From the Guidelines
Treatment for vasovagal syncope should primarily focus on lifestyle modifications and physical counterpressure maneuvers, with medications such as midodrine, fludrocortisone, or beta-blockers reserved for severe cases, as recommended by the 2017 ACC/AHA/HRS guideline 1. The first line of treatment involves lifestyle modifications such as:
- Staying well-hydrated
- Avoiding prolonged standing
- Recognizing warning signs (lightheadedness, nausea, sweating)
- Sitting or lying down immediately when symptoms begin Physical counterpressure maneuvers can be effective during prodromal symptoms, including:
- Crossing legs while tensing muscles
- Gripping hands while tensing arms
- Squatting These maneuvers have been shown to be effective in reducing syncope recurrence, with a relative risk reduction of 39% 1. For recurrent episodes, patients may also benefit from:
- Increasing salt and fluid intake (2-3 liters daily) 1
- Wearing compression stockings
- Practicing tilt training (standing against a wall for progressively longer periods) Medications such as midodrine (2.5-10 mg three times daily) 1, fludrocortisone (0.1-0.2 mg daily) 1, or beta-blockers like metoprolol (25-100 mg twice daily) 1 may be considered for severe cases, but patients should be monitored for medication side effects. In rare, severe cases unresponsive to other treatments, pacemaker implantation may be considered, particularly for those with significant cardioinhibitory response 1.
From the Research
Treatment Options for Vasovagal Syncope
- Lifestyle modifications are the cornerstone of treatment, including increased salt and water intake, and counterpressure maneuvers 2, 3, 4, 5
- Patients should be educated on how to respond to further episodes of syncope, especially if they experience prodromal warning signs 2
- Orthostatic training exercises may improve symptoms in patients with recurrent VVS, but are only effective in younger, highly motivated patients 2
- Midodrine is the only drug proven to prevent VVS recurrence, and its use is recommended as first-line therapy for patients with frequent presyncope or syncope 2, 6, 4, 5
- Fludrocortisone has shown promise in reducing syncope recurrences, but its use should be restricted due to limited evidence 2, 3, 6, 5
- β-Adrenergic antagonists and selective serotonin reuptake inhibitors have shown contradictory results and their use should be restricted 2, 6
- Implantation of a permanent pacemaker should be a measure of last resort in highly refractory cases, particularly in the cardioinhibitory type of VVS 2, 5
Pharmacological Therapies
- Midodrine, fludrocortisone, and β blockers modulate the sympathetic nervous system and increase systemic fluid volume 6
- Norepinephrine transport inhibitors and other treatments modulate other neurotransmitters or affect heart rate 6
- The most recent trials evaluating established and novel therapies are reviewed, and randomized placebo-controlled data are awaited to confirm the efficacy of these treatments 6