Reflex syncope in adults: Treatment
- David Benditt, MD
David Benditt, MD
- Professor of Medicine
- Director, Cardiac Arrhythmia Center
- University of Minnesota Medical School
Syncope is a clinical syndrome in which transient loss of consciousness (TLOC) is caused by a period of inadequate cerebral nutrient flow, most often the result of an abrupt drop of systemic blood pressure. Reflex syncope (previously termed neutrally-mediated syncope) is TLOC due to a reflex response that encompasses vasodilatation and/or bradycardia (rarely tachycardia), leading to systemic hypotension and cerebral hypoperfusion . Types of reflex syncope include vasovagal syncope, situational syncope, carotid sinus syncope, and some cases without apparent triggers (table 1).
Vasovagal syncope is the most common cause of syncope . Vasovagal syncope may be suggested or diagnosed by a specific history with well-known triggers, but a classic history is not required. Acute vasovagal reactions leading to syncope or presyncope are common also in a number of stressful settings, such as blood donation. The diagnosis can also be suggested by exclusion of other causes of syncope and by a characteristic response to upright tilt table testing during which the patient may become syncopal. In these cases, the syncope is due to hypotension that may be caused by severe bradycardia, vascular dilation (vasodepressor effect), or both. (See "Blood donor screening: Procedures and processes to enhance safety for the blood recipient and the blood donor", section on 'Vasovagal syncope'.)
The treatment of patients with vasovagal syncope and situational syncope will be reviewed here. Discussions of the clinical presentation and diagnostic evaluation of patients with reflex syncope, as well as the pathogenesis, etiology, evaluation and management of syncope in general, are discussed separately. (See "Syncope in adults: Epidemiology, pathogenesis, and etiologies" and "Syncope in adults: Clinical manifestations and diagnostic evaluation" and "Syncope in adults: Management".)
GENERAL APPROACH TO TREATMENT
No therapy has been proven consistently effective for recurrent vasovagal syncope. However, the following should be considered in all patients with suspected reflex syncope:
●Patients should be reassured about the benign nature of reflex syncope.
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- GENERAL APPROACH TO TREATMENT
- REASSURANCE AND PATIENT EDUCATION
- PHYSICAL COUNTERPRESSURE MANEUVERS
- VOLUME SUPPORT
- BETA BLOCKERS
- OTHER MEDICATIONS
- ORTHOSTATIC TRAINING PROGRAM
- CARDIAC PACEMAKERS
- Rationale and limitations
- Evidence on efficacy of pacemakers
- Major society guidelines on pacing
- DRIVING RESTRICTIONS FOR PATIENTS WITH VASOVAGAL SYNCOPE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS