From the Guidelines
Treatment for vasovagal syncope should primarily focus on lifestyle modifications and preventive measures, with medications reserved for severe cases, as recommended by the most recent guidelines 1. The goal of treatment is to reduce the frequency and severity of episodes, and to improve the patient's quality of life.
- Patients should avoid triggers like prolonged standing, hot environments, and dehydration.
- When feeling faint, they should immediately sit or lie down and elevate their legs to improve blood flow to the brain.
- Increasing salt and fluid intake (2-3 liters daily) can help maintain blood volume and pressure.
- Physical counterpressure maneuvers like leg crossing, muscle tensing, and squatting can be effective when warning symptoms occur, as supported by the 2019 guidelines 1. For recurrent episodes, compression stockings may help prevent blood pooling in the legs. Medication options include:
- Midodrine (2.5-10 mg three times daily) to constrict blood vessels, which is reasonable in patients with recurrent vasovagal syncope with no history of hypertension, heart failure, or urinary retention 1.
- Fludrocortisone (0.1-0.2 mg daily) to increase sodium retention and blood volume, which may be reasonable for patients with recurrent vasovagal syncope and inadequate response to salt and fluid intake, unless contraindicated 1.
- Beta-blockers like metoprolol (25-100 mg twice daily) to reduce the heart's response to adrenaline, which may be reasonable in patients 42 years of age or older with recurrent vasovagal syncope 1. In rare severe cases, pacemaker implantation might be considered, particularly for patients with significant cardioinhibitory responses (where heart rate drops dramatically), as suggested by the 2017 guidelines 1.
From the Research
Treatment Options for Vasovagal Syncope
The treatment of vasovagal syncope (VVS) typically involves a combination of lifestyle modifications and pharmacological interventions.
- Lifestyle modifications are the cornerstone of VVS treatment, including:
- Pharmacological interventions may be necessary for patients who experience frequent or severe episodes of VVS, including:
- Midodrine, which has shown promising results in reducing VVS recurrence 2, 3, 5, 6, 4
- Fludrocortisone, which may be effective in preventing VVS recurrence, although more research is needed 2, 3, 6, 4
- Other medications, such as beta-blockers, serotonin-specific reuptake inhibitors, and norepinephrine transport inhibitors, may be considered in certain cases, although their effectiveness is less clear 3, 6, 4
Special Considerations
- Patient education and reassurance are important components of VVS treatment, as patients should be taught how to respond to further episodes of syncope and how to manage their condition 5, 4
- Orthostatic training exercises may be beneficial for patients with recurrent VVS, particularly in younger, highly motivated patients 4
- Permanent pacemakers, such as closed-loop stimulation, may be considered in highly refractory cases, particularly in the cardioinhibitory type of VVS 5, 4