Syncope

World Journal of Pediatrics

Current diagnosis and management of children with
vasovagal syncope
Cheng Wang, Hui-Fen Zheng
Changsha, China

Background: Vasovagal syncope (VVS) is the most Introduction

S
common type of syncope and a wide variety of stimuli can yncope is defined as the abrupt and transient loss
Review article

trigger this reflex. The morbidity is high in children with of consciousness associated with loss of postural
VVS. The aim of this review is to describe the diagnosis tone, typically followed by a rapid recovery.
and treatment of children with VVS.
It is actually the decrease of brain blood flow for the
Data sources: Related articles in PUBMED and CNKI moment. The reported morbidity is 15% in children
in the last decade were reviewed. The data on the diagnosis aged under 18 years.[1] A variety of conditions can cause
and management of VVS were extracted and analyzed. syncope, but the most common cause is vasovagal
Results: The diagnosis of children with VVS includes syncope (VVS), which accounts for 80% in all cases of
basic method (inquiring history of syncope and physical unexplained syncope (UPS). VVS is a benign condition
examination), head-up tilt table test (baseline head-up tilt characterized by a self-limited episode of systemic
test, sublingual nitroglycerin tilt test and isoproterenol hypotension (less than 20 seconds) without nervous
head-up tilt test), and standing test. The therapy includes system signs. A wide variety of stimuli can trigger this
education, behavior modification, training, standing reflex and alternatively it is called neurocardiogenic
training, oral fluid therapy, pharmacological treatment syncope.[2] This article aims to provide an overview of
(beta blockers, fludrocortisone, alpha agonists, selective the diagnosis and management of VVS on the basis of
serotonin re-uptake inhibitors and captopril), and current evidence and our experience in this field.
permanent use of pacemaker.
Conclusions: Basic method (inquiring history of
98 syncope and physical examination) is most important.
Sublingual nitroglycerin tilt test is recommended in the
Diagnosis
Basic methods
diagnosis of VVS. Education, behavior modification,
training, standing training, and oral fluid therapy are A detailed history of syncope and physical examination
effective in preventing VVS, but the effect of all medicines can offer many important clues for the diagnosis.
needs to be further investigated. The history should include whether there are
prodromes such as lightheadedness, fatigue, pallor,
World J Pediatr 2007;3(2):98-103
diaphoresis, palpitation, chest distress, headache,
Key words: vasovagal syncope; tachypnea, stomachache, vomiting, blurred vision,
head-up tilt test; blackout, vertigo, nausea, fever, numbness, and
children; cyanosis, and whether there are motivations such as
diagnosis; prolonged standing, orthostatic change, emotional
therapy upset, sweltering environment, fatigue, defecation,
etc. Since physical examinations are often unfruitful,
a stepwise approach is necessary for determining
the diagnosis, such as 12-lead electrocardiography
Author Affiliations: Cardiovascular Laboratory, Department of Pediatrics, (ECG), 24-hour Holter monitoring, echocardiography,
The Second Xiangya Hospital, Central South University, Institute of exercise tests, cranial computed tomography (CT),
Pediatrics of Central South University, Changsha 410011, China (Wang C,
Zheng HF) electroencephalography (EEG), and tests of myocardial
enzyme, blood glucose and electrolytes.[3] Boehm et
Corresponding Author: Cheng Wang, MD, Cardiovascular Laboratory,
Department of Pediatrics, Second Xiangya Hospital, Central South al[4] thought that if a history of syncope caused by
University, Institute of Pediatrics of Central South University, Changsha exercise was elicited, this was unlikely to be VVS.
410011, China (Tel: 86-731-5295039; Email: ch.wang@163.com) But Vizmanos Lamotte et al[5] reported a patient with
©2007, World J Pediatr. All rights reserved. exercise-induced syncope, whose results of cardiac and

World J Pediatr, Vol 3 No 2 . May 15, 2007 . www.wjpch.com

Current diagnosis and management of children with vasovagal syncope

neurologic tests were negative. The tilt table test (TTT) signs and symptoms are absent.
with pharmacological challenge with isoproterenol On the basis of HR and BP, the response is
infusion induced arterial hypotension and presyncope, classified into three types: vasodepressor response (BP
and a diagnosis of neurally-mediated syncope was falls markedly, accompanying with an HR increase),
made. After initiating beta-blocker treatment, the cardio-inhibitory response (HR falls markedly without
patient was asymptomatic during a follow-up of 10 a BP decrease), and mixed response (both HR and BP
months. In addition, Kouakam et al[6] found that the risk fall markedly).
of recurrence in children and adolescents with a history
of syncope was not correlated to the tilt test result or Baseline head-up tilt test (BHUT)
prophylactic treatment. However, a number of syncope Stop using any cardiovascular active medicine for
attacks were predictive. Similarly, Diaz et al[7] showed over five half-life periods and any diets or drinks such
that the only predictor of recurrent syncope was a pre- as coffee, which may affect the autonomic nervous
test history. Children with only one syncope before test

Review article
system. With no flexion of ankle joint and knee joint,
experienced no recurrence and those with one or more the patient steps upon footboard supports and is fixed
episodes were estimated to have an increasingly higher on test table by a band after an 8-hour fasting. After a
recurrence rate. 10-minute pre-test rest, the head of the table is tilted
upward to an angle of 60 to 80 degrees (children 60
TTT degree) while hemodynamic and electrocardiographic
In 1986, TTT was found effective in detecting monitoring is performed. During the test, the patient
autonomic tone abnormalities. At present, head-up should be tilted to a desired angle smoothly and rapidly,
tilt-table test (HUTT) has been a gold standard for and possibly change quickly to a supine position (<15
evaluating patients with syncope. Udani et al[8] reported seconds). HR is monitored continuously with a standard
that HUTT was highly sensitive in the diagnosis of ECG monitor and BP is monitored with a standard
VVS in children or adolescents and it was relatively sphygmomanometer intermittently at a 5-minute
safe and easy to perform. Unprovoked HUTT in interval in addition to monitoring of clinical symptoms.
children was reproducible when repeated on different
The test lasts for 45 minutes unless hemodynamic
days, and the results were comparable to those in
collapse occurs in advance.
adults.[9] On the contrary, a few scholars held that
In this study, the test had a sensitivity of 37%-76%
HUTT had high false-negative and false-positive rates
and a specificity of 80%-100%. It was of more value
and should not be used to identify patients with VVS.[10] 99
in excluding VVS than diagnosing VVS.[11-15] Positive
In the past two decades, TTT has been improving,
responses appeared after tilting from 22.4±13.5 to 24.7
although not perfect. The standardized protocol for
TTT may contribute to its efficacy and comparability. ±12.9 minutes. Vasodepression response was the most
common type, accounting for 70.0%-80.4%.[16,17]
Laboratory environment, judgement standard and
response type Sublingual nitroglycerin tilt test (SNHUT)
TTT should be performed in a quiet room with lights Not in a supine position, the patient with negative
slightly dimmed and temperature comfortable so as response in BHUT uses nitroglycerin sublingually
to avoid any interference and reduce anxiety of the 4-6 μg/kg each time (maximum 300 μg). HR and BP
patient. Resuscitation equipments should be available are monitored every one minute. As soon as positive
such as first-aid medicine, oxygen, defibrillator, etc. response appears, the patient should be returned
Tilt tables should be equipped with footboard supports. quickly to a supine position. The result is deemed
Experienced nurses, technicians and physicians should negative without hemodynamic collapse and unusual
be present during the test. symptoms during a 20-minute period.
Positive result is considered if the patient has a Reports showed that SNHUT improved the
significant decrease in blood pressure (BP) (<80/50 positive response rate from 62.1% to 80.0% in pediatric
mmHg or at least a 25% drop of mean blood pressure patients,[16,17] and the time to syncope attack was
over basal levels) and/or heart rate (HR) (<50 beat/ reduced. Dindar et al[18] reported that SNHUT had a
min, among them HR<75 beat/min between 4 and 6 sensitivity of 77.5% and a specificity of 91.6%. Positive
years, HR<65 beat/min between 7 and 8 years, HR<60 response after sublingual use of nitroglycerin increased
beat/min over 8 years), sinus arrest (>3 seconds) or from 5.5±3.1 to 5.9±2.9 minutes.[14,15] Sublingual use of
junctional rhythm along with the development of nitroglycerin in children was effective and objective in
unusual symptoms. The result is negative when these diagnosing VVS.



Isoproterenol head-up tilt test (ISOHUT) The patient is taught to recognize early symptoms of
There are single-stage ISOHUT and multi-stage ISOHUT. the disease so as to take preventive measures. Other
In single-stage ISOHUT, the patient with a negative effective measures include prevention of dehydration
response to BHUT is given intravenous isoproterenol and prolonged standing, stay in warm environment, etc.
at a dose of 0.05 μg/kg per minute in a supine position.
When HR is stably increased (10% over the basal level), Behavior modification
the patient is tilted again, observed for 10 minutes or Physical maneuvers should be taken when early
till unusual symptoms appear. Multi-stage ISOHUT symptoms of VVS appear. The simplest counter-
is similar to single-stage ISOHUT in the begining. maneuver so far is assumption of a supine posture.
Isoproterenol at an initial dose of 0.02-0.04 μg/kg per The legs may be elevated to increase the venous return
minute is administered. If there is no positive response, to the heart. Sitting and squatting may also be used.
isoproterenol is administered at a dose of 0.04-0.06 μg/kg These counter-maneuvers decrease the pooling of
per minute after 10 minutes. The above procedures and venous blood in the lower extremities and abdomen,
Review article

observation are repeated until isoproterenol is given at a while increasing the peripheral arterial resistance. The
dose of 0.06-0.08 μg/kg per minute. resultant increase of venous return to the heart, cardiac
Alehan et al[19] evaluated 25 patients aged 8-15 years output, blood pressure, and cerebral perfusion leads
(median 11.8±2.1 years) after muti-stage ISOHUT. to the elimination of presyncope. The combination of
Compared to BHUT, the sensitivity and specificity of leg crossing and tension of the thigh and abdominal
multi-stage ISOHUT were increased from 48.5% to musculature is highly effective in preventing reflex
76.6% and from 86.7% to 93.4%, respectively. In 111 syncope in young patients.
patients with a history of syncope (median 55±20 years),
Shen et al[20] found that 56% had a positive vasovagal Standing training
response during the single-stage ISOHUT and 32% In highly motivated patients with recurrent symptoms,
during the passive tilt table test. The mean procedural progressively prolonged periods of enforced upright
times of the study population were 11.7±3.6 minutes posture or tilt training might reduce the recurrence
and 36.9±13.3 minutes for isoproterenol and passive tilt of VVS by lowering vascular compliance in the
table test, respectively. Scholars found that multi-stage compartments most responsible for venous pooling.[24]
ISOHUT had a higher sensitivy of 75.0%-83.6% and Raising the head of the bed during sleep (>10°)
a lower specificity of 66.7%-90.0% than BHUT.[19-22] contributes to the improvement of the symptoms.
Despite isoproterenol can increase the sensitivity of tilt
100 test, its venous cannulation may influence the stability Respiratory training
of the automatic nervous system with more side-effects. Paced breathing preventing VVS induced by HUTT
Therefore it is difficult to be used in pediatric patients. was observed in 10 patients (median 18.4±5.1 years) as
reported by Jauregui-Renaud et al.[25] They suggested
Standing test that respiratory training is useful to prevent VVS.
Standing test is a peculiar form of the tilt table test at
an inclination of 90°. Matsushima et al[23] examined Oral fluid therapy
children and adolescents with orthostatic symptoms by As a primary intervention, increased intake of fluid
two orthostatic tests, active standing test and head-up and salt is an effective treatment of VVS. Oral fluid
tilt test, and found that the standing test caused cardiac therapy may increase plasma volume and avoid the
sympathetic activation associated with an initial pressure hypercontractile state of the ventricle in the head-
drop, and was more prone to inducing syncope with up tilt test or the so-called "empty" effect induced
increased heart rate in some patients. Because standing by reduced cardiac filling. Thus the parasympathetic
is a daily postural motion, they concluded that standing output is not increased to prevent the onset of syncope.
test is potentially effective as HUTT for the diagnosis of A study showed that patients had a high positive but a
syncope; but it might lead to a sensation of inclination low negative predictive value of response to oral fluid
and something uncomfortable for the patient. therapy.[26] The patients with a positive response to oral
fluid-therapy were given 250-500 ml of normal saline
after recovery (about 10 minutes) and rested in a supine
Therapy position for 20 minutes. Again they were subjected to
Education and behavior modification and training HUTT and 78.9% of them showed a negative response.[15]
Education
The patient should be assured of the benign nature of Pharmacological treatment
VVS, but sometimes it may lead to injury to the body. Beta blockers



Beta-adrenergic receptor antagonists prevent the Alpha agonists
stimulation of left ventricular mechanoreceptors and the These drugs exert their effect peripherally by increasing
increase of circulating epinephrine. Previous studies vascular resistance and decreasing venous pool.
provided positive evidence for the benefits of β-blockade Midodrine is a representative in this drug group and
in treatment of VVS; but randomized controlled trials its potential side-effects include skin rash, paresthesia,
in the recent 5 years reported no difference between urinary retention, supine hypertension, etc. Perez-
placebo and β-blockade in the treatment of VVS.[1,27,28] Lugones et al[32] randomly allocated 61 patients with
The side-effects of β-blockade such as reduction of severe VVS to treatment either with midodrine or fluid,
heart rate and block of atrioventricular conduction salt tablets, and counseling. Midodrine was given at a
might aggravate syncope.[29] Flevari et al[27] conducted a starting dose of 5 mg three times a day and increased to
prospective, randomized, crossover study to assess the a dose of 15 mg three times a day when required. The
relative therapeutic efficacy of propranolol, nadolol and agent was given in the daytime every 6 hours. A 6-month
placebo in 30 patients with VVS and a positive head- follow-up revealed that 81% midodrine-treated patients

Review article
up tilt test. Therapy with each drug lasted for three and 13% fluid-therapy patients remained asymptomatic.
months. The results showed that propranolol, nadolol Midodrine appeared to be significantly effective in
and placebo were equally effective in the treatment of patients with VVS. To prevent recurrence of symptoms,
VVS, as demonstrated by a reduction in the recurrence the dose of treatment was adjusted. Kaufmann et al[33]
of syncope and presyncope, as well as an improvement investigated 12 patients with recurrence of neurally
in the patients' well-being. Madrid et al[28] performed mediated syncope, which was reproduced during the
a prospective, randomized, double-blind, placebo- head-up tilt test. The patients were randomized to
controlled study in 50 patients with recurrent VVS. receive midodrine (5 mg) or placebo on day 1 and the
The primary end point of the study was set at the opposite on day 3. One hour after administration of drug
time to the first recurrence of syncope. They found or placebo, the patients underwent head-up tilt test again.
that the recurrence of VVS in highly symptomatic The responses to head-up tilt were significantly different
patients treated with atenolol was similar to that of on the midodrine and placebo day. On the placebo day,
patients treated with placebo after follow-up for one 67% of the patients suffered from syncope, whereas only
year. Twenty-nine patients with VVS (6-16 years) 17% developed syncope on the midodrine day. These
took metoprolol 12.5 mg every time, twice a day for results indicated that midodrine significantly improved
1 week to 3 months. After the follow-up of 3 months, orthostatic tolerance during the head-up tilt test in
66.7% of these patients had a negative response to the patients with recurrent VVS.
head-up tilt test. Without serious side-effects, syncope 101
attacks were significantly reduced. Therefore, Jian et Selective serotonin re-uptake inhibitors
al[30] thought that metoprolol was effective and safe in Serotonin leads to bradycardia and pressure decrease
children with VVS. mediated by the parasympathetic nerve. Paroxetine
and sertraline have been used in patients with VVS.
Fludrocortisone In a randomized placebo-controlled study on 68 adult
Fludrocortisone, a synthetic mineralocorticoid, patients with refractory VVS, Di Girolamo et al[34] found
acts on the distal tubules of the kidney to retain a negative tilt test in 61.8% of the patients on paroxetine
sodium and hence expands blood volume and and 38.2% of placebo-treated controls after one month of
prevents relative central hypovolemia. Apart from treatment. Paroxetine was found to significantly improve
increasing pressure receptor sensitivity to circulating the symptoms of patients with VVS and was well
catecholamine and vessel reactivity to vaso-exciting tolerated by the patients. Lenk et al[35] studied 15 patients
material, fludrocortisone reduces the activities of the (median 12.9±2 years) with VVS, who were given 50
parasympathetic nerve and plays a part in the treatment mg oral sertraline hydrochloride daily. Intolerance to the
of VVS. Salim et al[31] studied 33 children (median 13.9 drug was seen in 3 patients, and 2 patients had syncopal
±2.5 years) with syncope, who were randomized in a episodes during the therapy. HUTT was then repeated
double-blind fashion to receive either fludrocortisone in 10 patients, of whom 6 showed negative results. They
0.1 mg/d and salt 1 g/d or placebo two capsules per day concluded that sertraline hydrochloride may be useful
for one year. After follow-up for one year, symptoms in preventing recurrent VVS, but clinical studies are
recurred in 55.6% children on fludrocortisone and salt essential before this treatment is recommended since
and in 35.7% children on placebo. Children on placebo serious asystole can develop.
had no symptoms until they discontinued their study
medications, which raised the potential effect of a Captopril
significant placebo with pharmacologic therapy. Captopril is one of angiotensin-converting-enzyme



inhibitors. It can prevent production of angiotensin II References
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2000;20:158-165. Accepted after revision December 23, 2006

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