Management of neurocardiogenic syncope
Syncope is a self limited loss of consciousness and postural tone. Neurally mediated syncope contributes just 24% of total syncope. Hallmark of neurocardiogenic syncope is hypotension and bradycardia, one component may be prominent
Patient education is an important aspect of management. This should include the nature of the disorder, avoidance of precipitating factors, natural history and prognosis.
Life style changes like avoidance of hypovolemia with extra fluid intake and increased salt intake may help. Tilt training may be useful. Isometric calf muscle exercise at the onset of prodrome can prevent the syncope or give time to adopt a position to prevent injury.
Betablockers diminsh the activation of left ventricular mechanoreceptors and were found useful in uncontrolled trials. POST trial which was recently reported in Circulation showed no difference in syncope free interval at 1 year.
Midodrine and paroxetine are the only drugs which have been shown to be of benefit in small randomized trials.
Patients who received pacemakers in open labeled trials showed benefit. But double blind randomized trials did not confirm the benefit (VPS II). DDD pacing with rate drop algorithm did not make a difference.
Pacing may have a role in those without a prodrome and in whom other measures have failed. It might give time for them to opt positions which may prevent injury.