Syncope toolkit
Management of syncope
See the section on Cardiac syncope for management of individual cardiac conditions.
In this section:
- Self-care measures
- Physical counterpressure manoeuvres
- Medication
- Pacemakers
- Psychological support
- Driving advice.
Self-care measures
The following are useful techniques to relieve symptoms and prevent syncope in the following conditions:
- Vasovagal syncope (VVS)
- Orthostatic hypotension (OH) - useful in many types of OH (but not in acute volume depletion)
- Postural tachycardia syndrome (PoTS).
Self-care measures include:
- Reduce or remove culprit medications
- Avoiding triggers such as prolonged standing, heat, alcohol
- Maintaining good fluid intake of 2-2.5 litres a day in adults - advise two cups of water before rising
- Additional salt, from 6-10g a day (unless contraindicated)
- Diet, for example regular meals, fibre to prevent straining in defaecation syncope and avoid heavy meals in post-prandial hypotension
- Compression such as waist high tights or compression sports clothing, abdominal binder
- Maintaining fitness
- Postural counterpressure-manoeuvres (see images below)
- Medical alert bracelets can be useful for people who faint regularly.
| Self management strategy | VVS | OH | PoTS |
|---|---|---|---|
| Stop medication that lowers blood pressure | Yes | Yes | Yes |
| Stop medication that can provoke tachycardia | Yes | ||
| Avoid triggers such as standing, heat, alcohol, rich meals | Yes | Yes | Yes |
| Maintain high fluid intake of 2-4 litres a day in adults | Yes | Yes | Yes |
| Rapid water drinking (two lots of 8oz boluses) | Yes | Yes | Yes |
| Additional salt (unless contraindicated) | Yes | Yes | Yes |
| Postural counterpressure manoeuvres (see image below) | Yes | Yes | Yes |
| Compression | Yes | Yes | |
| Maintain fitness | Yes | Yes | Yes |
| Elevate head end of the bed by 10-20 degrees | Yes |
Physical counterpressure manoeuvres
These measures can raise blood pressure in VVS and OH, and lower heart rate in PoTS.
Images used with consent of Prof Wouter Wieling.
This short YouTube video 'How can I prevent a syncopal episode?' describes how patients with vasovagal syncope can prevent syncope using postural countermeasures.
Medication
See the section on Cardiac syncope for medication in cardiac conditions.
Medication used in orthostatic hypotension, vasovagal syncope and PoTS:
- Medication should be used if self-management techniques have failed to improve symptoms and is used in combination with these
- The evidence base for medication is limited
- Drugs mostly aim to increase blood volume and constrict blood vessels. In PoTS some also aim to blunt the tachycardia
- The only medication listed below that has marketing authorisation (‘is licensed’) for the use indicated is midodrine for refractory orthostatic hypotension. Others may be prescribed under a shared care agreement.
Medication used in V V Syncope, OH and PoTS
Download Medication used in V V Syncope, OH and PoTS (52 KB PDF)
Evidence for medication in VVS, OH and PoTS
| Medication | Adult dose | VVS | OH | PoTS |
|---|---|---|---|---|
| Fludrocortisone | 0.1-0.3 mg OD | ++ | + | + |
| Midodrine | 2.5-10 mg TDS -last dose at about 6pm (higher dose sometimes used in PoTS) | ++ | + | ++ |
| B Blockers | Propranolol in PoTS 10-20mg QDS | + over 40 years old | ++ | |
| Pyridostigmine | 30-60mg TDS in PoTS and OH | + | + | |
| Octreotide | + | + | ||
| Ivabradine | 2.5-7.5 mg BD in PoTS | + | ||
| Methyl dopa | 125-250 mg OD or BD in PoTS | + | ||
| Clonidine | 0.1-0.2 mg On or BD in PoTS | + | ||
| Desmopressin | 0.1-0.2mg od as needed | + | + | |
| Droxidopa | 100-600mg tds | + | + | |
| Intravenous fluids (when acutely decompensated) | 1-2 litres | + | + |
+ may be used in this condition, weaker evidence
++ stronger evidence for use of this medication
Pacemakers
In vasovagal syncope with asystole, cardiac pacing may be effective in preventing syncope when tilt testing is negative. Pacing shows less benefit in tilt positive patients, possibly because the latter may faint primarily due to the vasodepressor response (blood pooling) which will not respond to pacing. The former may have more dominance of cardio-inhibition (vagal) response.
Pacemakers should be avoided if possible in people under the age of 40.
Psychological support
Syncope and quality of life
There are significant quality of life implications for people experiencing syncope.
"The experience of VVS is at best inconvenient, and may be [self]-perceived as threatening and disabling.” (Gracie, Baker, Freeston and Newton 2014)
Quality of life impact has been equated to severe rheumatoid arthritis or chronic low back pain. Fear of an episode can result in a pattern of avoidance behaviours, which can increase the likelihood of further anxiety-precipitated neuro-cardiogenic or non-haemodynamic syncopal events. This can lead to a vicious cycle of increased fear, avoidance and despondency.
Associated isolation and impacts on activity levels can lead to depression, which has been demonstrated to have implications for adherence to health-related behaviours in other health conditions including cardiovascular disease.
Psychological assessment and therapeutic intervention
Psychiatric or psychological assessment may be considered for all patients experiencing syncope. As well as adjustment-related distress, it has been suggested that psychological issues can be associated with the development and maintenance of VVS. Rates of anxiety and depression are higher in people experiencing VVS than for matched healthy controls, and worsen with the increasing frequency of episodes and certainly treatment of any co-morbid psychiatric disorders using current treatment guidelines will be critical to optimise outcome.
Pharmacological treatment
There has been some evidence of serotonin’s role in blood pressure regulation in VVS, and some evidence that SSRIs can be beneficial, but trial data is unconvincing. However, it is unclear whether this is due to a direct effect on the physiological mechanism, the effect of an improvement in mood, or the interaction of these.
Psychotherapy
Currently the efficacy of CBT for syncope has been demonstrated in a series of case-studies (Newton, 2003) leading to a decrease in episodes and subjective improvement in quality of life and return to work or school.
This study focused on identifying and restricting unhelpful beliefs, addressing maladaptive somatic attention, reducing avoidance, improving a sense of control over symptoms with applied tension for example, as well as the individual’s more idiosyncratic challenges such as sleep, relationship struggles associated with compromised health and avoidance, and hopelessness about the future.
Other important factors include treating underlying disorders, reducing guilt, shame and frustration associated with ill-health, and helping patients focus on how to still live a rewarding and fulfilling life even with their physical limitations.
Driving advice
Assess all syncope patients for fitness to drive. As driving advice is changed regularly, always check the DVLA website (or equivalent organisation if outside the UK) for up to date guidance. At the time of writing in 2020:
- Group 1 drivers - in general, patients with uncomplicated vasovagal syncope that only occurs when standing may drive and need not notify the DVLA
- Group 2 drivers – all group 2 drivers with syncope of any cause should cease driving immediately and must notify the DVLA
- There are many more complicated scenarios including syncope whilst seated, cough syncope, cardiac syncope, and unexplained syncope where guidance is complex and variable, and the guidelines should be consulted for detailed advice.
*Record the advice that you have provided regarding driving in the patient’s medical records.
Visit GOV.UK for up to date advice about driving in the UK.