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TREATMENT OF VASOVAGAL SYNCOPE
June 8, 2018, London UK
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Where to go for help
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Syncope: HRS Definition
▪ Syncope is defined as:
—a transient loss of consciousness,
—associated with an inability to maintain postural tone,
—rapid and spontaneous recovery,
—and the absence of clinical features specific for another form of transient loss of consciousness such as epileptic seizure.
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Syncope
VasovagalCardiac
Carotid sinus
Orthostatic
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Vasovagal Syncope: HRS Definition
▪ Vasovagal syncope is defined as a syncope syndrome that usually:
1. occurs with upright posture held for more than 30 seconds or with exposure to emotional stress, pain, or medical settings;
2. features diaphoresis, warmth, nausea, and pallor;
3. is associated with hypotension and relative bradycardia, when known; and
4. is followed by fatigue.
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Physiology of Symptoms and Signs
Decreased cardiac output
Hypotension
• Weakness
• Lightheadness
Retinal hypoperfusion
• Blurred vision, grey vision, coning down
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Decreased cardiac output
Reflex cutaneous vasoconstriction
• Maintains core blood volume
• Pallor, looks grey or very white
Physiology of Symptoms and Signs
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Vasovagal reflex
Worsened hypotension• More weakness• More lightheadness
Vagal• Nausea and vomiting• Diarrhea• Abdominal discomfort
Physiology of Symptoms and Signs
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Increase arterial conductance
SYNCOPE
Rapid transit of core blood to skin• Hot flash• Warmth and discomfort• Lasts seconds• Pink skin
Physiology of Symptoms and Signs
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Collapse
• Preload restored
• Reflexes end
• Skin colour recovers
• Exhausted
Physiology of Symptoms and Signs
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Why do we need to treat people?
• Impact on life
• Work, school, driving
• Quality of life
• Injury
• Anxiety
• Everyone is different 11
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STRATEGY
First: Listen
Second: Teach
Third: Drugs
Fourth: Pace, rarely
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Prognosis depends on previous year
7% recurrence
46% recurrence
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TREATING VASOVAGAL SYNCOPE
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TREATING VASOVAGAL SYNCOPE
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VVS Treatment Strategy
▪ Occasional episode
— reassure, fluid/salt, counterpressure maneuvers
▪ No episode in previous year
—no Rx
▪ Recurrent VVS
—conservative Rx, eliminate drugs causing hypotension
▪ Recurrent VVS
— fludrocortisone,
—midodrine or
—β-blockers (over age 40)16
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Placebo vs no pill control
Flevari et al J Am Coll Cardiol 40:499, 2003
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Meta analysis of recurrences without treatment
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SALT AND FLUID
Orthostatic stress almost always involved
Many patients avoid salt actively
Intravenous saline prevents positive tilt
tests and vasovagal syncope
Simple, safe, inexpensive
Probably need 6 gm salt per day
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PHYSICAL MANOUEVRES
Shuffling and leg crossing
Lying down
Squatting
Isometric leg crossing
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PC-TRIAL
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Active treatments to consider
• Fludrocortisone
• Midodrine
• Beta blockers
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POST2: Fludrocortisone in VVS
Pl – 60.0%
F – 43.6%
P=0.066 (Logrank)
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Post Hoc Analysis Outcome Results
after 2 weeks 0.2 mg treatment
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Prevention of Syncope Trial (POST)β-Blockers for VVS
0 3 6 9 12
0.0
0.2
0.4
0.6
0.8
1.0
Metoprolol (N=107)
Months to Syncope
Syncop
e-F
ree S
urv
ival
R Sheldon et al., Circulation. 2006;113(9):1164-70.
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0 3 6 9 12
0.0
0.2
0.4
0.6
0.8
1.0Age <42
Metoprolol (N=57)
Placebo (N=56)
0 3 6 9 12
0.0
0.2
0.4
0.6
0.8
1.0
Metoprolol (N=49)
Placebo (N=42)
Age ≥ 42
Months to Syncope
Syn
co
pe
-Fre
e S
urv
iva
l
POST: Treatment by Age Group
P<0.05
R Sheldon et al., Circulation. 2006;113(9):1164-70.
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POST 5
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MIDODRINE EFFECTS
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POST 4
• Prodrug for alpha1 adrenergic agonist
•Does not penetrate blood brain barrier
•Metabolite half life 2.5 hours
•Increases venoconstriction and arteriolar
constriction
•Increases preload and peripheral resistance
•Start at 5 mg po tid q4h
•Piloerection, paresthesias, hypertension,
urinary retention
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MIDODRINE
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Non-invasive treatment of vasovagal syncope
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Start with clinical trial of florinef in normotensive
patients
Treat patients who have fainted in the previous year
Teach increased salt and fluid intake in patients with
normal blood pressure
Teach patients to use physical manoeuvres
Use metoprolol in patients >40 years, especially with
co-morbidities such as hypertension
Midodrine in normotensive patients with frequent
syncope
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STRATEGY
1. We as physicians are the best treatment
2. Reduce hypotensive drugs
3. Teach, teach, teach
4. Commit to seeing again if unsure
5. Florinef or midodrine
6. Beta blockers
7. Rarely pacemakers