Neurocardiogenic Syncope

  • J. Anthony GomesEmail author


Typically, syncope is a self-limiting loss of consciousness secondary to loss of postural tone with spontaneous and complete recovery. It is indeed a common and costly problem. It accounts for 1 million patients in the USA with more than 500,000 new patients per year. This chapter addresses neurocardiogenic syncope, its mechanism, diagnostic evaluation, and treatment. It also addresses postural orthostatic tachycardia (POTS) syndrome and its treatment.


Syncope Vasovagal Situational Neurocardiogenic Tilt table test Postural orthostatic tachycardia 


  1. 1.
    Sebastian AA. Dictionary of the history of medicine. Pearl River: Pantheon Publishing Group Inc; 1999. p. 377–698.Google Scholar
  2. 2.
    History of syncope. In: Chopra HK, Nanda NC (editors). Textbook of cardiology: a clinical and historical perspective. 1st ed. New Delhi, Panama City, London, Dhaka, Kathmar: Jaypee Brothers Medical Publishers Ltd.; 2013.Google Scholar
  3. 3.
    Porzionato A, Macchi V, Stecco C, et al. The anatomical school of Padua. Anat Record. 2012;295(6):902–16.Google Scholar
  4. 4.
    Girolamo Mercuriale – Wikipedia.
  5. 5.
    Sheldon RS, Grubb BP, Olshansky B, et al. 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015;12:e41–63.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Probst MA, Kanzaria HK, Gbedemah M, et al. National trends in resource utilization associated with ED visits for syncope. Am J Emerg Med. 2015;33:998–1001.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Sun BJ, Emond JA, Camargo CA. Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol. 2005;95:668–71.PubMedGoogle Scholar
  8. 8.
    Shinohara T, Ebata Y, Ayabe R, et al. Cardiac autonomic dysfunction in patients with head-up tilt test-induced vasovagal syncope. Pacing Clin Electrophysiol. 2014;37:1694–701.PubMedGoogle Scholar
  9. 9.
    Morillo CA, Eckberg DL, Ellenbogen KA, et al. Vagal and sympathetic mechanisms in patients with orthostatic vasovagal syncope. Circulation. 1997;96:2509–13.PubMedGoogle Scholar
  10. 10.
    Iacoviello M, Forleo C, Guida P, et al. Independent role of reduced arterial baroreflex sensitivity during head-up tilt testing in predicting vasovagal syncope recurrence. Europace. 2010;12:1149–55.PubMedGoogle Scholar
  11. 11.
    Verheyden B, Liu J, van Dijk N, et al. Steep fall in cardiac output is main determinant of hypotension during drug-free and nitroglycerine-induced orthostatic vasovagal syncope. Heart Rhythm. 2008;5:1695–701.PubMedGoogle Scholar
  12. 12.
    Galetta F, Franzoni F, Plantinga Y, et al. Endothelial function in young subjects with vaso-vagal syncope. Biomed Pharmacother. 2006;60:448–52.PubMedGoogle Scholar
  13. 13.
    Goldstein DS, Holmes C, Frank SM, et al. Sympathoadrenal imbalance before neurocardiogenic syncope. Am J Cardiol. 2003;91:53–8.PubMedGoogle Scholar
  14. 14.
    Ditting T, Hilgers KF, Scrogin KE, et al. Mechanosensitive cardiac C-fiber response to changes in left ventricular filling, coronary perfusion pressure, hemorrhage, and volume expansion in rats. Am J Physiol Heart Circ Physiol. 2005;288:H541–52.PubMedGoogle Scholar
  15. 15.
    Kenny RA, Ingram A, Bayliss J, Sutton R. Head-up tilt: a useful test for investigating unexplained syncope. Lancet. 1986;1:1352–5.PubMedGoogle Scholar
  16. 16.
    Kapoor WN, Smith MA, Miller NL. Upright tilt testing in evaluating syncope: a comprehensive literature review. Am J Med. 1994;97:78–88.PubMedGoogle Scholar
  17. 17.
    Saklani P, Krahn A, Klein G. Syncope. Circulation. 2013;127:1330–9.PubMedGoogle Scholar
  18. 18.
    Natale A, Akhtar M, Jazayeri M, et al. Provocation of hypotension during head-up tilt testing in subjects with no history of syncope or presyncope. Circulation. 1995;92:54–8.PubMedGoogle Scholar
  19. 19.
    Schondorf R, Low PA. Idiopathic postural orthostatic tachycardia syndrome: an attenuated form of acute pandysautonomia? Neurology. 1993;43:132–7.PubMedGoogle Scholar
  20. 20.
    Low PA, Opfer-Gehrking TL, Textor SC, et al. Postural tachycardia syndrome (POTS). Neurology. 1995;45:S19–25.PubMedGoogle Scholar
  21. 21.
    Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neutrally mediated syncope and the postural tachycardia syndrome. Auton Neurosci. 2011;161:46–8.PubMedGoogle Scholar
  22. 22.
    Garland EM, Raj SR, Black BK, et al. The hemodynamic and neurohumoral phenotype of postural tachycardia syndrome. Neurology. 2007;69:790–8.PubMedGoogle Scholar
  23. 23.
    Low PA, Sandroni P, Joyner M, et al. Postural tachycardia syndrome (POTS). J Cardiovasc Electrophysiol. 2009;20:352–8.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Lambert E, Lambert GW. Sympathetic dysfunction in vasovagal syncope and the postural orthostatic tachycardia syndrome. Front Physiol. 2014;5:280.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Stewart JM, Shaban MA, Fialkoff T, et al. Mechanisms of tilt-induced vasovagal syncope in healthy volunteers and postural tachycardia syndrome patients without past history of syncope. Physiol Rep. 2019;7(13):e14148.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Van Dijk N, Quartieri F, Blanc JJ, et al. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the physical counterpressure manoeuvres trial (PC-trial). J Am Coll Cardiol. 2006;48:1652–7.PubMedGoogle Scholar
  27. 27.
    Sheldon R, Connolly S, Rose S, et al. Prevention of syncope trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation. 2006;113:1164–70.PubMedGoogle Scholar
  28. 28.
    Salim MA, Di Sessa TG. Effectiveness of fludrocortisone and salt in preventing syncope recurrence in children: a double-blind, placebo-controlled, randomized trial. J Am Coll Cardiol. 2005;45:484–8.PubMedGoogle Scholar
  29. 29.
    Perez-Luogones A, Schweikert R, Pavia S, et al. Usefulness of midodrine in patients with severely symptomatic neurocardiogenic syncope: a randomized control study. J Cardiovasc Electrophysiol. 2001;12:935–8.Google Scholar
  30. 30.
    Romme JJCM, van Dijk N, Go-Schön IK, et al. Effectiveness of midodrine treatment in patients with recurrent vasovagal syncope not responding to non-pharmacological treatment (STAND-trial). Europace. 2011;13:1639–47.PubMedGoogle Scholar
  31. 31.
    Sheldon RS, Morillo CA, Klingenheben T, et al. Age-dependent effect of beta-blockers in preventing vasovagal syncope. Circ Arrhythm Electrophysiol. 2012;5:920–6.PubMedGoogle Scholar
  32. 32.
    Grubb BP, Karas BJ. The potential role of serotonin in the pathogenesis of neurocardiogenic syncope and related autonomic disturbances. J Interv Card Electrophysiol. 1998;2:325–32.PubMedGoogle Scholar
  33. 33.
    Di Girolamo E, Di Iorio C, Sabatini P, et al. Effects of paroxetine hydrochloride, a selective serotonin reuptake inhibitor, on refractory vasovagal syncope: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol. 1999;33:1227–30.PubMedGoogle Scholar
  34. 34.
    Theodorakis GN, Leftheriotis D, Livanis EG, et al. Fluoxetine vs. propranolol in the treatment of vasovagal syncope: a prospective, randomized, placebo-controlled study. Europace. 2006;8:193–8.PubMedGoogle Scholar
  35. 35.
    Connolly SJ, Sheldon R, Roberts RS, Gent M. The North American Vasovagal Pacemaker Study (VPS): a randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope. J Am Coll Cardiol. 1999;33:16–20.PubMedGoogle Scholar
  36. 36.
    Sutton R, Brignole M, Menozzi C, et al. Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope: pacemaker versus no therapy: a multicenter randomized study. Circulation. 2000;102:294–9.PubMedGoogle Scholar
  37. 37.
    Connolly SJ, Sheldon R, Thorpe KE, et al. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: second Vasovagal Pacemaker Study (VPS II): a randomized trial. JAMA. 2003;289:2224–9.PubMedGoogle Scholar
  38. 38.
    Raviele A, Giada F, Menozzi C, et al. A randomized, double-blind, placebo-controlled study of permanent cardiac pacing for the treatment of recurrent tilt-induced vasovagal syncope: the vasovagal syncope and pacing trial (SYNPACE). Eur Heart J. 2004;25:1741–8.PubMedGoogle Scholar
  39. 39.
    Brignole M, Menozzi C, Moya A, et al. 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.PubMedGoogle Scholar
  40. 40.
    Brignole M, Donateo P, Tomaino M, et al. 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.PubMedGoogle Scholar
  41. 41.
    Palmisano P, Zaccaria M, Luzzi G, et al. Closed-loop cardiac pacing versus conventional dual-chamber pacing with specialized sensing and pacing algorithms for syncope prevention in patients with refractory vasovagal syncope: results of a long-term follow-up. Europace. 2012;14:1038–43.PubMedGoogle Scholar
  42. 42.
    Winker R, Barth A, Bidmon D, et al. Endurance exercise training in orthostatic intolerance: a randomized, controlled trial. Hypertension. 2005;45:391–8.PubMedGoogle Scholar
  43. 43.
    McDonald C, Frith J, Newton JL. Single centre experience of ivabradine in postural orthostatic tachycardia syndrome. Europace. 2011;13:427–30.PubMedGoogle Scholar
  44. 44.
    Jacob G, Shannon JR, Black B, et al. Effects of volume loading and pressor agents in idiopathic orthostatic tachycardia. Circulation. 1997;96:575–80.PubMedGoogle Scholar
  45. 45.
    Gordon VM, Opfer-Gehrking TL, Novak V, Low PA. Hemodynamic and symptomatic effects of acute interventions on tilt in patients with postural tachycardia syndrome. Clin Auton Res. 2000;10:29–33.PubMedGoogle Scholar
  46. 46.
    Stewart JM, et al. Mechanism of vasovagal syncope in the young: reduced systemic vascular resistance versus reduced cardiac output. J Am Heart Assoc. 2017;6:e0044. Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Icahn School of MedicineMount Sinai HospitalNew YorkUSA

Personalised recommendations