Management of neurocardiogenic syncope

Management of neurocardiogenic syncope

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.

Lifestyle 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.

Beta Blockers diminish the activation of left ventricular mechanoreceptors and were found useful in uncontrolled trials. But POST trial showed no difference in syncope free interval at 1 year [1].

Midodrine and paroxetine are the only drugs which have been shown to be of benefit in small randomized trials. Comparison of Outcomes With Midodrine and Fludrocortisone for Objective Recurrence in Treating Syncope (COMFORTS Trial) is evaluating these drugs and is expected to be completed in December 2023 [2].

Patients who received pacemakers in open labeled trials showed benefit. But double blind randomized trials did not confirm the benefit (VPS II) [3]. 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.

References

  1. 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 Mar 7;113(9):1164-70.
  2. Comparison of Outcomes With Midodrine and Fludrocortisone for Objective Recurrence in Treating Syncope (COMFORTS Trial)
  3. Connolly SJ, Sheldon R, Thorpe KE, Roberts RS, Ellenbogen KA, Wilkoff BL, Morillo C, Gent M; VPS II Investigators. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial. JAMA. 2003 May 7;289(17):2224-9.