Management of Recurrent Syncope

Clinical Presentation and Diagnosis

The European Society of Cardiology suggests that a slow, controlled descent during episodes is typical of vasovagal syncope, rather than a dangerous cardiac or neurologic cause 1
The American College of Emergency Physicians notes that brief post-event confusion is consistent with syncope's typical 20-30 second recovery period, rather than the prolonged postictal state of seizures 2
The European Heart Journal states that a clear trigger, such as smoking, can contribute to situational syncope, particularly in smokers with lung disease 1
The American College of Physicians recommends that a negative cardiac and seizure workup, including 3-day EEG monitoring and cardiac monitoring, can help rule out other causes of syncope 3, 4

The American College of Physicians suggests that continued use of a recliner to minimize fall risk is appropriate, and staff should ensure the patient avoids standing immediately after smoking 1, 3
The American Geriatrics Society recommends that a wheelchair provides baseline fall protection 3

The European Heart Journal recommends that smoking cessation is the definitive treatment for situational vasovagal syncope triggered by smoking 1
The American College of Cardiology suggests that education about recognizing prodromal symptoms, such as lightheadedness and visual changes, is essential for managing vasovagal syncope 3, 6, 7
The American Heart Association recommends that physical counterpressure maneuvers, such as leg crossing and arm tensing, can help abort syncope episodes 7

The American College of Physicians recommends that formal orthostatic vital signs should be documented to assess for orthostatic hypotension, which is defined as a ≥20 mmHg systolic or ≥10 mmHg diastolic drop 8
The American Geriatrics Society suggests that a critical medication assessment should be performed to review all current medications for vasoactive drugs, and discontinue or reduce any unnecessary blood pressure-lowering medications 4, 5, 8

The European Society of Cardiology recommends that the patient should be reassessed in 2-4 weeks to document the frequency of episodes after smoking cessation counseling, verify orthostatic vital signs, and assess the effectiveness of physical counterpressure maneuvers 4, 6, 7, 8