treatments.

• #17 Vasovagal Syncope | Cedars-Sinai

  https://www.cedars-sinai.org/health-library/diseases-and-conditions/v/vasovagal-syncope.html

  Occasionally, you may need medicine to help control vasovagal syncope. However, research on these medicines has revealed uncertain benefits in vasovagal syncope. These are usually only considered when a person has multiple episodes of fainting. Some of the medicines your healthcare provider may advise a trial of include: Alpha-1-adrenergic agonists to increase blood pressure, Corticosteroids to help increase the sodium and fluid levels, Serotonin reuptake inhibitors (SSRIs), to moderate the nervous system response. […] If these medicines are ineffective, healthcare providers sometimes try orthostatic training. This method uses a tilt table to gradually increase the amount of time spent upright. Rarely, in cases where a significant slowing of the heartbeat or pausing is found, a heart pacemaker is needed.

• #18 Midodrine as a Treatment Option for Recurrent Vasovagal Syncope | AAFP

  https://www.aafp.org/pubs/afp/issues/2024/0700/fpin-hda-recurrent-vasovagal-syncope.html

  Midodrine can treat recurrent vasovagal syncope in adults and children. It reduces the recurrence rate by at least 30% compared with placebo (number needed to treat [NNT] = 6). (Strength of Recommendation [SOR]: A, systematic review and meta-analysis of randomized controlled trials [RCTs].) Midodrine may also delay syncope recurrence compared with placebo. (SOR: B, single RCT.) A guideline from three cardiology organizations recommends midodrine as a reasonable treatment option for adults and children with recurrent vasovagal syncope without a history of hypertension, heart failure, or urinary retention. (SOR: B, evidence-based guideline.) […] A 2022 systematic review and meta-analysis of seven placebo-controlled RCTs (n = 319) evaluated midodrine for the treatment of recurrent vasovagal syncope.

• #19 Midodrine is safe and effective in the treatment of reflex syncope – The British Journal of Cardiology

  https://bjcardio.co.uk/2016/06/midodrine-is-safe-and-effective-in-the-treatment-of-reflex-syncope/

  Midodrine is safe and effective in the treatment of reflex syncope. […] In our experience, midodrine gives consistently good results in patients with reflex syncope. […] Overall, 143 (73%) patients improved on a mean dose of 10 mg a day of midodrine. […] In conclusion, in patients with reflex syncope, midodrine shows clinical benefit in greater than 70%, with 24% having complete symptom resolution. […] Midodrine, an alpha-adrenergic agonist, has been used in patients who are not responding to non-pharmacological treatments. […] Patients with continuing syncope were offered midodrine as first-line treatment. […] The usual starting dose was 2.5 mg three times daily. […] Regular follow-up assessed symptoms and side effects. […] This study found that midodrine gave a statistically significant benefit in over 70% of our patients, and complete resolution of syncope in 35%. […] If simple lifestyle measures, avoidance of precipitating circumstances, and salt and fluid supplementation prove to be inadequate; midodrine can be effective in some patients.

• #20 Treatment of Syncope – Syncope

  https://syncope.co.uk/syncope-fainting-blacking-out-passing-out/treatment/

  Reassurance about the benign nature of Autonomic Mediated Syncope (Neurocardiogenic Syncope, Vasovagal Syncope), avoidance of situations likely to induce an attack, and use of simple non-drug counter-measures is often all that is required in the management of the condition. However, treatment with low dose medication may be necessary. Occasionally pacemaker implantation may be required. […] Various medications have been used to treat Autonomic Mediated Syncope (Neurocardiogenic Syncope, Vasovagal Syncope). […] Beta blockers (Antihypertensive and antianginal drugs) such as Bisoprolol at low dose can be effective. […] Fludrocortisone (a mineralocorticoid used to treat low blood pressure) increases blood pressure by reducing urinary sodium and water loss. […] Small doses of an SSRI (Selective Serotonin Re-uptake Inhibitors used to treat depression) such as Fluoxetine (Prozac) or Paroxetine (Seroxat) can be effective.

• #21 Syncope Treatment & Management: Approach Considerations, Prehospital Care, Emergency Department Care

  https://emedicine.medscape.com/article/811669-treatment

  In patients with vasovagal syncope (VVS), physical counterpressure maneuvers can be beneficial to those who have a sufficiently long prodromal period (class IIa). […] In those with recurrent VVS without a history of hypertension, heart failure, or urinary retention, use of midodrine is reasonable (class IIa). […] In a 2023 systematic review and meta-analysis of 18 studies comprising data from 1130 participants to evaluate the utility of nonpharmacologic and nonpacing therapies to prevent VVS, Alharbi et al reported yoga (largest effect size), physical counterpressure maneuvers, and yoga (lowest effect size) show potential in preventing recurrent VVS and can be considered as viable treatment options. […] Serotonin-specific reuptake inhibitors appear to show potential in preventing vasovagal syncope. In a 2024 systematic review and meta-analysis of 3 studies comprising data from 204 patients, Raj et al found these agents substantially lowered the likelihood of a patient having at least one recurrence of vasovagal syncope as well as provided significant protection against clinical presyncope.

• #22 Update on treatment strategies for vasovagal syncope – Cardiac Rhythm News

  https://cardiacrhythmnews.com/update-treatment-strategies-vasovagal-syncope/

  These apparently good results of open studies are in sharp contrast with those of the long-term placebo-controlled trials that have been performed until now in patients with VVS. […] One of the few drugs that has shown some efficacy is midodrine. […] Another drug that can be used but only in patients older than 42 years is metoprolol. […] Finally, also fludrocortisone seems to be useful at least in young patients. […] Amongst electrical options, we have two possibilities: pacemaker and ablation. […] In conclusion, until now there are only very limited data on the benefits of pacemaker implantation in patients with VVS. […] Finally, cardioneuroablation for VVS was first proposed by Pachon in 2005. […] It is clear that these results, although interesting, need to be confirmed by future randomised, multicentre trials before considering cardioneuroablation a consolidated therapy for VVS.

• #23 Ivabradine for the treatment of vasovagal syncope | REC: CardioClinics

  https://www.reccardioclinics.org/es-ivabradine-for-treatment-vasovagal-syncope-articulo-S2605153223002881

  Ivabradine for the treatment of vasovagal syncope […] Ivabradina para el tratamiento del sncope vasovagal […] Table 1. Clinical and follow-up data from vasovagal syncope patients treated with ivabradine.

• #24 Management of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia and Vasovagal Syncope | AER Journal

  https://www.aerjournal.com/articles/management-postural-tachycardia-syndrome-inappropriate-sinus-tachycardia-and-vasovagal?language_content_entity=en

  Fludrocortisone might be useful in the treatment of POTS through enhanced sodium retention and plasma volume expansion, although its effectiveness for POTS has not been tested in randomised clinical trials. […] Midodrine is a prodrug whose metabolite is a peripheral alpha-1 adrenergic receptor agonist that constricts both veins and arteries. It significantly reduces orthostatic tachycardia. […] Low-dose oral propranolol (1020 mg) is effective at lowering standing heart rate and may improve symptoms in POTS patients acutely, while higher doses are less effective. […] Ivabradine slows sinus rates without impacting blood pressure. About 60 % of POTS patients treated with ivabradine in an open-label study improved. […] Pyridostigmine is a peripheral acetylcholinesterase inhibitor that increases synaptic acetylcholine in the autonomic ganglia and at peripheral muscarinic receptors. It blunts orthostatic tachycardia and may improve chronic symptoms in most patients, but has side-effects including diarrhoea and abdominal pain that can limit its tolerability.

• #25 Clinical Efficacy of Empirical Therapy in Children with Vasovagal Syncope

  https://www.mdpi.com/2227-9067/9/7/1065

  The recurrence rate of syncope or presyncope was 55% for the patients who received conventional treatment, 41% for those who received conventional treatment plus oral rehydration salts, 34% for those who received conventional treatment plus metoprolol, and 40% for those who received conventional treatment plus midodrine hydrochloride. […] The results suggested that the effectiveness of empirical unselected conventional or different empirical pharmacological modalities for pediatric vasovagal syncope was limited if the treatment was implemented, regardless of the mechanisms underlying vasovagal syncope. […] Therefore, individualized therapy, instead of empirical unselected therapy, might be a promising treatment strategy. The limited therapeutic values indicated that different mechanisms might require different treatments.

• #26

  https://link.springer.com/article/10.1007/s11739-022-03102-w

  Vasovagal syncope (VVS) is the most common cause of transient loss of consciousness. […] Most patients with VVS do well after specialist evaluation, reassurance and education. Adequate hydration, increased salt intake when not contraindicated, and careful withdrawal of diuretics and specific hypotension-inducing drugs are a reasonable initial strategy. Physical counterpressure maneuvers might be helpful but can be of limited efficacy in older patients and those with short or no prodromes. […] Almost a third of VVS patients continue to faint despite these conservative measures. Metoprolol was not helpful in a pivotal randomized clinical trial. Fludrocortisone and midodrine significantly reduce syncope recurrences with tolerable side effects, when titrated to target doses. Pacing therapy with specialized sensors appears promising in carefully selected population who have not responded conservative measures. Cardioneuroablation may be helpful but has not been studied in a formal clinical trial.

• #27 Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7252686/

  The majority of patients with NCS experience only rare, sporadic episodes of such in their lifetime, for which no specific treatment is required. A subgroup of patients, however, will experience recurrent episodes, which can be emotionally distressing or even disruptive to daily life. […] The initial treatments recommended for patients with recurrent NCS are conservative measuresthat is, nonpharmacological and noninvasive therapies that can be easily implemented into patients everyday lives. These measures include increasing fluid and salt intake, employing physical countermaneuvers, exercise training, and tilt training. […] When conservative treatment fails or is insufficient in reducing syncope burden, the most reasonable next step for many patients is pharmacologic therapy. […] In patients with NCS due to a predominant cardioinhibitory component, there are data to suggest that cardiac pacing may be beneficial in preventing syncope.

• #28 Treatment Options for Vasovagal Syncope: A Clinical Dilemma

  https://www.acc.org/Education-and-Meetings/Patient-Case-Quizzes/2022/02/10/13/41/Treatment-Options-for-Vasovagal-Syncope

  Answer choice A is an incorrect choice. Midodrine is a Class IIa recommendation and is one of the few pharmacologic options for some patients in vasovagal syncope, along with fludrocortisone or selective serotonin reuptake inhibitors, but patient education should be the first approach. Midodrine metabolites cause direct vaso- and venoconstriction via alpha receptor activation. This can help prevent reduction in preload (and an effect on afterload), and thus cardiac output. Randomized controlled trials have been performed and support its use, particularly in patients without significant comorbidities. It is contraindicated in patients with hypertension, urinary retention, heart failure, glaucoma, or liver disease. […] Answer choice B is an incorrect choice. Pacemaker placement may seem reasonable given asystole seen on the ILR associated with a syncopal event; however, patient selection is important. Although some randomized placebo-controlled data show benefit in patients with a cardioinhibitory response, this is only for symptomatic patients with frequent recurrent episodes. Studies have been performed in older individuals and, although an occasional pacemaker may be helpful in select younger patients, this is often a treatment of last resort and for patients with a cardioinhibitory response. Dual-chamber pacemaker placement for vasovagal syncope is currently an ACC/AHA Class IIb recommendation for patients 40 years of age if either prolonged asystole or sinus arrest are present. However, the Heart Rhythm Society (HRS) consensus document gives pacemakers a class IIb recommendation for younger patients refractory to medical therapy and the ACCF/AHA pacemaker/implantable cardioverter-defibrillator guideline gives pacemakers a Class IIb indication for vasovagal syncope. Tilt-table testing may be important, as patients with a cardioinhibitory response tended to respond better to pacing with closed-loop stimulation pacing versus placebo, whereas those with a purely vasodepressor response did not and would not be expected to respond. These studies, however, have been performed in patients older than this patient. ILRs have also been helpful in management if the episodes occur infrequently. In this patient, a disconnect between the tilt response (vasodepressor) and clinical episode (cardioinhibitory) is seen; this discrepancy is not uncommon.

• #29 Pacemaker for vasovagal syncope: good for few

  https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-2/Pacemaker-for-vasovagal-syncope-good-for-few-Title-Pacemaker-for-vasovagal-s

  The decision to implant a pacemaker needs to be kept in the clinical context of a benign condition which affects frequently young patients. Thus, cardiac pacing should be a last resort choice for a very small and selected proportion of patients affected by severe vasovagal syncope. […] In general, initial treatment of all forms of neurally-mediated reflex syncope comprises reassurance on the benign nature of the syndrome, education regarding avoidance of triggering events and predisposing factors, recognition of premonitory symptoms and maneuvers to abort the episode, the avoidance of volume depletion and prolonged upright posture. The above measures are sufficient for the vast majority of the patients affected by vasovagal syncope. […] Among those settings, cardiac pacing may be reserved to those patients with cardioinhibitory vasovagal syncope with a frequency 5 attacks per year or severe physical injury or accident and age 40.

• #30 Neurocardiogenic Syncope Symptoms & Treatment | Baptist Health

  https://www.baptisthealth.com/care-services/conditions-treatments/neurocardiogenic-syncope

  Baptist Health is known for advanced, superior care in the diagnosis, management and treatment of neurocardiogenic syncope. […] If you experience neurocardiogenic syncope, your physician may recommend: […] Most cases of neurocardiogenic syncope do not require treatment. Your physician may work with you to find ways to stay hydrated, keep your blood sugar stable, manage stress or identify your triggers and reduce your chances of injury when you encounter these triggers. […] In some cases, drugs used to treat low blood pressure or anxiety disorders may be prescribed. […] Physical therapy techniques, such as foot exercises, wearing compression stockings or tensing your leg muscles when standing may be suggested. If you’re under a lot of emotional stress, your physician may refer you to a therapist. […] In very rare cases, inserting an electrical pacemaker to regulate the heartbeat may help some people with neurocardiogenic syncope who haven’t been helped by other treatments.

• #31 Cardioneuroablation for Vasovagal Syncope | AER Journal

  https://www.aerjournal.com/articles/cardioneuroablation-treating-vasovagal-syncope-current-status-and-future-directions?language_content_entity=en

  Syncope is defined by transient and spontaneous loss of consciousness with rapid recovery. Vasovagal syncope (VVS) is the most common form of syncope and is strongly associated with hypervagotonia. There is, however, a lack of effective therapies for VVS. Cardioneuroablation (CNA) is an emerging and promising intervention for VVS with favourable outcomes. CNA has been shown to suppress excessive excitation of vagal activity through ablating the cardiac ganglionated plexi. […] Results of traditional treatments, including increased salt and water intake, physical counterpressure manoeuvres, drug therapy with fludrocortisone or midodrine, have been disappointing. […] In the past two decades, cardioneuroablation (CNA) has been employed to treat functional bradyarrhythmia and VVS by ablating the neuromyocardial interface on the endocardium and the ganglionated plexi (GP), intrinsic structures located in the epicardial atrial fat pads. CNA can inhibit excessive excitation of vagal activity and rebalance the autonomic nervous system.

• #32 Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7252686/

  Most recently, investigators have begun testing a novel approach to treating refractory NCS: radiofrequency catheter ablation. Studies have shown that vagal innervation to the heart is primarily supplied through ganglia located in the atrial wall and specific epicardial fat pads. […] The results of the existing studies suggest that the ablation of cardiac ganglia may provide long-lasting effects for patients suffering from refractory syncope, but it is important to keep in mind that these are only preliminary studies for a new procedure.

• #33 Cardioneuroablation, new treatment for vasovagal syncopeBlog barnaclínic

  https://www.barnaclinic.com/blog/en/blog/cardioneuroablation/

  Cardioneuroablation, a new treatment for vasovagal syncope, available at barnaclnic+ […] One of these new solutions is cardioneuroablation, a procedure capable of specifically and effectively addressing a medical condition that can have a significant impact on patients quality of life: vasovagal syncope. […] The fact that we can now offer the innovative cardioneuroablation at barnaclnic+ is due to the fact that our arrhythmia section is one of the most cutting-edge units in the world for the treatment and management of arrhythmias using catheter ablation techniques. […] There are some patients who present a very marked response with a drop-in heart rate, which is called cardio inhibition and it is in these patients that we can act through cardioneuroablation. […] In this way, cardioneuroablation is used in situations where the activity of the autonomic nervous system contributes significantly to the appearance of syncope due to a decrease in heart rate, being used in selected cases in which the symptoms of reflex syncope are very repetitive or occur in contexts in which they significantly affect the quality of life.

• #34 Treatment of Vasovagal Syncope with Cardioneuroablationlogo-32logo-40logo-60NEJM Journal WatchnejmJW_1L_RGB-b

  https://www.jwatch.org/na55281/2022/09/28/treatment-vasovagal-syncope-with-cardioneuroablation

  Ablating ganglionated plexi in the right and left atria appears to reduce recurrence of vasovagal syncope. […] Vasovagal syncope is extremely common and lacks effective therapies. […] During 2-year follow-up, the primary endpoint of recurrent syncope occurred in 2 patients (8%) in the ablation group compared with 13 patients (54%) in the control group. […] Cardioneuroablation appears to reduce syncope relatively dramatically. […] However, at the current time, this therapy should be reserved for the most severely afflicted patients.

• #35 Catheter Ablation as a Treatment for Vasovagal Syncope: The Time has Come to Shift Towards Placebo-controlled Trials – touchCARDIOLOGY

  https://touchcardio.com/syncope/journal-articles/catheter-ablation-as-a-treatment-for-vasovagal-syncope-the-time-has-come-to-shift-towards-placebo-controlled-trials/

  Vasovagal syncope (VVS), a common autonomic disorder, often sees limited effectiveness with conventional treatments. Cardioneuroablation (CNA), which targets the cardiac ganglionated plexi to modulate heart rate and rhythm, has surfaced as a potential alternative. […] Despite widespread favourable outcomes reported in clinical trials, CNA has not achieved widespread acceptance and is absent from current syncope treatment guidelines, largely because of the lack of placebo-controlled randomized controlled trials (RCTs). […] The true therapeutic value of CNA can only be confirmed through methodologically robust, placebo-controlled RCTs. This is a critical step before CNA can be endorsed as a standard intervention and incorporated into guidelines. […] Despite promising clinical outcomes, CNA efficacy has yet to be validated through randomized, placebo-controlled trials. These trials are necessary to overcome the substantial placebo effect observed in previous studies. The current guidelines for VVS treatment do not include CNA.

• #36 What Is Vasovagal Syncope? – Manhattan Center for CBT

  https://manhattancbt.com/vasovagal-syncope/

  Cognitive-behavioral therapy can help reduce vasovagal syncope when due to any of the first three triggers listed above. […] Exposure therapy, a form of CBT, is a highly effective treatment for reducing anxiety and fear. Working with a CBT therapist, you practice exposing yourself to the things that trigger your vasovagal syncope, while practicing other skills that prevent you from fainting. […] Applied tension is another proven technique that helps you artificially raise your blood pressure. This can help you stop a fainting episode from happening when you are triggered or notice signs that a fainting episode may be about to happen. […] When used together, these CBT techniques can reduce the frequency of vasovagal syncope, and the anxiety around fainting.

• #37 Connecting Vasovagal Syncope to Anxiety Reactions

  https://ocdla.com/connecting-vasovagal-syncope-to-anxiety-reactions-2-2-10086

  Research reports have found that Cognitive Behavioral Therapy (CBT) has been the most useful in helping treat clients who are suffering from anxiety and have a history of Vasovagal Syncope. […] One of the methods used to help treat patients alongside CBT has been the Applied Tension Technique. This technique involves the patient purposefully tensing their muscles to raise their blood pressure and prevent it from dropping to the point of fainting. With a technique such as this one in place, therapy can concentrate more on the cognitive construct of the issue being dealt with. CBT is helpful because it gives an individual the tools to change the way they react to outside things that may trigger their anxiety, thus preventing a fainting episode. […] A big part of CBT is working on desensitization through Exposure and Response Prevention (ERP). Essentially, exposing the client to something triggering when they are placed in an atmosphere with some control. […] The therapist will gradually help the patient face these unwanted fears while providing the tools needed to overcome the anxiety.

• #38 Reflex syncope – Wikipedia

  https://en.wikipedia.org/wiki/Reflex_syncope

  Treatment for reflex syncope focuses on avoidance of triggers, restoring blood flow to the brain during an impending episode, and measures that interrupt or prevent the pathophysiologic mechanism described above. […] The cornerstone of treatment is avoidance of triggers known to cause syncope in that person. However, research has shown that people show great reductions in vasovagal syncope through exposure-based exercises with therapists if the trigger is mental or emotional, e.g., sight of blood. […] A technique known as „applied tension” may be additionally useful in those who have syncope with exposure to blood. […] Because vasovagal syncope causes a decrease in blood pressure, relaxing the entire body as a mode of avoidance is not favorable. […] Before known triggering events, the affected person may increase consumption of salt and fluids to increase blood volume.

• #39 Syncope Information | Mount Sinai – New York

  https://www.mountsinai.org/health-library/condition/syncope

  To avoid fainting. […] Any serious underlying health condition should be treated. When a person faints: […] When an irregular heartbeat causes fainting, your doctor may prescribe medications such as beta-blockers or antiarrhythmics. Your doctor may also prescribe steroids (such as fludrocortisone) or salt tablets to help you control the amount of sodium and fluids in your body. […] If fainting is caused by a heart condition, such as a slow or rapid heartbeat, you may need a pacemaker. […] Although there are no specific treatments for fainting, a number of alternative therapies can help protect the heart and blood vessels. […] Hypnosis, deep breathing, relaxation techniques, and biofeedback may help you avoid fainting. These techniques may also help you control fainting related to regulation of your blood pressure. […] Acupuncture may help treat fainting. A clinical analysis of 102 serious cases of loss of consciousness reported that acupuncture helped in a large number of these cases.

• #40 A Cognitive Behavioural Intervention for the Treatment of Vasovagal and Unexplained Syncope

  https://file.scirp.org/Html/7-2100689_46216.htm

  Vasovagal syncope and unexplained syncope are the most commonly observed types of syncope in outpatient and hospital settings. […] Medical interventions usually target at the physiological mechanisms responsible for loss of consciousness in an attempt to limit the frequency of recurrences. […] In the present pilot study, four participants presenting significant psychological distress and recurrent syncope were treated using a multimodal intervention targeting at both the medical and psychological aspects of the problem. Results showed a significant reduction in the frequency of syncope/presyncope, in the level of emotional distress experienced, as well as improved functional status in three of the four participants. Several recommendations are made to medical practitioners and psychologists, in view of identifying patients likely to benefit from this type of intervention or components thereof.

• #41 A Cognitive Behavioural Intervention for the Treatment of Vasovagal and Unexplained Syncope

  https://file.scirp.org/Html/7-2100689_46216.htm

  Conventional treatments for VVS include medication, education and, in severe cases, a pacemaker for patients with significant bradycardia. […] Complementary treatments include orthostatic training, applied tension and psychologically oriented interventions (e.g., cognitive-behavioural strategies). […] To date, education and applied tension have proven effective in reducing syncope occurrence. […] Education is a simple and safe strategy that can benefit patients with VVS. […] Applied tension is another strategy that can be helpful to patients presenting a prodromal phase prior to loss of consciousness. […] Finally, the consequences of fainting (e.g., psychological distress, impaired functioning, reduced quality of life) and the presence of psychological factors that trigger or maintain syncope recurrence have led a few investigators over the past decade to examine the efficacy of cognitive-behavioural strategies (e.g., relaxation, cognitive restructuring and gradual exposure for patients with VVS) in reducing syncope recurrence. […] A multimodal intervention for these populations should ideally contribute to improved management of syncope by focusing on the psychological consequences, triggers and maintenance of syncope recurrence.

• #42 Management and therapy of vasovagal syncope: A review

  https://www.wjgnet.com/1949-8462/full/v2/i10/308.htm

  Management and therapy of vasovagal syncope: A review. […] This review focuses on the management of vasovagal syncope and discusses the non-pharmacological and pharmacological treatment options, especially the use of midodrine and selective serotonin reuptake inhibitors. […] The cornerstone of therapy for young patients with vasovagal syncope remains education and reassurance, except in rare and isolated cases of patients with a high frequency of recurrent episodes despite nonpharmacological measures. […] The main goal of treatment is to reduce syncope recurrence and physical trauma. […] Patients with a high risk of recurrence or injury can be identified by risk scores and may require tailored treatment. […] Once the diagnosis is clear the next questions that arise include, who needs therapy and what kind? Every patient benefits from information and education; some patients need medical therapy and only a few people need a pacemaker.

• #43 Treatment of Neurocardiogenic Syncope: From Conservative to Cutting-edge

  https://www.innovationsincrm.com/cardiac-rhythm-management/articles-2018/july/1274-treatment-of-neurocardiogenic-syncope

  Neurocardiogenic syncope is the most frequent cause of syncope in the general population. Conventional treatment usually follows a tiered approach for neurocardiogenic syncope, as follows: first, lifestyle modification, including increased fluid intake and the introduction of physical counterpressure maneuvers, is tried; then the use of targeted pharmacologic therapy, particularly agents that support blood pressure or that drive blood pressure is attempted; and, finally, pacemaker implantation in patients with a predominant cardioinhibitory component to their syncopal episodes is performed. […] More recently, autonomic modulation with cardiac ganglion ablation has emerged as a promising treatment modality for patients refractory to traditional approaches. […] The least-invasive options include lifestyle changes and counterpressure maneuvers, as well as a wide range of pharmacologic therapies. More invasive therapies have been used in patients with syncope due to a predominant cardioinhibitory response. These approaches include pacemaker implantation and, more recently, cardiac ganglion ablation, a new treatment modality that does not require permanent device implantation.

• #44 Vasovagal Syncope: A Review of Current and Future Strategies – touchCARDIOLOGY

  https://touchcardio.com/syncope/journal-articles/vasovagal-syncope-a-review-of-current-and-future-strategies/

  Vasovagal syncope is common, and while it is usually associated with a benign prognosis, it results in significant physical and psychological morbidity for affected individuals. […] Despite comprehensive understanding of the underlying pathophysiology, there have been few definitive therapeutic advances until recent randomized, controlled trials in pharmacotherapy, pacing and cardioneuroablation. […] We also discuss current and emerging therapies. While some practical, conservative measures remain effective and are recommended, newer interventions, such as pacing and ganglionic plexus ablation, may bring relief for some patients. […] Comprehensive multidisciplinary rehabilitation programmes for recurrent VVS have shown significant improvements in health-related quality of life, fewer recurrent syncopal episodes, plus fewer medical consultations, hospitalizations and traumatic injuries, compared with standard care.

• #45 Diagnosing and Treating Vasovagal Syncope | Banner Health

  https://www.bannerhealth.com/services/heart/vasovagal-syncope

  Vasovagal syncope treatment options include lifestyle changes to help treat syncope such as staying hydrated, talking to your provider about adding more salt to your diet, taking breaks from standing, learning relaxation techniques to help cope with stress, tensing your leg muscles periodically or wearing compression stockings to help keep blood from pooling in the legs, and getting regular physical activity. […] If you’re still having symptoms after adjusting your lifestyle, your provider may recommend medications. Prescribed medications may help regulate blood pressure or heart rate. Alpha-1-adrenergic agonists can raise blood pressure, corticosteroids increase sodium and fluid levels and selective serotonin reuptake inhibitors (SSRIs) can help manage the nervous system. […] Counseling may help if anxiety or stress are triggering your fainting episodes.

• #46 Diagnosing and Treating Vasovagal Syncope | Banner Health

  https://www.bannerhealth.com/services/heart/vasovagal-syncope

  If a slow heart rate (bradycardia) is causing vasovagal syncope, your provider may recommend a pacemaker to maintain your heart rate and prevent fainting episodes. However, it’s rare to need a pacemaker for vasovagal syncope. […] Be sure to see your health care provider for follow-up appointments to make sure your treatment plan is working well.

• #47 Treatment of Syncope – Syncope

  https://syncope.co.uk/syncope-fainting-blacking-out-passing-out/treatment/

  Midodrine (a vasoconstrictor) acts by constricting the arterioles that control blood pressure. […] Disopyramide (anti-arrhythmic drug) minimises vagotonic reflex slowing of the heart. […] If one drug is not effective, it is always worthwhile trying one of the others from a different class. […] The fact that so many different medications are used in the treatment of Autonomic Mediated Syncope (Neurocardiogenic Syncope, Vasovagal Syncope) indicates that none is entirely effective. Sometimes, a combination of drugs is required. […] Abolition of symptoms indicates successful treatment. […] Medication should be reduced once symptoms have been abolished for a year or so. If symptoms do not recur as the dose is reduced, then the medication may be discontinued. […] Occasionally permanent pacemaker implantation is necessary generally when tilt table testing elicits prolonged cardiac standstill. […] Scientific medical opinion is still divided about the role of pacemakers in vasovagal syncope.

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