Vasovagal (Cardioneurogenic) Syncope

The Most Common Cause Of Fainting

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Fainting. Betty Dupuis/E+/Getty Images

Syncope — commonly called fainting — is the medical term for a temporary loss of consciousness. Any episode of syncope is important for at least two reasons. First, syncope can cause injury, so it is important to try to prevent it from recurring. And second, syncope can sometimes be a sign of a serious underlying medical problem. While several medical conditions can lead to syncope, by far the most common type of syncope is vasovagal syncope.

Overview

Vasovagal syncope (also called cardioneurogenic syncope) is a temporary loss of consciousness caused by a neurological reflex that produces either sudden dilation of the blood vessels in the legs, or a very slow heart rate (bradycardia), or both.

Vasovagal syncope accounts for more than half of all episodes of syncope. While doctors often refer to it as a "simple fainting spell," the mechanism of vasovagal syncope actually is not all that simple. And misunderstanding how vasovagal syncope works can lead to problems in making the correct diagnosis or in choosing adequate treatment.

Causes

Vasovagal syncope occurs when something triggers the vasovagal reflex, causing the blood vessels to suddenly dilate. Dilation of the blood vessels causes a significant proportion of the blood volume to pool in the legs. This blood pooling is often accompanied by a slowing of the heart rate.

As a result, the blood pressure suddenly drops. If the fall in flood pressure is enough to rob the brain of its needed blood flow, fainting occurs.

The vasovagal reflex works like this: First, a person is exposed to some noxious stimulus (such as a painful needle stick in a finger) that triggers the reflex.

The triggering event stimulates certain nerves (the pain nerves of the finger), which send an electrical signal to the vasomotor center in the brainstem, the portion of the brain that determines the body's vascular (blood vessel) tone. The vasomotor center, in response, sends signals to the blood vessels, causing them to dilate. This produces blood pooling, which leads to syncope. The same stimulation of the brainstem may also send signals to the heart (through the vagus nerve) to produce a drop in the heart rate.

In most people with vasovagal syncope, the dilation of blood vessels appears to be the predominant factor that causes loss of consciousness. In some people, however, the slowing of the heart rate plays a major role.

The "trigger" that initiates a vasovagal reflex can be any of a number of different things. Pain is a particularly common cause of fainting. Other common triggering events include having your blood drawn, being exposed to the sight of blood, having difficult urination or defecation, severe coughing, painful swallowing, receiving upsetting news, sudden fright, or standing motionless for long periods of time. (This is why soldiers standing at parade rest, or singers in a choir, will sometimes faint.) In fact, if fainting follows any of these events, vasovagal syncope is almost certainly the cause.

Symptoms

While the loss of consciousness with vasovagal syncope can be quite sudden, more typically it is preceded by a few seconds or a few minutes of warning symptoms. These warning symptoms often include lightheadedness, ringing in the ears, visual disturbances, sweating and/or nausea. This is followed by a sensation of "graying out," followed immediately by loss of consciousness.

Vasovagal syncope almost always occurs when the victim is standing or sitting upright (when blood pooling in the legs can occur), and it virtually never happens while lying down.

People who have vasovagal syncope usually regain consciousness after a few seconds, once they have fallen (or, if they're lucky, are helped) to the ground.

This is because once on the ground, gravity no longer causes the blood to pool in the legs and the blood pressure improves almost immediately.

So, if you see somebody faint, you should help them get their head down and elevate their legs. Holding them in an upright position — even if you add the additional "treatment" of yelling in their ears or slapping them — is not helpful.

After an episode of vasovagal syncope, many people will feel terrible for a few hours or even for the next day or two. During this “post-vagal” period they commonly experience extreme fatigue, nausea, dizziness and loss of appetite. 

It is particularly important to note that, until these lingering post-vagal symptoms disappear, they are particularly prone to fainting again.

People who have had one or two episodes of vasovagal syncope are frequently able to recognize the warning symptoms, so they will know when another event is about to occur. More importantly, if they do recognize the warning symptoms, they can prevent the blackout simply by lying down and elevating their legs. (Stopping an episode is not possible with most other forms of syncope.) Further, if they can avoid actually blacking out, they can usually also avoid the lingering post-vagal period that often follows such an episode.

On the other hand, trying to "fight off" an impending episode of vasovagal syncope by forcing yourself to remain upright and willing yourself not to faint almost never works out very well.

Older people with vasovagal syncope are more likely to have "atypical" symptoms. Their syncope may occur without any identifiable trigger, and without any warning symptoms. Making the correct diagnosis in these cases can present a real challenge to the doctor.

In general, vasovagal syncope is not itself life-threatening — but injuries that result from falling may be. And if episodes are frequent enough this condition can certainly be quite disruptive to a normal life.

Who Is Affected?

The reflex that causes vasovagal syncope can occur to some extent in everyone, so almost anyone can have a vasovagal episode if a sufficiently strong triggering event occurs. Indeed, it is likely that most people will have a fainting episode sometime during their lives.

Vasovagal syncope can occur at any age, but it is much more common in adolescents and young adults than in older people.

Some people are particularly prone to vasovagal episodes, and may faint even with relatively mild triggering events. These people tend have recurrent episodes of syncope, beginning in adolescence. They will often experience syncope following several different kinds of triggering events.

In some people, vasovagal syncope is so frequent and so difficult to treat that they become virtually disabled by it. These individuals often have a form of dysautonomia (imbalance of the autonomic nervous system) that makes them very prone to the vasovagal reflex that causes this condition. They also often have other persistent symptoms typical of the dysautonomias, such as abdominal bloating or cramps, diarrhea, constipation, extreme fatigue and various aches and pains.

Diagnosis

Doctors who are skilled at correctly diagnosing vasovagal syncope understand that this condition is almost always situational. Vasovagal syncope is particularly likely to occur after a viral illness, after exercise, after a warm shower or early in the morning — in other words, any time relative dehydration is likely to be present. (When you are dehydrated, dilation of the blood vessels in the legs is more likely to produce a significant drop in your blood pressure.)

Given these characteristic features and the situational nature of this condition, doctors should be able to make the correct diagnosis in the vast majority of patients simply by asking right questions and listening carefully to the answers. Unfortunately, too many doctors fail to take a careful enough medical history; as a result, they end up doing unnecessary tests and procedures looking for cardiac or neurological disease.

The physical examination of people with vasovagal syncope is usually completely normal. However, the exam is very helpful in diagnosing the similar conditions of orthostatic hypotension or postural orthostatic tachycardia syndrome (POTS), and can be quite helpful in sorting through the likely possibilities.

While in most cases the diagnosis of vasovagal syncope ought to be made by taking a medical history and doing a physical examination, testing is sometimes helpful. In particular, a tilt table study can be helpful if the medical history is not typical for vasovagal syncope, or if it is difficult to distinguish between vasovagal syncope and orthostatic hypotension.

Treatment

There are several approaches to treating vasovagal syncope, and while the condition cannot be "cured," in the vast majority of people with vasovagal syncope it can be controlled sufficiently to allow for a completely normal life. Read about treating vasovagal syncope.

Sources:

Chen-Scarabelli C, Scarabelli TM. Neurocardiogenic Syncope. BMJ 2004; 329:336.

Sumner GL, Rose MS, Koshman ML, et al. Recent History of Vasovagal Syncope in a Young, Referral-based Population is a Stronger Predictor of Recurrent Syncope Than Lifetime Syncope Burden. J Cardiovasc Electrophysiol 2010; 21:1375

Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the Diagnosis and Management of Syncope (version 2009). Eur Heart J 2009; 30:2631.

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