In the syndrome of chronic orthostatic hypotension, from central or peripheral sympathetic failure, special mineralocorticoid preparations—such as fludrocortisone acetate (Florinef) 0.05 to 0.4 mg/d in divided doses—and increased salt intake to expand blood volume are helpful. The α1-agonist midodrine, beginning with 2.5 mg every 4 h and slowly increasing the dose to 5 mg every 4 to 6 h, has been used successfully in several studies, but this medication has the potential to worsen the situation and must be used with care. Domperidone may be helpful in patients with parkinsonism but it may prolong the Q-T interval. Sleeping with the head posts of the bed elevated on wooden blocks 8 to 12 in high and wearing a snug elastic abdominal binder and elastic stockings are measures that often prove helpful. Tyramine and monoamine oxidase inhibitors have given limited relief in some cases of Shy-Drager syndrome, and β-blockers (propranolol or pindolol) and indomethacin (25 to 50 mg tid) in others. These and other approaches that have proved useful in treating orthostatic hypotension are reviewed by Mathias and
Kimber. Anticholinesterase drugs such as pyridostigmine are entering a phase of popularity for the treatment of many forms of orthostatic hypotension (Singer and colleagues).
Neurally mediated syncope (neurocardiogenic or vasodepressor syncope), identified largely by the clinical circumstances and by tilt-table testing, may be prevented by the use of β-adrenergic blocking agents. Our colleagues in cardiology have recently favored acebutolol 400 mg daily, in part because of its partial α-adrenergic activity, which raises baseline blood pressure, but atenolol 50 mg may be as effective. The anticholinergic agent disopyramide has also been used (Milstein et al). Several other drugs (e.g., ephedrine, metoclopramide, dihydroergotamine) have been variably successful in individual patients, but their utility as standard medications remains to be established; the β-blocking agents are generally preferred.
The treatment of carotid sinus syncope involves, first of all, instructing the patient in measures that minimize the hazards of a fall (see in the following text). A loose collar should be worn, and the patient should learn to turn his whole body, rather than the head alone, when looking to one side. Atropine or one of the sympathomimetic group of drugs may be used, respectively, in patients with pronounced bradycardia or hypotension during attacks. If atropine is not successful, and it is certainly not practical for any period of time, and the syncopal attacks are incapacitating, the insertion of a dual-chamber pacemaker should be considered. Radiation or surgical denervation of the carotid sinus had apparently yielded favorable results in some patients, but it is no longer practiced. Vagovagal attacks usually respond well to an anticholinergic agent (propantheline, 15 mg tid). Syncope arising from glossopharyngeal neuralgia tends to benefit from medications that reduce the incidence of episodes, such as gabapentin.
In the elderly person, a faint carries the additional hazard of a fracture or other trauma as a consequence of the fall. Therefore the patient subject to recurrent syncope should cover the bathroom floor and bathtub with mats and have as much of his home carpeted as is feasible. Especially important is the floor space between the bed and the bathroom, because this is the route along which faints in elderly persons most commonly occur. Outdoor walking should be on soft ground rather than hard surfaces, and the patient should avoid standing still for prolonged periods, which is more likely than walking to induce an attack. Padded hip protectors, now available as a commercial product, should be considered in elderly patients at risk of recurrent falls of any kind but evidence of their effectiveness in large populations is, so far lacking.