Vasovagal Syncope: What to Do When Physical Counter-Pressure Manoeuvres Have Not Reduced Syncopal Recurrences
Clinical scenario
This protocol addresses patients with vasovagal syncope (VVS) who remain symptomatic after a first-line physical management approach. The clinical goal is unchanged: reduction of syncopal recurrences.
Previous treatment & unmet goal
Prior line
The preceding protocol comprised isometric physical counter-pressure manoeuvres (PCM) of the legs or arms — used in patients with prodromes who are under 60 years of age — alongside tilt training considered for education of younger patients.
Goal not achieved: syncopal recurrences were not sufficiently reduced, warranting escalation to this next protocol.
Next step: treatment direction
At this stage, pharmacological therapy is considered — with specific agents evaluated in the orthostatic form of VVS and selected according to individual patient haemodynamic profile and comorbidities. The complete regimen, eligibility criteria, and decision pathway are in the full protocol.
References
DOI: 10.1093/eurheartj/ehy037
- Fludrocortisone may be considered in young patients with the orthostatic form of VVS, low–normal values of arterial BP, and the absence of contraindication to the drug.
- Fludrocortisone should not be used in patients with hypertension or heart failure.
- Midodrine may be considered in patients with the orthostatic form of VVS.
- There is moderate evidence that fludrocortisone may be effective in reducing syncopal recurrences in young patients with low–normal values of arterial BP and without comorbidities.
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