From the Guidelines
The most effective management of vasovagal syncope due to cough involves immediate interventions such as assuming a safe position, like 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. When a person experiences signs or symptoms of presyncope, such as pallor, sweating, lightheadedness, visual changes, and weakness, of vasovagal or orthostatic origin, the priority is to maintain or assume a safe position. Some key points to consider in the management of vasovagal syncope due to cough include:
- Recognizing presyncope symptoms, such as lightheadedness, nausea, and pallor, and taking immediate action to prevent full syncope by sitting or lying down.
- Using PCMs, such as leg crossing, muscle tensing, or squatting, to interrupt the parasympathetic surge and hypotension that characterize the vasovagal response triggered by coughing episodes, as supported by the 2019 ILCOR systematic review 1.
- Addressing the underlying cough is essential, which may involve treating conditions like asthma, GABA, or chronic bronchitis with appropriate medications.
- Pharmacological management specifically for vasovagal reactions may include fludrocortisone or midodrine, but the evidence for beta-blockers is lacking, as noted in the 2001 European Heart Journal guidelines 1.
- Patients should be counseled to maintain adequate hydration, moderate salt intake, and avoid known triggers. It is essential to prioritize the most recent and highest quality study, which in this case is the 2019 American Heart Association and American Red Cross guidelines 1, to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.
From the Research
Management of Vasovagal Syncope due to Cough
- Vasovagal syncope is a common cause of transient loss of consciousness, and it can be triggered by various factors, including coughing 2.
- The management of vasovagal syncope due to cough involves a combination of conservative measures and pharmacological therapies.
- Conservative measures include adequate hydration, increased salt intake, and careful withdrawal of diuretics and specific hypotension-inducing drugs 3.
- Physical counterpressure maneuvers might be helpful, but they can be of limited efficacy in older patients and those with short or no prodromes 3.
- Pharmacological therapies, such as fludrocortisone and midodrine, can significantly reduce syncope recurrences with tolerable side effects, when titrated to target doses 4, 3.
- In some cases, pacing therapy with specialized sensors or cardioneuroablation may be considered, but these options are typically reserved for patients who have not responded to conservative measures 5, 3.
Treatment of Underlying Causes
- If the cough is caused by an underlying condition, such as an infectious exacerbation of chronic obstructive pulmonary disease, treatment of the underlying condition may help to reduce the frequency and severity of vasovagal syncope episodes.
- Antibiotics, such as azithromycin or amoxicillin, may be effective in treating infectious exacerbations of chronic obstructive pulmonary disease, but they should be used judiciously and only when necessary 6.