Introduction on Home Orthostatic Training in Elderly Patients with Vasovagal Syncope – A Prospective Randomised Controlled Trial

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Introduction on Home Orthostatic Training in Elderly Patients with Vasovagal Syncope – A Prospective Randomised Controlled Trial

Vasovagal syncope (VVS) is most common cause of syncope,¹ with 37 % of the population suffering at least one attack during their life time.² Head up tilt-table testing (HUTT) was first evaluated and used for the diagnosis of VVS in 1986.^3–4 Prior to this, diagnosis relied purely on the clinical history and exclusion of other conditions. With almost 40 % of patients with VVS experiencing no prodrome⁵ prior to syncope, and the general acceptance that it was a condition of the young, VVS was significantly undiagnosed – particularly in the elderly.^4,6–7 The exact mechanism of VVS is complex. It involves several autonomic reflexes, of which some are exaggerated (parasympathetic) and others depressed (sympathetic), resulting in a reduction in blood pressure and/or pulse rate and subsequent cerebral hypoperfusion and syncope.^8–10 The mechanism can differ with subsequent attacks and from patient-to-patient. Most patients respond to the European Society of Cardiology (ESC) recommendation¹¹ of lifestyle modification and withdrawal of vasoactive medications; however, a significant number of patients continue to have repeated syncopal and pre-syncopal attacks. There is no associated increase in mortality, so the condition is often referred to as benign. Despite this, in patients with refractory VVS the condition can be frightening, disabling and have significant impact on quality of life¹² and there is an urgent need for an effective treatment option in these refractory patients. Permanent pacemakers¹³ and drug treatment, in particular beta-blockers¹⁴, selective serotonin reuptake inhibitors, fludrocortisone¹⁵ and midodrine,¹⁶ have not been proven or not adequately assessed to be beneficial in VVS and are therefore not routinely used.

Home orthostatic training (HOT) has been shown to improve autonomic measures after repeat assessments in non-age selected cohorts.^17–19 However, HOT has not been tested in an exclusively elderly population. Therefore the aim of this study was to evaluate the effect of HOT on autonomic reflexes in elderly patients with VVS. Our research questions were:

• Are there different mechanisms of vasovagal syncope in elderly and young populations?
• What therapies are efficacious in vasovagal syncope?
• Are autonomic measurements useful in the assessment of vasovagal syncope?