A 45-year-old woman is being evaluated for recurrent syncope. Tilt-table testing is positive (hypotension + bradycardia at 60° head-up tilt after 15 minutes, type 2B — VASIS classification). ECG and echo are normal. What is the most appropriate management?
- A Implantable cardioverter-defibrillator (ICD)
- B Permanent pacemaker implantation
- C Beta-blocker therapy
- D Non-pharmacological measures (hydration, counterpressure maneuvers, salt intake) + midodrine if refractory ✓
Explanation
Vasovagal syncope (neurocardiogenic syncope), confirmed by positive tilt-test, is managed first with non-pharmacological therapy: increased salt and fluid intake (>2–3 L/day), physical counterpressure maneuvers (leg-crossing, squatting), tilt training, and avoidance of triggers. Per ESC 2018 syncope guidelines, pharmacological therapy (midodrine or fludrocortisone) is added only if recurrent disabling episodes persist. Beta-blockers are ineffective and may worsen outcomes. Pacemaker implantation is reserved for documented cardioinhibitory syncope (Type 2B/3 with prolonged asystole >3 seconds) in selected older patients. ICD is not indicated for neurocardiogenic syncope.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.