What is the treatment of reflex syncope according to European Society of Cardiology (ESC) guidelines?

Treatment of Reflex Syncope According to ESC Guidelines

According to the European Society of Cardiology (ESC) guidelines, the cornerstone of treatment for reflex syncope is education and reassurance regarding the benign nature of the condition, along with lifestyle measures and physical counterpressure maneuvers. 1

Initial Management Approach

Patient Education and Lifestyle Measures (Class I, LOE: B)

• Explanation of diagnosis, reassurance about prognosis, and education about triggers and avoidance strategies 1
• Awareness and avoidance of potential triggers:
  • Hot crowded environments
  • Volume depletion
  • Prolonged standing
  • Alcohol consumption
  • Vasodilating medications
• Maintain adequate hydration (approximately 2L of fluid daily) 1
• Liberal salt intake (unless contraindicated) 1
• Early recognition of prodromal symptoms

Physical Counterpressure Maneuvers (Class IIa, LOE: B)

• Recommended for patients with prodromes who are <60 years of age 1
• Most effective techniques:
  • Leg crossing with muscle tensing (buttocks together, knees straightened)
  • Hand gripping (squeezing a rubber ball or similar object)
  • Arm tensing (making fists and tensing arm muscles) 1
• These maneuvers can increase blood pressure rapidly and significantly, aborting syncope long enough to achieve a safe position 1

Second-Line Treatments

Orthostatic Training (Class IIb, LOE: B)

• May be considered for education of young patients 1
• More beneficial in highly motivated younger patients with recurrent vasovagal symptoms 1
• Involves progressively prolonged periods of enforced upright posture

Pharmacological Therapy

1. Beta-blockers: Not indicated (Class III, LOE: A) 1

   • ESC guidelines explicitly recommend against beta-blockers for reflex syncope

2. Midodrine (Class IIb, LOE: B)

   • May be considered in patients with orthostatic form of vasovagal syncope 1
   • Caution in older males due to potential urinary outflow issues 1
   • "Pill in the pocket" strategy (single dose before prolonged standing) may be useful in selected cases 1

3. Fludrocortisone (Class IIb, LOE: B)

   • May be considered in young patients with orthostatic form of vasovagal syncope, low-normal blood pressure, and absence of contraindications 1

4. Modification of Hypotensive Medications (Class IIa, LOE: B)

   • Reduction or discontinuation of hypotensive drugs should be considered in patients with vasodepressor syncope 1

Cardiac Pacing

• Cardiac pacing should be considered (Class IIa, LOE: B) in patients >40 years with spontaneously documented symptomatic asystole during monitoring 1
• Plays a small role in therapy for reflex syncope unless severe spontaneous bradycardia is detected during prolonged monitoring 1
• Pacing may affect the cardioinhibitory component but has no effect on the vasodepressor component, which is often dominant 1

Treatment Algorithm Based on Clinical Presentation

1. For all patients with reflex syncope:

   • Education and reassurance
   • Trigger avoidance
   • Adequate fluid and salt intake

2. For patients with recognizable prodromal symptoms:

   • Physical counterpressure maneuvers training

3. For patients with continued symptoms despite initial measures:

   • Consider orthostatic training in younger patients
   • Consider pharmacological therapy (midodrine or fludrocortisone) based on patient characteristics

4. For patients >40 years with documented asystole:

   • Consider cardiac pacing

Special Considerations

• Treatment should be intensified when:

  • Very frequent syncope affects quality of life
  • Recurrent syncope occurs without or with very short prodrome, risking trauma
  • Syncope occurs during high-risk activities (driving, machine operation, etc.) 1

• The ISSUE 2 study showed that in patients with documented asystole during spontaneous syncope, pacemaker therapy reduced syncope recurrence compared to non-pacemaker therapy (10% vs. 41%, p=0.002) 1

By following this evidence-based approach, most patients with reflex syncope can achieve significant reduction in syncope burden and improvement in quality of life.