From the Guidelines
Seated syncope can be effectively managed by maintaining a safe position, such as sitting or lying down, and using physical counterpressure maneuvers (PCMs) like leg crossing, arm tensing, or squatting to increase blood pressure and prevent syncope. The general population can experience syncope at some point in their lives, and it can lead to physical injury, morbidity, and significant healthcare costs 1. Vasovagal syncope and orthostatic syncope are relatively benign but can cause injury and lifestyle impairment, especially with recurrent episodes.
Key Strategies for Managing Seated Syncope
- Maintaining adequate hydration by drinking at least 2-3 liters of water daily and increasing salt intake to 6-10 grams per day to expand blood volume
- Using physical counterpressure maneuvers (PCMs) like leg crossing, arm tensing, or squatting to increase blood pressure and prevent syncope 1
- Wearing compression garments like waist-high compression stockings (20-30 mmHg) to improve venous return 1
- Making positional changes slowly, especially when rising from seated positions
- Considering medication options like fludrocortisone (starting at 0.1 mg daily) to retain sodium and water, and midodrine (2.5-10 mg three times daily) to increase peripheral vascular resistance 1
Importance of Early Recognition and Intervention
Early recognition of presyncope signs and symptoms, such as pallor, sweating, lightheadedness, visual changes, and weakness, is crucial for initiating appropriate action to prevent syncope 1. First aid providers can encourage individuals to perform PCMs until symptoms resolve or syncope occurs, and if no improvement occurs within 1 to 2 minutes, or if symptoms worsen or reoccur, providers should initiate a call for additional help 1.
Developing a Personalized Treatment Plan
Patients should discuss these options with their healthcare provider to develop a personalized treatment plan based on their specific symptoms and medical history. This plan may include a combination of lifestyle modifications, physical counterpressure maneuvers, and medication options to effectively manage seated syncope and prevent future episodes.
From the Research
Potentially Solutions for Seated Syncope
- The primary classifications of syncope are cardiac, reflex (neurogenic), and orthostatic 2
- Evaluation focuses on history, physical examination (including orthostatic blood pressure measurements), and electrocardiographic results 2
- For patients with suspected cardiac syncope, monitoring is indicated until a diagnosis is made 3
- For patients with suspected reflex syncope or orthostatic hypotension, outpatient evaluation with tilt-table testing is appropriate 3
- Midodrine has been proposed in the management of patients with symptomatic orthostatic hypotension (SOH) and recurrent reflex syncope (RRS) 4
- Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures 5
Medication-Based Solutions
- Midodrine improves clinical important outcomes in patients with SOH and RRS, with low to moderate confidence 4
- Fludrocortisone may not be harmful in the long term for familial dysautonomia, but its effects on blood pressure, orthostatic symptoms, or adverse events in people with orthostatic hypotension and diabetes or Parkinson disease are uncertain 5
- Compared with users of midodrine, users of fludrocortisone had higher rates of all-cause hospitalizations, especially among patients with congestive heart failure 6
Non-Medication Based Solutions
- Increasing fluid and salt intake and venous compression methods are mechanical and positional measures that can be used alongside pharmacological therapy for orthostatic hypotension 5
- Tilt-table testing is a useful diagnostic tool for patients with suspected reflex syncope or orthostatic hypotension 3
- Syncope units have been shown to improve the rate of diagnosis while reducing cost, and are highly recommended 3