Syncope medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Overview

Medical therapy is the mainstay of the treatment based on the cause and mechanism of syncope for preventing syncope recurrences and traumatic injuries and prolonging survival. All patients with cardiac syncope should be hospitalized. If the mechanism of syncope is bifascicular block, permanent pacemaker is recommended. In the setting of inferior myocardial infarction and complete heart block, implantation of permanent pacemaker is not the first decision and the best approach is treatment of myocardial infarction. In syncope secondary to documented ventricular tachyarrhythmia (VT), ventricualr fibrillation (VF) due to structural heart disease such as ischemic and non-ischemic cardiomyopathy and decreased left ventricular ejection fraction treatment of arrhythmia and ICD implantation is warranted. In VT secondary to sarcoidosis and frequent syncope due to reentry arrhythmia loop around the granulom formation in myocardium, ICD implantation is necessary. In inherent causes of ventricular tachyarrhythmia such as long QT syndrome, short QT syndrome, Brugada, cathecolaminegic polymorphic ventricular tachycardia (CPVT), arrhythmogenic right ventricular dysplasia (ARVC) making decision for ICD implantation is associated with documented ventricular tachyarrhythmia. For other type of syncope increasing salt and discontinuation of causing medications and education of the patient is recommended. Patients with neurally mediated syncope should be educated about participate factors such as dehydration, prolong standing, alcohol, diuretic, vasodilators and sitting down or lie-down at the onset of symptoms and doing counterpressure maneuvers (hand gripping, leg crossing, arm tensing). Medications may be helpful in neurally mediated syncope include betablocker, midodrine, SSRI.

Medical Therapy

• Medical therapy is the mainstay of the treatment based on the cause and mechanism of syncope for preventing syncope recurrences and traumatic injuries and prolong survival.

• All patients with cardiac syncope should be hospitalized.
• If the mechanism of syncope is bifascicular block, permanent pacemaker is recommended.
• In the setting of inferior myocardial infarction and complete heart block, implantation of a permanent pacemaker is not the first decision and the best approach is the treatment of myocardial infarction.
• In syncope secondary to documented VT, VF due to structural heart disease such as ischemic and non-ischemic cardiomyopathy and decreased left ventricular ejection fraction treatment of arrhythmia and ICD implantation is warranted.
• In the first 24-48 hours of myocardial infarction and occurence of VT or VF, ICD implantation is not indicated.
• In VT secondary to sarcoidosis and frequent syncope due to reentry arrhythmia loop around the granuloma formation in myocardium, ICD implantation is necessary.
• In inherent causes of ventricular tachyarrhythmia such as Long QT syndrome, Short QT syndrome, Brugada, Catecolaminegic polymorphic ventricular tachycardia (CPVT), Arrhythmogenic right ventricular dysplasia(ARVC) making decision for ICD implantation is associated with documented ventricular tachyarrhythmia.
• For other types of syncope increasing salt intake and discontinuation of causing medications and education of the patient are recommended.
• Patients with neurally mediated syncope should be educated about participate factors such as dehydration,prolong standing, alcohol,diuretic, vasodilators and sitting down or lie-down at the onset of symptoms and doing counterpressure maneuvers( hand gripping, leg crossing, arm tensing).
• Medications may be helpful in neurally mediated syncope include betablocker,midodrine, SSRI.

Recommendation for treatment of Reflex-Mediated Syncope according to 2017 AHA/ACC/HRS Guideline

Recommendations for treatment of Reflex syncope

Vasovagal syncope : (Class I, Level of Evidence C)

❑Avoidance of triggers(prolonged standing, warm environments, coping with dental and medical setting

Vasovagal syncope : (Class IIa, Level of Evidence B)

❑ Supine position for prevention of faint and injury in short prodrome phase ❑ Physical counter maneuvers (leg crossing, limbs or abdominal contraction, squatting in long prodrome phase ❑ Midodrine in recurrent vasovagal syncope without history of hypertension, heart failure, urinary retension

Vasovagal syncope : (Class IIb, Level of Evidence B)

❑ Lacking evidence about the benefit of orthostasis training such as repeating tilt table test until negative result or 30-60 minutes standing against a wall daily ❑ Flodrocortisone in patients with inadequate response to salt, fluide intake ❑ Betablocker in patients with recurrent vasovagal syncope ,older than 42 years ❑ Elimination or reduction the medications causing hypotension and syncope ❑ Selective serotonin reuptake inhibitors such as fluoxetine ,paroxetine for prevention of recurrent vasovagal syncope ❑ Dual chamber pacing in patients older than 40 years and recurrent syncope with pause > 3 seconds related with syncope or asymptomatic pause >6 seconds

Carotide sinus syndrome : (Class IIa, Level of Evidence B)

❑ Cardiac pacemaker implantation in recurrent cardioinhibitory or mixed syncope

Carotide sinus syndrome : (Class IIb, Level of Evidence B)

❑ Dual-chamber pacemaker in older patients with underlying sinus node dysfunction or conduction abnormality

Recommendation for treatment of Cardiac Syncope according to 2017 AHA/ACC/HRS Guideline

Recommendations for treatment of cardiac syncope

Bradyarrhythmia (Class I, Level of Evidence C):

❑ Implantation of dual-chamber permanent pacemaker in chronic bifascicular block but without documented high grade AV block

Supraventricular tachycardia(Class I, Level of Evidence C) :

❑ Treatment of the arrhythmia based on guideline directed medical theray Uncommon causes of syncope especially in younger patients In the syncope related to SVT , vasovagal syncope or ventricular arrhythmia should be investigated In the syncope related to rapid atrail fibrillation without preexcitation, vasovagal syncope and sinus node dysfunction in the presence of long pause should be considered

Ventriculat arrhythmia : (Class I, Level of Evidence C)

❑ Treatment of tachyarrhythmia based on the guideline and underlying cardiac causes of ventricular arrhythmia ❑ Making decision for ICD implantation related to the recurrence of tachyarrhythmia In ventricular tachycardia with the rate>200 min, the incidence of syncope and near syncope is 65%

Ischemic and non ischemic cardiomyopathy:(Class I, Level of Evidence C)

❑ Treatment of underlying causes of cardiomyopathy ❑ ICD implantation in the presence of ventricular arrhythmia during electrophysiological study

Valvular heart disease : (Class I, Level of Evidence C)

❑Aortic valve replacement should be considered in patients with severe AS and exersional syncope In the syncope related to severe aortic stenosis, the mechanism of syncope is low cardiac out put state

Hypertrophic cardiomyopathy (Class I , Level of Evidence C):

❑ Inadequate data about the relation between unexplained syncope as the predictor of SCD ❑ ICD implantation indicated only in patients with a recent history of more than one episode of syncope suspected to be ventricular tachyarrhythmia

Arrhythmogenic right ventricular cardiomyopathy : (Class I , Level of Evidence B)

❑ ICD implantation indicated in the setting of sustain VT leading syncope

Cardiac sarcoidosis : (Class I , Level of Evidence B)

❑ ICD implantation indicated in the presence of syncope due to ventricular tachycardia ❑ Mechanism of ventricular tachycardia is macro reentry around granulomas and triggered activity and automaticity due to myocardial inflammation ❑ Inadequate data about The role of immunosuppression therapy in decreasing ventricular arrhythmia ❑ Immunosuppression therapy, permanent pacemaker in irreversible cases is recommended in AV block

Brugada : (Class IIa, Level of Evidence B)

❑ ICD implantation in suspected arrhythmia leading syncope

Brugada : (Class IIb, Level of Evidence B)

❑ EPS may be helpful for finding ventricular arrhythmia leading syncope

Brugada : (Class III, Level of Evidence B)

❑ ICD is not recommended in patients suspected reflex mediated syncope

Short QT syndrome : (Class IIb, Level of Evidence C)

❑ ICD implantation in the presence of documented ventricular arrhythmia and family history of SCD Short QT syndrome definition: QTc interval≤340 ms Syncope is not the risk factor of SCD in the absent of documented VT or VF

Long QT syndrome : (Class I, Level of Evidence B)

❑ Beta-blocker therapy in patients with frequent episodes of syncope reduces risk of fatal arrhythmia specially in LQTS1 Long QT syndrome definition: QTc interval ≥ 500 ms

Long QT syndrome : (Class IIa, Level of Evidence B)

❑ICD implantation in syncope related arrhythmia in patients are on betablocker or intolerant to betablocker ❑ Left cardiac sympathectomy in frequent episodes of syncope arrhythmia in patients are on betablocker or intolerant to betablocker (LOR=C)

Catecholaminergic polymorphic ventricular tachycardia(CPVT) : (Class I, Level of Evidence C)

❑ Exercise restriction in patients suspected arrhythmia leading syncope ❑ Betablocker therapy for reduction of sympathetic activity in stress-induced tachyarrhythmia CPVT definition: catecholamine-induced (often exertional) bidirectional VT or polymorphic VT in the setting of a structurally normal heart and normal resting ECG

CPVT : (Class IIa, Level of Evidence C)

❑ Flecainide in patients with syncope arrhythmia in spite of betablocker therapy ❑ICD implantation in patients with arrhythmia leading syncope in spite of optimal medical therapy ([[LOR=B)

Cathecolaminergic polymorphic ventricular tachycardia(CPVT) : (Class IIb, Level of Evidence C)

❑ Verapamil in patients with syncope arrhythmia during exercise in spite of betablocker therapy

Recommendation for treatment of syncope due to dehydration and medications according to AHA/ACC/HRS Guideline

Class I, Level of evidence:C

Fluid rescucitation orally or intravenous is useful for syncope related to hypotension or exercise associated hypotension due to peripheral vasodialation

Class IIa, Level of evidence:B

Reducing or withdrawing medications causing hypotension and syncope such as diuretics, vasodilators, venodilators, sedatives, negative chronotropes

Class IIa, Level of evidence:C

Salt and fluid intake in syncope due to dehydration

Educational points for Patients

Recommended treatment is to allow the person to lie on the ground with his or her legs slightly elevated. As the dizziness and the momentary blindness passes, the person may experience visual disturbances in the form of small bright dots (phosphene). These will also pass within a few minutes. After initial stabilization, the treatment of syncope depends on the causes.

Reflex mediated Syncope

• Educating patients not to wear tight collars for preventing carotid sinus hypersensitivity syncope, cough suppression by medication for preventing situational syncope,physical counterpressure maneuvers at the onset of neurally mediated syncope (common faint).

Orthostatic Hypotension

• The patient should be careful when changing positions from sitting to standing.