Medication Summary

The goals of pharmacotherapy are to prevent complications and to reduce morbidity.

Class Summary

These agents improve conduction through the atrioventricular node by reducing vagal tone via muscarinic receptor blockade. For patients with infranodal block, this therapy is ineffective.

Atropine (Atropair, Isopto Atropine, Atropisol)

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Anticholinergic (or parasympatholytic) drug that exerts its action by competitively inhibiting acetylcholine at muscarinic receptors on postganglionic smooth muscle. Can counteract rapidly heightened vagal tone in response to pathologic carotid sinus syndrome. Additionally, can reverse bradycardia and lessen degree of heart block when vagal activity is etiologic factor. Usual doses are used to reduce severe bradycardia and syncope associated with hyperactive carotid sinus reflex.

Class Summary

Parenterally injected dextrose is used in patients unable to sustain adequate oral intake. Its direct oral absorption results in a rapid increase in blood glucose concentrations.

Dextrose (D-Glucose)

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Nutrient replenisher, serves to restore blood glucose levels. Each 100 mL of 5% dextrose contains 5 g of dextrose, whereas each 100 mL of 10% dextrose contains 10 g of dextrose.

Should be given only after demonstrated hypoglycemia.

Class Summary

CNS agents of the 1,4-benzodiazepine class exert their effects by binding at stereo-specific receptors in the CNS. Their exact mechanism of action has not been clearly elucidated. Benzodiazepines cause a dose-related CNS depression, which varies from mild sedation to hypnosis.

Alprazolam (Xanax)

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Indicated for treatment of anxiety and management of panic attacks. Following PO administration, absorbed readily. Peak concentrations in plasma occur 1-2 h following administration.

Class Summary

Midodrine forms an active metabolite, desglymidodrine, which is an alpha1-agonist that acts on receptors of the arteriolar and venous vasculature, producing an increase in vascular tone and elevation of BP. This drug has minimal beta effects and diffuses poorly across the blood-brain barrier.

Midodrine HCl (ProAmatine)

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Increases standing, sitting, and supine systolic and diastolic BP in patients with orthostatic hypotension of various etiologies. Standing systolic BP elevated by approximately 15-30 mm Hg at 1 h after 10-mg dose, with some effect persisting for 2-3 h. Has no clinically significant effect on standing or supine pulse rates in patients with autonomic failure.

Questions

Walsh K, Hoffmayer K, Hamdan MH. Syncope: diagnosis and management. Curr Probl Cardiol. 2015 Feb. 40 (2):51-86. [QxMD MEDLINE Link].
[Guideline] Huff JS, Decker WW, Quinn JV, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007 Apr. 49(4):431-44. [QxMD MEDLINE Link]. [Full Text].
Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009 Nov. 30(21):2631-71. [QxMD MEDLINE Link].
Rockx MA, Hoch JS, Klein GJ, et al. Is ambulatory monitoring for "community-acquired" syncope economically attractive? A cost-effectiveness analysis of a randomized trial of external loop recorders versus Holter monitoring. Am Heart J. 2005 Nov. 150(5):1065. [QxMD MEDLINE Link].
Gibson TC, Heitzman MR. Diagnostic efficacy of 24-hour electrocardiographic monitoring for syncope. Am J Cardiol. 1984 Apr 1. 53(8):1013-7. [QxMD MEDLINE Link].
Ungar A, Mussi C, Nicosia F, et al. The "syncope and dementia" study: a prospective, observational, multicenter study of elderly patients with dementia and episodes of "suspected" transient loss of consciousness. Aging Clin Exp Res. 2015 Dec. 27 (6):877-82. [QxMD MEDLINE Link].
Tretter JT, Kavey RE. Distinguishing cardiac syncope from vasovagal syncope in a referral population. J Pediatr. 2013 Dec. 163(6):1618-1623.e1. [QxMD MEDLINE Link].
Chen L, Chen MH, Larson MG, Evans J, Benjamin EJ, Levy D. Risk factors for syncope in a community-based sample (the Framingham Heart Study). Am J Cardiol. 2000 May 15. 85(10):1189-93. [QxMD MEDLINE Link].
Savage DD, Corwin L, McGee DL, Kannel WB, Wolf PA. Epidemiologic features of isolated syncope: the Framingham Study. Stroke. 1985 Jul-Aug. 16(4):626-9. [QxMD MEDLINE Link].
Pratt JL, Fleisher GR. Syncope in children and adolescents. Pediatr Emerg Care. 1989 Jun. 5(2):80-2. [QxMD MEDLINE Link].
Brignole M, Menozzi C, Moya A, et al. Pacemaker therapy in patients with neurally mediated syncope and documented asystole: Third International Study on Syncope of Uncertain Etiology (ISSUE-3): a randomized trial. Circulation. 2012 May 29. 125(21):2566-71. [QxMD MEDLINE Link].
Benditt DG, Can I. Initial evaluation of "syncope and collapse" the need for a risk stratification consensus. J Am Coll Cardiol. 2010 Feb 23. 55(8):722-4. [QxMD MEDLINE Link].
Middlekauff HR, Stevenson WG, Stevenson LW, Saxon LA. Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. J Am Coll Cardiol. 1993 Jan. 21(1):110-6. [QxMD MEDLINE Link].
Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med. 2002 Sep 19. 347(12):878-85. [QxMD MEDLINE Link].
Suzuki M, Hori S, Nakamura I, Soejima K, Aikawa N. Long-term survival of Japanese patients transported to an emergency department because of syncope. Ann Emerg Med. 2004 Sep. 44(3):215-21. [QxMD MEDLINE Link].
Reed MJ, Mills NL, Weir CJ. Sensitive troponin assay predicts outcome in syncope. Emerg Med J. 2012 Dec. 29(12):1001-3. [QxMD MEDLINE Link].
Martin TP, Hanusa BH, Kapoor WN. Risk stratification of patients with syncope. Ann Emerg Med. 1997 Apr. 29(4):459-66. [QxMD MEDLINE Link].
Sarasin FP, Hanusa BH, Perneger T, Louis-Simonet M, Rajeswaran A, Kapoor WN. A risk score to predict arrhythmias in patients with unexplained syncope. Acad Emerg Med. 2003 Dec. 10(12):1312-7. [QxMD MEDLINE Link].
Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004 Feb. 43(2):224-32. [QxMD MEDLINE Link].
Thiruganasambandamoorthy V, Hess EP, Alreesi A, Perry JJ, Wells GA, Stiell IG. External validation of the San Francisco Syncope Rule in the Canadian setting. Ann Emerg Med. 2010 May. 55(5):464-72. [QxMD MEDLINE Link].
Birnbaum A, Esses D, Bijur P, Wollowitz A, Gallagher EJ. Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Ann Emerg Med. 2008 Aug. 52(2):151-9. [QxMD MEDLINE Link].
Reed MJ, Newby DE, Coull AJ, Prescott RJ, Jacques KG, Gray AJ. The ROSE (risk stratification of syncope in the emergency department) study. J Am Coll Cardiol. 2010 Feb 23. 55(8):713-21. [QxMD MEDLINE Link].
Costantino G, Perego F, Dipaola F, et al. Short- and long-term prognosis of syncope, risk factors, and role of hospital admission: results from the STePS (Short-Term Prognosis of Syncope) study. J Am Coll Cardiol. 2008 Jan 22. 51(3):276-83. [QxMD MEDLINE Link].
Andrea U, Attilio DR, Franco G, et al. Early and late outcome of treated patients referred for syncope to emergency department: the EGSYS 2 follow-up study. Eur Heart J. 2010 Feb 18. [QxMD MEDLINE Link].
Colivicchi F, Ammirati F, Melina D, Guido V, Imperoli G, Santini M. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J. 2003 May. 24(9):811-9. [QxMD MEDLINE Link].
Dipaola F, Costantino G, Perego F, Borella M, Galli A, Cantoni G. San Francisco Syncope Rule, Osservatorio Epidemiologico sulla Sincope nel Lazio risk score, and clinical judgment in the assessment of short-term outcome of syncope. Am J Emerg Med. 2010 May. 28(4):432-9. [QxMD MEDLINE Link].
Serrano LA, Hess EP, Bellolio MF, et al. Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2010 Oct. 56(4):362-373.e1. [QxMD MEDLINE Link].
Atkins D, Hanusa B, Sefcik T, Kapoor W. Syncope and orthostatic hypotension. Am J Med. 1991 Aug. 91(2):179-85. [QxMD MEDLINE Link].
Calkins H, Shyr Y, Frumin H, Schork A, Morady F. The value of the clinical history in the differentiation of syncope due to ventricular tachycardia, atrioventricular block, and neurocardiogenic syncope. Am J Med. 1995 Apr. 98(4):365-73. [QxMD MEDLINE Link].
Guse SE, Neuman MI, O'Brien M, et al. Implementing a guideline to improve management of syncope in the emergency department. Pediatrics. 2014 Nov. 134 (5):e1413-21. [QxMD MEDLINE Link].
Martin GJ, Adams SL, Martin HG, Mathews J, Zull D, Scanlon PJ. Prospective evaluation of syncope. Ann Emerg Med. 1984 Jul. 13(7):499-504. [QxMD MEDLINE Link].
Dovgalyuk J, Holstege C, Mattu A, Brady WJ. The electrocardiogram in the patient with syncope. Am J Emerg Med. 2007 Jul. 25(6):688-701. [QxMD MEDLINE Link].
Sulke N, Sugihara C, Hong P, Patel N, Freemantle N. The benefit of a remotely monitored implantable loop recorder as a first line investigation in unexplained syncope: the EaSyAS II trial. Europace. 2016 Jun. 18 (6):912-8. [QxMD MEDLINE Link].
Rangel I, Freitas J, Correia AS, Sousa A, Lebreiro A, de Sousa C, et al. The usefulness of the head-up tilt test in patients with suspected epilepsy. Seizure. 2014 Feb 17. [QxMD MEDLINE Link].
Azizi Malamiri R, Momen AA, Nikkhah A, et al. Usability of the head upright tilt test for differentiating between syncopal and seizure-like events in children. Acta Neurol Belg. 2015 Dec. 115 (4):575-9. [QxMD MEDLINE Link].
Klemenc M, Strumbelj E. Predicting the outcome of head-up tilt test using heart rate variability and baroreflex sensitivity parameters in patients with vasovagal syncope. Clin Auton Res. 2015 Dec. 25 (6):391-8. [QxMD MEDLINE Link].
Quinn J, McDermott D. Electrocardiogram findings in emergency department patients with syncope. Acad Emerg Med. 2011 Jul. 18(7):714-8. [QxMD MEDLINE Link].
Claydon VE, Schroeder C, Norcliffe LJ, Jordan J, Hainsworth R. Water drinking improves orthostatic tolerance in patients with posturally related syncope. Clin Sci (Lond). 2006 Mar. 110(3):343-52. [QxMD MEDLINE Link].
Shen WK, Decker WW, Smars PA, et al. Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management. Circulation. 2004 Dec 14. 110(24):3636-45. [QxMD MEDLINE Link].
Sheldon R, Connolly S, Rose S, et al. Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation. 2006 Mar 7. 113(9):1164-70. [QxMD MEDLINE Link].
Brignole M, Arabia F, Ammirati F, et al., for the Syncope Unit Project 2 (SUP 2) investigators. Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study. Europace. 2016 Sep. 18 (9):1427-33. [QxMD MEDLINE Link].

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Author

Rumm Morag, MD, FACEP Member of Salem Emergency Physician Services, PC (SEPS), Salem Hospital

Rumm Morag, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Canadian Association of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

David A Peak, MD Associate Residency Director of Harvard Affiliated Emergency Medicine Residency; Attending Physician, Massachusetts General Hospital; Assistant Professor, Harvard Medical School

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, American Medical Association

Disclosure: Partner received salary from Pfizer for employment.

Syncope Medication

Medication Summary

Anticholinergics

Class Summary

Atropine (Atropair, Isopto Atropine, Atropisol)

Atropine (Atropair, Isopto Atropine, Atropisol)

Nutrient Supplements