Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
ABSTRACT
Syncope is very common in the general population. The evaluation of syncope is sometimes difficult because the occurrence of syncope is unpredictable and diverse factors and diseases may involve in the occurrence of syncope. Therefore, a detailed history taking is a very important step of initial evaluation of syncope. Initial evaluation of syncope consists of careful history taking, physical examination, including orthostatic BP measurements, and 12 lead electrocardiogram. After initial evaluation of syncope, further diagnostic tests are performed based on the risk stratification. Risk stratification is important in managing syncope. Syncope from cardiac disease could cause sudden cardiac death if proper treatment was not made for underlying heart disease. The management of syncope depends on the cause of syncope. Therefore, the treatment modalities in all causes of syncope could not be described in this paper. Neurally mediated syncope is the most common cause of syncope. Therefore, the management of neurally mediated syncope is mentioned as follows: In the past, several drugs such as beta-blockers, disopyramide, theophylline, etilefrine, midodrine, serotonine reuptake inhibitors were used to prevent the recurrence of syncope in neutrally mediated syncope. While the effects of drugs have been satisfactory in uncontrolled studies or shortterm controlled trials, placebo-controlled prospective trials did not show a benefit of trial drug over placebo. Currently, beta-blocker is not recommended in the treatment of neurally mediated syncope. But, midodrine may indicate in patients refractory to lifestyle measures. The role of pacing therapy for neurally mediated syncope has been also controversial. Several multicenter, randomized controlled trials showed contradicting results. Therefore, pacing should not consider as the treatment for neurally mediated syncope without severe spontaneous bradycardia. Tilt training was introduced to prevent the recurrence of symptoms in patients with recurrent neurally mediated syncope. Previous several non-randomized studies showed the dramatic significant benefit of tilt training. However, this treatment was difficult to continue because of the low compliance of patients. Recently, small-scaled, randomized controlled trials failed to confirm shortterm effectiveness of tilt training in reducing the positive response of head-up tilt testing. Therefore, tilt training may be used in the younger, very symptomatic, well-motivated patients. Considering no established pharmacological and non-pharmacological treatment, education to avoid triggering factor and specific situation and reassurance are very important in managing patient with neurally mediated syncope. Physical counter-pressure maneuvers such as leg crossing or hand grip and arm tensing are emerging as a new non-pharmacological physical treatment of neurally mediated syncope.
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