Diagnosis and Management of Vasovagal Syncope in the Elderly

Vasovagal syncope is a common disorder characterized by arterial vasodilatation and bradycardia, resulting in a decrease in systemic blood pressure and diminished central perfusion. Although vasovagal syncope has a benign prognosis and most patients experience infrequent episodes that do not require any specific treatment, highly symptomatic patients may manifest a severe impairment in quality of life with important therapeutic implications. Its recurrence and incidence increase with age owing to physiological changes in the neurocardiovascular, endocrine and renal systems. This review will briefly discuss the diagnosis and epidemiology of syncope. In addition, current knowledge on physiopathology and diagnostic strategies of vasovagal syncope, in particular the head-up tilt test and the implantable loop recorder, are summarized. The present article also gives an overview of the pharmacological options for the treatment of vasovagal syncope, and the recent clinical experiences with alternative therapeutic approaches, such as tilt training and isometric arm counter-pressure manoeuvres. The role of cardiac pacing with and without dedicated algorithms is discussed: the importance of the contractility-related rate responsive systems (closed-loop stimulation and peak endocardial acceleration) is emphasized.