From the Guidelines
Recurrent syncope is typically diagnosed and managed based on the underlying cause, with a focus on cardiac, orthostatic, and reflex-mediated causes. The diagnosis and management of recurrent syncope involve a thorough evaluation to identify the underlying cause, which can be cardiac, orthostatic, or reflex-mediated, such as vasovagal syncope (VVS) 1.
Diagnosis
- The initial evaluation should include a thorough medical history, physical examination, and electrocardiogram (ECG) to identify potential cardiac causes of syncope 1.
- Patients with suspected cardiac syncope may require further testing, such as echocardiography, stress testing, and electrophysiological studies 1.
- Tilt testing and carotid massage may be used to diagnose neurally mediated syncope, including VVS 1.
Management
- Hospital evaluation and treatment are recommended for patients with serious medical conditions potentially relevant to the cause of syncope 1.
- Patients with presumptive reflex-mediated syncope, such as VVS, can be managed in the outpatient setting in the absence of serious medical conditions 1.
- Treatment of VVS typically involves reassurance, education, and lifestyle modifications, such as avoiding volume depletion and prolonged exposure to upright posture and/or hot confining environments 1.
- Medications such as midodrine and fludrocortisone may be effective in treating VVS, but the evidence is limited 1.
- Pacemaker or implantable cardioverter-defibrillator (ICD) placement may be considered in patients with arrhythmic syncope or other cardiac causes of syncope 1.
Special Considerations
- Patients with recurrent syncope despite conservative therapy may require more aggressive treatment, including medication or device therapy 1.
- Patients with unexplained syncope and structural heart disease or abnormal ECG findings require further cardiac evaluation and may be at higher risk of arrhythmias and mortality 1.
- Psychiatric assessment may be recommended in patients with frequent recurrent syncope and multiple other somatic complaints, as psychiatric illness may be a contributing factor 1.
From the Research
Diagnosis of Recurrent Syncope
- The diagnosis of recurrent syncope can be made by clinical method associated with the electrocardiogram in up to 50% of patients 2
- A detailed history can often yield an accurate diagnosis in most young patients, while older patients may require a more comprehensive diagnostic assessment 3
- The initial assessment for all patients presenting with syncope includes a detailed history, physical examination, and electrocardiography 4
Management of Recurrent Syncope
- The backbone of therapy is educating the patient, avoiding precipitating factors, maintaining hydration, and the application of physical counter-pressure maneuvers 3, 5
- Conservative management with education, exercise, and physical maneuvers, and aggressive volume repletion is adequate for controlling symptoms in most patients 6
- Pharmacologic interventions may be appropriate for some patients, but have limited evidence of efficacy in preventing syncope 5, 4
- Drug therapy is rarely warranted, but may include fludrocortisone, alpha-agonists, and selective serotonin reuptake inhibitors 3
- Permanent cardiac pacing is rarely needed and randomized trials do not support its use 3
Treatment Options
- Non-pharmacological approaches, such as education and physical maneuvers, are often effective in managing recurrent syncope 6, 5
- Pharmacological approaches, such as vasopressor agents, beta-blockers, and neurohormonal agents, may be necessary for some patients 6
- Device-based therapy, such as pacemakers or radiofrequency ablation, may be considered for patients with refractory syncope 6