What is the diagnosis and treatment for Vasovagal (Vasovagal) syncope?

From the Guidelines

Vasovagal syncope should be diagnosed and treated by maintaining or assuming a safe position, such as sitting or lying down, and using physical counterpressure maneuvers (PCMs) to prevent syncope, as recommended by the 2019 American Heart Association and American Red Cross guidelines 1.

Diagnosis

The diagnosis of vasovagal syncope is based on the presence of characteristic symptoms, including pallor, sweating, lightheadedness, visual changes, and weakness, which occur before the loss of consciousness. These symptoms are known as presyncope and can last for a few seconds before the onset of vasovagal syncope.

Treatment

The treatment of vasovagal syncope involves:

• Maintaining or assuming a safe position, such as sitting or lying down, to prevent injury
• Using PCMs, such as leg crossing with muscle tensing or hand gripping, to increase blood pressure and prevent syncope
• Staying well-hydrated by drinking 2-3 liters of fluid daily and increasing salt intake to 6-10 grams per day if not contraindicated by other health conditions
• Avoiding known triggers, such as prolonged standing, hot environments, dehydration, or the sight of blood
• Considering medications, such as fludrocortisone, midodrine, or beta-blockers, for recurrent episodes

Physical Counterpressure Maneuvers (PCMs)

PCMs are a crucial part of the treatment of vasovagal syncope, as they can help prevent syncope by increasing blood pressure and improving symptoms. The 2019 American Heart Association and American Red Cross guidelines recommend the use of PCMs, particularly lower-body PCMs, as a first-line treatment for vasovagal syncope 1.

Recurrent Episodes

For patients with recurrent episodes of vasovagal syncope, tilt table testing may be employed to teach the patient to recognize early prodromal symptoms, and tilt training may be considered, particularly in younger, very symptomatic, well-motivated patients 1. Medications, such as fludrocortisone, midodrine, or beta-blockers, may also be prescribed to help manage symptoms. In severe cases unresponsive to other treatments, a pacemaker might be considered.

From the Research

Diagnosis and Treatment of Vasovagal Syncope

The diagnosis and treatment of vasovagal syncope (VVS) involve a combination of non-pharmacological and pharmacological approaches.

• The treatment begins with patient education about the mechanism of fainting and the non-lethal nature of VVS 2.
• Non-pharmacological approaches include:
  • Increases in dietary salt and water intake 3, 4, 2
  • The use of compression garments 2
  • Physical counter-maneuvers 5, 2
  • Tilt-training 2
  • Aggressive volume repletion 5
• Pharmacological approaches include:
  • Vasopressor agents 5
  • Beta-blockers 5, 3, 6
  • Neurohormonal agents 5
  • Midodrine 3, 4
  • Fludrocortisone 3, 6, 4
  • Paroxetine 3
  • Atenolol 3
• For select patients, and those patients more refractory to medications, procedural treatments may be an option, including:
  • Pacemakers 5
  • Radiofrequency ablation 5

Treatment Outcomes

The outcomes of treatment for VVS can be measured in terms of:

• Time to first syncopal episode 4
• Recurrence rate of VVS 4
• Time interval between first and second episodes 4
• Changes in quality of life (QoL) 4, 2
• Major and minor adverse drug reactions 4