Current approach to the treatment of vasovagal syncope in adults

Intern Emerg Med. 2023 Jan;18(1):23-30. doi: 10.1007/s11739-022-03102-w. Epub 2022 Sep 18.


Vasovagal syncope (VVS) is the most common cause of transient loss of consciousness. Although not associated with mortality, it causes injuries, reduces quality of life, and is associated with anxiety and depression. The European and North American cardiac societies recently published syncope clinical practice guidelines. Most patients with VVS do well after specialist evaluation, reassurance and education. Adequate hydration, increased salt intake when not contraindicated, and careful withdrawal of diuretics and specific hypotension-inducing drugs are a reasonable initial strategy. Physical counterpressure maneuvers might be helpful but can be of limited efficacy in older patients and those with short or no prodromes. Orthostatic training lacks long term efficacy and is troubled by non-compliance. Yoga might be helpful, although the biomedical mechanism is unknown. Almost a third of VVS patients continue to faint despite these conservative measures. Metoprolol was not helpful in a pivotal randomized clinical trial. Fludrocortisone and midodrine significantly reduce syncope recurrences with tolerable side effects, when titrated to target doses. Pacing therapy with specialized sensors appears promising in carefully selected population who have not responded conservative measures. Cardioneuroablation may be helpful but has not been studied in a formal clinical trial.

Keywords: CLS pacemaker; Fludrocortisone; Injuries; Midodrine; Quality of life; Vasovagal syncope.

Publication types

  • Review

MeSH terms

  • Adult
  • Aged
  • Humans
  • Midodrine* / therapeutic use
  • Quality of Life
  • Randomized Controlled Trials as Topic
  • Syncope, Vasovagal* / therapy


  • Midodrine