How to manage a patient presenting with syncope


Application of data

Treatment of syncope will depend on its etiology. Patients with neurally mediated syncope should be educated about avoiding or mitigating potential triggers (for example, orthostatic hypotension, emotional stress, severe cough, straining during urination) and recognizing prodromal symptoms. Such patients should also be counseled regarding physical counter-pressure maneuvers (for example, limb/abdominal contraction, leg crossing, hand grip) and increasing fluid and salt intake. Midodrine, an alpha-adrenergic vasoconstricting agent, may also be considered in patients with recurrent situational neutrally mediated syncope, to be taken an hour before situations that may induce syncope. Patients with carotid sinus syncope should be considered for pacemaker placement. For patients with orthostatic hypotension, potential exacerbating drugs should be held if possible and the patients counseled on liberalizing fluid and salt intake, along with rapid cool water ingestion and physical counter-pressure maneuvers. Abdominal binders, compression stockings, and midodrine, fludrocortisone, or pyridostigmine can also be considered. Treatment of syncope due to cardiac causes depends on the specific cause and should be based on established guidelines. Finally, PE should be treated with anticoagulation and, if needed, more aggressive measures (for example, thrombolysis).

Bottom Line

Our patient likely suffered from neurally mediated vasovagal syncope due to warm conditions, supported by a previous syncopal event under similar conditions. She should be counseled regarding potential physical counter-pressure maneuvers and increased fluid and salt intake when working under warm conditions.

Dr. Roberts, Dr. Krason, and Dr. Manian are hospitalists at Massachusetts General Hospital in Boston.


1. Shen W-K et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope. J Am Coll Cardiol. 2017 Aug 1;70(5):e39-e110.

2. Sheldon R. How to differentiate syncope from seizure. Cardiol Clin. 2015 Aug;33(3):377-85.

3. Del Rosso A et al. Relation of clinical presentation of syncope to the age of patients. Am J Cardiol. 2005 Nov 15;96(10):1431-5.

4. Blanc JJ. Syncope: Definition, epidemiology, and classification. Cardiol Clin. 2015 Aug;33(3):341-5.

5. Matthews IG et al. Syncope in the older person. Cardiol Clin. 2015 Aug;33(3):411-21.

6. Costantino G et al. Syncope risk stratification tools vs clinical judgment: An individual patient data meta-analysis. Am J Med. 2014 Nov;127(11):1126.e13-25.

7. Chiu DT et al. Are echocardiography, telemetry, ambulatory electrocardiography monitoring, and cardiac enzymes in emergency department patients presenting with syncope useful tests? A preliminary investigation. J Emerg Med. 2014;47:113-8.

8. Prandoni P et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med. 2016 Oct;375(20):1524-31.

9. Sheldon RS et al. Standardized approaches to the investigation of syncope: Canadian Cardiovascular Society position paper. Can J Cardiol. 2011 Mar-Apr;27(2):246-253.

10. Moya A et al. Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009 Nov;30(21):2631-71.

Additional reading

1. Brignole M, Hamdan MH. New concepts in the assessment of syncope. J Am Coll Cardiol. 2012 May; 59(18):1583-91.

2. Rosanio S et al. Syncope in adults: systematic review and proposal of a diagnostic and therapeutic algorithm. Int J Cardiol. 2013 Jan;162(3):149-57.


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