What is the appropriate next step for a patient who experienced syncope, described as a 'swimming' sensation, suggestive of a vasovagal (vasovagal syncope) episode?

From the Guidelines

For a patient experiencing syncope at work described as "swimming-something," which suggests a vasovagal episode, ambulatory blood pressure monitoring would be the appropriate next step. This 24-hour monitoring can detect orthostatic hypotension, blood pressure fluctuations, or hypotensive episodes that may be triggering the syncope. The ambulatory monitor will record blood pressure at regular intervals throughout normal daily activities, providing valuable data about potential cardiovascular causes of fainting. Additionally, the patient should be advised to keep a symptom diary during the monitoring period to correlate any symptoms with blood pressure readings. A complete cardiac workup including ECG should follow if ambulatory monitoring reveals abnormalities. The description of "swimming-something" suggests lightheadedness or dizziness preceding the syncopal event, which is characteristic of reduced cerebral perfusion that occurs in vasovagal syncope when blood pressure drops suddenly, as supported by the guidelines for the diagnosis and management of syncope 1.

Key Considerations

• The patient's symptoms suggest a vasovagal episode, which is a common cause of syncope.
• Ambulatory blood pressure monitoring is a non-invasive and useful tool for detecting orthostatic hypotension or other blood pressure abnormalities that may be contributing to the syncope.
• The patient should be advised to keep a symptom diary to correlate symptoms with blood pressure readings.
• A complete cardiac workup, including ECG, should be performed if ambulatory monitoring reveals any abnormalities, as recommended by the guidelines for the management of transient loss of consciousness 1.
• The use of physical counterpressure maneuvers (PCMs) may be beneficial in preventing syncope, as suggested by the 2019 American Heart Association and American Red Cross focused update for first aid 1.

Management

• Ambulatory blood pressure monitoring is the recommended initial step in the management of this patient.
• Lifestyle modifications, such as increasing fluid and salt intake, avoiding triggers, and performing PCMs, may also be beneficial in preventing future episodes of syncope.
• Further evaluation, including cardiac imaging and electrophysiological studies, may be necessary if the patient's symptoms persist or worsen despite initial management.

From the Research

Assessment and Management of Syncope

• The patient's description of the episode as "swimming-something" suggests a possible vasovagal scenario, which is a type of reflex syncope 2.
• The goals of the clinical assessment of a patient with syncope are to identify the precise cause and to quantify the risk to the patient, which depends on the underlying disease rather than the mechanism of the syncope 2.
• A structured approach to the patient with syncope is required, including history-taking, physical examination, and orthostatic blood pressure measurements (OBPM) 3.

Diagnostic Evaluation

• Orthostatic hypotension (OH) is caused by an abnormal drop in systolic blood pressure upon standing, and is defined as a decrease of >20 mmHg in systolic blood pressure or a reflex tachycardia of >20 beats/minute within 3 minutes of standing 4.
• Tilt table testing (TTT) can be used to study short-term blood pressure and heart rate regulation during orthostatic challenges, and can provoke a vasovagal reflex in many syncope patients 5.
• Ambulatory blood pressure (BP) monitoring can be useful to assess for orthostatic hypotension or other BP abnormalities that might be contributing to the syncope 2, 4.

Treatment and Management

• Treatment for recurrent vasovagal syncope includes increased salt and water intake and various drug treatments, most of which are still under investigation 4.
• Patients with reflex or orthostatic syncope should be managed by addressing any exacerbating medication and providing general measures to increase blood pressure, such as physical counter-pressure maneuvers 2.
• Education on prodromes and recognition of hypotensive symptoms can help patients with reflex syncope to perform physical counter-manoeuvres for syncope prevention (biofeedback) 5.