{"id":1123,"date":"2016-09-22T15:57:03","date_gmt":"2016-09-22T15:57:03","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1123"},"modified":"2017-08-21T10:48:35","modified_gmt":"2017-08-21T10:48:35","slug":"primary-care-corner-with-geoffrey-modest-md-fludrocortisone-for-vasovagal-syncope","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/09\/22\/primary-care-corner-with-geoffrey-modest-md-fludrocortisone-for-vasovagal-syncope\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Fludrocortisone for Vasovagal Syncope"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>Vasovagal syncope is pretty common,\u00a0but there are no documented effective treatments. Fludrocortisone has potential\u00a0by improving venous return: its efficacy\u00a0was evaluated in the Prevention of Syncope Trial 2 &#8212; POST 2 trial (see\u00a0Sheldon R. JACC 2016; 68: 1).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>210 patients (71% female, median age 30, BMI 24, HR 70 bpm, BP 112\/70) with a mean of 15\u00a0syncopal episodes over 9 years<\/li>\n<li>Randomized\u00a0to fludrocortisone at the highest tolerated doses (from 0.05-0.2\u00a0mg\/d, titrated over 2 weeks, with most achieving the 0.2\u00a0\u00a0mg dose)\u00a0vs placebo and followed for 1 year<\/li>\n<li>Inclusion criteria: &gt;13\u00a0yo, &gt;2 lifetime syncopal episodes; exclusions: diabetes, hepatic disease BP&gt;135\/85, &#8220;significant comorbidities&#8221;, or if when standing 5 minutes they had postural tachycardia of &gt;30 bpm, or orthostatic hypotension of &gt;20\/10 mmHg.<\/li>\n<\/ul>\n<p>Results<\/p>\n<ul>\n<li>96 patients had at least 1 syncopal episode<\/li>\n<li>Overall there was a 31%\u00a0marginally non-significant reduction in syncope in those on fludrocortisone [HR 0.69 (0.46-1.03), p=0.069]: 44.0% vs 60.5%. the most benefit was in those with systolic BP&lt;110, BMI&gt;20, and syncope frequency &gt;7\/yr<\/li>\n<li>But, in multivariable model, fludrocortisone conferred\u00a0a significant\u00a037% decrease [HR 0.63\u00a0(0.42-0.94), p=0.024]<\/li>\n<li>And, when analysis was restricted to being on the fludrocorisone after dose stabilization, there was\u00a0an even more significant 49% decrease [HR 0.51 (0.28-0.89), p=0.019]: approx 60% vs 30% in those achieving the 0.2\u00a0mg dose<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>There are a myriad of etiologies for syncope to consider, especially cardiac or neurologic (all excluded in the above study). And the preferred treatment for the syncope is to treat the underlying condition.<\/li>\n<li>The above applies to\u00a0those with classic &#8220;fainting&#8221; episodes:\u00a0vasovagal syncope, which can happen even in patients with underlying cardiac or neuro morbidities, often triggered by stress, noxious stimuli, anxiety (including venipuncture, blood donation), prolonged standing or sitting, heat exposure, exertion, orthostasis,\u00a0 (and in older people can be associated with micturition, defecation, cough), and clinically associated with the typical prodrome of light-headedness, along with vagal symptoms of nausea, pallor, diaphoresis. Symptoms typically gets better with lying down, though there can be some residual fatigue. And there can be brief episodes of myoclonic\/involuntary\u00a0esp. limb movements. But there should be no post-ictal state<\/li>\n<li>Fludrocortisone seemed pretty effective when at the 0.2\u00a0mg dose, and likely more effective than midodrine (a few small studies finding effectiveness but less impressively)<\/li>\n<li>Fludrocortisone has been used effectively in those with autonomic failure and orthostatic hypotension, presumably from its increased renal sodium absorption and\u00a0plasma volume expansion.<\/li>\n<li>In my experience, fludrocortisone is very well-tolerated in fragile patients with multiple comorbidities:\u00a0I have prescribed\u00a0fludrocortisone (sometimes with midodrine) very effectively\u00a0in my reasonably large group of older patients with orthostatic hypotension, presumably from autonomic dysfunction (workup otherwise negative, or perhaps some diabetes, but often just from aging&#8230;). In this young group in the study above, without comorbidities and with just vasovagal syncope, there were no serious adverse events.\u00a0And for those with orthostatic hypotension, of course, caffeine helps (1-3 cups of coffee\/d, or 2-5 cups of tea). And, though I\u00a0have not used them, NSAIDs can also help when used with fludrocortisone.<\/li>\n<li>So, bottom line: vasovagal syncope is common (overall about 20-35% of syncope causes), a pretty high % (up to 34% in one study) have no warning symptoms prior to syncope, and can be associated with bad accidents (e.g., car crashes), so the above study may really prove to be clinically\u00a0useful. One wonders if using the max dose of 0.3 mg might be even more useful, and I do have several elderly patients tolerating this dose well)<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Fludrocortisone for Vasovagal Syncope  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/09\/22\/primary-care-corner-with-geoffrey-modest-md-fludrocortisone-for-vasovagal-syncope\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1123","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1123","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1123"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1123\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1123"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1123"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1123"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}