Putting it together: A new treatment algorithm for vasovagal syncope and related disorders

The consensus process that culminated in this symposium established an algo rithm to guide the diagnosis and treatment of patients with vasovagal synco pe and related disorders. In some patients, the hemodynamic response to sta nding may identify an abnormality-postural orthostatic tachycardia syndrome or orthostatic hypotension-that can often be treated without further testi ng. When the response to standing is normal, tilt-table testing maybe usefu l in making the diagnosis of vasovagal syncope and guiding treatment. In so me patients, however, the diagnosis is clear from the history, and tilt-tab le testing may not be necessary. Not all patients with:vasovagal syncope ne ed to be treated, and many can be treated effectively with education, reass urance, and a simple increase in dietary salt. In evaluating the results of tilt-table testing, an important consideration is the distinction between vasovagal syncope and the dysautonomic response to tilt characterized by a gradual and progressive decrease in blood pressure that leads to syncope. C urrent practice patterns suggest that beta blockers, ftudrocortisone, and m idodrine, are commonly used to treat patients with vasovagal syncope, and p atients with the dysautonomic response are generally treated with fludrocor tisone and midodrine. Permanent pacing with specialized pacing algorithms s hould be considered for patients with frequent vasovagal syncope that is re fractory to medical therapy. The guidelines proposed here are an amalgam of clinical experience, expert opinion, and research evidence; however, they do not suggest a standard of care for all patients. (C) 1999 by Excerpta Me dica, Inc.