Syncope and Collapse: Therapy

General Measures [ESC Syncope Guidelines 2018 + S1 Guideline 2020]

  • Immediately call 911! (Call 112)
  • Clarification:
    • Is it syncope or are there other reasons for the circulatory collapse?
    • Is there a risk that the patient could suffer a cardiovascular event or die?
  • The following questions should be asked by the clinician when evaluating fainting in the emergency department:
    • Is there a serious cause for the loss of consciousness?
    • If the cause is unknown, what is the risk that the loss of consciousness may have serious causes?
    • Should the patient be admitted as an inpatient?
      • Asymptomatic patients with unexplained syncope are considered high-risk if the following findings are present:
        • Family history of sudden cardiac death or death of a family member less than 30 years of age.
        • Advanced age or serious morbidity (concomitant disease).
        • History or clinical signs of heart failure (cardiac insufficiency).
        • Abnormal electrocardiogram (ECG; recording of the electrical activity of the heart muscle).
        • Hematocrit (proportion of cellular components in the volume of blood) < 30 or evidence of clinically relevant volume deficiency.
      • Symptomatic high-risk patients and patients with cardiac (heart-related) or cerebrovascular (brain vessel-related) syncope require further evaluation and must be admitted as inpatients.
      • For fall sequelae requiring treatment, inpatient admission occurs regardless of the risk situation.
      • Asymptomatic patients with unclear syncope and low risk can be discharged promptly – further assessment is performed on an outpatient basis.
    • Medication history (for neurogenic orthostatic hypotension/orthostatic hypotension): “Triggering or exacerbating medications such as alpha-blockers, diuretics, vasodilators, dopamine agonists, tricyclic antidepressants, or venodilators should be reduced, stopped, or changed” [S1 Guideline].

Therapy [ESC Syncope Guidelines 2018 + S1 Guideline 2020]

Carotid sinus massage (unilateral pressure on the carotid sinus); indication:

  • Patient > 40 years
  • Cause of syncope unclear and reflex mechanism not excluded.

Orthostatic vasovagal syncope.

Patients with vasovagal syncope (VVS; synonym: reflex syncope):

  • Education about the favorable prognosis of vasovagal syncope (VVS) (no heart disease, no reduced life expectancy).
  • Avoidance of trigger mechanisms: e.g., lack of fluids, prolonged standing, overheated rooms.
  • Physical measures: General, circulation-strengthening measures.
  • Medication in young patients with hypotension: see below drug therapy.
  • Young patients with prodromes (early symptoms of disease): counterpressure maneuvers (including tilt training, if needed).
  • Elderly patients with dominant cardioinhibitory reflex syncope: Implantation of a cardiac pacemaker (HSM).
  • Elderly patients with hypertension: discontinuation of antihypertensive (antihypertensive) therapy or dose reduction until a target systolic blood pressure is reached (according to lead lines; see hypertension (hypertension) below).

Patients suffering from reflex syncope (e.g., vasovagal syncope, situational syncope, carotid sinus hypersensitivity) or orthostatic hypotension* must be educated and reassured about the diagnosis. They must be informed about the risks of recurrence and measures to prevent recurrence. The following advice should be given in this regard, among others:

General, circulation-strengthening measures may contribute to improvement:

  • Slow getting up in the morning
  • Sufficient fluid (about 1.5-2.0 (2.5) l/day) and salt intake (5-6 g/day)
  • Alternating showers
  • Brush massages
  • Sauna visits
  • Wearing an elastic abdominal bandage (abdominal bandage) and / or compression stockings.
  • Sports: swimming, running and tennis are recommended.
  • Regular standing training (daily at least 30 minutes of leaning standing (in a safe environment), with feet about 20 cm from the wall) in patients with orthostatic vasovagal syncope.
  • Sleeping with the upper body elevated
  • Isometric countermaneuvers in the syncopal prodromal phase (precursor phase of syncope):
    • Squatting or crossing the legs or tensing the gluteal, abdominal, leg, and arm muscles (= physical counterpressure maneuvers).
  • If necessary, interruption of antihypertensive (blood pressure-lowering) therapy or dose reduction.

Selected patients with or without short prodromes (uncharacteristic signs or even early symptoms of disease): insertion of an implantable event recorder (event recorder).

* Orthostatic hypotension is defined by a drop in blood pressure within 3 minutes of changing position from lying to standing; systolic blood pressure drops by more than 20 mmHg or to a value below 90 mmHg absolute; diastolic blood pressure drops by more than 10 mmHg. Neurogenic orthostatic hypotension (NOH).

Treatment of causative underlying diseases such as diabetes mellitus or Parkinson’s syndrome.

Avoidance of triggering mechanisms through behavioral interventions:

  • Avoidance of warm or hot environments (e.g., hot baths, showers, saunas due toincreased venous pooling).
  • Getting up after night sleep: no abrupt getting up due torisk of blood pressure lowering
    • If necessary, before getting up preventive drinking half a liter of water.
    • Bes. careful getting up when going to the toilet at night.
  • Postprandial state (after eating): increased risk of orthostatic hypotension due to vasodilation conditioned by sumptuous meals and/or alcohol consumption.
    • Avoid meals before prolonged periods of standing.
    • Alcohol consumption at a later time or not at all

Physical measures

  • Wearing an elastic abdominal bandage (abdominal bandage) and / or compression stockings.
  • Sufficient fluid (approx. 1.5-2.0 (2.5) l/day) and saline intake (5-10 g/day) – esp. shortly before standing load and before meals
  • Sleeping with elevated headboard, i.e. head end of the bed elevated by 20-30 cm.

Medication to reduce orthostatic hypotension:

  • Midodrine (alpha-sympathomimetic; 3 × 2.5-10 mg/d) to improve vasoconstriction (vasoconstriction).
  • Fludrocortisone (mineralocorticoid; 1-2 × 0.5 mg/d) for volume augmentation (approved for short-term therapy only)

Postural tachycardia syndrome.

Behavioral avoidance of trigger mechanisms:

  • Frequent small meals instead of one large meal
  • Avoidance of excessive bed rest and physical sparing
  • Slowly get up from lying or sitting down
  • Sufficient fluid (about 1.5-2.0 (2.5) l / day) and salt intake (5-10 g / day) – insb. shortly before standing load and before meals
  • Endurance training (30 to 45 minutes, three times a week).

Conventional non-surgical therapy methods

Specific therapy of the leading arrhythmia. If structural (cardiac or cardiopulmonary) disease is present, treatment of it. Cardiac syncope

  • Pacemaker (HSM) or pacemaker (PM)/pacemaker – for bradyarrhythmias (very slow heartbeat with a rate below 50 beats per minute with no discernible rhythm).
  • Implantable cardioverter/defibrillator (ICD) – for hemodynamically unstable tachyarrhythmias (too fast and absolutely unrhythmic heartbeat: the heart rate is usually well above 90/minute).
  • Catheter ablation – for ventricular and supraventricular tachyarrhythmias (tachyarrhythmias coming from the ventricle (ventricular) or the atrium (supraventricular))Catheter ablation (Latin ablatio “ablation, detachment”) of the tissue parts that send pathological (pathological) electrical impulses is performed by means of a catheter-based procedure via inducing a scar.

ICD implantation

  • In patients with unexplained syncope and a high risk of sudden cardiac death (PHT; see related condition of the same name), weigh the benefits of ICD implantation against the risks.
  • In the presence of syncope and impaired left ventricular ejection fraction, but above 35% (i.e., without an undisputed ICD indication), there is an ICD indication (IIa C) [Syncope Guidelines 2018].