Syncope Treatment Guidelines
Treatment of syncope should be directed at the underlying cause and mechanism, with specific interventions tailored to the type of syncope identified through diagnostic evaluation. 1
Initial Risk Stratification
Risk stratification is essential for determining treatment approach:
High-Risk Features (requiring urgent evaluation)
- Suspected or known significant heart disease
- ECG abnormalities suggesting arrhythmic syncope
- Syncope during exercise
- Syncope causing severe injury
- Family history of sudden death 1
Low-Risk Features
- Presumptive vasovagal syncope without serious medical conditions
- Recurrent episodes similar to previously diagnosed episodes
- No injury or concerning features 1
Treatment Based on Syncope Type
1. Reflex (Neurally Mediated) Syncope
First-line interventions:
- Patient education about triggers and prognosis (Class I recommendation) 2
- Avoidance of trigger events when possible (Class I) 2
- Physical counterpressure maneuvers (leg crossing, hand grip, arm tensing) 2, 1
Second-line interventions:
- Volume expansion through:
- Tilt training for vasovagal syncope (Class II) 2
- Midodrine for refractory cases 1
- Head-up tilt sleeping (>10°) for posture-related syncope (Class II) 2
For cardioinhibitory reflex syncope:
- Cardiac pacing for patients with:
Important note: Beta-blockers are not supported by evidence and may worsen bradycardia in cardioinhibitory cases (Class III) 2
2. Orthostatic Hypotension
Non-pharmacological measures:
- Eliminate offending medications (especially diuretics, vasodilators) (Class I) 2
- Avoid alcohol 2
- Physical countermeasures:
- Dietary modifications:
- Physical exercise of leg and abdominal muscles (especially swimming) 2
- Avoid rapid positional changes 3
Pharmacological options (if non-pharmacological measures fail):
- Fludrocortisone (0.1-0.2 mg daily) 2, 1, 3
- Midodrine (vasoconstrictor) 1, 3
- Desmopressin for intravascular volume expansion 3
- Octreotide for postprandial hypotension 3
3. Cardiac Syncope
- Treatment must target the specific structural cardiac lesion or arrhythmia causing syncope 1
- Urgent cardiology consultation for:
- Arrhythmic causes requiring pacemaker/ICD placement
- Structural heart disease requiring intervention 1
- Temporary pacing for bradyarrhythmias 1
- Antiarrhythmic medications for tachyarrhythmias 1
Special Populations
Older Adults (>75 years)
- A comprehensive multidisciplinary approach in collaboration with geriatric care experts is beneficial (Class IIa) 2
- Consider syncope as a cause of nonaccidental falls (Class IIa) 2
- Assess for polypharmacy and drug interactions 2
- Evaluate for frailty (weight loss, weakness, exhaustion, reduced activity, physical slowing, cognitive decline) 2
- Carotid sinus massage is particularly recommended for diagnostic evaluation 1
Follow-up and Monitoring
- Syncope Observation Units in the ED can improve diagnostic yield and reduce hospital admissions for intermediate-risk patients 1
- Continuous cardiac monitoring for patients with unexplained syncope and cardiac risk factors 1
- Regular follow-up to assess treatment efficacy and recurrence 1
Driving Recommendations
- Driving restrictions should be considered based on:
- Frequency and severity of syncope
- Presence of prodromal symptoms
- Occupational considerations (commercial drivers require stricter assessment) 2
Remember that the primary goals of syncope treatment are to prevent recurrences, limit physical injuries, and improve quality of life 2. Treatment success depends on accurate diagnosis of the underlying cause and mechanism of syncope.