Progress in the pharmacological management of vasovagal syncope

Vasovagal syncope is a frequent problem affecting nearly half the population. The symptom burden is wide, ranging from once to hundreds of times. It reduces quality of life and causes injuries. Physicians, particularly front-line physicians such as family doctors, need a simple, practical approach.

We provide context on syncope frequency, competing diagnoses, and natural history, usually characterized by improvement and remissions. Quality of life is reduced and accompanied by anxiety and improves with care. Injuries are common but serious injuries are rare. Treatment begins with advice on salt and fluid intake and physical maneuvers. Fludrocortisone, midodrine, and 2 serotonin-specific reuptake inhibitors are effective, and beta blockers should not be used. Atomoxetine is under investigation. Pacemakers and ablation must be reserved for the rare patient who has not responded to more conservative treatments.

Patients usually do well and respond to ongoing support and simple dietary advice and physical tips. Some benefit from fludrocortisone, midodrine, or serotonin-specific reuptake inhibitors. Almost all patients eventually stop fainting, and invasive treatments should be used last and for the very few highly afflicted patients who do not improve with safer measures.