1

Neurocardiogenic

Neurocardiogenic

Syncope

Syncope

Christopher Bonnet, M.D.

Christopher Bonnet, M.D.

Director, Clinical

Director, Clinical

Electrophysiology

Electrophysiology

Definition of Syncope

Definition of Syncope

Abrupt and transient loss of

Abrupt and transient loss of

consciousness

consciousness

Loss of postural tone

Loss of postural tone

Spontaneous and rapid recovery

Spontaneous and rapid recovery

Transient loss of

Transient loss of

consciousness with

consciousness with

prompt spontaneous

prompt spontaneous

recovery

recovery

2

Presyncope

Presyncope

, Syncope and SCD

, Syncope and SCD

Presyncope Syncope Sudden Cardiac Death

SCD vs. Syncope

SCD vs. Syncope

S Y N C O P E S C D

CPR

Electric or

Pharmacologic cardioversion

No CPR

Spontaneous recovery

Epidemiolgy

Epidemiolgy

of Syncope

of Syncope

3.0% in men and 3.5 % in women

3.0% in men and 3.5 % in women

according to Framingham study

according to Framingham study

accounts for 6% of hospital admissions

accounts for 6% of hospital admissions

and 3% of emergency room visits annually

and 3% of emergency room visits annually

incidence increases with age with a sharp

incidence increases with age with a sharp

rise at age 70

rise at age 70

3

Recurrence rate

Recurrence rate

Review of 433 patients, the cumulative

Review of 433 patients, the cumulative

incidence of syncope at three years was:

incidence of syncope at three years was:

31% for patients with cardiovascular

31% for patients with cardiovascular

etiology

etiology

36% for those with

36% for those with

noncardiovascular

noncardiovascular

causes

causes

43% for those with syncope of unknown

43% for those with syncope of unknown

etiology

etiology

Clinical Significance of Syncope

Clinical Significance of Syncope

• Injuries - occur in 35% of syncopal attacks

•Psychological impact

•Prognosis dependent on underlying disease

General Classification of Syncope

General Classification of Syncope

NONCARDIAC CARDIAC

UNDETERMINED

CAUSE

4

Syncope

Syncope

Orthostatic Neurogenic Cardiogenic Neurocardiogenic

Unknown

Data modified from Linzer M et.al. Ann. Intern. Med 1997; 126-989

Based on the population-based studies in unselected patients with syncope

34%8% 10% 18% 24%

Migraines,

TIA,

Seizures

Organic Heart

Disease

AS, HCM, CHD,

ACS 4%

Arrhythmias

14%

Vasovagal Syncope

(VVS) 18%

Situational (cough,

micturition, defecation,

swallow) 5%

Carotid Sinus

Hypersensitivity (CSH)

1%

TYPES

History: syncope triggered

by emotional stress, painful

or noxious stimuli, fear,

prolonged standing,

associated with prodromal

symptoms (dizzy,

lightheaded, pale,

diaphoretic, nauseated…)

Uncommon causes of Syncope

Uncommon causes of Syncope

CVD

CVD

Arrhythmia causes : SVT

Arrhythmia causes : SVT

Nonarrhythmic

Nonarrhythmic

causes : PE, Pulmonary HTN, Dissecting aortic

causes : PE, Pulmonary HTN, Dissecting aortic

aneurysm,

aneurysm,

subclavian

subclavian

steal,

steal,

atrial

atrial

myxoma

myxoma

, cardiac

, cardiac

tamponade

tamponade

Noncardiovascular

Noncardiovascular

diseases

diseases

Hyperventilation

Hyperventilation

Migraine

Migraine

Carcinoid

Carcinoid

syndrome

syndrome

Metabolic: Hypoglycemia and hypoxia

Metabolic: Hypoglycemia and hypoxia

Multivessel

Multivessel

obstructive

obstructive

cerebrovascular

cerebrovascular

disease

disease

5

Characteristics of

Characteristics of

Syncopal

Syncopal

Symptoms

Symptoms

Before Syncope

During Syncope

After Syncope

S y m p t o m s

Etiology

Orthostatic

Hypotension

Neurogenic

Syncope

Cardiogenic

Syncope

Neurocardiogenic

Syncope

Patient was sitting

or lying down

Headache;

visual disturbances

No prodromal

symptoms

Prodrome with

feelings of warmth,

nausea; situational

trigger present

Loss of consiousness

usually with prodrome

Patient had sudden

loss of consciousness

Convulsions; seizure;

urinary & fecal

incontinence

Rising from sitting or

lying position;

begins feeling lightheaded

No residual effects

Residual effects;

paitent is disoriented

after event

No residual effects

Residual feelings

of nausea

and warmth

Physical Exam

Physical Exam

Check orthostatic BP

Check orthostatic BP

’

’

s

s

Carotid sinus massage if attached to a

Carotid sinus massage if attached to a

monitor

monitor

Cardiac exam (R/O aortic

Cardiac exam (R/O aortic

stenosis

stenosis

, HCM

, HCM

and arrhythmia)

and arrhythmia)

Neurologic exam

Neurologic exam

–

–

if negative, further

if negative, further

neurologic

neurologic

eval

eval

. is of very low yield (head

. is of very low yield (head

CT or MRI, carotid

CT or MRI, carotid

dopplers

dopplers

)

)

ECG Abnormalities Suggesting an

ECG Abnormalities Suggesting an

Arrhythmic Cause of Syncope

Arrhythmic Cause of Syncope

1)

1)

Bifascicular

Bifascicular

block, defined as either LBBB or RBBB combined

block, defined as either LBBB or RBBB combined

with left anterior or posterior fascicular block

with left anterior or posterior fascicular block

2) Other

2) Other

intraventricular

intraventricular

conduction abnormalities (QRS duration

conduction abnormalities (QRS duration

=> 0.12 sec.

=> 0.12 sec.

3)

3)

Mobitz

Mobitz

Type II 2 degree AV block

Type II 2 degree AV block

4)

4)

Asymtpomatic

Asymtpomatic

sinus

sinus

bradycardia

bradycardia

(<50

(<50

bpm

bpm

) or

) or

sinoatrial

sinoatrial

block

block

5)

5)

Preexcitation

Preexcitation

complexes (WPW syndrome)

complexes (WPW syndrome)

6) Prolonged QT interval

6) Prolonged QT interval

7) ECG typical of

7) ECG typical of

Brugada

Brugada

syndrome (RBBB with ST elevation

syndrome (RBBB with ST elevation

in lead V1 to V3)

in lead V1 to V3)

8) ECG suggestive of

8) ECG suggestive of

arrhythmogenic

arrhythmogenic

right ventricular dysplasia

right ventricular dysplasia

(ARVD) (negative T waves in right

(ARVD) (negative T waves in right

precordium

precordium

, epsilon

, epsilon

waves, and ventricular late potentials)

waves, and ventricular late potentials)

9) Q wave suggestive of myocardial

9) Q wave suggestive of myocardial

infacrtion

infacrtion

Data from Data from BrignoleBrignole, M, , M, AlboniAlboni, , BendittBenditt, D, et. Al, , D, et. Al, EurEur Heart J 2001, 22:1256Heart J 2001, 22:1256

6

Indications for Ambulatory ECG Monitoring to Assess

Indications for Ambulatory ECG Monitoring to Assess

Symptoms Possibly Related to Rhythm Disturbances

Symptoms Possibly Related to Rhythm Disturbances

Class I

Class I

1) Patients with unexplained syncope, near syncope, or

1) Patients with unexplained syncope, near syncope, or

episodesic

episodesic

dizziness in whom the cause is not obvious

dizziness in whom the cause is not obvious

2) Patients with unexplained recurrent palpitation

2) Patients with unexplained recurrent palpitation

Class

Class

IIb

IIb

1) Patients with episodic shortness of breath, chest pain t

1) Patients with episodic shortness of breath, chest pain t

hat is

hat is

not otherwise explained

not otherwise explained

2) Patient with neurological events when transient

2) Patient with neurological events when transient

atrial

atrial

fibrillation or flutter is suspected

fibrillation or flutter is suspected

3) Patients with symptoms such as syncope, near syncope,

3) Patients with symptoms such as syncope, near syncope,

episodic dizziness, or palpitation in whom a probable cause

episodic dizziness, or palpitation in whom a probable cause

other than an

other than an

arrhyhmia

arrhyhmia

has been identified but in whom

has been identified but in whom

symptoms persists despite treatment of this other cause

symptoms persists despite treatment of this other cause

SYNCOPE

SYNCOPE

Inpatient versus outpatient evaluation

Inpatient versus outpatient evaluation

Usually dependent on severity (i.e. injury

Usually dependent on severity (i.e. injury

or MVA)

or MVA)

Structural heart disease suggests a more

Structural heart disease suggests a more

malignant etiology and usually requires

malignant etiology and usually requires

hospitalization

hospitalization

Neurocardiogenic

Neurocardiogenic

Syncope

Syncope

7

Neurocardiogenic

Neurocardiogenic

Syncope

Syncope

Also known as the common faint

Also known as the common faint

Neurally

Neurally

mediated syndrome (NMS),

mediated syndrome (NMS),

vasovagal

vasovagal

syncope (VVS) or

syncope (VVS) or

vasodepressor syncope

vasodepressor syncope

Often a diagnosis by exclusion

Often a diagnosis by exclusion

Rule out

Rule out

cardiogenic

cardiogenic

and

and

neurogenic

neurogenic

causes first

causes first

Review of 641 patients with recurrent

Review of 641 patients with recurrent

syncope in whom a cardiac, neurologic

syncope in whom a cardiac, neurologic

and metabolic etiology of syncope had

and metabolic etiology of syncope had

been excluded,

been excluded,

neurocardiogenic

neurocardiogenic

syncope

syncope

was considered the cause in

was considered the cause in

35%

35%

of

of

patients.

patients.

In a prospective study of 341 patients with

In a prospective study of 341 patients with

syncope,

syncope,

33 percent

33 percent

had

had

neurocardiogenic

neurocardiogenic

syncope.

syncope.

Incidence of NeurocardiogenicSyncope

Neurocardiogenic

Neurocardiogenic

Syncope

Syncope

Reflex response causing

Reflex response causing

vasodilation

vasodilation

and

and

bradycardia

bradycardia

resulting in

resulting in

systemic hypotension and

systemic hypotension and

cerebral

cerebral

hypoperfusion

hypoperfusion

8

Presumed Mechanism of

Presumed Mechanism of

Neurocardiogenic

Neurocardiogenic

Syncope

Syncope

Central venous volume

Orthostatic stress

Blood volume

Baroreceptor

unloaded

Adrenergic tone

Myocardial

contractility

Heart rate

Activation of

cardiopulmonary

mechanoreceptors

Parasympathetic

activation

Bradycardia

Hypotension

Vasodilation

Central vasomotor

activation

Sympathetic withdrawal

Circulating epinephrine

(adrenals)

S Y N C O P E

Diaphoresis, nausea

vomiting, and dyspnea

Cerebral hypoperfusion

and cerebral anoxia

Pathophysiology

Pathophysiology

Both neural (

Both neural (

Bezold

Bezold

-

-

Jarisch

Jarisch

and carotid sinus

and carotid sinus

reflexes) and endogenous chemical pathways are

reflexes) and endogenous chemical pathways are

thought to play a role

thought to play a role

3 types of autonomic responses seen:

3 types of autonomic responses seen:

1)

1)

Cardioinhibitory

Cardioinhibitory

-

-

increased parasympathetic tone

increased parasympathetic tone

manifested as sinus

manifested as sinus

bradycardia

bradycardia

, PR prolongation,

, PR prolongation,

and advanced

and advanced

atrioventricular

atrioventricular

block

block

2) Vasodepressor response

2) Vasodepressor response

-

-

decreased sympathetic

decreased sympathetic

tone

tone

which leads to hypotension

which leads to hypotension

3) Mixed

3) Mixed

cardioinhibitory

cardioinhibitory

and vasodepressor

and vasodepressor

response

response

60 degrees

TILT TABLE TEST or

HEAD-UP TILT (HUT) TESTING

Test Sensitivity: 67 - 83%

Test Specificity: 75%

Procedure:

Involves tilting patient from supine to

60 - 80 degrees angle to reproduce

syncope

Two Phases:

Passive Phase :without drug

Active phase: isoproterenol infusion

a) 1 ug/min

b) 3-5 ug/min

9

Tilt Table Test

Tilt Table Test

Indications:

Indications:

1) Work

1) Work

-

-

up of syncope in patients

up of syncope in patients

with structurally normal heart

with structurally normal heart

(normal ECG, ECHO, stress

(normal ECG, ECHO, stress

test or a non

test or a non

-

-

diagnostic

diagnostic

Holter

Holter

)

)

2) Men > 45 y.o. and women

2) Men > 45 y.o. and women

> 55 y.o. should undergo

> 55 y.o. should undergo

stress testing before the test

stress testing before the test

3) Women of child bearing age

3) Women of child bearing age

should have a pregnancy

should have a pregnancy

test

test

Upright Tilt Table Test

Upright Tilt Table Test

Measure HR and BP

Measure HR and BP

while tilting them

while tilting them

upright

upright

Attempt to elicit

Attempt to elicit

symptoms

symptoms

Cannot be used to

Cannot be used to

test efficacy of

test efficacy of

pharmacologic

pharmacologic

therapy

therapy

Carotid Sinus Massage

Carotid Sinus Massage

Indication:

Indication:

a) patients > 40 years old with unknown etiology

a) patients > 40 years old with unknown etiology

of syncope after initial evaluation

of syncope after initial evaluation

Procedure:

Procedure:

b) Continuous ECG and BP monitoring mandatory

b) Continuous ECG and BP monitoring mandatory

c) Carotid massage done for 5

c) Carotid massage done for 5

-

-

10 sec. in both supine and erect

10 sec. in both supine and erect

positions

positions

Positive Result:

Positive Result:

a) symptoms are reproduced during or immediately after the

a) symptoms are reproduced during or immediately after the

massage

massage

b)

b)

asystole

asystole

longer than 3 sec. and or

longer than 3 sec. and or

c) a fall in SBP of =>50 mmHg

c) a fall in SBP of =>50 mmHg

Data from Brignole, M, Albani, O Benditt, D, et. Al., Eur Heart J 2001; 22:1256

10

Preventive Measures

Preventive Measures

Avoid dehydration and severe dieting

Avoid dehydration and severe dieting

Liberal salt intake if not contraindicated

Liberal salt intake if not contraindicated

Counterpressure

Counterpressure

support garments from

support garments from

ankles to waist

ankles to waist

Avoid prolonged periods of motionless

Avoid prolonged periods of motionless

standing

standing

Once with

Once with

prodromal

prodromal

or trigger

or trigger

-

-

assume

assume

a recumbent position and cough

a recumbent position and cough

Avoid triggers like heat exposure,

Avoid triggers like heat exposure,

painful stimuli

painful stimuli

Treatment

Treatment

Reassurance, education, avoidance

Reassurance, education, avoidance

Support stockings, salt liberalization

Support stockings, salt liberalization

Beta blockers

Beta blockers

Midodrine

Midodrine

Selective Serotonin Reuptake Inhibitors

Selective Serotonin Reuptake Inhibitors

Fludrocortisone

Fludrocortisone

(

(

Florinef

Florinef

)

)

Drug therapy is often not very effective

Drug therapy is often not very effective

11

Non

Non

-

-

random, observational

random, observational

RCTs

RCTs

comparing

comparing

vs

vs

RCTs

RCTs

comparing

comparing

vs

vs

What are the indications for pacemaker

What are the indications for pacemaker

therapy in

therapy in

neurocardiogenic

neurocardiogenic

syncope?

syncope?

2727 dualdual--chamber pacemakerschamber pacemakers

with ratewith rate--drop responsedrop response

54 pts

54 pts

2727 No pacemakerNo pacemaker

Included

Included

>6 lifetime episodes

>6 lifetime episodes

+ tilt

+ tilt

-

-

table test

table test

–

–

(relative

(relative

bradycardia

bradycardia

)

)

Primary outcome: first recurrence of syncope

54 days54 days112 days112 daysTime to Time to

recurrencerecurrence

19/27 (70%)19/27 (70%)6/27 (22%)6/27 (22%)Recurrence of Recurrence of

SyncopeSyncope

No pacemakerNo pacemakerPacemakerPacemaker

Excluded

Excluded

Vascular, coronary, myocardial

Vascular, coronary, myocardial

or conduction system disease

or conduction system disease

The North American

The North American

Vasovagal

Vasovagal

Pacemaker Study (VPS)

Pacemaker Study (VPS)

J. Am. Coll Cardiol. 1999;33:16-20

VPS

VPS

Limitations:

Limitations:

Unblinded

Unblinded

Small study size

Small study size

Time to first

Time to first

occurrence

occurrence

vs

vs

total

total

disease burden

disease burden

J. Am. Coll Cardiol. 1999;33:16-20

12

Vasovagal

Vasovagal

Syncope International

Syncope International

Study (VASIS)

Study (VASIS)

Repeat tilt testing: no differenceRepeat tilt testing: no difference

Pacer arm 10/17 + testsPacer arm 10/17 + tests

–– 5 had no 5 had no bradycardiabradycardia, 5 pacer did , 5 pacer did

not prevent syncopenot prevent syncope

–– 1/7 pacer activated in 1/7 pacer activated in negneg testtest

>

>

3 episodes in last 2 yrs

3 episodes in last 2 yrs

Tilt test

Tilt test

cardioinhibition

cardioinhibition

–– VentricVentric. Rate <40 for 10 sec. Rate <40 for 10 sec

–– AsystoleAsystole >3sec>3sec

Circulation 2000;102:294-299

Permanent cardiac pacing versus medical treatment for the

Permanent cardiac pacing versus medical treatment for the

prevention of recurrent

prevention of recurrent

vasovagal

vasovagal

syncope

syncope

93 pts

93 pts

46 47

46 47

DDD pacemaker

DDD pacemaker

atenolol

atenolol

+ rate drop 100mg daily

+ rate drop 100mg daily

Unblinded

Unblinded

older, highly symptomatic

older, highly symptomatic

patients with an

patients with an

asystolic

asystolic

response to tilt testing in pacer

response to tilt testing in pacer

group

group

Circulation 2001;104;52-57

VPS II

VPS II

>3 episodes in 2 years

>3 episodes in 2 years

+tilt test

+tilt test

–

–

HR x BP< 6000/min

HR x BP< 6000/min

-

-

mmHg

mmHg

Risk of syncope at 6

Risk of syncope at 6

months: 40% ODO,

months: 40% ODO,

31% DDD

31% DDD

–

–

RRR 30% (P = 0.14)

RRR 30% (P = 0.14)

Compared to VPS I

Compared to VPS I

Fewer events in non

Fewer events in non

-

-

paced group in VPS II

paced group in VPS II

(40%

(40%

vs

vs

70%)

70%)

JAMA 2003;289:2224-2229

13

SYNPACE

SYNPACE

6 events lifetime

6 events lifetime

+tilt test

+tilt test

–

–

Asystolic

Asystolic

: >3

: >3

secs

secs

–

–

Mixed:

Mixed:

bradycardic

bradycardic

<60bpm

<60bpm

but no

but no

asystole

asystole

–

–

Vasodepressor: hypotension

Vasodepressor: hypotension

only, were excluded

only, were excluded

29 pts randomized to pacemaker

29 pts randomized to pacemaker

ON (16) or OFF (13)

ON (16) or OFF (13)

Syncope recurred 8 (50%) in ON

Syncope recurred 8 (50%) in ON

group, 5 (38%) in OFF group

group, 5 (38%) in OFF group

No significant difference

No significant difference

Syncopal

Syncopal

rates lower

rates lower

postimplantation

postimplantation

for both

for both

groups

groups

Non

Non

-

-

significant trend of pacing

significant trend of pacing

prolonging time to first

prolonging time to first

occurrence

occurrence

Euro Heart J 2004;25:1741-1748

Conclusions

Conclusions

ACC/AHA/HRS 2008 Guidelines for Device

ACC/AHA/HRS 2008 Guidelines for Device

-

-

based Therapy

based Therapy

Class Class IIaIIa

Permanent pacing is reasonable for syncope without clear Permanent pacing is reasonable for syncope without clear

provocative events and with a hypersensitive provocative events and with a hypersensitive cardioinhibitorycardioinhibitory

response of 3 seconds or longer.response of 3 seconds or longer.

Class Class IIbIIb

Permanent pacing may be considered for Permanent pacing may be considered for

significantly symptomatic significantly symptomatic neurocardiogenicneurocardiogenic syncope syncope

associated with associated with bradycardiabradycardia documented spontaneously or at documented spontaneously or at

the time of tiltthe time of tilt--table testing.table testing.

Class IIIClass III

Permanent pacing is not indicated for situational Permanent pacing is not indicated for situational vasovagalvasovagal

syncope in which avoidance behavior is effective and syncope in which avoidance behavior is effective and

preferred.preferred.

64yo F

HPI: walks in

the door, finds

her friends

down, runs to

call 911, steps

on a banana

peel, falls, no LOC

66yo F

HPI: Attending

to her friends

when she falls

to floor, +LOC,

+loss bladder,

+jerking

movements of her arms and legs

59yo F

HPI: vomiting +

diarrhea x3 days,

stands up rapidly

from supine, falls

back onto couch,

+LOC

case

case

85yo F

HPI: LOC while sitting

on toilet, no head

trauma

PMH: Afib, HTN, HL,

recurrent syncope

-previous syncope: sitting in church, at

restaurant, bowel movement

-hx + tilt table test, ILR: bradycardic to 40s

14

Recommendations for Driving

Recommendations for Driving

in Patients with Syncope

in Patients with Syncope

Diagnosis

Diagnosis

Disqualifying

Disqualifying

Criteria

Criteria

NMS (

NMS (

Neurally

Neurally

mediated syncope)

mediated syncope)

VVS and CSH

VVS and CSH

-

-

Single episodes, mild symptoms No restric

Single episodes, mild symptoms No restric

tions

tions

-

-

Severe symptoms Un

Severe symptoms Un

til symptoms

til symptoms

controlled

controlled

-

-

Situational forms

Situational forms

No restrictions

No restrictions

Syncope of uncertain cause In case of severe sync

Syncope of uncertain cause In case of severe sync

ope

ope

until cause identified,

until cause identified,

especially in patients with

especially in patients with

hea

hea

rt disease or at least 6

rt disease or at least 6

mon

mon

ths without symptoms

ths without symptoms

before (re)

before (re)

-

-

licensing

licensing

Recommendations for Driving

Recommendations for Driving

in Patients with Syncope

in Patients with Syncope

Diagnosis Disqualifying cri

Diagnosis Disqualifying cri

teria

teria

Cardiac

Cardiac

Arrhytmias

Arrhytmias

Any disturbance of cardiac

Any disturbance of cardiac

rhythm which is likely to cause

rhythm which is likely to cause

which is likely to cause syncope

which is likely to cause syncope

Pacemaker implant Within one week

Pacemaker implant Within one week

Successful catheter ablation

Successful catheter ablation

ICD Within 6 mont

ICD Within 6 mont

hs if no

hs if no

arrhythmia recurrence

arrhythmia recurrence

and no dis

and no dis

abling symptoms at

abling symptoms at

time of ICD discharge.

time of ICD discharge.

If prophylactic ICD placement

If prophylactic ICD placement

-

-

one week then no restrictions

one week then no restrictions

15

ESC Recommendations for

ESC Recommendations for

Treatment of

Treatment of

Neurocardiogenic

Neurocardiogenic

Syncope

Syncope

Class I

Class I

1) Explanation of the risk

1) Explanation of the risk

Conclusions

Conclusions

ACC/AHA/HRS 2008 Guidelines for ACC/AHA/HRS 2008 Guidelines for

DeviceDevice--based Therapybased Therapy

Class Class IIaIIa

Permanent pacing is reasonable for Permanent pacing is reasonable for

syncope without clear provocative syncope without clear provocative

events and with a hypersensitive events and with a hypersensitive

cardioinhibitorycardioinhibitory response of 3 seconds response of 3 seconds

or longer.or longer.

Class Class IIbIIb

Permanent pacing may be considered Permanent pacing may be considered

for significantly symptomatic for significantly symptomatic

neurocardiogenicneurocardiogenic syncope associated syncope associated

with with bradycardiabradycardia documented documented

spontaneously or at the time of tiltspontaneously or at the time of tilt--

table testing.table testing.

Class IIIClass III

Permanent pacing is not indicated for Permanent pacing is not indicated for

situational situational vasovagalvasovagal syncope in which syncope in which

avoidance behavior is effective and avoidance behavior is effective and

preferred.preferred.

European Society of Cardiology European Society of Cardiology

Guidelines on Management of Guidelines on Management of

Syncope 2004Syncope 2004

Class IIIClass III

Cardiac pacing in patients with Cardiac pacing in patients with

cardioinhibitorycardioinhibitory vasovagalvasovagal syncope syncope

with a frequency >5 attacks per year or with a frequency >5 attacks per year or

severe physical injury or accident and severe physical injury or accident and

age>40age>40

TTT/HUT (8/30/99)

TTT/HUT (8/30/99)

* Nausea, diaphoresis, & altered gaze

*

16

Pacing

Pacing

DDD type of pacemaker

DDD type of pacemaker

Case to case basis

Case to case basis

Rx

Rx

Neurocardiogenic

Neurocardiogenic

syncope

syncope

Beta

Beta

-

-

blockers

blockers

-

-

most commonly effective

most commonly effective

therapy

therapy

SSRI :

SSRI :

sertraline

sertraline

,

,

flouxetine

flouxetine

or

or

paroxetine

paroxetine

Midodrine

Midodrine

(alpha 1 adrenergic agonist)

(alpha 1 adrenergic agonist)

Florinef

Florinef

Theophylline

Theophylline