Vasovagal Syncope

Aka: Vasovagal Syncope, Neurocardiogenic Syncope, Reflex Mediated Syncope, Micturition Syncope, Cough Syncope, Tussive Syncope, Situational Syncope, Physical Counterpressure Maneuvers for Presyncope

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II. Definitions

  1. Vasovagal Syncope
    1. Dysautonomic response to upright Posture
    2. Includes
      1. Orthostatic Hypotension
      2. Postural Orthostatic Tachycardia Syndrome (POTS)

III. Causes

  1. See Syncope
  2. Vasovagal Syncope
  3. Other Reflex Mediated Syncope causes
    1. Situational Syncope
      1. Urination (Micturition Syncope) or with Defecation
      2. Cough Syncope (Tussive Syncope) or sneezing
      3. Valsalva (brass instrument playing, weight lifting)
      4. Hyperventilation
    2. Carotid Sinus Syncope
    3. Glossopharyngeal neuralgia (uncommon)
      1. Syncope occurs with Swallowing, talking, sneezing
    4. Trigeminal Neuralgia

IV. Phases

  1. Precipitating event (e.g. stress, prolonged standing)
    1. Prolonged standing
    2. Sitting
    3. Heat
    4. Stress
  2. Prodrome (present in 50% of cases)
    1. Duration: Seconds to minutes
    2. Symptoms
      1. Diaphoresis (most common)
      2. Epigastric Pain
      3. Fatigue
      4. Nausea
      5. Pallor
      6. Dizziness, Light Headedness or Vertigo
    3. Palliative
      1. Lying down may prevent loss of consciousness and relieve symptoms
      2. See Physical Counterpressure Maneuvers below
  3. Loss of consciousness
    1. May occur without prodrome in half of cases
    2. Brief Seizure-like activity (Myoclonus) may occur on collapse in 5% of cases
  4. Post-Syncope
    1. Duration: Hours
    2. Symptoms
      1. Confusion
      2. Dizziness or Vertigo
      3. Nausea
      4. Malaise

V. Management: General

  1. General prevention measures
    1. Move to supine position to prevent falls at onset of symptoms
  2. Physical counterpressure maneuvers at start of Presyncope symptoms (esp. Isometric Muscle Contraction)
    1. Cross Legs and flex Muscles of legs
    2. Squat
    3. Tense lower extremities
    4. Flex abdominal Muscles
    5. Hand grip (imagine squeezing a stress ball)
    6. Try to pull apart hands with interlocked fingers
    7. References
      1. First Aid Interventions for Presyncope (ILCOR)
        1. https://costr.ilcor.org/document/first-aid-interventions-for-presyncope
  3. Increase volume status
  4. Consider increased dietary salt when appropriate
  5. Adjust medications to lower dose
    1. Alpha Adrenergic Antagonist (Prazosin)
    2. Antianginal nitrates (Nitroglycerin)

VI. Management: Medical

  1. Expected medication course
    1. Continue medication for 1 year then taper off
  2. Indications for medical management (see below)
    1. More than two syncopal episodes
    2. Increasingly recurrent syncopal episodes
    3. Syncope without warning or prodrome
    4. Syncope in high risk occupation
      1. Airplane pilot
      2. Truck driver

VII. Approach Step 1: Assess Hemodynamic response to standing

  1. No Hemodynamic Response
    1. See Step 2 below
  2. Blood Pressure decreases: Orthostatic Hypotension
    1. Criteria
      1. Systolic Blood Pressure decreases more than 20 mmHg
      2. Systolic Blood Pressure <90 mmHg within 3 minutes
    2. Management
      1. See Orthostatic Hypotension for management
      2. Increased salt intake
      3. Consider Fludrocortisone (water and salt retention) in refractory cases
      4. Consider Midodrine (Vasoconstrictor) in refractory cases
  3. Pulse increase: Postural Orthostatic Tachycardia (POTS)
    1. Criteria
      1. Heart Rate increases more than 30 beats per minute
      2. Heart Rate >120 beats per minute
    2. Management
      1. Fludrocortisone (water and salt retention)
      2. Midodrine (Vasoconstrictor)
      3. Beta Blockers

VIII. Approach Step 2: Tilt Test not done (Empiric Therapy)

  1. No Hypertension
    1. See Orthostatic Hypotension
    2. Consider Tilt Test
    3. Consider Fludrocortisone (water and salt retention)
    4. Consider Midodrine (Vasoconstrictor)
  2. Hypertension
    1. First line
      1. Beta Blocker
    2. Second line
      1. Clonidine
      2. Disopyramide
      3. Selective Serotonin Reuptake Inhibitor (SSRI)
        1. Paroxetine (Paxil) 20 mg orally daily
        2. Di Girolamo (1999) J Am Coll Cardiol 33:1227-30 [PubMed]
    3. Third line
      1. Dual Chamber Pacemaker

IX. Approach Step 3: Obtain Tilt Test

  1. Tilt Test Criteria
    1. No concurrent medications
    2. Tilt for 45 minutes at 60 to 70 degrees
  2. Gradual fall in Blood Pressure: Dysautonomic Syncope
    1. Fludrocortisone (water and salt retention)
    2. Midodrine (Vasoconstrictor)
  3. Abrupt fall in Blood Pressure: Vasovagal Syncope
    1. Non-pharmacologic measures are preferred (see above)
    2. Heart Rate increases prior to Blood Pressure drop
      1. Consider Beta Blocker
    3. No change in Heart Rate prior to Hypotension
      1. Previously Fludrocortisone was trialed, but not found effective
    4. Refractory cases
      1. Consider dual chamber Pacemaker

X. References

  1. Bloomfield (1999) Am J Cardiol 84:33Q-9Q [PubMed]
  2. Fenton (2000) Ann Intern Med 133:722 [PubMed]
  3. Kapoor (2000) N Engl J Med 343:1856-62 [PubMed]
  4. Runser (2017) Am Fam Physician 95(3): 303-12 [PubMed]

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Related Studies

Ontology: Vasovagal syncope (C0042420)

Definition (MSH) Loss of consciousness due to a reduction in blood pressure that is associated with an increase in vagal tone and peripheral vasodilation.
Concepts Disease or Syndrome (T047)
MSH D019462
ICD10 R55
SnomedCT 206728007, 162265001, 139534004, 158136005, 127380002, 230663003, 398665005, 398652001, 29423006
English SYNCOPE VASOVAGAL, SYNCOPE VAGOVAGAL, VASOVAGAL REACTION, Neurocardiogenic Syncope, Neurocardiogenic Syncopes, Neurogenic Syncope, Neurogenic Syncopes, Syncope, Neurocardiogenic, Syncope, Neurogenic, Syncope, Vasovagal, Syncopes, Neurocardiogenic, Syncopes, Neurogenic, Syncopes, Vasovagal, Vasovagal Syncopes, [D]Vasovagal attack (context-dependent category), Syncope/vasovagal faint, [D]Vasovagal attack, Vasovagal syncope, vasovagal syncope (diagnosis), vasovagal syncope, Faint, Neurally Mediated, Faints, Neurally Mediated, Neurally Mediated Faint, Neurally Mediated Faints, Syncope vagovagal, Vasovagal reaction, Vagal reaction, Neurocardiogenic syncope, Syncope vasovagal, Vaso vagal attack, Syncope, Vasovagal, Neurally-Mediated, Syncope, Vasodepressor, Syncopes, Vasodepressor, Vasodepressor Syncope, Vasodepressor Syncopes, Syncope, Vasovagal [Disease/Finding], Attack(s);vasovagal, neurogenic syncope, neurocardiogenic syncope, reaction vasovagal, syncope vasovagal, gower's syndrome, syncope neurocardiogenic, vasovagal syndrome, episodes vasovagal, episodes vagal vaso, attacks vagal, attacks vagal vaso, vaso vagal attack, vasovagal attack, vasovagal episode, syncope vasodepressor, vasodepressor syncope, vagal attack, vagal reaction, vasovagal reaction, reactions vasovagal, vaso vagal episode, vasovagal syncopes, Syncope/vasovagal faint (finding), [D]Vasovagal attack (situation), Vasovagal syncope (finding), Vasodepressor syncope (disorder), Vasodepressor syncope, Vaso vagal episode, Vasovagal attack, Gower's syndrome, Vagal attack, Vasovagal attack (disorder), Vasovagal syncope (disorder), attack; vasovagal, syndrome; vasovagal, vasovagal; attack, vasovagal; syndrome, Vasovagal Syncope, vasovagal attacks
Spanish SINCOPE VASOVAGAL, [D]crisis vasovagal (categoría dependiente del contexto), SINCOPE VAGOVAGAL, Reacción vasovagal, Síncope vasovagal, Reacción vagal, Síncope neurocardiogénico, Crisis vasovagal, síncope vasodepresor, [D]crisis vasovagal (situación), síncope/desvanecimiento vasovagal, síncope/desvanecimiento vasovagal (hallazgo), [D]crisis vasovagal, síncope vasovagal (hallazgo), ataque vasovagal (trastorno), ataque vasovagal, síncope vasovagal, síncope vasovagal (trastorno), Síncope Neurocardiogénico, Síncope Neurogénico, Síncope Vasodepresor, Síncope Vasovagal
Swedish Svimning, vasovagal
Finnish Vasovagaalinen synkopee
French Syncope neurologique, REACTION VAGALE VASCULAIRE, SYNCOPE VAGO-VAGALE, SYNCOPE VASO-VAGOTONIQUE, Réaction vagale, Attaque vaso-vagale, Syncope vaso-vagale, Syncope vagovagale, Réaction vaso-vagale, Malaise vagal, Syncope vagale, Syncope neurocardiogénique, Syncope réflexe, Syncope vasovagale
Russian NEIROGENNYI OBMOROK, OBMOROK SOSUDISTOVAGUSNYI, NEIROKARDIOGENNYI OBMOROK, НЕЙРОГЕННЫЙ ОБМОРОК, НЕЙРОКАРДИОГЕННЫЙ ОБМОРОК, ОБМОРОК СОСУДИСТОВАГУСНЫЙ
Portuguese REACCAO VASOVAGAL, SINCOPE VAGO-VAGAL, SINCOPE VASO-VAGAL, Reacção vagal, Síncope vasovagal, Crise vasovagal, Ataque vasovagal, Síncope neurocardiogénica, Reacção vasovagal, Síncope Neurocardiogênica, Síncope Neurogênica, Síncope Vasodepressora, Síncope Vasovagal
German SYNKOPE VAGOVASAL, SYNKOPE VASOVAGAL, vasovagaler Kollaps, neurokardiogene Synkope, vasovagale Reaktion, vagale Reaktion, Synkope vasovagal, vasovagale Synkope, Synkope, neurogene, Synkope, neurokardiogene, Synkope, vasovagale, Synkope, vasodepressive
Italian Sincope neurocardiogenica, Sincope vasodepressoria, Sincope neurogenica, Sincope neuro-mediata, Sincope vasovagale neuro-mediata, Sincope vagovagale, Crisi vasovagale, Reazione vagale, Reazione vasovagale, Sincope vasovagale
Dutch vagale reactie, neurocardiogene syncope, vasovagale aanval, vasovagale reactie, syncope vasovagaal, vaso-vagale aanval, syncope vagovagaal, aanval; vasovagaal, syndroom; vasovagaal, vasovagaal; aanval, vasovagaal; syndroom, Defecatiesyncope, Mictiesyncope, Syncope, cardiovagale, Syncope, neurocardiogene, Syncope, neurogene, Syncope, orthostatische, Syncope, vasovagale, Vasodepressiesyncope, Vasovagale syncope
Czech Vagová reakce, Vazovagální reakce, Vazovagální záchvat, Vagovagální synkopa, Záchvat vazovagální, Vazovagální synkopa, Neurokardiogenická synkopa, vazovagální synkopa, vasodepresorická synkopa, synkopa vazovagální, neurokardiogenní synkopa
Japanese ｹｯｶﾝﾒｲｿｳｼﾝｹｲｾｲﾎｯｻ, 血管迷走神経性反応, ｼﾝｹｲｼﾝｿﾞｳｾｲｼｯｼﾝ, 神経心臓性失神, 血管迷走神経性発作, ｹｯｶﾝﾒｲｿｳｼﾝｹｲｾｲｼｯｼﾝ, 迷走神経性反応, ﾒｲｿｳｼﾝｹｲｾｲﾊﾝﾉｳ, ｹｯｶﾝﾒｲｿｳｼﾝｹｲｾｲﾊﾝﾉｳ, 血管拡張性失神, 失神-血管迷走神経性, 情動性失神, 神経原性失神, 血管緊張低下性失神, 血管迷走神経反射性失神, 血管迷走神経性失神, 失神-神経原性, 失神-血管緊張低下性, 失神-血管迷走神経反射性
Polish Omdlenie wazowagalne, Omdlenie z podrażnienia nerwu błędnego, Omdlenie neurogenne, Omdlenie neurokardiogenne, Zespół nerwu błędnego
Hungarian Vasovagalis reakció, Vagovagalis syncope, Vasovagalis syncope, Vagus-reakció, Vaso-vagalis roham, Vasovagalis roham, Neurocardiogen syncope
Norwegian Synkope, nevrokardiogen, Vasovagal synkope, Nevrokardiogen synkope, Synkope, vasovagal
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Syncope, Tussive (C0234435)

Concepts Disease or Syndrome (T047)
MSH D013575
SnomedCT 207067001, 90129003
English [D]Cough syncope (context-dependent category), [D]Cough syncope, Syncopes, Tussive, Tussive Syncope, Tussive Syncopes, cough syncope, tussive syncope, syncope cough, laryngeal vertigo, coughing syncope, Charcot vertigo, [D]Cough syncope (situation), Laryngeal vertigo, Tussive syncope, Cough syncope, Laryngeal syncope, Tussive syncope (disorder), syncope; tussive, tussive; syncope, Tussive syncope (finding), Syncope, Tussive
Dutch hoestsyncope, syncope; tussief, tussief; syncope
French Syncope tussive, Syncope de la toux, Toux syncopale
German Hustensynkope
Italian Sincope da accesso di tosse, Sincope da tosse, Sincope tussiva
Portuguese Síncope tússica, Síncope tussígena
Spanish Síncope tusivo, [D]síncope tusígeno (categoría dependiente del contexto), [D]síncope tusígeno, [D]síncope por tos, [D]síncope tusígeno (situación), Síncope tusígeno, síncope laríngeo, síncope por tos, síncope tusivo, vértigo laríngeo, síncope tusivo (hallazgo), síncope tusivo (trastorno)
Czech Kašlová synkopa, tusigenní synkopa, Tusigenní synkopa
Hungarian Köhögési syncope
Norwegian Synkope etter hosting
Japanese ｶﾞｲｿｳｼｯｼﾝ, 咳嗽失神
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Syncope, Situational (C0340854)

Concepts Disease or Syndrome (T047)
MSH D013575
SnomedCT 234167006
French Syncope situationnelle, Syncope de situation
English Situational Syncope, Situational Syncopes, Syncopes, Situational, Situational syncope, Situational syncope (disorder), Situational syncope (finding), Syncope, Situational
Czech situační synkopa
Norwegian Synkope, situasjonsbetinget, Situasjonsbetinget synkope
Italian Sincope situazionale
Spanish síncope circunstacial (hallazgo), síncope circunstacial, síncope situacional, síncope situacional (hallazgo), síncope situacional (trastorno)
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Syncope, Micturition (C0340855)

Concepts Disease or Syndrome (T047)
MSH D013575
SnomedCT 206730009, 234168001
English [D]Micturition syncope (context-dependent category), [D]Micturition syncope, Micturition Syncope, Micturition Syncopes, Syncopes, Micturition, micturition syncope, Syncope micturition, [D]Micturition syncope (situation), Micturition syncope, Micturition syncope (disorder), Micturition syncope (finding), Syncope, Micturition
Dutch urinelozingssyncope
French Syncope à la miction, Syncope de la miction
German Synkope bei Miktion
Italian Sincope postminzionale, Sincope minzionale
Portuguese Síncope da micção
Spanish Síndrome de micturición, [D]síncope durante la micción (categoría dependiente del contexto), [D]síncope durante la micción, [D]síncope durante la micción (situación), síncope de micción, síncope miccional, síncope de micción (hallazgo), síncope de micción (trastorno)
Japanese 排尿性失神, ﾊｲﾆｮｳｾｲｼｯｼﾝ
Czech Mikční synkopa, urinární synkopa
Hungarian Syncope, vizeletürítéses
Norwegian Vannlatingssynkope, Synkope etter urinering
Derived from the NIH UMLS (Unified Medical Language System)

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