Abstract.
Reflex syncope is a common medical problem. Vasovagal reflex syncope is the most frequent form. Although the prognosis of the disorder is excellent, it may impose substantial changes in life style and cause profound psychological distress. Thus, management of this disorder is an important issue. This chapter, based on a review of the literature and the authors’ clinical experience, encompasses the non-pharmacological measures used in the management of reflex syncope.
The cornerstone of the non-pharmacological management of patients with reflex syncope is education and reassurance regarding the benign nature of the condition. Patients should be instructed to avoid potential triggers. A tilt table test can be employed to teach the patient to recognize early premonitory symptoms. There are several physical maneuvers (e. g., leg crossing, muscle tensing and squatting) that are effective in combating orthostatic intolerance. For the majority of patients this approach is adequate.
Patients with frequent attacks of reflex syncope are advised to increase their dietary salt intake. Exercise training also increases orthostatic tolerance. In highly motivated patients with recurrent syncope, raising the head of the bed to permit gravitational exposure during sleep and prolonged periods of enforced maintenance of the upright posture (tilt-training) can be considered. Preliminary data suggest that water drinking may improve orthostatic tolerance. Abdominal belts may also be effective in highly symptomatic subjects with reflex syncope.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Abe H, Kohshi K, Nakashima Y (2003) Efficacy of orthostatic self-training in medically refractory neurocardiogenic syncope. Clin Exp Hypertens 25:487–493
Allan SC, Taylor CG, Hall VE (1945) A study of orthostatic insufficiency by the tiltboard method. Am J Physiology 143:11–20
Arbeille P, Fomina G, Achaibou F, Pottier J, Kotovskaya A (1995) Cardiac and vascular adaptation to 0 g with and without thigh cuffs (Antares 14 and Altair 21 day Mir spaceflights). Acta Astronaut 36:753–762
Bouvette CM, McPhee BR, Opfer-Gehrking TL, Low PA (1996) Role of physical countermaneuvers in the management of orthostatic hypotension: efficacy and biofeedback augmentation. Mayo Clin Proc 71:847–853
Brignole M, Alboni P, Benditt DG, Bergfeldt l, Blanc JJ, Bloch Thomsen PE, Dijk JGv, Fitzpatrick A, Hohnloser S, Janousek J, Kapoor WN, Kenny RA, Kulakowski P, Moya A, Raviele A, Sutton R, Theodorakis G, Wieling W (2001) Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J 22:1256–1306
Brignole M, Croci F, Menozzi C, Solano A, Donateo P, Oddone D, Puggioni E, Lolli G (2002) Isometric arm counterpressure maneuvers to abort impending vasovagal syncope. J Am Coll Cardiol 40:2054–2060
Cariga P, Mathias CJ (2001) Haemodynamics of the pressor effect of oral water in human sympathetic denervation due to autonomic failure. Clin Sci 101:313–319
Custaud MA, Millet C, Frutoso J, Maillet A, Gauquelin G, Gharib C, Fortrat JO (2000) No effect of venoconstrictive thigh cuffs on orthostatic hypotension induced by head-down bed rest. Acta Physiol Scand 170:77–85
Dambrink JH, Imholz BP, Karemaker JM, Wieling W (1991) Postural dizziness and transient hypotension in two healthy teenagers. Clin Auton Res 1:281–287
Denq JC, Opfer-Gehrking TL, Giuliani M, Felten J, Convertino VA, Low PA (1997) Efficacy of compression of different capacitance beds in the amelioration of orthostatic hypotension. Clin Auton Res 7:321–326
Di Girolamo E, Di Iorio C, Leonzio L, Sabatini P, Barsotti A (1999) Usefulness of a tilt training program for the prevention of refractory neurocardiogenic syncope in adolescents: A controlled study. Circulation 100:1798–1801
Dijk N van, Harms MP, Linzer M, Wieling W (2000) Treatment of vasovagal syncope: pacemaker or crossing legs. Clin Auton Res 10:347–349
Dijk N van, Krediet CT, Bruin IGJMd, Lieshout JJv, Wieling W (2003) Physical counterpressure maneuvers to prevent and abort vasovagal syncope: a novel effective treatment? In: Raviele A (ed) Cardiac Arrhythmias. Springer-Verlag, pp 633–639
Dijk N van, Velzeboer SCJM, Destree-Vonk A, Linzer M, Wieling W (2001) Psychological treatment of malignant vasovagal syncope due to blood phobia. Pacing Clin Electrophysiol 24:122–124
Ector H, Reybrouck T, Heidbuchel H, Gewillig M, Van de Werf F (1998) Tilt training: a new treatment for recurrent neurocardiogenic syncope and severe orthostatic intolerance. Pacing Clin Electrophysiol 21:193–196
El-Sayed H, Hainsworth R (1995) Relationship between plasma volume, carotid baroreceptor sensitivity and orthostatic tolerance. Clin Sci (Colch.) 88:463–470
El-Sayed H, Hainsworth R (1996) Salt supplement increases plasma volume and orthostatic tolerance in patients with unexplained syncope. Heart 75:134–140
Engel GL, Romano J (1947) Studies of syncope: IV. Biologic interpretation of vasodepressor syncope. Psychosom Med 9:288–294
Fenton AM, Hammill SC, Rea RF, Low PA, Shen WK (2000) Vasovagal syncope. Ann Intern Med 133:714–725
Evaluation of tilt training in the treatment of recurrent neurally mediated syncope. Europace Supplements 2:B195
Grimm W, Degenhardt M, Hoffman J, Menz V, Wirths A, Maisch B (1997) Syncope recurrence can better be predicted by history than by head-up tilt testing in untreated patients with suspected neurally mediated syncope. Eur Heart J 18:1465–1469
Hainsworth R (2000) Head-up sleeping for posturally related syncope. Clin Auton Res 10(4):225–226
Harkel ADt, Lieshout JJv, Wieling W (1994) Effects of leg muscle pumping and tensing on orthostatic arterial pressure: a study in normal subjects and patients with autonomic failure. Clin Sci (Lond) 87:553–558
Hellstrom K, Fellenius J, Ost LG (1996) One versus five sessions of applied tension in the treatment of blood phobia. Behav Res Ther 34:101–112
Henry R, Rowe J, O’Mahony D (1999) Haemodynamic analysis of efficacy of compression hosiery in elderly fallers with orthostatic hypotension. Lancet 354:45–46
Hill L (1895) The influence of the force of gravity in the circulation of the blood. J Physiol 18:15–53
Imholz BPM, Wieling W, Montfrans GAv, Wesseling KH (1998) Fifteen years experience with finger arterial pressure monitoring: assessment of the technology. Cardiovasc Res 38:605–616
Jordan J, Shannon JR, Black BK, Ali Y, Farley M, Costa F, Diedrich A, Robertson RM, Biaggioni I, Robertson D (2000) The Pressor Response to Water Drinking in Humans. A Sympathetic Reflex? Circulation 101:504–509
Jordan J, Shannon JR, Grogan E, Biaggioni I, Robertson D (1999) A potent pressor response elicited by drinking water. Lancet 353:723
Kapoor WN (2000) Syncope. N Engl J Med 343:1856–1862
Khurana RK, Lynch JJ, Craig FW (1997) A novel psychophysiological treatment for vasovagal syncope. Clin Auton Res 7:191–197
Kozak MJ (1985) The psychophysiological process of therapy in a case of injury-scene-elicited fainting. J Behav Ther & Exp Psychiat 16:139–145
Krediet CT (2002) Initial orthostatic hypotension in a 37-year old horse rider. Clin Auton Res 12:202
Krediet CT, Wieling W (2003) Manoeuvres to combat vasovagal syncope. Europace 5:303
Krediet CTP, van Dijk N, Linzer M, van Lieshout JJ, Wieling W (2002) Management of Vasovagal Syncope: Controlling or Aborting Faints by Leg Crossing and Muscle Tensing. Circulation 106:1684–1689
Lieshout JJv, Harkel ADt, Wieling W (1992) Physical manoeuvres for combating orthostatic dizziness in autonomic failure. Lancet 339:897–898
Lieshout JJv, Pott F, Madsen PL, Goudoever Jv, Secher NH (2001) Muscle Tensing During Standing: Effects on Cerebral Tissue Oxygenation and Cerebral Artery Blood Velocity. Stroke 32:1546–1551
Lindgren KN, Kraft D, Ballard RE, Tucker A, Hargens AR (1998) Venoconstrictive thigh cuffs impede fluid shifts during simulated microgravity. Aviat Space Environ Med 69:1052–1058
Linzer M, Pontinen M, Gold DT, Divine GW, Felder A, Brooks WB (1991) Impairment of physical and psychosocial function in recurrent syncope. J Clin Epidemiol 44:1037–1043
Lu CC, Diedrich A, Tung CS, Paranjape SY, Harris PA, Byrne DW, Jordan J, Robertson D (2003) Water ingestion as prophylaxis against syncope. Circulation 108:2660–2665
Matsnev EI, Yakovleva IY, Tarasov IK, Alekseev VN, Kornilova LN, Mateev AD, Gorgiladze GI (1983) Space motion sickness: phenomenology, countermeasures, and mechanisms. Aviat Space Environ Med 54:312–317
Mayerson HS, Burch GE (1940) Relationships of tissue (subcutaneous and intramuscular) and venous pressures to syncope induced in man by gravity. Am J Physiol 128:258–269
Mtinangi BL, Hainsworth R (1998) Early effects of oral salt on plasma volume, orthostatic tolerance, and baroreceptor sensitivity in patients with syncope. Clin Auton Res 8:231–235
Mtinangi BL, Hainsworth R (1998) Increased orthostatic tolerance following moderate exercise training in patients with unexplained syncope. Heart 80:596–600
Mtinangi BL, Hainsworth R (1999) Effect of moderate excercise training on plasma volume, baroreceptor sensitivity and orthostatic tolerance in healthy subjects. Exp Physiol 84:121–130
Newton JL, Kenny RA, Baker CR (2003) Cognitive behavioural therapy as a potential treatment for vasovagal/neurocardiogenic syncope–a pilot study. Europace 5:299–301
Omboni S, Smit AA, Lieshout JJv, Settels JJ, Langewouters GJ, Wieling W (2001) Mechanisms underlying the impairment in orthostatic tolerance after nocturnal recumbency in patients with autonomic failure. Clin Sci (Colch.) 101:619–620
Ost LG, Hellstrom K, Kaver A (1992) One versus five sessions of exposure in the treatment of injection phobia. Behavior Therapy 23:263–282
Ost LG, Sterner U (1987) Applied tension. A specific behavioral method for treatment of blood phobia. Behav Res Ther 25:25–29
Piorry PA (1826) Recherches sur l’influence de la pesanteur sur le cours du sang; diagnostic de la syncope et de l’apoplexie; cause et traitement de la syncope. Arch Gen Med 12:527–544
Reybrouck T, Heidbuchel H, Van De WF, Ector H (2002) Long-term follow-up results of tilt training therapy in patients with recurrent neurocardiogenic syncope. Pacing Clin Electrophysiol 25:1441–1446
Rose MS, Koshman ML, Spreng S, Sheldon R (2000) The relationship between health-related quality of life and frequency of spells in patients with syncope. J Clin Epidemiol 53:1209–1216
Sabin N (2001) The use of applied tension and cognitive therapy to manage syncope (common faint) in an older adult. Aging Ment Health 5:92–94
Saul JP (1999) Syncope: etiology, management, and when to refer. J South Carolina Med Assoc 95:385–387
Schroeder C, Bush V, Norcliffe L, Luft F, Tank J, Jordan J, Hainsworth R (2002) Water drinking acutely improves orthostatic tolerance in healthy subjects. Circulation 106:2806–2811
Sewall H (1916) The clinical relations of gravity, posture and circulation. Am J Med Sci 151:491–505
Shannon JR, Diedrich A, Biaggioni I, Tank J, Robertson RM, Robertson D, Jordan J (2002) Water Drinking as a Treatment for Orthostatic Syndromes. Am J Med 112:355–360
Sharpey-Schafer EP (1956) Emergencies in general practice. Syncope. Br Med J 1:506–509
Sheldon R, Rose S (2001) Components of clinical trials for vasovagal syncope. Europace 3:233–240
Sheldon R, Rose S, Flanagan P, Koshman ML, Killam S (1996) Risk factors for syncope recurrence after a positive tilt-table test in patients with syncope. Circulation 93:973–981
Shichiri M, Tanaka H, Takaya R, Tamai H (2002) Efficacy of high sodium intake in a boy with instantaneous orthostatic hypotension. Clin Auton Res 12:47–50
Smit AAJ, Wieling W, Fujimura O, Denq JC, Opfer-Gehrking TL, Akario M, Karemaker JM, Low PA (2004) Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic failure. Clin Auton Res (in press)
Smit AAJ, Halliwill JR, Low PA, Wieling W (1999) Pathophysiological basis of orthostatic hypotension in autonomic failure. J Physiol 519:1–10
Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ, Levy D (2002) Incidence and Prognosis of Syncope. N Engl J Med 347:878–885
Sutton R (1999) Vasovagal syncope: prevalence and presentation. An algorithm of management in the aviation environment. Eur Heart J (Supplement 1):D109–D113
Sutton R, Bloomfield DM (1999) Indications, Methodology, and Classification of Results of Tilt-Table Testing. Am J Cardiol 84:10Q–19Q
Tanaka H, Yamaguchi H, Tamai H (1997) Treatment of orthostatic intolerance with inflatable abdominal band (letter). Lancet 349:175
Thijs RD, Reijntjes RH, van Dijk JG (2003) Water drinking as a potential treatment for idiopathic exercise-related syncope. A case report. Clin Auton Res 13:103–105
Vogt FB, Johnson PC (1967) Effectiveness of extremity cuffs or leotards in preventing or controlling the cardiovascular deconditioning of bedrest. Aerospace Medicine 38:702–707
White WD, Sheldon RS, Ritchie DA (2003) Learning needs of patients with vasovagal syncope. Can J Cardiovasc Nurs 13:26–30
Wieling W, Lieshout JJv, Hainsworth R (2002) Extracellular fluid volume expansion in patients with posturally related syncope. Clin Auton Res 12:242–249
Wieling W, Lieshout JJv, Leeuwen AMv (1993) Physical manoeuvres that reduce postural hypotension in autonomic failure. Clin Auton Res 3:57–65
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Wieling, W., Colman, N., Krediet, C.T.P. et al. Nonpharmacological treatment of reflex syncope. Clin Auton Res 14 (Suppl 1), i62–i70 (2004). https://doi.org/10.1007/s10286-004-1009-x
Issue Date:
DOI: https://doi.org/10.1007/s10286-004-1009-x