From the Guidelines
The treatment for neurocardiogenic syncope primarily focuses on lifestyle modifications, including increasing fluid and salt intake, avoiding triggers, and recognizing warning signs, as well as physical counterpressure maneuvers and medications when necessary, as recommended by the 2017 ACC/AHA/HRS guideline 1.
Lifestyle Modifications
- Increasing fluid and salt intake to maintain blood volume
- Avoiding triggers like prolonged standing or hot environments
- Learning to recognize warning signs to sit or lie down before fainting
Physical Counterpressure Maneuvers
- Leg crossing, muscle tensing, and squatting can help prevent episodes by increasing blood pressure when symptoms begin, as supported by the 2017 ACC/AHA/HRS guideline 1 and the 2009 European Heart Journal guidelines 1
Medications
- Midodrine (2.5-10 mg three times daily) can be beneficial in patients with syncope due to neurogenic OH, as it improves symptoms of OH in patients with neurogenic OH, with a dose-dependent effect, usually corresponding to an increase in standing blood pressure 1
- Fludrocortisone (0.1-0.2 mg daily) may be beneficial in patients with syncope due to neurogenic OH, as it increases plasma volume, with a resultant improvement in symptoms of OH, although its use may be limited by supine hypertension 1
- Other medications, such as droxidopa, pyridostigmine, and octreotide, may be considered in specific cases, as recommended by the 2017 ACC/AHA/HRS guideline 1
Additional Considerations
- Compression garments can be beneficial in patients with syncope and OH, as they improve orthostatic symptoms and blunt associated decreases in blood pressure 1
- Encouraging increased salt and fluid intake may be reasonable in selected patients with neurogenic OH, although the data are limited and the long-term effects are unknown 1
From the FDA Drug Label
Midodrine has been used in patients concomitantly treated with salt-retaining steroid therapy (i.e., fludrocortisone acetate), with or without salt supplementation. The treatment for neurocardiogenic syncope may involve the use of midodrine, a medication that can help increase blood pressure and reduce symptoms of orthostatic hypotension.
- Key considerations:
- Midodrine should be used with caution in patients with renal impairment, hepatic impairment, or those taking certain medications that can interact with midodrine.
- Patients should be monitored for supine hypertension and advised to avoid taking their dose if they are to be supine for any length of time.
- The potential for drug-drug interactions should be carefully evaluated, particularly with medications that can increase blood pressure or affect renal function 2.
From the Research
Treatment Approaches for Neurocardiogenic Syncope
The treatment for neurocardiogenic syncope typically follows a tiered approach, as outlined in the study by 3. This approach includes:
- Lifestyle modification, such as increased fluid intake and physical counterpressure maneuvers
- Targeted pharmacologic therapy, including agents that support blood pressure or drive blood pressure
- Pacemaker implantation in patients with a predominant cardioinhibitory component to their syncopal episodes
Pharmacologic Treatments
Pharmacologic treatments for neurocardiogenic syncope aim to modulate the syncope reflex, as discussed in the study by 4. These treatments include:
- Fludrocortisone and sodium chloride to increase systemic fluid volume
- Midodrine, β blockers, and norepinephrine transport inhibitors to modulate the sympathetic nervous system
- Other treatments that modulate neurotransmitters or affect heart rate
Specific Pharmacologic Agents
Several studies have investigated the use of specific pharmacologic agents in the treatment of neurocardiogenic syncope, including:
- Midodrine, which has been shown to be effective in patients refractory to beta-blockers, as reported in the studies by 5 and 6
- Methylphenidate, which has been investigated as a potential treatment for refractory neurocardiogenic syncope, as discussed in the study by 7
Emerging Treatments
In addition to conventional treatments, emerging therapies such as autonomic modulation with cardiac ganglion ablation have been proposed as potential treatment modalities for patients with neurocardiogenic syncope, as mentioned in the study by 3.