eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology
Syncope: Treatment & Medication
Updated: Nov 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Typical neurocardiogenic syncopes rarely require medication in childhood. In general, addressing certain behavioral aspects with the patient is sufficient as the only therapeutic measure. However, for many individuals, treatment outcome may be difficult to predict; a significant patients continue to experience syncope despite medical therapy.
- For patients with typical features of neuroregulatory syncope, the most important initial step is to reassure the patient and to provide instructions regarding avoidance of both dehydration and postural hypotension.
- Therapy aimed at preventing an exaggerated reflex may be achieved by increasing intravascular volume with an increased dietary salt intake, prescribed sodium chloride tablets, or salt-retaining fluorinated corticosteroid.
- Alternately, peripheral venous pooling and cardiac hypercontractility can be avoided with beta-blockers. Cardiac hypercontractility and the vagal portion of the autonomic reflex can also be inhibited with negative inotropic anticholinergic medication (eg, disopyramide).
- Alpha-adrenergic agents have also been effective in patients with cardioinhibitory syncope.
- Specialized permanent pacing designs have been effective in revealing the paradoxical relative bradycardia of the Bezold-Jarisch reflex and respond with high-rate dual-chamber pacing.
Consultations
Consider consultation with a neurologist for patients with syncope that remains unexplained following complete cardiac investigations.
Diet
Salt substitutes should be avoided. Salt may be added to the diet of an individual with neuroregulatory syncope (ie, common faint) who cannot voluntarily maintain adequate hydration.
Activity
Patients should avoid situations in which syncope might result in injury while they are undergoing evaluation or if an effective therapy has not been identified.
Medication
Electrolytes
These agents are used to correct disturbances in fluid and electrolyte homoeostasis or acid-base balance. They are used to reestablish osmotic equilibrium of specific ions.
Sodium chloride
Sodium is the principle cation of extracellular fluid, and chloride is the principle anion of extracellular fluid.
Adult
900-1000 mg PO tid; titrate to maintain electrolyte homeostasis
Pediatric
15 mg/kg PO tid; titrate to maintain electrolyte homeostasis
May decrease levels of lithium when administered concurrently
Hypernatremia
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in CHF, hypertension, edema, liver cirrhosis, renal insufficiency, and sodium toxicity
Mineralocorticoids
These agents are used to treat syncope secondary to orthostatic hypotension. They act on fluid and electrolyte balance and enhance sodium reabsorption in the kidney, resulting in expanded extracellular fluid volume. They increase renal excretion of potassium and hydrogen ions.
Fludrocortisone (Florinef)
Increases standing blood pressure. Acts to increase sodium retention and expand plasma volume.
Adult
0.1-0.2 mg/d PO
Pediatric
0.05-0.1 mg/d PO
Antagonizes effects of anticholinergics; rifampin, hydantoins, and barbiturates decrease effects of fludrocortisone; decreases salicylate levels
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Taper dose gradually when therapy is discontinued; caution in Addison disease, potassium loss, and sodium retention
Beta-adrenergic blocking agents
These agents inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation. Peripheral venous pooling and cardiac hypercontractility can be avoided through the use of beta-blockers.
Propranolol (Inderal)
Class II antiarrhythmic nonselective beta-adrenergic receptor blocker with membrane-stabilizing activity that decreases automaticity of contractions.
Adult
10-30 mg PO tid/qid; alternatively, administer total daily dose as SR product qd
Pediatric
0.5-1 mg/kg/d PO divided q6-8h initially; titrate upward q3-5d prn; typical dose is 2-4 mg/kg/d; not to exceed 16 mg/kg/d or 60 mg/d
In older children, total daily dose may be administered as SR product qd
Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease propranolol effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity of propranolol; toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines may increase with propranolol
Documented hypersensitivity; uncompensated CHF; bradycardia; cardiogenic shock; AV conduction abnormalities
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; withdraw drug slowly and monitor closely
Atenolol (Tenormin)
Selectively blocks beta1 receptors with little or no effect on beta2 receptors.
Adult
50 mg PO qd; increase to 100 mg/d prn
Pediatric
0.8-1.5 mg/kg PO qd; not to exceed 2 mg/kg/d
Coadministration with aluminum salts, barbiturates, calcium salts, cholestyramine, NSAIDs, penicillins, and rifampin may decrease effects; haloperidol, hydralazine, loop diuretics, and MAOIs may increase toxicity of atenolol
Documented hypersensitivity; CHF; pulmonary edema; cardiogenic shock; AV conduction abnormalities; heart block (without a pacemaker)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may reduce symptoms of acute hypoglycemia and mask signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism and cause thyroid storm; monitor patients closely and withdraw drug slowly; during an IV, carefully monitor BP, heart rate, and ECG
Alpha-adrenergic agonists
These agents may improve the hemodynamic status in patients with cardioinhibitory syncope by increasing myocardial contractility and heart rate, resulting in increased cardiac output. They also increase peripheral resistance by causing vasoconstriction. Increased cardiac output and increased peripheral resistance lead to increased blood pressure.
Midodrine (ProAmatine, Amatine)
Active metabolite, desglymidodrine, is an alpha1 agonist. Desglymidodrine is structurally similar to methoxamine and produces alpha-adrenergic receptor stimulation of arterial and venous systems.
Adult
10 mg PO tid; administer doses 4 h apart
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Drugs that stimulate alpha-adrenergic agonists may enhance or potentiate pressor effects of midodrine; coadministration with cardiac glycosides psychopharmacologic agents, or beta-blockers may enhance or precipitate bradycardia, AV block, or arrhythmia
Documented hypersensitivity; acute renal disease; severe organic heart disease; pheochromocytoma; urinary retention; persistent and excessive supine hypertension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in diabetes or visual complications; discontinue midodrine and reevaluate if any signs or symptoms suggesting bradycardia occur
Vagal inhibitors
Cardiac hypercontractility and the vagal portion of the autonomic reflex can be inhibited with a negative inotropic anticholinergic medication (eg, disopyramide).
Disopyramide (Norpace)
Class 1A antiarrhythmic. Possesses anticholinergic, peripheral vasoconstrictive, and negative inotropic effects. Decreases conduction velocity and myocardial excitability.
Adult
<50 kg: 100 mg PO q6h or 200 mg q12h if controlled release
>50 kg: 150 mg PO q6h or 300 mg q12h if controlled release
Not to exceed 400 mg PO q6h for severe refractory VT
Pediatric
<1 year: 10-30 mg/kg/d PO divided q6h
1-4 years: 10-20 mg/kg/d PO divided q6h
4-12 years: 10-15 mg/kg/d PO divided q6h
>12 years: 6-15 mg/kg/d PO divided q6h
Phenytoin, rifampin, and phenobarbital may decrease effects; toxicity increases with erythromycin and sparfloxacin; levels of digoxin increase
Documented hypersensitivity; preexisting second or third-degree AV block; coadministration with sparfloxacin; history of complete heart block; sick sinus syndrome; cardiogenic shock; CHF; prolonged baseline QTc (>460 ms)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in preexisting urinary retention, hypotension during initiation of therapy, and angle-closure glaucoma (including family history)
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| Overview: Syncope |
| Differential Diagnoses & Workup: Syncope |
 Treatment & Medication: Syncope |
| Follow-up: Syncope |
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References
Mark AL. The Bezold-Jarisch reflex revisited: clinical implications of inhibitory reflexes originating in the heart. J Am Coll Cardiol. Jan 1983;1(1):90-102. [Medline].
Silver ES, Pass RH, Hordof AJ, Liberman L. Paroxysmal AV block in children with normal cardiac anatomy as a cause of syncope. Pacing Clin Electrophysiol. Mar 2008;31(3):322-6. [Medline].
[Guideline] Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. May 27 2008;51(21):e1-62. [Medline].
Driscoll DJ, Jacobsen SJ, Porter CJ, Wollan PC. Syncope in children and adolescents. J Am Coll Cardiol. Apr 1997;29(5):1039-45. [Medline].
Vignati G, Annoni G. Characterization of supraventricular tachycardia in infants: clinical and instrumental diagnosis. Curr Pharm Des. 2008;14(8):729-35. [Medline].
Frustaci A, Priori SG, Pieroni M. Cardiac histological substrate in patients with clinical phenotype of Brugada syndrome. Circulation. Dec 13 2005;112(24):3680-7.
Schwartz PJ, Spazzolini C, Crotti L, et al. The Jervell and Lange-Nielsen syndrome: natural history, molecular basis, and clinical outcome. Circulation. Feb 14 2006;113(6):783-90. [Medline].
Chandar JS, Wolff GS, Garson A, et al. Ventricular arrhythmias in postoperative tetralogy of Fallot. Am J Cardiol. Mar 1 1990;65(9):655-61. [Medline].
Nakazawa M, Shinohara T, Sasaki A, et al. Arrhythmias late after repair of tetralogy of fallot: a Japanese Multicenter Study. Circ J. Feb 2004;68(2):126-30. [Medline].
Vohra J, Sathe S, Warren R, et al. Malignant ventricular arrhythmias in patients with mitral valve prolapse and mild mitral regurgitation. Pacing Clin Electrophysiol. Mar 1993;16(3 Pt 1):387-93. [Medline].
Al Dhahri KN, Potts JE, Chiu CC, Hamilton RM, Sanatani S. Are Implantable Loop Recorders Useful in Detecting Arrhythmias in Children with Unexplained Syncope?. Pacing Clin Electrophysiol. Aug 19 2009;[Medline].
Aldor E, Heeger H. Ventricular fibrillation under quinidine medication--quinidine syncope. Med Klin. Mar 3 1978;73(9):325-8. [Medline].
Balaji S, Oslizlok PC, Allen MC, et al. Neurocardiogenic syncope in children with a normal heart. J Am Coll Cardiol. Mar 1 1994;23(3):779-85. [Medline].
Boehm KE, Morris EJ, Kip KT, et al. Diagnosis and management of neurally mediated syncope and related conditions in adolescents. J Adolesc Health. Jan 2001;28(1):2-9. [Medline].
Borggrefe M, Wolpert C, Antzelevitch C, et al. Short QT syndrome. Genotype-phenotype correlations. J Electrocardiol. Oct 2005;38(4 Suppl):75-80. [Medline].
Bunce NH, Lorenz CH, Keegan J, et al. Coronary artery anomalies: assessment with free-breathing three-dimensional coronary MR angiography. Radiology. Apr 2003;227(1):201-8. [Medline]. [Full Text].
Carniel E, Sinagra G, Bussani R, et al. Fatal myocarditis: morphologic and clinical features. Ital Heart J. Sep 2004;5(9):702-6. [Medline].
Clark CT, Resenblatt R, Somberg JC. Neurocardiogenic syncope with Addison's disease. Am J Ther. Sep 2000;7(5):328-31. [Medline].
Cooper LT, Berry GJ, Shabetai R. Idiopathic giant-cell myocarditis--natural history and treatment. Multicenter Giant Cell Myocarditis Study Group Investigators. N Engl J Med. Jun 26 1997;336(26):1860-6. [Medline].
Dallengach-Hellweg G. [Morphologically demonstrable bases of a) normal menstruation and its disturbances b) nidation c) detachment of the placenta during birth]. Verh Dtsch Ges Pathol. 1976;375-81. [Medline].
Davis AM, Wilkinson JL. The long QT syndrome and seizures in childhood. J Paediatr Child Health. Oct 1998;34(5):410-1. [Medline].
De Rosa G, Piastra M, Pardeo M, et al. Exercise-unrelated sudden death as the first event of anomalous origin of the left coronary artery from the right aortic sinus. J Emerg Med. Nov 2005;29(4):437-41. [Medline].
Eckart RE, Jones SO, Shry EA, et al. Sudden death associated with anomalous coronary origin and obstructive coronary disease in the young. Cardiol Rev. Jul-Aug 2006;14(4):161-3. [Medline].
Fruhwald FM, Eber B, Schumacher M, et al. Syncope in dilated cardiomyopathy is a predictor of sudden cardiac death. Cardiology. May-Jun 1996;87(3):177-80. [Medline].
Grubb BP. Cerebral syncope: new insights into an emerging entity. J Pediatr. Apr 2000;136(4):431-2. [Medline].
Hauer KE. Discovering the cause of syncope. A guide to the focused evaluation. Postgrad Med. Jan 2003;113(1):31-8, 95; quiz 2. [Medline].
Johnsrude CL. Current approach to pediatric syncope. Pediatr Cardiol. Nov-Dec 2000;21(6):522-31. [Medline].
Knight BP, Goyal R, Pelosi F, et al. Outcome of patients with nonischemic dilated cardiomyopathy and unexplained syncope treated with an implantable defibrillator. J Am Coll Cardiol. Jun 1999;33(7):1964-70. [Medline].
Kumpf M, Sieverding L, Gass M, et al. Anomalous origin of left coronary artery in young athletes with syncope. BMJ. May 13 2006;332(7550):1139-41. [Medline].
Lewis DA, Dhala A. Syncope in the pediatric patient. The cardiologist's perspective. Pediatr Clin North Am. Apr 1999;46(2):205-19. [Medline].
McElhinney DB, Chatterjee KM, Reddy VM. Double-chambered right ventricle presenting in adulthood. Ann Thorac Surg. Jul 2000;70(1):124-7. [Medline].
Mohindra R, Pannu HS, Mohan B, et al. Syncope in a middle aged male due to acute rheumatic fever. Indian Heart J. Nov-Dec 2004;56(6):668-9. [Medline].
Morin MJ, Hopkins RA, Ferguson WS, Ziegler JW. Intracardiac yolk sac tumor and dysrhythmia as an etiology of pediatric syncope. Pediatrics. Apr 2004;113(4):e374-6. [Medline]. [Full Text].
Oh JH, Kapoor WN. Psychiatric illness and syncope. Cardiol Clin. May 1997;15(2):269-75. [Medline].
Papper EM. A democratic education--an excercise in collegiality. (A possible view of Diogenes were he to examine our present educational process). J Fla Med Assoc. Dec 1979;66(12):1219-21. [Medline].
Patel ND, Singh BK, Mathew ST. The heterogeneous spectrum of the long QT syndrome. Eur J Intern Med. Jul 2006;17(4):235-40. [Medline].
Patel RA, DiMarco JP, Akar JG, et al. Chagas myocarditis and syncope. J Cardiovasc Magn Reson. 2005;7(4):685-8. [Medline].
Probst V, Evain S, Gournay V, et al. Monomorphic ventricular tachycardia due to Brugada syndrome successfully treated by hydroquinidine therapy in a 3-year-old child. J Cardiovasc Electrophysiol. Jan 2006;17(1):97-100. [Medline].
Rogers SO, Leacche M, Mihaljevic T, et al. Surgery for anomalous origin of the right coronary artery from the left aortic sinus. Ann Thorac Surg. Nov 2004;78(5):1829-31. [Medline].
Rosenfeld ME, Beckerman B, Ward MF, Sama A. Lyme carditis: complete AV dissociation with episodic asystole presenting as syncope in the emergency department. J Emerg Med. Jul-Aug 1999;17(4):661-4. [Medline].
Samoil D, Grubb BP, Kip K, Kosinski DJ. Head-upright tilt table testing in children with unexplained syncope. Pediatrics. Sep 1993;92(3):426-30. [Medline].
Shonk JR, Vogel-Claussen J, Halushka MK, et al. Giant cell myocarditis depicted by cardiac magnetic resonance imaging. J Comput Assist Tomogr. Nov-Dec 2005;29(6):742-4. [Medline].
Tanel RE, Walsh EP. Syncope in the pediatric patient. Cardiol Clin. May 1997;15(2):277-94. [Medline].
Vasiljevic Z, Dmitrovic R, Naumovic Z, et al. Common form of Lyme borreliosis carditis--complete heart block with syncope: report on 3 cases. Cardiology. Jan-Feb 1996;87(1):76-8. [Medline].
Webb CL, Dick M, Rocchini AP, et al. Quinidine syncope in children. J Am Coll Cardiol. May 1987;9(5):1031-7. [Medline].
Wieling W, Smit AA, de Jong-de Vos van Steenwijk CC, et al. Pathophysiological mechanisms underlying vasovagal syncope in young subjects. Pacing Clin Electrophysiol. Aug 1997;20(8 Pt 2):2034-8. [Medline].
Wolff GS. Unexplained syncope: clinical management. Pacing Clin Electrophysiol. Aug 1997;20(8 Pt 2):2043-7. [Medline].
Further Reading
Keywords
syncope, faint, common faint, loss of consciousness, vasovagal syncope, vasodepressor syncope, neuroregulatory syncope, neurogenic syncope, neurocardiogenic syncope, presyncope, atrial fibrillation, supraventricular tachycardia, SVT, pulmonary hypertension
