Treatment Approach for Neurological Syncope

Initial Management

The American Heart Association recommends patient education regarding avoidance of triggering factors and recognition of prodromal symptoms 3, 4
The American Heart Association suggests teaching patients maneuvers to abort episodes, such as assuming a supine posture when prodromal symptoms occur 4, 1
Increased fluid and salt intake is recommended to maintain adequate intravascular volume, as suggested by the American College of Cardiology 1
Physical counter-pressure maneuvers, such as leg crossing and handgrip, can increase blood pressure through isometric contraction, according to the American College of Cardiology 1
Compression garments, at least thigh-high, are recommended to improve orthostatic symptoms, as suggested by the American College of Cardiology 1, 2

Acute water ingestion (≥240-480 mL) is recommended for temporary relief of neurogenic orthostatic hypotension, with peak effect occurring 30 minutes after ingestion, as suggested by the American College of Cardiology 1
Midodrine is beneficial in patients with syncope due to neurogenic orthostatic hypotension, providing dose-dependent improvement in standing blood pressure, according to the American College of Cardiology 1
Droxidopa improves symptoms of neurogenic orthostatic hypotension in patients with Parkinson disease, pure autonomic failure, and multiple system atrophy, as suggested by the American College of Cardiology 1
Fludrocortisone increases plasma volume with resultant improvement in orthostatic symptoms, according to the American College of Cardiology 1

For specific types of situational syncope, addressing trigger factors directly is recommended, such as suppressing the cause of cough, as suggested by the European Society of Cardiology 4, 2
Reduction or removal of hypotensive drugs and diuretics is recommended where appropriate and safe, according to the American College of Cardiology 1
Consider implantable loop recorder for patients with recurrent unexplained syncope with clinical features suggesting arrhythmic etiology, as suggested by the European Society of Cardiology 3, 2
Psychiatric assessment is recommended for patients with frequent recurrent syncope who have multiple other somatic complaints or when initial evaluation raises concerns for stress, anxiety, or other psychiatric disorders, according to the European Society of Cardiology 3, 4

Regular assessment of treatment efficacy and medication side effects is recommended, particularly supine hypertension with vasopressor medications, as suggested by the American College of Cardiology 1, 2
Re-evaluation of diagnosis is recommended if treatment is ineffective, considering consultation with appropriate specialty services, according to the European Society of Cardiology 3, 5