From the Guidelines
Medications for syncope depend on the underlying cause, and for neurogenic orthostatic hypotension, midodrine (2.5-10mg three times daily) or droxidopa (100-600mg three times daily) may be prescribed to increase blood pressure and prevent fainting episodes, as recommended by the 2017 ACC/AHA/HRS guideline 1.
Medication Options
- Midodrine: increases blood pressure by constricting blood vessels, with a dose-dependent effect, usually corresponding to an increase in standing blood pressure 1.
- Droxidopa: improves symptoms of neurogenic orthostatic hypotension by increasing blood pressure when standing, with potential benefits in reducing falls 1.
- Fludrocortisone: increases plasma volume, resulting in improved symptoms of orthostatic hypotension, but may be limited by supine hypertension and other side effects 1.
Lifestyle Measures
- Increased salt and fluid intake: may be reasonable in selected patients with neurogenic orthostatic hypotension, unless contraindicated, to improve blood pressure and reduce symptoms 1.
- Compression garments: can be beneficial in patients with syncope and orthostatic hypotension, improving orthostatic symptoms and blunting associated decreases in blood pressure 1.
- Physical counter-pressure maneuvers: can be beneficial in patients with neurogenic orthostatic hypotension with syncope, increasing blood pressure and improving orthostatic tolerance 1.
Diagnosis and Treatment
Before starting any medication, it's essential to have a proper diagnosis of the syncope cause through tests like ECG, echocardiogram, or tilt-table testing 1.
Key Considerations
- The choice of medication should be based on the underlying cause of syncope and individual patient factors, such as medical history and potential side effects 1.
- Lifestyle measures should accompany medication therapy to optimize treatment outcomes 1.
From the FDA Drug Label
Patients who experience any signs or symptoms suggesting bradycardia (pulse slowing, increased dizziness, syncope, cardiac awareness) should be advised to discontinue midodrine and should be re-evaluated. The medication midodrine can be used to treat orthostatic hypotension, which is a cause of syncope (fainting), as it acts to increase blood pressure. However, it is not explicitly stated as a treatment for syncope.
- Midodrine should be used with caution in patients with a history of syncope. 2
From the Research
Medications for Treating Syncope
The following medications can be used to treat syncope (fainting):
- Midodrine: a first-line therapy for patients having frequent presyncope or syncope, or for those with brief or no prodromes 3, 4, 5, 6
- Fludrocortisone: may be used to increase systemic fluid volume, although its effectiveness is still being evaluated 4, 7
- Beta-blockers: may be used to modulate the sympathetic nervous system, although their routine use is discouraged 3, 4, 7
- Serotonin-specific reuptake inhibitors: may be used to modulate neurotransmitters, although their effectiveness is still being evaluated 3, 7
- Fluoxetine and atomoxetine: may be suitable candidates for VVS therapy, although more research is needed 5
Non-Pharmacologic Therapies
In addition to medications, the following non-pharmacologic therapies can be used to treat syncope:
- Conservative measures: first-line treatment, including increasing fluid and salt intake, unless contraindicated 3, 4, 5, 7
- Physical counterpressure maneuvers: can be taught to patients to help prevent syncope 3, 5, 7
- Patient education and reassurance: important for managing syncope and preventing recurrence 5, 7