Medical Therapy and Physical Maneuvers in the Treatment of the Vasovagal Syncope and Orthostatic Hypotension

Abstract

Patients with vasovagal syncope and neurogenic orthostatic hypotension can both present with pre-syncope and syncope resulting from systemic hypotension. While not directly responsible for increased mortality, both of these conditions can have a tremendous deleterious impact on the daily lives of patients. This negative impact can take the form of both physical symptoms and injury, but also a psychological impact from living in fear of the next syncopal episode. Despite these similarities, these are different disorders with fixed damage to the autonomic nerves in neurogenic orthostatic hypotension, as opposed to a transient reflex hypotension in “neurally mediated” vasovagal syncope. The treatment approaches for both disorders are parallel. The first step is to educate the patient about the pathophysiology and prognosis of their disorder. Next, offending medications should be withdrawn when possible. Non-pharmacological therapies and maneuvers can be used, both in an effort to prevent the symptoms and to prevent syncope at the onset of presyncope. This is all that is required in many patients with vasovagal syncope. If needed, pharmacological options are also available for both vasovagal syncope and neurogenic orthostatic hypotension, many of which are focused on blood volume expansion, increasing cardiac venous return, or pressor agents to increase vascular tone. There is a paucity of high quality clinical trial data to support the use of these pharmacological agents. We aim to review the literature on these different therapy choices and to give recommendations on tailored approaches to the treatment of these conditions.

Depressive Symptoms and Orthostatic Hypotension Are Risk Factors for Unexplained Falls in Community‐Living Older People

“…This might in turn enable a reduction in the use of antidepressants—an established risk factor. Regarding orthostatic hypotension, antihypertensive and psychotropic drugs that can contribute to orthostatic hypotension might be addressed in medication reviews, and adjunct therapies involving physical maneuvers, the use of compression stockings, and ensuring optimal fluid intake might be recommended.…”

Postural Tachycardia Syndrome: Beyond Orthostatic Intolerance

“…Patients with vasovagal syncope are able to maintain their BP for several minutes following HUT and then experience a rapid drop in BP as stroke volume and cardiac output decrease. Ensuing cerebral hypoperfusion causes a sudden loss of consciousness [39;40]. Patients with POTS, on the other hand, have a fairly steady BP when tilted up, but orthostatic tachycardia is enhanced as sympathetic tone increases to compensate for the decrease in circulating blood volume [2].…”

Autonomic Dysfunction in Cardiology: Pathophysiology, Investigation, and Management

“…Patients should be educated that VVS is itself not associated with mortality, 12, 13 to lie down at onset of prodromal symptoms, and to avoid triggers for syncopal episodes 19 . Dietary sodium and water intake should be increased in patients without renal failure, heart failure, or hypertension.…”