What is the management for vasovagal (vasovagal syncope) syncope?

From the Guidelines

For vasovagal syncope, the most effective management strategy is to educate patients on the diagnosis and prognosis, and to recommend physical counter-pressure maneuvers, such as leg crossing with muscle tensing, to help abort an episode when warning symptoms occur 1. When someone is experiencing an episode, they should be helped to a safe position, such as sitting or lying down, to prevent injury from falling. Some key points to consider in managing vasovagal syncope include:

• Maintaining a safe position, such as sitting or lying down, to prevent injury from falling
• Using physical counterpressure maneuvers, such as leg crossing with muscle tensing, to help abort an episode when warning symptoms occur
• Staying well-hydrated and avoiding triggers like prolonged standing or hot environments
• Consuming adequate salt, unless contraindicated, and using compression stockings to improve venous return
• Considering medications, such as fludrocortisone or midodrine, for recurrent episodes, under the guidance of a physician. It is also important to note that beta-blockers may not be effective in preventing vasovagal syncope, and may even be harmful in some cases 1. Overall, the goal of management is to reduce the frequency and severity of episodes, and to improve the patient's quality of life. Some of the key recommendations for managing vasovagal syncope include:
• Patient education on the diagnosis and prognosis 1
• Physical counter-pressure maneuvers, such as leg crossing with muscle tensing 1
• Avoidance of triggers, such as prolonged standing or hot environments 1
• Staying well-hydrated and consuming adequate salt, unless contraindicated 1
• Considering medications, such as fludrocortisone or midodrine, for recurrent episodes 1.

From the Research

Management of Vasovagal Syncope

• Vasovagal syncope is a common disorder that affects at least 20% of people at some time in their lives 2.
• The management of vasovagal syncope includes conservative measures such as liberalizing fluid and salt intake, unless contraindicated, and teaching physical counterpressure maneuvers 3.

Pharmacological Therapies

• Midodrine is considered a first-line therapy for patients with frequent presyncope or syncope, or those with brief or no prodromes 3, 4.
• Fludrocortisone and beta-blockers may also be used, but their effectiveness is still being evaluated in clinical trials 4, 5, 6.
• A randomized clinical trial found that midodrine can reduce the recurrence of syncope in healthy, younger patients with a high syncope burden 5.

Treatment Strategies

• Patients with vasovagal syncope should be encouraged to drink 2 to 3 liters of fluids per day and consume 10 grams of NaCl per day 6.
• Counter-pressure maneuvers should be practiced by all patients 3, 6.
• Medications such as midodrine and fludrocortisone may be prescribed for patients who experience frequent syncope episodes, with the goal of reducing recurrence and improving quality of life 5, 6.

Ongoing Research

• The COMFORTS trial is currently underway to compare the effectiveness of midodrine and fludrocortisone in preventing recurrences of vasovagal syncope and improving quality of life 6.
• The results of this trial will provide valuable information on the optimal treatment strategies for patients with vasovagal syncope.