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Vasovagal Syncope

Aka: Vasovagal Syncope, Neurocardiogenic Syncope

I. See Also

  1. Vasodepressor Syncope

II. Causes

  1. See Syncope

III. Definition: Vasovagal Syncope

  1. Dysautonomic response to upright Posture
  2. Includes
    1. Orthostatic Hypotension
    2. Postural Orthostatic Tachycardia Syndrome (POTS)

IV. Phases

  1. Precipitating event (e.g. stress, prolonged standing)
    1. Prolonged standing
    2. Sitting
    3. Heat
    4. Stress
  2. Prodrome (present in 50% of cases)
    1. Duration: Seconds to minutes
    2. Symptoms
      1. Diaphoresis (most common)
      2. Epigastric Pain
      3. Fatigue
      4. Nausea
      5. Pallor
      6. Dizziness or Vertigo
    3. Palliative
      1. Lying down may prevent loss of consciousness and relieve symptoms
  3. Loss of consciousness
    1. May occur without prodrome in half of cases
    2. Brief Seizure-like activity (Myoclonus) may occur on collapse in 5% of cases
  4. Post-Syncope
    1. Duration: Hours
    2. Symptoms
      1. Confusion
      2. Dizziness or Vertigo
      3. Nausea
      4. Malaise

V. Management: General

  1. General prevention measures
  2. Increase volume status
  3. Consider increased dietary salt when appropriate
  4. Adjust medications to lower dose
    1. Alpha Adrenergic Antagonist (Prazosin)
    2. Antianginal nitrates (Nitroglycerin)

VI. Management: Medical

  1. Expected medication course
    1. Continue medication for 1 year then taper off
  2. Indications for medical management (see below)
    1. More than two syncopal episodes
    2. Increasingly recurrent syncopal episodes
    3. Syncope without warning or prodrome
    4. Syncope in high risk occupation
      1. Airplane pilot
      2. Truck driver

VII. Approach Step 1: Assess Hemodynamic response to standing

  1. No Hemodynamic Response
    1. See Step 2 below
  2. Blood Pressure decreases: Orthostatic Hypotension
    1. Criteria
      1. Systolic Blood Pressure decreases more than 20 mmHg
      2. Systolic Blood Pressure <90 mmHg within 3 minutes
    2. Management
      1. Increased salt intake
      2. Fludrocortisone (water and salt retention)
      3. Midodrine (Vasoconstrictor)
  3. Pulse increase: Postural Orthostatic Tachycardia (POTS)
    1. Criteria
      1. Heart Rate increases more than 30 beats per minute
      2. Heart Rate >120 beats per minute
    2. Management
      1. Fludrocortisone (water and salt retention)
      2. Midodrine (Vasoconstrictor)
      3. Beta Blockers

VIII. Approach Step 2: Tilt Test not done (Empiric Therapy)

  1. No Hypertension
    1. Fludrocortisone (water and salt retention)
    2. Midodrine (Vasoconstrictor)
    3. Consider Tilt Test
  2. Hypertension
    1. First line
      1. Beta Blocker
    2. Second line
      1. Clonidine
      2. Disopyramide
      3. Selective Serotonin Reuptake Inhibitor (SSRI)
        1. Paroxetine (Paxil) 20 mg PO qd
        2. Di Girolamo (1999) J Am Coll Cardiol 33:1227-30 [PubMed]
    3. Third line
      1. Pacemaker

IX. Approach Step 3: Obtain Tilt Test

  1. Tilt Test Criteria
    1. No concurrent medications
    2. Tilt for 45 minutes at 60 to 70 degrees
  2. Gradual fall in Blood Pressure: Dysautonomic Syncope
    1. Fludrocortisone (water and salt retention)
    2. Midodrine (Vasoconstrictor)
  3. Abrupt fall in Blood Pressure: Vasovagal Syncope
    1. Heart Rate increases prior to Blood Pressure drop
      1. First Line
        1. Beta Blocker
      2. Second Line
        1. Fludrocortisone (water and salt retention)
        2. Midodrine (Vasoconstrictor)
      3. Third line
        1. Pacemaker
    2. No change in Heart Rate prior to Hypotension
      1. First Line
        1. Fludrocortisone (water and salt retention)
      2. Second Line
        1. Beta Blocker
        2. Midodrine (Vasoconstrictor)
      3. Third line
        1. Pacemaker

X. References

  1. Bloomfield (1999) Am J Cardiol 84:33Q-9Q [PubMed]
  2. Fenton (2000) Ann Intern Med 133:722 [PubMed]
  3. Kapoor (2000) N Engl J Med 343:1856-62 [PubMed]

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Ontology: Vasovagal syncope (C0042420)

Definition (MSH) Loss of consciousness due to a reduction in blood pressure that is associated with an increase in vagal tone and peripheral vasodilation.
Concepts Disease or Syndrome (T047)
MSH D019462
ICD10 R55
SnomedCT 206728007, 162265001, 139534004, 158136005, 127380002, 230663003, 398665005, 398652001, 29423006
English SYNCOPE VASOVAGAL, SYNCOPE VAGOVAGAL, VASOVAGAL REACTION, Neurocardiogenic Syncope, Neurocardiogenic Syncopes, Neurogenic Syncope, Neurogenic Syncopes, Syncope, Neurocardiogenic, Syncope, Neurogenic, Syncope, Vasovagal, Syncopes, Neurocardiogenic, Syncopes, Neurogenic, Syncopes, Vasovagal, Vasovagal Syncopes, [D]Vasovagal attack (context-dependent category), Syncope/vasovagal faint, [D]Vasovagal attack, Vasovagal syncope, vasovagal syncope (diagnosis), vasovagal syncope, Faint, Neurally Mediated, Faints, Neurally Mediated, Neurally Mediated Faint, Neurally Mediated Faints, Syncope vagovagal, Vasovagal reaction, Vagal reaction, Neurocardiogenic syncope, Syncope vasovagal, Vaso vagal attack, Syncope, Vasovagal, Neurally-Mediated, Syncope, Vasodepressor, Syncopes, Vasodepressor, Vasodepressor Syncope, Vasodepressor Syncopes, Syncope, Vasovagal [Disease/Finding], Attack(s);vasovagal, neurogenic syncope, neurocardiogenic syncope, reaction vasovagal, syncope vasovagal, gower's syndrome, syncope neurocardiogenic, vasovagal syndrome, episodes vasovagal, episodes vagal vaso, attacks vagal, attacks vagal vaso, vaso vagal attack, vasovagal attack, vasovagal episode, syncope vasodepressor, vasodepressor syncope, vagal attack, vagal reaction, vasovagal reaction, reactions vasovagal, vaso vagal episode, vasovagal syncopes, Syncope/vasovagal faint (finding), [D]Vasovagal attack (situation), Vasovagal syncope (finding), Vasodepressor syncope (disorder), Vasodepressor syncope, Vaso vagal episode, Vasovagal attack, Gower's syndrome, Vagal attack, Vasovagal attack (disorder), Vasovagal syncope (disorder), attack; vasovagal, syndrome; vasovagal, vasovagal; attack, vasovagal; syndrome, Vasovagal Syncope, vasovagal attacks
Spanish SINCOPE VASOVAGAL, [D]crisis vasovagal (categoría dependiente del contexto), SINCOPE VAGOVAGAL, Reacción vasovagal, Síncope vasovagal, Reacción vagal, Síncope neurocardiogénico, Crisis vasovagal, síncope vasodepresor, [D]crisis vasovagal (situación), síncope/desvanecimiento vasovagal, síncope/desvanecimiento vasovagal (hallazgo), [D]crisis vasovagal, síncope vasovagal (hallazgo), ataque vasovagal (trastorno), ataque vasovagal, síncope vasovagal, síncope vasovagal (trastorno), Síncope Neurocardiogénico, Síncope Neurogénico, Síncope Vasodepresor, Síncope Vasovagal
Swedish Svimning, vasovagal
Finnish Vasovagaalinen synkopee
French Syncope neurologique, REACTION VAGALE VASCULAIRE, SYNCOPE VAGO-VAGALE, SYNCOPE VASO-VAGOTONIQUE, Réaction vagale, Attaque vaso-vagale, Syncope vaso-vagale, Syncope vagovagale, Réaction vaso-vagale, Malaise vagal, Syncope vagale, Syncope neurocardiogénique, Syncope réflexe, Syncope vasovagale
Russian NEIROGENNYI OBMOROK, OBMOROK SOSUDISTOVAGUSNYI, NEIROKARDIOGENNYI OBMOROK, �ЕЙРОГЕ��ЫЙ ОБМОРОК, �ЕЙРОК�РДИОГЕ��ЫЙ ОБМОРОК, ОБМОРОК СОСУДИСТОВ�ГУС�ЫЙ
Portuguese REACCAO VASOVAGAL, SINCOPE VAGO-VAGAL, SINCOPE VASO-VAGAL, Reacção vagal, Síncope vasovagal, Crise vasovagal, Ataque vasovagal, Síncope neurocardiogénica, Reacção vasovagal, Síncope Neurocardiogênica, Síncope Neurogênica, Síncope Vasodepressora, Síncope Vasovagal
German SYNKOPE VAGOVASAL, SYNKOPE VASOVAGAL, vasovagaler Kollaps, neurokardiogene Synkope, vasovagale Reaktion, vagale Reaktion, Synkope vasovagal, vasovagale Synkope, Synkope, neurogene, Synkope, neurokardiogene, Synkope, vasovagale, Synkope, vasodepressive
Italian Sincope neurocardiogenica, Sincope vasodepressoria, Sincope neurogenica, Sincope neuro-mediata, Sincope vasovagale neuro-mediata, Sincope vagovagale, Crisi vasovagale, Reazione vagale, Reazione vasovagale, Sincope vasovagale
Dutch vagale reactie, neurocardiogene syncope, vasovagale aanval, vasovagale reactie, syncope vasovagaal, vaso-vagale aanval, syncope vagovagaal, aanval; vasovagaal, syndroom; vasovagaal, vasovagaal; aanval, vasovagaal; syndroom, Defecatiesyncope, Mictiesyncope, Syncope, cardiovagale, Syncope, neurocardiogene, Syncope, neurogene, Syncope, orthostatische, Syncope, vasovagale, Vasodepressiesyncope, Vasovagale syncope
Czech Vagová reakce, Vazovagální reakce, Vazovagální záchvat, Vagovagální synkopa, Záchvat vazovagální, Vazovagální synkopa, Neurokardiogenická synkopa, vazovagální synkopa, vasodepresorická synkopa, synkopa vazovagální, neurokardiogenní synkopa
Japanese ｹｯｶ�ﾒｲｿｳｼ�ｹｲｾｲﾎｯｻ, 血管迷走神経性�応, ｼ�ｹｲｼ�ｿﾞｳｾｲｼｯｼ�, 神経心臓性失神, 血管迷走神経性発作, ｹｯｶ�ﾒｲｿｳｼ�ｹｲｾｲｼｯｼ�, 迷走神経性�応, ﾒｲｿｳｼ�ｹｲｾｲﾊ�ﾉｳ, ｹｯｶ�ﾒｲｿｳｼ�ｹｲｾｲﾊ�ﾉｳ, 血管拡張性失神, 失神-血管迷走神経性, 情動性失神, 神経原性失神, 血管緊張低下性失神, 血管迷走神経�射性失神, 血管迷走神経性失神, 失神-神経原性, 失神-血管緊張低下性, 失神-血管迷走神経�射性
Polish Omdlenie wazowagalne, Omdlenie z podrażnienia nerwu błędnego, Omdlenie neurogenne, Omdlenie neurokardiogenne, Zespół nerwu błędnego
Hungarian Vasovagalis reakció, Vagovagalis syncope, Vasovagalis syncope, Vagus-reakció, Vaso-vagalis roham, Vasovagalis roham, Neurocardiogen syncope
Norwegian Synkope, nevrokardiogen, Vasovagal synkope, Nevrokardiogen synkope, Synkope, vasovagal
Derived from the NIH UMLS (Unified Medical Language System)

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