Evidence-based treatment for vasovagal syncope

Only a minority of patients with vasovagal syncope require treatment, and most can be managed conservatively. Patients should be encouraged to liberalize their fluid and salt intake, unless they have contraindications such as hypertension. All patients should be taught physical counterpressure maneuvers. Midodrine is the first-line therapy for patients having frequent presyncope or syncope or for those with brief or no prodromes. The routine use of beta-blockers, serotonin-specific reuptake inhibitors, fludrocortisone, and pacemakers is discouraged. Whether loop recorders can be used to target treatment is under investigation, as is fludrocortisone.