Management Of Syncope Research Articles

Anomalous origin of right coronary artery from left anterior descending coronary artery presenting with syncope – a case report

Introduction and importance: Non-dominant right coronary artery (RCA) is supposed to be benign as it does not result in large myocardial infarction. Still, in this case, non-dominant RCA from left anterior descending (LAD) artery not only produces ischemia but also results in incessant ventricular tachycardia, which is a life-threatening arrhythmia because of compromised blood flow. However, RCA is free of atherosclerotic plaque, which is the main cause of ischemia/infarction and subsequent arrhythmia. Case presentation: A 21-year-old male was admitted to the emergency cardiology ward of the National Institute of Cardiology following an episode of syncope. The patient reported a sudden loss of consciousness without preceding symptoms. Clinical discussion: The present case highlights the importance of a comprehensive evaluation and diagnosis in the management of syncope in young patients. The case presented here revealed a rare finding of a single coronary artery with a left main origin and an anomalous RCA emerging from the LAD artery. This is a very unusual presentation, with less than 50 occurrences recorded in the medical literature. This abnormality is classified as a single coronary artery anomaly (CAA), which means that the coronary arteries arise from a single coronary ostium within the aorta. Conclusion: In conclusion, CAA is an uncommon cause of SCA that can easily be overlooked without a systematic approach. In this report, we discuss the case of a patient who was discovered to have an anomalous RCA that branched off from the LAD artery.

Diagnostic yield of actionable arrhythmias in patients referred with syncope and collapse using ePatch extended holter

Abstract Background/Introduction Cardiac syncope commonly points to a potentially lethal disease process and carries one-year mortality up to 30%. Current guidelines on management of syncope suggest choosing ambulatory monitoring modality based upon the likelihood of symptoms during the monitoring period and is frequently undertaken with short duration (0-2 days) or extended wear Holter (EWH) monitoring (3-14 days). Purpose Determine the diagnostic yield (DY) of actionable arrhythmias (AA) in patients referred for syncope and collapse prescribed short or extended ambulatory monitoring. Methods A retrospective analysis was conducted for patients wearing the Philips ePatch between July 1st, 2022, and June 30th, 2023, with ICD-10 referral code R55 (Syncope and Collapse). Monitoring duration was grouped by 0-2, 3-7, and 8-14 days of wear time. Wear time was defined as number of hours with analysable ECG data. Arrhythmia detection was defined as either non-AA (did not meet urgent or emergent criteria) or AA (met urgent and/or emergent criteria). Urgent criteria were defined as Atrial Fibrillation/Flutter (>10 seconds), Ventricular Tachycardia (>100 BPM for >3 beats), Severe Tachycardia (>170 BPM for ≥30 seconds), Pause/Asystole (≥3 seconds), Severe Bradycardia (<35 BPM), and 2nd Degree or Higher AV Block. Emergent criteria were defined as VT (>100 BPM for ≥30 beats), Severe Tachycardia (≥220 BPM for ≥30 seconds), Pause/Asystole (≥10 seconds), and Severe Bradycardia (<20 BPM). Results The DY for any urgent and/or emergent AA was 6.8%, 11.0%, and 20.4% at 0-2, 3-7 and 8-14 days of wear time, respectively (p<0.00001 for all). For urgent AA, DY increased 1.6X at 3-7 vs 0-2 days, 1.9X at 8-14 vs 3-7 days and 3X at 8-14 vs 0-2 days of wear time (p<0.05 for all); for emergent AA, the DY increased 5X at 3-7 vs 0-2 days, 1.6X at 8-14 vs 3-7 days, and 8.2X at 8-14 vs 0-2 days of wear time (p<0.05 for all) (Graph 1). When examining tachyarrhythmias vs bradyarrhythmias, similar multiplicative yields in AA were noted between short, intermediate, and extended duration monitoring; statistical significance was noted for all arrhythmia subtypes (p<0.01), except for Severe Tachycardia and Bradycardia which were not significant between 0-2 and 3-7 days of wear time (Graph 2). Conclusion(s) In patients referred for ambulatory monitoring with syncope and collapse, urgent and emergent actionable arrhythmias increase significantly when extending from short to intermediate to long duration monitoring, with both tachyarrhythmias and bradyarrhythmias demonstrating similar increases in occurrence. Accordingly, EWH monitoring in patients referred with syncope and collapse has greater potential to identify arrhythmic aetiologies than use of standard duration Holter.

A higher peak heart rate during head-up tilt test predicts the therapeutic efficacy of metoprolol in vasovagal syncope

BackgroundAlthough beta blockers, such as metoprolol, have been widely used in the management of vasovagal syncope (VVS), their efficacy remains debated, with larger studies showing limited benefit. Identifying patient-specific characteristics that predict a positive response to metoprolol could optimize its use. This study aims to investigate the key factors that may determine which VVS patients are suitable candidates for metoprolol treatment.MethodsThis retrospective study was conducted at a single center. Patients diagnosed with VVS and treated with metoprolol for a minimum of three months were included. A 50% reduction in syncope symptom score (SS) after three months of metoprolol treatment was used to define metoprolol responders, while those who did not achieve this reduction were classified as non-responders. After a three-month follow-up, patients were divided into two groups: responders and non-responders. Baseline data—including age, gender, comorbidities, laboratory tests, and the type of VVS—were analyzed for each patient. Changes in heart rate (HR) and blood pressure during the head-up tilt test (HUTT) were also evaluated between the two groups. Logistic regression analysis was performed to identify potential predictors of metoprolol response, and receiver operating characteristic (ROC) curve analysis was used to assess the value of these predictors in selecting potential responders.ResultsA total of 168 VVS patients were enrolled between January 2016 and December 2020. Of these, 100 patients responded positively to metoprolol, while 68 did not. No significant differences in baseline characteristics or HUTT results were observed between the two groups (p > 0.05). However, responders exhibited a significantly higher peak HR compared to non-responders during the HUTT (120.13 ± 19.33 vs. 106.60 ± 22.32, p < 0.001). The increase in HR was also more pronounced in responders (0.60 ± 0.23 vs. 0.41 ± 0.25, p < 0.001). Additionally, HR variability was significantly greater in responders than in non-responders (16.18 ± 5.51 vs. 12.61 ± 5.50, p < 0.001).ConclusionHigher peak HR, larger increases in HR, and greater HR variability during the HUTT may serve as reliable predictors of a positive response to metoprolol in patients with VVS.

172 A Prospective Trial of the Effect of Canadian Syncope Risk Score Recommendations on Emergency Physician Management of Unexplained Syncope

172 A Prospective Trial of the Effect of Canadian Syncope Risk Score Recommendations on Emergency Physician Management of Unexplained Syncope

Successful Management of Syncope and Sustained Ventricular Tachycardia/Fibrillation in a Nonagenarian with Do-Not-Resuscitation Status: A Case Report

Successful Management of Syncope and Sustained Ventricular Tachycardia/Fibrillation in a Nonagenarian with Do-Not-Resuscitation Status: A Case Report

Implantable cardiac monitor and leadless pacemaker in the management of syncope due to intermittent high-degree atrioventricular block: a case report

BackgroundLead dislodgements, tricuspid valve failure, and wound infections are prominent issues addressed by leadless pacemakers (LPM). These devises have emerged as viable alternatives to conventional transvenous pacemakers. LPMs offer minimized complications and effective pacing, particularly beneficial for elderly patients with a low body mass index (BMI) who are at heightened infection of risk. The Micra AV leadless pacemaker was released in the US in 2020, featuring a VDD pacing mode akin to conventional pacemakers. It senses atrial activity to pace ventricular beats while maintaining the natural atrioventricular activation sequence. Micra AV achieves atrioventricular synchronization through mechanical sensing principles. Ongoing research aims to assess its efficacy, implantation feasibility, and clinical safety.Case presentationAn 83-year-old man with a history of syncope was the focus of this case study. An implantable cardiac monitor (ICM) recorded occasional high-degree atrioventricular block in the patient. Subsequently, the Micra AV was implanted via the left femoral vein, and its settings were adjusted in accordance with data obtained from the ICM. No significant issues regarding pacing threshold or impedance were found during the follow-up examinations post-surgery. Importantly, the patient experienced a noticeable reduction in symptoms compared to before the implantation.DiscussionThis case underscores the significance of ICM monitoring in elucidating cardiac events leading to syncope and guiding appropriate treatment. It also highlights the successful outcomes and reliable implantation of the Micra AV for managing high-degree atrioventricular block. This study contributes to the growing body of evidence supporting the adoption of leadless pacemakers as a viable option for patients requiring cardiac pacing, particularly those vulnerable to complications associated with traditional pacemakers. It provides real-world evidence of Micra AV’s efficacy and safety, further validating its role in clinical practice.

Interhospital variability in hospital admissions for patients with low-risk syncope presenting to the emergency department

Guidelines and risk scores have sought to standardize the management of syncope in the emergency department (ED), but variation in practice remains. The purpose of this study was to explore factors associated with admission for patients presenting to the ED with low-risk syncope. Our study population included adult patients in the Nationwide Emergency Department Sample between 2006 and 2019 who presented to an ED with a primary diagnosis of syncope. Multivariable hierarchical logistic regression analyses determined the association of patient or hospital factors with admission. Reference effect measures methodology assessed the relative contributions of patient, hospital, and unmeasured hospital factors. Of the 3,206,739 qualifying encounters during the study period, 804,398 (25.1%) met low-risk criteria. Of these patients, 20,260 were admitted to the hospital (2.5%). Factors associated with increased odds of admission included increasing age and weekend presentation to the hospital, while female sex, lack of medical insurance, hospital region, teaching status, and higher ED volume decile were associated with lower odds of admission. Reference effect measures methodology demonstrated that unmeasured site variability contributed the widest range of odds for admission (odds ratio [OR] 5th percentile vs 95th percentile 0.23-4.38) compared with the composite patient (OR 0.33-3.68) or hospital (OR 0.65-1.30) factors. Admission patterns for low-risk syncope varies widely across institutions. Unmeasured site variation contributes significantly to the variability in admission rates, suggesting which hospital a patient presents to plays a disproportionate role in admission decisions. Further guidance to reduce practice variation in syncope care in the ED is needed.

A systematic review on physiological role of yoga and pranayama in management of orthostatic hypotension and vasovagal syncope

OH and VVS are increasingly recognized as important causes of impairment of quality of life and potentially of poor prognosis. Existing management therapies have modest effect. Recently few studies have emerged and have demonstrated the efficacy of yoga and pranayama in disorders having autonomic imbalance, suggesting its possible efficacy in OH and VVS.This review aims to determine the effectiveness of yogic practices in patients with orthostatic hypotension (OH) and recurrent vasovagal syncope (VVS). A Medline search was done in Google chrome to review relevant articles in English literature considering the eligibility criteria that the article should focus on yoga and pranayama and its physiological effects on OH and VVS. The main outcome expected was attenuation of OH and frequency of attacks of syncope and presyncope.: Out of the total 86 articles searched, 7 articles (3 RCTs, 3 observational/interventional, 1 review) full filled the eligibility criteria and depicted that yogic practices can have positive impact in attenuation of orthostatic hypotension and reduce the frequency of attacks of syncope and presyncope, among patients with recurrent VVS. However, we recommend higher-quality RCTs in future to confirm our results.

Syncope and unresponsiveness in an adolescent with comorbid cardiac disease: an illustrative case report and literature review of Functional Neurologic Symptom Disorder.

This case report with associated literature review explores the challenges, opportunities, and current evidence in creating a thoughtful diagnostic and management plan for an adolescent with Functional Neurologic Symptom Disorder and comorbid cardiac disease. We perform a literature review utilizing PubMed to identify the current evidence base related to Pediatric Functional Neurologic Symptom Disorder in the setting of comorbid cardiac disease. Ultimately, 25 manuscripts were identified for inclusion in this study. We report the recent epidemiology, screening, diagnostic, and treatment measures utilized in pediatric syncope with a focus on differentiating psychogenic causes from serious cardiac and benign etiologies. We further describe how psychiatric and psychological factors influence assessment, management, and outcomes. This study provides current, evidence-based suggestions for the assessment, diagnosis, and management of pediatric syncope with emphasis on recognizing psychogenic causes of syncope. It includes description of a novel case of Functional Neurologic Symptom Disorder in a pediatric patient with structural cardiac disease. The study highlights how the absence of standardized guidelines, heterogeneity in care delivery, and lack of concurrent mental health management led to worse outcomes.

Pacing or ablation for vasovagal syncope: one size does not fit all.

Practical decision pathway for the management of vasovagal syncope. Please see text for details. White circles demonstrate sites of grouping of autonomic ganglia defined as ganglionated plexi (GP). The superior right atrial GP (RSGP) located on the posterosuperior surface of the right atrium adjacent to the junction of the superior vena cava and the right atrium; the superior left atrial GP (LSGP) is on the posterosuperior surface of the left atrium between the pulmonary veins; the inferior (posterior) right atrial GP (RIGP) located adjacent to the interatrial groove; the inferior left atrial GP (LIGP) is identified on the posterolateral surface of the left atrium; and the Marshall tract GP (MTGP) located adjacent the vein of Marshall. *Response to atropine which accelerates sinus node automaticity and increases the speed of atrioventricular conduction should be evaluated in all cases prior recommending CNA to confirm adequate procedural response. A sinus rate increase of ≥25% or a sinus rate ≥90 bpm in the first 15 min after infusion should be considered as a positive response.7,13 CLS, closed loop stimulation; CNA, cardioneuroablation; HUT, head-up tilt table test; and ILR, implantable loop recorder.

Stellate ganglia stimulation counteracts vagal stimulation by significantly increasing heart rate and blood pressure.

Vasovagal syncope (VVS) is the leading cause of syncope. The most frequent mechanism is that of a cardioinhibitory response, vasodepressor response, or mixture of both. Neural stimulation that negates or overcomes the effects of vagal tone may be used as a treatment strategy for VVS. Six male canines were studied. Stimulation (10-Hz, 2ms pulse duration, 2min duration) of the cervical vagus (CV), thoracic vagus (TV), and stellate ganglia (SG) was performed using needle electrodes at 3V, 5V, and 10V output. SG stimulation at an output of 10V overlaying TV stimulation at the same output was performed. Heart rate (HR), blood pressure (BP), and cardiac output (CO) were measured before, during, and after stimulation. Right cervical vagal stimulation was associated with significant hemodynamic changes. HR, SBP, and DBP were reduced (107±16 vs. 78±15bpm [P<0.0001], 116±24 vs. 107±28mmHg [P=0.002] and 71±18 vs. 58±20mmHg [P<0.0001]), respectively, while left cervical vagal stimulation had minimal changes. CV stimulation was associated with greater hemodynamic changes than TV stimulation. Left and right SG stimulation significantly increased systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR at 5V and 10V, which could be observed within 30s after stimulation. An output-dependent increase in hemodynamic parameters was seen with both left and right SG stimulation. No difference between left and right SG stimulation was seen. SG stimulation overlay significantly increased HR, BP, and CO from baseline vagal stimulation bilaterally. Stellate ganglia stimulation leads to increased HR and BP despite significant vagal stimulation. This may be exploited therapeutically in the management of vasovagal syncope.

Pelatihan Caregiver Lansia tentang Tatalaksana Awal pada Kondisi Pingsan dan Serangan Stroke

Introduction: The community partnership program activity "Training for Elderly Caregivers on Initial Management in Syncope Conditions and Stroke Attacks at LKS-LU Pangesti Lawang" is an activity intended for elderly caregivers who are responsible for the health of the elderly at LKS-LU Pangesti Lawang. Objective: The purpose of this community partnership program is to facilitate elderly caregivers in carrying out initial management of syncope conditions and stroke attacks at LKS-LU Pangesti Lawang. Considering that the elderly are a special group that is vulnerable and at risk of experiencing various problems related to their health. Decreased physical, mental and social abilities have health impacts and risks for various neurovascular diseases. Method: This training was carried out in the form of: Providing education and sharing about physiological changes in the elderly, especially about changes in the cardiovascular systems and neurovascular systems as well as providing education and training on early management in syncope conditions and stroke attacks. Result: The implementation of activity with the title "Elderly Caregiver Training on Early Management in Syncope Conditions and Stroke Attacks at LKS-LU Pangesti Lawang" went well and smoothly. The activity was carried out with a 100% participant attendance rate. The material on Initial management of Syncope and Stroke Attacks has been delivered according to the topic by the speakers and the active participants in the discussion carried out. The indicator of the success of this activity is from the results of the evaluation on the participants when the training was carried out, most of the participants were able to answer pre and posttest questions and demonstrations. The results obtained were as follows, the average score of the participants' pretests was 64, and the average score of posttests was 70. Average scores of initial management practices in syncope conditions and strokes with good results. Conclusion: On this basis, it can also be concluded that the purpose of training that wants to increase the knowledge and understanding of health cadres regarding Early Management in Syncope Conditions and Stroke Attacks in LKS-LU Pangesti Lawang has been achieved.

1287 THE VALUE OF A MULTIDISCIPLINARY TEAM (MDT) IN MANAGING PATIENTS WITH COMPLEX OR UNEXPLAINED SYNCOPE

Abstract Introduction Syncope is a common clinical problem with a lifetime prevalence of 20%.1 Syncope shares clinical features with other disorders including seizures, metabolic disturbances and sleep disorders.2 The assessment and management of syncope can be challenging. The syncope service at the QEUH is run by geriatricians and cardiologists with an interest in syncope. Although MDTs are recognised key components in contemporary patient care in areas such as heart failure and cancer management, there is no guidance on MDT working in syncope management.3/4 In November 2017, a syncope MDT was introduced at the QEUH involving cardiologists, geriatricians, a neurologist and cardiac physiologists. This in-person MDT occurs monthly with outcomes recorded on electronic medical records in addition to a database. The aim of this review was to understand the potential impact of the MDT on diagnostic yield and time to further investigation or management. Method A retrospective case note analysis was performed for patients reviewed at the Syncope MDT between November 2017 and December 2021. Results 103 patients were discussed with an average age of 64 years. The main reason for referral was cardiology specialist advice (65%), neurology specialist advice (19.4%) and complex case review (13.6%). After MDT discussion, the percentage of patients with unexplained TLoC reduced from 26.2% to 14.6% without requirement for additional investigations. 8.7% of patients were started on anti-epileptic medication prior to outpatient neurology review after a diagnosis of seizure disorder was established and 23.1% of patients were streamlined for pacemaker or ILR insertion. Conclusion Introduction of a syncope MDT reduces unexplained syncope rates in complex patients, streamlines investigations, reduces the need for multi-speciality outpatient reviews and allows earlier introduction of anti-epileptic medication for those with a new seizure disorder. These benefits improve the patient experience by reducing time to diagnosis and treatment.

Recurrent syncope in long survivors and its association with geriatric syndromes.

Syncope is a common clinical condition in the elderly, associated with significant morbidity and risk of recurrence. Recurrent syncope causing a repeated reduction in the cerebral blood flow can predispose to progressive neurodegeneration, a decline in overall health and functionality. Hence, this study was conducted to study the common causes of recurrent syncope and its association with various geriatric syndromes. This case-control study recruited 50 cases of recurrent syncope and 50 controls, aged 75 years and older. A detailed history and sequential evaluation for aetiologies of recurrent syncope were done. Cognition, frailty, activities of daily living, depression, and nutrition were assessed using various scales. Most (80%, 80/100) of the participants were males and the mean age was 80.04 ± 4.3 years. In the syncope group, 42% (21/50) of patients had arrhythmia, and 30% (15/30) had valvular heart disease. Recurrent syncope was significantly associated with lower scores on Montreal cognitive assessment scale (OR: 6.47 P < 0.001), four or more comorbidities (OR: 6.29 P < 0.001), and hearing impairment (OR: 6.21 P< 0.004) on multivariate logistic regression analysis. Recurrent syncope is significantly associated with cognitive impairment, the presence of four or more comorbidities, and hearing impairment. Conduction abnormality was the most common etiology of recurrent cardiovascular syncope. Structured evaluation and appropriate management of recurrent syncope might reduce the decline in physical, cognitive, and psychological reserve. A follow-up longitudinal study is needed to establish this.

110 DEVELOPMENT AND DELIVERY OF A MULTI-DISCIPLINARY HYBRID EDUCATION PROGRAM IN SYNCOPE AND RELATED DISORDERS DURING THE COVID-19 PANDEMIC

Abstract Background Syncope and related disorders is an important area for training of all health professionals. During the COVID-19 pandemic, we adapted the delivery of our annual face-to-face certified program to a 9-month hybrid program. Here, we describe the development, delivery, and evaluation of such new program. Methods A pre-existing curriculum was modified to incorporate online content, online lecture delivery and interactive group learning, in addition to individual practical placements in a syncope management unit, in line with government and hospital infection control guidance at the time. Monthly content included video consultant case presentations, ECG analysis and interpretation, and instructional videos of diagnostic testing and relevant technologies. A comprehensive online week-long lecture program was developed. Results The lecture week included 30 clinical lectures, 10 clinical case presentations and 10 ‘how to’ practical videos for testing/monitoring procedures. Further learning over zoom incorporated learner case presentations in a small group format. At the completion of the course the leaners attended a final online half day of lectures and completed the multi choice question examination. Conclusion “Thank you so much for putting together such a fantastic week of training.” “The quality and expertise of the speakers was outstanding.” “I have taken a huge amount away to incorporate into my practice and local unit.” The above learner feedback is consistent with our aim to deliver a high-quality specialist program for those interested in advancing the management of syncope and related disorders. Over time, this specialist training will aid the development of regional syncope management units across Ireland. The benefits of a hybrid learning model include multiple options to cater for all categories of learners, thus suggesting it is the cornerstone of future learning modalities.

The Diagnosis and Management of Vasovagal Syncope in Pediatric Patients

Vasovagal syncope is the most common cause of syncope in pediatric patients. The present study is aim to provide a comprehensive literature review of the latest advances in the diagnosis and treatment of vasovagal syncope in children. Diagnosis of vasovagal syncope is based on clinical history. For patients with suspected VVS but lack of confident diagnosis after initial assessment, head-up tilt test is helpful. There are four options for treatment of vasovagal syncope: conservative therapy, pharmacologic therapy, pacemaker therapy, and catheter ablation of ganglionated plexi. Conservative therapy (health education, avoidance of triggers, salts and water intake, physical countermeasures and orthostatic training) is recommended for patients with occasional syncope. Pharmacological therapy should be considered for patients with recurrent syncope or for whom conservative therapy has failed. Patients with the predominantly cardioinhibitory response, associated with repeated injury, limited prodromes, and documented asystole may benefit from cardiac pacing. Catheter ablation of ganglionated plexi is a new strategy, its efficacy and safety in pediatric patients should be verified by randomized controlled trials.

Evaluation of periprocedural anxiety during Gamma Knife radiosurgery (GKRS) frame fixation for brain lesions

IntroductionApplication of stereotaxy frame for gamma knife under local anesthesia creates anxiety and phobia in many patients. Vasovagal syncopal attacks and events of bradycardia are not infrequently seen. We tried to analyse the various factors affecting these events and set standards and safety recommendations for the procedure. Materials and methodsThis prospective study was carried out in Gamma Knife Centre, AIIMS, New Delhi over a 6 month period between June, 2021- November, 2021. All patients coming to Gamma knife for various etiologies were asked to fill Hamilton Anxiety Rating Scale (HAM-A) before frame application. Baseline pulse rate was evaluated and with every pin application pulse rate was recorded. A VAS (visual analogue scale) for pain was also administered after the procedure. Twenty percent fall in pulse rate were considered as significant bradycardia. Intraprocedural syncopal events were also recorded. ResultsA total of 141 patients were studied of which 6% patients had intraprocedural syncopal attacks requiring medical treatment while 32% patients had bradycardia. Having previous surgery, having breakfast before the procedure, duration of pin application, quantity of local anaesthetia, primary diagnosis, sex of patients were not found to alter the syncope or bradycardia events. Patients who were found anxious (score > 18 on HAM-A) had a significantly higher risk of having a procedural event. Previous history of syncope was also associated with 1.7 times more chances of developing Intraprocedural bradycardia. ConclusionsFrame application for gamma-knife is a relatively safe procedure however procedure rooms should be equipped with emergency drugs and fluids for management of syncope. A Simple anxiety questionnaire can predict ‘at risk’ patients’ for procedural events

Salt supplementation in the management of orthostatic intolerance: Vasovagal syncope and postural orthostatic tachycardia syndrome.

Salt supplementation is a common non-pharmacological approach to the management of recurrent orthostatic syncope or presyncope, particularly for patients with vasovagal syncope (VVS) or postural orthostatic tachycardia syndrome (POTS), although there is limited consensus on the optimal dosage, formulation and duration of treatment. Accordingly, we reviewed the evidence for the use of salt supplementation to reduce susceptibility to syncope or presyncope in patients with VVS and POTS. We found that short-term (~3months) salt supplementation improves susceptibility to VVS and associated symptoms, with little effect on supine blood pressure. In patients with VVS, salt supplementation is associated with increases in plasma volume, and an increase in the time taken to provoke a syncopal event during orthostatic tolerance testing, with smaller orthostatic heart rate increases, enhanced peripheral vascular responses to orthostatic stress, and improved cerebral autoregulation. Responses were most pronounced in those with a baseline sodium excretion <170mmol/day. Salt supplementation also improved symptoms, plasma volume, and orthostatic responses in patients with POTS. Salt supplementation should be considered for individuals with recurrent and troublesome episodes of VVS or POTS without cardiovascular comorbidities, particularly if their typical urinary sodium excretion is low, and their supine blood pressure is not elevated. The efficacy of the response, in terms of the improvement in subjective and objective markers of orthostatic intolerance, and any potential deleterious effect on supine blood pressure, should be routinely monitored in individuals on high salt regimes.

Evaluation of the use and applicability of the ESC 2018 recommendations on risk stratification of syncope in the emergency department

Complications related to syncope vary according to its etiology, which remains undetermined in approximately 20% of cases. The use of a risk stratification and patient referral protocol, such as the one proposed in the ESC 2018 recommendations, could be a solution to improve the management of syncope. To evaluate the use of syncope risk stratification protocols in an emergency department. The secondary objective is to evaluate the applicability of the ESC recommendations and their ability to stratify the risk of complications after an episode of syncope. Observational, retrospective, monocentric study conducted in the emergency department of the university hospital of Brest during February 2018 for the reasons “discomfort with or without loss of consciousness”, “chest pain”, “tachycardia”, “bradycardia”, and “suspected pulmonary embolism”. Patients who presented with a real episode of syncope or presyncope were classified into three risk groups (low, intermediate and high) according to the ESC recommendations. In total, 436 patients met the initial search criteria, of which 100 were included. No records mentioned the use of a risk stratification protocol. ESC recommendations were applicable to 87% of the records. Thirty-one percent of patients were classified as low risk, and of these, 3 patients (10%) were rehospitalized or had a complication at 1 year. Twenty-three percent of the patients were classified as intermediate risk, among them 8 patients (35%) were rehospitalized or had a complication at 1 year. Forty-six percent of the patients were at high-risk, among them 23 (50%) were rehospitalized or had a complication at 1 year ( Fig. 1 ). The use of risk stratification protocols for syncope management is not a common practice in the emergency department. According to our study, the ESC recommendations are easily applicable and seem to effectively classify patients into three risk groups. A larger study therefore seems warranted to confirm these findings.

Management of vasovagal syncope.

Vasovagal syncope (VVS) is a very common form of fainting. Treatment begins with patient education about the mechanism of fainting, and the non-lethal nature of vasovagal syncope. In this article, we review several non-pharmacological approaches that form the foundation of our current treatments. These include increases in dietary salt and water intake, the use of compression garments, physical counter-maneuvers and tilt-training. When these approaches are inadequate, medications can sometimes be effective. While the evidence base for the pharmacological treatment of VVS is modest, recent trial data have found drugs to be useful in placebo-controlled randomized trials. For select patients, and those patients more refractory to medications, procedural treatments may be an option. In this review, we discuss the current state of evidence for the non-pharmacological and pharmacological treatments for VVS, as well as some novel, emerging therapies for VVS.