Does A Therapy for Reflex Vasovagal Syncope Really Exist?
Syncope is a temporary loss of consciousness due to transient global cerebral hypoperfusion. Reflex syncope is the most frequent, representing 21% of all types of syncopal events, and includes: (a) the vasovagal syncope (classical type); (b) the situational syncope; (c) the carotid sinus syncope and (d) non-classical forms. An accurate anamnesis and physical examination are fundamental for the diagnosis. Although limited evidence is available regarding the efficacy of some treatments, a number of these can be successfully used in the clinical practice. It is, however, important to personalize the therapeutic approach in order to achieve an efficient reduction or suppression of syncopal episodes. Patients should be reassured about the benignity of these events and the possibility of reducing their frequency over time. They should be also educated on how to recognize and abort incoming syncopal episodes. Patients may be advised to increase their introit in water and salt, as well as to reduce vasoactive medications, if no contraindications exist. Orthostatic training may be beneficial but only in very motivated young patients capable of strictly adhering to the exercise plan. So far, any proposed pharmacological treatment has demonstrated very limited efficacy and, therefore, it should be tried in case of failure of non-pharmacological approaches. Pacemaker implantation is clearly indicated in patients with documented cardioinhibitory syncope in the absence of a vasodepressor component, which can compromise their quality of life. Despite the American and European guidelines for the treatment of syncope are similar, still some differences can be denoted. Aim of this study is to evaluate the management of patients with recurrent syncopal episodes focusing on pharmacological and non-pharmacological approaches.
KeywordsReflex syncope Vasovagal syncope Treatment Pacemaker American and European guidelines Blood pressure
Compliance with Ethical Standards
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
This article does not contain any studies with animals performed by any of the authors.
- 1.Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG, ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883–948. https://doi.org/10.1093/eurheartj/ehy037.CrossRefGoogle Scholar
- 11.Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2017;70:620.CrossRefGoogle Scholar
- 12.Brignole M, Ammirati F, Arabia F, Quartieri F, Tomaino M, Ungar A, Lunati M, Russo V, Del Rosso A, Gaggioli G, Syncope Unit Project (SUP) Two Investigators. Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes. Eur Heart J. 2015;36:1529–35.CrossRefGoogle Scholar
- 18.Van Dijk N, Quartieri F, Blanc JJ, Garcia-Civera R, Brignole M, Moya A, Wieling W, PCTrial Investigators. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the Physical Counterpressure Manoeuvres Trial (PC-Trial). J Am Coll Cardiol. 2006;48:1652–7.CrossRefGoogle Scholar
- 19.Tomaino M, Romeo C, Vitale E, Kus T, Moya A, van Dijk N, Giuli S, D’Ippolito G, Gentili A, Sutton R, International Study on Syncope of Uncertain Etiology 3 (ISSUE 3) Investigators. Physical counter-pressure manoeuvres in preventing syncopal recurrence in patients older than 40 years with recurrent neurally mediated syncope: a controlled study from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3). Europace. 2014;16:1515–20.CrossRefGoogle Scholar
- 26.Kinay O, Yazici M, Nazli C, Acar G, Gedikli O, Altinbas A, Kahraman H, Dogan A, Ozaydin M, Tuzun N, Ergene O. Tilt training for recurrent neurocardiogenic syncope: effectiveness, patient compliance, and scheduling the frequency of training sessions. Jpn Heart J. 2004;45:833–43.CrossRefGoogle Scholar
- 32.Evidence Review Committee Members, Varosy PD, Chen LY, et al. Pacing as a treatment for reflex-mediated (vasovagal, situational, or carotid sinus hypersensitivity) syncope: a systematic review for the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017;2017(14):e255.Google Scholar
- 33.Brignole M, Menozzi C, Moya A, Andresen D, Blanc JJ, Krahn AD, Wieling W, Beiras X, Deharo JC, Russo V, Tomaino M, Sutton R, International Study on Syncope of Uncertain Etiology 3 (ISSUE-3) Investigators. Pacemaker therapy in patients with neurally mediated syncope and documented asystole: Third International Study on Syncope of Uncertain Etiology (ISSUE-3): a randomized trial. Circulation. 2012;125:2566–71.CrossRefGoogle Scholar
- 36.Brignole M, Donateo P, Tomaino M, Massa R, Iori M, Beiras X, Moya A, Kus T, Deharo JC, Giuli S, Gentili A, Sutton R, International Study on Syncope of Uncertain Etiology 3 (ISSUE-3) Investigators. Benefit of pacemaker therapy in patients with presumed neurally mediated syncope and documented asystole is greater when tilt test is negative: an analysis from the third International Study on Syncope of Uncertain Etiology (ISSUE-3). Circ Arrhythm Electrophysiol. 2014;7:10–6.CrossRefGoogle Scholar
- 37.Brignole M, Deharo JC, Menozzi C, Moya A, Sutton R, Tomaino M, Ungar A. The benefit of pacemaker therapy in patients with neurally mediated syncope and documented asystole: a meta-analysis of implantable loop recorder studies. Europace. 2018;20(8):1362–6. https://doi.org/10.1093/europace/eux321.CrossRefGoogle Scholar
- 39.Brignole M, Arabia F, Ammirati F, et al. Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study. Europace. 2016;18(9):1427–33. https://doi.org/10.1093/europace/euv343 (Epub 2015 Nov 26).CrossRefGoogle Scholar
- 43.SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC Jr, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT. A randomized trial of intensive versus standard blood pressure control. N Engl J Med. 2015;373:2103–16.CrossRefGoogle Scholar
- 47.Sheldon R, Raj SR, Rose MS, Morillo CA, Krahn AD, Medina E, Talajic M, Kus T, Seifer CM, Lelonek M, Klingenheben T, Parkash R, Ritchie D, McRae M, Sheldon RS, Rose SM, Ritchie DA, McCrae M, Morillo C, Malcolm VM, Krahn AD, Spindler B, Medina E, Talajic M, Kus T, Langlois A, Lelonek M, Raj S, Seifer C, Gardner M, Romeo M, Poirier P, Simpson C, Abdollah H, Reynolds J, Dorian P, Birnie D, Giuffre M, Gilligan D, Benditt D, Sheldon RS, Raj SR, Rose MS, Krahn A, Morillo C, Medina E. Fludrocortisone for the prevention of vasovagal syncope: a randomized, placebo-controlled trial. J Am Coll Cardiol. 2016;68(1):1–9. https://doi.org/10.1016/j.jacc.2016.04.030 (ISSN 0735-1097).CrossRefGoogle Scholar
- 48.Raviele A, Brignole M, Sutton R, Alboni P, Giani P, Menozzi C, Moya A, for Vasovagal Syncope International Study (VASIS) Investigators. Effect of etilefrine in preventing syncopal recurrence in patients with vasovagal syncopea double-blind, randomized, placebo-controlled trial. Circulation. 1999;99:1452–7.CrossRefGoogle Scholar
- 58.Madrid AH, Ortega J, Rebollo JG, Manzano JG, Segovia JG, Sanchez A, Pena G, Moro C. Lack of efficacy of atenolol for the prevention of neurally mediated syncope in a highly symptomatic population: a prospective, double-blind, randomized and placebo-controlled study. J Am Coll Cardiol. 2001;37:554–9.CrossRefGoogle Scholar
- 59.Sheldon R, Connolly S, Rose S, Klingenheben T, Krahn A, Morillo C, Talajic M, Ku T, Fouad-Tarazi F, Ritchie D, Koshman ML, POST Investigators. Prevention of syncope trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation. 2006;113:1164–74.CrossRefGoogle Scholar
- 61.Canney M, O’Connell MD, Murphy CM, et al. Single agent antihypertensive therapy and orthostatic blood pressure behaviour in older adults using beat-to-beat measurements: the Irish Longitudinal Study on Ageing. PLoS One. 2016;11(1):e0146156. https://doi.org/10.1371/journal.pone.0146156.CrossRefGoogle Scholar
- 65.Márquez MF, Urias-Medina K, Gómez-Flores J, Sobrino A, Sotomayor-González A, González-Hermosillo A, Cárdenas M. Comparison of metoprolol vs clonazepam as a first treatment choice among patients with neurocardiogenic syncope. Gac Med Mex. 2008;144(6):503–7.Google Scholar
- 77.Yao Y, Shi R, Wong T, Zheng L, Chen W, Yang L, Huang W, Bao J, Zhang S. Endocardial autonomic denervation of the left atrium to treat vasovagal syncope: an early experience in human. Circ Arrhythm Electrophysiol. 2012;5(2):279–86. https://doi.org/10.1161/CIRCEP.111.966465 (Epub 2012 Jan 24).CrossRefGoogle Scholar