Vasovagal Syncope Treatment

[gertie]

I'm still trying to figure what treatment might help me. My BP avg is 140/70 until I have a painful BM & pass out & then of course my BP drops. I don't want anything that will lower BP because that will just cause me more syncope. I've been researching but I don't know what to do. My PCP has heard of Dys but he doesn't know much more but he is willing to listen to any suggestions I have. Does anyone have any suggestions on what will calm the vasovagal nerve? I was on high doses of Neurontin for years for seizures & that seemed to help but I felt very sluggish all the time. I'm sorry if I've asked this b/4 but I'm feeling desperate again. thanks.

[firewatcher]

I'm still trying to figure what treatment might help me. My BP avg is 140/70 until I have a painful BM & pass out & then of course my BP drops. I don't want anything that will lower BP because that will just cause me more syncope. I've been researching but I don't know what to do. My PCP has heard of Dys but he doesn't know much more but he is willing to listen to any suggestions I have. Does anyone have any suggestions on what will calm the vasovagal nerve? I was on high doses of Neurontin for years for seizures & that seemed to help but I felt very sluggish all the time. I'm sorry if I've asked this b/4 but I'm feeling desperate again. thanks.

Prospective evaluation of non-pharmacological treatment in vasovagal syncope.

Romme JJ, Reitsma JB, Go-Sch?n IK, Harms MP, Ruiter JH, Luitse JS, Lenders JW, Wieling W, van Dijk N.

Europace. 2010 Jan 3.

Aims Initial treatment of vasovagal syncope (VVS) consists of assuring an adequate fluid and salt intake, regular exercise and application of physical counterpressure manoeuvres. We examined the effects of this non-pharmacological treatment in patients with frequent recurrences. Methods and results One hundred patients with >/=3 episodes of VVS in the 2 years prior to the start of the study openly received non-pharmacological treatment. We evaluated this treatment both with respect to syncopal recurrences, factors associated with recurrence, and quality of life (QoL). The median number of syncopal recurrences was lower in the first year of non-pharmacological treatment compared with the last year before treatment (median 0 vs. 3; P < 0.001), but 49% of patients experienced at least one recurrence. In multivariable analysis, a higher syncope burden prior to inclusion was significantly associated with syncopal recurrence. Disease-specific QoL improved over time, with larger improvements for patients with more reduction in syncope burden. Conclusion In patients with frequent recurrences of VVS, non-pharmacological treatment has a beneficial effect on both syncopal recurrence and QoL, but nearly half of these patients still experience episodes of syncope.

PMID: 20047924

Efficacy of midodrine hydrochloride in the treatment of children with vasovagal syncope [Article in Chinese]

Liu XY, Wang C, Wu LJ, Hu CY, Lin P, Li MX, Cui XL, Xie ZW.

Zhonghua Yi Xue Za Zhi. 2009 Jul 28;89(28):1951-4.

OBJECTIVE: To explore the efficacy of midodrine hydrochloride in the treatment of vasovagal syncope (VVS) in children. METHODS: Forty-eight children with unexplained syncope and prodromata (21 males, 27 females, aged 6 -17 years, mean 11 years +/- 3 years) were randomly assigned into 3 groups. They were health education group, oresol group and midodrine hydrochloride group respectively. Oresol group was comprised of children given oresol as first-line therapy in addition to health education and midodrine hydrochloride group patients given midodrine hydrochloride on the basis of oresol group. Repeated head-up tilt testing (HUTT) and follow-ups of at least 6 months were conducted to evaluate the therapeutic efficacy, side effects of midodrine hydrochloride and hemodynamic changes in treating pediatric VVS. RESULTS: (1) The HUTT-based effective rate of 3 group was 20.0% (2/10), 60.9% (14/23) and 80.0% (12/15) respectively. It was significantly higher in cases of midodrine hydrochloride group and oresol group than that of health education group (P < 0.05). However,there was no significant difference in the HUTT-based effective rate between oresol group and midodrine hydrochloride group (P > 0.05). (2) During the follow-up period, the recurrence rate of syncope was significantly lower in midodrine hydrochloride group than in other two groups (P < 0.05). However, there was no significant difference in the recurrence rate of syncope between health education and oresol groups (P > 0.05). (3) There was no statistic difference in supine hemodynamic indices (HR, SBP, DBP) between before and after treatment in 3 groups. After midodrine therapy, the effects of midodrine upon changes in systolic and diastolic pressures and heart rate, between upright beginning and supine positions, were statistically significant (P <0.05). CONCLUSION: Health education and oresol are conventional therapies for pediatric VVS. The efficacy can be enhanced by supplementing midodrine hydrochloride. Such a regimen is effective and safe in treating pediatric VVS.

PMID: 19950567

Seizure-like activities during head-up tilt test-induced syncope.

Song PS, Kim JS, Park J, Yim HR, Huh J, Kim JH, On YK.

Yonsei Med J. 2010 Jan 31;51(1):77-81. Epub 2009 Dec 29.

PURPOSE: Some patients with neurally mediated reflex syncope may be misdiagnosed as epilepsy because myoclonic jerky movements are observed during syncope. The seizure-like activities during the head-up tilt test (HUT) have been rarely reported. The purpose of this study was to assess the characteristics of these seizure-like activities and evaluate whether there are differences in the clinical characteristics and hemodynamic parameters of patients with neurally mediated reflex syncope with and without seizure-like activities during HUT-induced syncope. MATERIALS AND METHODS: The medical records of 1,383 consecutive patients with a positive HUT were retrospectively reviewed, and 226 patients were included in this study. RESULTS: Of 226 patients, 13 (5.75%) showed seizure-like activities, with 5 of these (2.21%) having multifocal myoclonic jerky movements, 5 (2.21%) having focal seizure-like activity involving one extremity, and 3 (1.33%) having upward deviation of eye ball. Comparison of patients with and without seizure-like activities revealed no significant differences in terms of clinical variables and hemodynamic parameters during HUT. CONCLUSION: Seizure-like activities occurred occasionally during HUT-induced syncope in patients with neurally mediated reflex syncope. The seizure-like activities during HUT might not be related to the severity of the syncopal episodes or hemodynamic changes during HUT.

PMID: 20046517

[juliegee]

Hi Alicia-

In addition to Jennifer's ideas, I have a few of my own :-) When you bear down to have your BM, that's what clamps off your vagus nerve. You need to make having a BM easier.

I recall that you didn't react well to Miralax. I'd recommend working with your GI to figure out a way to make your BM's almost effortless. I suspect that you are really backing up and avoiding defecating (who can blame you?), but with the amount of force & fluid loss that occurs with a larger BM, the more likely you are to have symptoms. I have been where you are & was repeatedly hospitalized for bowel obstructions. When they finally came, I thought I'd die with each one. My GI actually recommended a colonoscopy prep daily When I heard that, I wasn't sure I wanted to live. I am so grateful that daily mega-doses of Miralax have truly saved my life.

You need to figure out what you can tolerate, like daily Phillips MOM, stool softeners, mineral oil, etc. I take a half a phenergan following my Miralax to help with any nausea- also helps me sleep. The key is daily maintenance for a poop that just plops out I'm guessing that you have some neuropathy of your GI tract due to your dysautonomia. The nerves in healthy people propel the waste out. Our nerves don't work so we need to use "tricks" to make this happen.

I saw that midrodine was one of the meds mentioned in Jennifer's articles. Interestingly, that one also cause "D" (I think.) May solve all of your problems.

Drink, drink, drink & coffee (if you can tolerate it) every AM.

Hugs-

Julie

[flop]

The vagus nerve wanders all over the body (named vagus from the Latin for "wanderer" as in vagrant). One of the places that it innervates is the rectum. Trying to pass a firm BM stretches the rectum and stimulates the vagal nerve which then triggers the syncopal episode.

As Julie said I think the best way to improve your symptoms is to try to improve your GI system. Have you ever tried a pro-kinetic treatment such as tacking erythromycin long term (an antibiotic that causes most people to have diarrhoea as a side effect as it speeds up transit through the GI tract).

In the UK the most commonly prescribed treatment for constipation is lactulose (fig syrup) it is what I was given during my recent hospital stay when morphine meant that I hadn't moved my bowels for 10 days. There are lots of other laxatives available that work in different ways (stool softeners, bulk forming, osmotic laxatives and stimulant laxatives). If you are very backed up I would avoid the stimulant sort initially as they will cause painful cramps but they may be helpful once things are moving. Initially you may need strong treatment with frequent enemas or colonoscopy prep so that you can get things moved and then use normal laxatives to keep you regular.

Sorry if this is too much information!

Flop

[gertie]

Thanks everyone for your replies. Very helpful explanations of the VV. I have IBS so Erythromycin ,or usually any antibiotic, causes me severe colon distress. The last time I had Erythromycin I passed out just from taking it. I am very sensitive to meds. I have been using warm prune juice & it looks like I may have to stay with a natural product. Someone suggested mineral oil with metamucil but I'm not sure MO is safe to use. I'll keep trying.

[flop]

I like to stick to natural stuff too as much as possible, this is one reason I like lactulose (fig syrup) as it is really gentle but effective. If the prune juice helps you, have you tried actually eating prune fruits? (Prunes for breakfast is a very traditional British "old wives tale" that actually works).

Flop

[dsdmom]

If you haven't tried lactulose, I think that might be a good possibility. I had to take it while I was pregnant. If i remember correctly it is really just a sugar. You may do ok with that.

Also - with the erythomycin, were you on a high/normal dose? I believe small doses can be used to stimulate the GI tract and maybe you could tolerate that?

[erickamcc0523]

I have heard of people drinking aloe vera juice to help... lubricate things and get them moving better. I haven't tried it myself (yet), but I have seen it next to the other bm "helpers"... I might try it soon.

[gertie]

I don't know what I would do without your support. I thought the Midodrine would be worth trying but I see it raises the BP by constricting the blood vessels. The problem I have had with that type med is it triggers migraines. The meds that cause fluid retention cause migraines & meniere's so it seems every way I turn I hit a brick wall. Erythromycin in very low dose still causes me to faint or seizure. My Gi suggested miralax & metamucil. The metamucil had me so compacted I got a fissure & the miralax caused worst headache I ever had. It's been a nightmare. My only hope is to use a natural product like the fig or aloe. I can't talk to anyone in the family about this because no one has heard of anyone passing out during a BM. I can tell it embarrasses my DH. If someone calls for me & I'm recovering from an episode rather than telling them I'm sick he just says I'm "out" for awhile, which I am. ha! ha! Thanks again!

[erik]

Magnesium makes my stool beyond soft. That is a common side-effect I guess. Maybe worth investigating. I'd hate to suggest something that backfires and makes you feel worse, and it seems it could if your digestion is sensitive... but I mention it because it certainly helps stuff get through yet doesn't feel like a regular "laxative" to me. (Coincidentally, Mg is a credited with migraine prevention for some folks)

Zofran is said to tone down the vagus. Might be other meds credited with this too, I can't recall right now. Seems many other meds would implicitly tone things down in general as well (perhaps things in the topiramate, carbamazapine, valproate world, which also serve as migraine prophylaxis for some). I don't know precisely what that it means to lessen vagal tone. Seems that implies a simultaneous inhibition of sympathetic, parasympathetic, and some sensing nerves? I don't think researchers know if signals themselves are miscalibrated, if the parts of the brain responding to them are off, or what... so perhaps best to consider specific symptoms/locations that one might ideally target. Targeting the "whole vagus" might be appropriate or might not... I wouldn't know. Not sure if Zofran or similar has been used in Vasovagal circumstance or not???

[gertie]

Thanks Erik, I'm researching all your suggestions.

[flop]

I'd forgotten about aloe vera juice! I bought some from the health store after my holistic health practitioner advised me that it can help calm down the digestive system (I get awful bloating and cramps). It did work for the cramps etc but I had to stop taking it as it made my BMs too soft. About 30 mls a day is enough for most people. I will advise that the plain aloe vera juice has a unique taste (I thought it was horrible!) but I got one flavoured with cranberry and it was perfectly acceptable to my taste buds (despite looking a funny colour!).

I hope you find a combo of natural products that help your GI system - that is probably the best way to treat your syncope.

Flop

[juliegee]

Hi Alicia-

Re. the zofran.....I'd be careful with that. It's an anti-emetic (anti nausea med), like phenergan. Unlike phenergan, it does NOT make you sleepy. BUT, like all antiemtics, it will s-l-o-w down your digestion, thereby possibly worsening the constipation.

Back when my son was taking "Z" as he called it. It was also very expensive, $30 a pill. (May be a generic by now.) It is used primarily for patients undergoing chemo- to help with the nausea. Insurance companies will cover it sparingly and for a very short time.

Eric is brilliant (as always!) for coming up with the idea.....but it may worsen things in the long run.

I love the fig stuff & aloe vera juice, etc.

Be Well-

Julie

[Noreen]

Alicia-

Don't worry about giving Midodrine a try. My migraine history goes back almost four decades and I have found no correlation between my use of midodrine and migraines. However, there has been significant decrease in headaches caused by head striking floor (just looking for the humor here)

Water, water, and more water. And, if we are going to try for the things that the hospitals said to go for after 10 days of no BM - I eventuslly had my husband bring in Dannon Activia yogurt. The prune juice, coffee, and enemas, weren't working but the yogurt did. I tried it because I had a friend with a problem who swore by the stuff. I would think it worth a try for a couple weeks.

Good luck,

Noreen