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What can I do when first-line measures are not enough for vasovagal syncope?

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Vasovagal syncope is usually benign, and although it often recurs, increasing fluid and salt intake and performing counter-pressure maneuvers are usually sufficient.1 However, if patients continue to have syncopal episodes despite these first-line measures, other options include drug therapy with midodrine, fludrocortisone, beta-blockers, or selective serotonin reuptake inhibitors; orthostatic training; and, in some cases, pacemaker implantation. The 2017 guidelines from the American College of Cardiology, American Heart Association, and Heart Rhythm Society (ACC/AHA/HRS) are helpful in the management of these patients.1


Although vasovagal syncope is considered benign, it can result in injury and can significantly affect quality of life.

The diagnosis can often be established in the initial evaluation with a structured history, physical examination, and electrocardiography. If the diagnosis is still unclear, tilt-table testing can be useful and has an ACC/AHA/HRS class IIa (moderate) recommendation.1 Once the diagnosis of vasovagal syncope is made, first-line measures can be instituted.


An explanation of the diagnosis, education on avoiding triggers such as prolonged standing and warm environments, coping with potentially stressful visits to the doctor or dentist, and reassurance that the condition is benign are all strongly recommended (class I).1

Initial measures include performing physical counter-pressure maneuvers (class IIa), increasing salt and fluid intake (class IIb) in the absence of contraindications, and, in selected patients, reducing or withdrawing hypotensive medications when appropriate (class IIb).

Physical counter-pressure maneuvers are recommended for patients whose syncopal episodes have a sufficiently long prodromal period. Maneuvers include the following:

  • Leg crossing: crossing the legs while tensing leg, abdominal, and buttock muscles
  • Handgrip: maximally contracting a rubber ball or other object in the dominant hand
  • Squatting
  • Limb or abdominal contractions
  • Arm tensing: contracting both arms by gripping one hand with the other and abducting both arms.2

The effectiveness of counter-pressure maneuvers was studied by van Dijk et al2 in a multicenter prospective randomized clinical trial that included 223 patients with recurrent vasovagal syncope associated with prodromal symptoms. They concluded that these maneuvers decreased the recurrence of syncopal episodes, with a relative risk reduction of 0.36 (95% confidence interval 0.11–0.53, P < .005) and were low-cost and risk-free.

Confirming the diagnosis of vasovagal syncope with tilt-table testing may reassure the patient. It can also help the patient learn to identify the symptoms associated with a vasovagal episode, which in turn may encourage timely use of physical counter-pressure maneuvers at the onset.

The evidence for increasing salt and fluid intake for patients with vasovagal syncope is limited. But in the absence of a contraindication such as hypertension, renal disease, or heart failure, it may be reasonable to encourage the ingestion of 2 L to 3 L of fluid per day and a total of 6 g to 9 g of salt per day (around 1 to 2 heaping teaspoons of salt).1

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