What is the treatment for near syncope episodes?

Treatment for Near Syncope Episodes

For patients experiencing near syncope (presyncope), physical counterpressure maneuvers should be the first-line treatment, combined with patient education, trigger avoidance, and volume expansion strategies. 1, 2

Understanding Near Syncope (Presyncope)

Presyncope is the prodrome of syncope that may last for a few seconds and includes symptoms such as:

• Lightheadedness or dizziness
• Blurry or tunnel vision
• Nausea
• Sensation of warmth
• Diaphoresis (sweating)
• Pallor

These symptoms represent a critical window where intervention can prevent complete loss of consciousness.

Treatment Algorithm

Step 1: Immediate Management

When presyncope symptoms occur:

1. Maintain or assume a safe position (sitting or lying down) 1
2. Implement physical counterpressure maneuvers (PCMs) 1, 2
   • Lower-body PCMs (most effective):
     • Leg crossing with tensing of leg, abdominal, and buttock muscles
     • Squatting
   • Upper-body PCMs:
     • Arm tensing (gripping hands and pulling in opposite directions)
     • Isometric handgrip (clenching fist with maximum contraction)
     • Neck flexion (touching chin to chest)

Step 2: Long-term Prevention Strategies

1. Education and lifestyle modifications 1, 2

   • Avoid triggers (hot crowded environments, prolonged standing)
   • Recognize prodromal symptoms early
   • Avoid rapid position changes
   • Avoid agents that lower blood pressure (α-blockers, diuretics, alcohol)

2. Volume expansion strategies 1, 2

   • Increased salt intake
   • Adequate fluid intake (2-2.5 liters per day)
   • Head-up tilt sleeping (>10°)

Step 3: Pharmacological Interventions (for refractory cases)

If symptoms persist despite non-pharmacological measures:

1. Fludrocortisone (0.1-0.2 mg daily) 2, 3

   • Mechanism: Volume expansion and increased sodium retention
   • Caution: Monitor for hypertension, edema, and electrolyte imbalances

2. Midodrine 1, 2, 4

   • Mechanism: Alpha-1 adrenergic agonist causing vasoconstriction
   • Dosing: Start with 2.5 mg and titrate as needed
   • Caution: Take last dose 3-4 hours before bedtime to avoid supine hypertension

Step 4: Advanced Interventions

For severe, refractory cases with documented cardioinhibitory response:

• Cardiac pacing (only for patients >40 years with >5 attacks per year or severe physical injury) 2

Special Considerations

• Activate emergency services if no improvement occurs within 1-2 minutes, if syncope occurs, or if symptoms worsen 1

• Do not use PCMs when symptoms of heart attack or stroke accompany presyncope 1

• Beta-blockers are not recommended as they may worsen bradycardia in cardioinhibitory cases 2

• More aggressive treatment is warranted for patients in high-risk settings (e.g., vehicle drivers, machine operators, pilots) 2

Effectiveness of Treatment

Physical counterpressure maneuvers have been shown to significantly reduce syncope recurrence in a multicenter prospective trial, with a 39% relative risk reduction compared to conventional therapy alone 1. These maneuvers work by inducing a significant blood pressure increase during impending syncope, allowing patients to avoid or delay losing consciousness.

Regular follow-up is necessary to assess treatment effectiveness and re-evaluate if the syncope pattern changes or new symptoms develop 2.