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Topic 111958 Version 20.0 https://www.uptodate.com/contents/reflex-syncope-in-adults-and-adolescents-treatment/print 17/20 7/6/23, 2:38 PM Reflex syncope in adults and adolescents: Treatment - UpToDate GRAPHICS Major cardiovascular causes of syncope Reflex-mediated* Vasovagal Orthostatic vasovagal syncope: usually after prolonged standing, frequently in a warm environment, etc Emotional vasovagal syncope: secondary to fear, pain, medical procedure, etc Unknown trigger Situational Micturition, defecation Swallowing Coughing/sneezing Carotid sinus syndrome Orthostatic hypotension* Medication-related Diuretics (eg, thiazide or loop diuretics) Vasodilators (eg, dihydropyridine calcium channel blockers, nitrates, alpha blockers, etc) Antidepressants (eg, tricyclic drugs, SSRIs, etc) Volume depletion Hemorrhage Gastrointestinal losses (ie, vomiting or diarrhea) Diminished thirst drive (primarily in older patients) Autonomic failure Primary: pure autonomic failure, Parkinson disease, multiple system atrophy, Lewy body dementia Secondary: diabetes mellitus, amyloidosis, spinal cord injuries, autoimmune neuropathy (eg, Guillain-Barr ), paraneoplastic neuropathy Cardiac Tachyarrhythmias Ventricular tachycardia Supraventricular tachycardias Bradyarrhythmias (with inadequate ventricular response) Sinus node dysfunction https://www.uptodate.com/contents/reflex-syncope-in-adults-and-adolescents-treatment/print 18/20 7/6/23, 2:38 PM Reflex syncope in adults and adolescents: Treatment - UpToDate Atrioventricular block Structural disease Severe aortic stenosis Hypertrophic cardiomyopathy Cardiac tamponade Prosthetic valve dysfunction Congenital coronary anomalies Cardiac masses and tumors (eg, atrial myxoma) Cardiopulmonary/vascular Pulmonary embolus Severe pulmonary hypertension Aortic dissection SSRI: selective serotonin reuptake inhibitor. Reflex-mediated syncope and syncope due to orthostatic hypotension are more likely to occur, or are more severe, when other factors may also be contributing, such as medication(s) causing low blood pressure, volume depletion, pulmonary diseases causing reduction in brain oxygen supply, alcohol use, and/or environmental factors (excessive heat or humidity). Adapted from: Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883. Graphic 118175 Version 4.0 https://www.uptodate.com/contents/reflex-syncope-in-adults-and-adolescents-treatment/print 19/20 7/6/23, 2:38 PM Reflex syncope in adults and adolescents: Treatment - UpToDate Contributor Disclosures David Benditt, MD Equity Ownership/Stock Options: Medtronic [Pacemakers/event recorders and defibrillators]. Grant/Research/Clinical Trial Support: Medtronic [Pacemakers/event recorders and defibrillators]; St Jude Medical [Pacemakers/event recorders and defibrillators]. Consultant/Advisory Boards: Medtronic [Pacemakers/event recorders and defibrillators]; Zoll [Pacemakers/event recorders and defibrillators]. Other Financial Interest: Advanced CPR Solutions [Outside director]. All of the relevant financial relationships listed have been mitigated. Peter Kowey, MD, FACC, FAHA, FHRS Equity Ownership/Stock Options: VuMedi [Arrhythmias]. Consultant/Advisory Boards: Abbvie [Arrhythmias]; Acesion Pharma [Arrhythmias]; Allergan [Arrhythmias, cardiac safety of non-cardiac drugs]; Anthos [Anticoagulants]; Boehringer-Ingelheim [Arrhythmias]; Bristol-Meyers-Squibb [Arrhythmias]; Daiichi Sankyo [Arrhythmias]; Gilead [Arrhythmias]; Huya [Arrhythmias]; InCarda Therapeutics [Arrhythmias]; INSTA [Arrhythmias]; Johnson & Johnson [Arrhythmias]; Medtronic [Arrhythmias]; Milestone [Arrhythmias]; Novartis [Arrhythmias, cardiac safety of non-cardiac drugs]; Pfizer [Arrhythmias]; Sanofi [Arrhythmias]; Takeda [Arrhythmias]. All of the relevant financial relationships listed have been mitigated. Susan B Yeon, MD, JD, FACC No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/reflex-syncope-in-adults-and-adolescents-treatment/print 20/20