Vasovagal response - Wikipedia, the free encyclopedia

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Vasovagal response
From Wikipedia, the free encyclopedia

A vagal episode or vasovagal

Vasovagal episode

response or vasovagal attack[1] (also

called neurocardiogenic syncope) is a
malaise mediated by the vagus nerve.
When it leads to syncope or "fainting",
it is called a vasovagal syncope, which
is the most common type of fainting.[2]
Vasovagal syncope is most commonly
discovered in adolescents and in older
adults.[3]
There are different syncope syndromes
which all fall under the umbrella of
vasovagal syncope. The common
element among these conditions is the
central mechanism leading to loss of
consciousness. The differences among
them are in the factors that trigger this
mechanism.

Contents
1 Signs and symptoms
2 Cause
3 Pathophysiology
4 Diagnosis
5 Treatment
6 Prognosis
7 See also
8 References
9 External links

Vagus nerve
Classification and external resources
Specialty

Neurology

ICD-10

R55
(http://apps.who.int/classifications/icd10/browse/2015/en#/R55)

Signs and symptoms

Episodes of vasovagal response are
typically recurrent, and usually occur
when the predisposed person is exposed
to a specific trigger. Prior to losing
consciousness, the individual frequently
https://en.wikipedia.org/wiki/Vasovagal_response

ICD-9-CM 78.2 (http://www.icd9data.com/getICD9Code.ashx?

icd9=78.2)
DiseasesDB 13777 (http://www.diseasesdatabase.com/ddb13777.htm)
MeSH

D019462 (https://www.nlm.nih.gov/cgi/mesh/2015/MB_cgi?
field=uid&term=D019462)
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experiences early signs or symptoms

such as lightheadedness, nausea, the feeling of being extremely hot or cold (accompanied by sweating), ringing
in the ears (tinnitus), an uncomfortable feeling in the heart, fuzzy thoughts, confusion, a slight inability to
speak/form words (sometimes combined with mild stuttering), weakness and visual disturbances such as lights
seeming too bright, fuzzy or tunnel vision, black cloud-like spots in vision, and a feeling of nervousness can
occur as well. The symptoms last for a few seconds before the loss of consciousness (if it is lost), which
typically happens when the person is sitting up or standing. When sufferers pass out, they fall down (unless this
is impeded) and, when in this position, effective blood flow to the brain is immediately restored, allowing the
person to regain consciousness; if the person does not fall into a fully flat, supine position, and the head remains
elevated above the trunk, a state similar to a seizure; may result from the blood's inability to return quickly to
the brain, the neurons in the body will fire off and generally cause muscles to twitch very slightly, but mostly
remain very tense. Fainting occurs with the loss of oxygen to the brain.[4]
The autonomic nervous system's physiologic state (see below) leading to loss of consciousness may persist for
several minutes, so
If sufferers try to sit or stand when they wake up, they may pass out again
The person may be nauseated, pale, and sweaty for several minutes or hours

Cause
Vasovagal syncope occurs in response to a trigger, with a corresponding malfunction in the parts of the nervous
system that regulate heart rate and blood pressure. When heart rate slows, blood pressure drops, and the
resulting lack of blood to the brain causes fainting and confusion.[5]
Typical triggers for vasovagal episodes include:[6]
Prolonged standing or upright sitting
After or during urination (micturition syncope)
Standing up very quickly (orthostatic hypotension)
During or post-biopsy procedures.
Stress directly related to trauma[7]
Stress
Postural orthostatic tachycardia syndrome (POTS) Multiple chronic episodes are experienced daily by
many patients diagnosed with this syndrome. Episodes are most commonly manifested upon standing up.
Any painful or unpleasant stimuli, such as:
Trauma (such as hitting one's funny bone)
Watching or experiencing medical procedures (such as venipuncture or injection)
High pressure on or around the chest area after heavy exercise
Severe menstrual cramps
Sensitivity to pain
Arousal or stimulants, e.g. sex, tickling, or adrenaline
Sudden onset of extreme emotions
Lack of sleep
Dehydration
Hunger
Being exposed to high temperatures
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In health care, such as nursing care, digital rectal procedures (e.g., digital disimpaction)
Random onsets due to nerve malfunctions
Pressing upon certain places on the throat, sinuses, and eyes (also known as vagal reflex stimulation when
performed clinically)
Use of certain drugs that affect blood pressure, such as cocaine, alcohol, marijuana, inhalants, and
opiates[8]
The sight of blood[9]
Serotonin level / SSRI [10]
Swallowing[11]
(Less commonly) Low blood sugar[12]
Time varying magnetic field [13] (e.g., transcranial magnetic stimulation)

Pathophysiology
Regardless of the trigger, the mechanism of syncope is similar in the various vasovagal syncope syndromes. In
it, the nucleus tractus solitarii of the brainstem is activated directly or indirectly by the triggering stimulus,
resulting in simultaneous enhancement of parasympathetic nervous system (vagal) tone and withdrawal of
sympathetic nervous system tone.
This results in a spectrum of hemodynamic responses:
1. On one end of the spectrum is the cardioinhibitory response, characterized by a drop in heart rate
(negative chronotropic effect) and in contractility (negative inotropic effect) leading to a decrease in
cardiac output that is significant enough to result in a loss of consciousness. It is thought that this
response results primarily from enhancement in parasympathetic tone.
2. On the other end of the spectrum is the vasodepressor response, caused by a drop in blood pressure (to as
low as 80/20) without much change in heart rate. This phenomenon occurs due to vasodilation, probably
as a result of withdrawal of sympathetic nervous system tone.
3. The majority of people with vasovagal syncope have a mixed response somewhere between these two
ends of the spectrum.
One account for these physiological responses is the Bezold-Jarisch reflex.

Diagnosis
In addition to the mechanism described above, a number of other medical conditions may cause syncope.
Making the correct diagnosis for loss of consciousness is one of the most difficult challenges that a physician
can face. The core of the diagnosis of vasovagal syncope rests upon a clear description by the patient of a
typical pattern of triggers, symptoms, and time course. It is also pertinent to differentiate lightheadedness,
seizures, vertigo, and hypoglycemia as other causes.
In patients with recurrent vasovagal syncope, diagnostic accuracy can often be improved with one of the
following diagnostic tests:
1. A tilt table test (results should be interpreted in the context of patients' clinical presentations and with an
understanding of the sensitivity and specificity of the test)[14]
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2.
3.
4.
5.

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Implantation of an insertable loop recorder

A Holter monitor or event monitor
An echocardiogram
An electrophysiology study

Treatment
Treatment for vasovagal syncope focuses on avoidance of triggers, restoring blood flow to the brain during an
impending episode, and measures that interrupt or prevent the pathophysiologic mechanism described above.
The cornerstone of treatment is avoidance of triggers known to cause syncope in that person. However, a
new development in psychological research has shown that patients show great reductions in vasovagal
syncope through exposure-based exercises with therapists if the trigger is mental or emotional, e.g. sight
of blood.[15] However, if the trigger is a specific drug, then avoidance is the only treatment.
Because vasovagal syncope causes a decrease in blood pressure, relaxing the entire body as a mode of
avoidance is not favorable.[15] A patient can move or cross his/her legs and tighten leg muscles to keep
blood pressure from dropping so drastically before an injection.[16]
Before known triggering events, the patient may increase consumption of salt and fluids to increase blood
volume. Sports drinks or drinks with electrolytes may be particularly helpful.
Discontinuation of medications known to lower blood pressure may be helpful, but stopping
antihypertensive drugs can also be dangerous in some people. Taking antihypertensive drugs may worsen
the syncope, as the hypertension may have been the body's way to compensate for the low blood pressure.
Patients should be educated on how to respond to further episodes of syncope, especially if they
experience prodromal warning signs: they should lie down and raise their legs, or at least lower their head
to increase blood flow to the brain. If the individual has lost consciousness, he or she should be laid down
with his or her head turned to the side. Tight clothing should be loosened. If the inciting factor is known,
it should be removed if possible (for instance, the cause of pain).
Wearing graded compression stockings may be helpful.
There are certain orthostatic training exercises which have been proven to improve symptoms in people
with recurrent vasovagal syncope. A technique called "Applied Tension" which involves learning to tense
the muscles in the torso, arms, and legs is effective for vasovagal syncope.
Certain medications may also be helpful:
Beta blockers (-adrenergic antagonists) were once the most common medication given; however,
they have been shown to be ineffective in a variety of studies and are thus no longer prescribed. In
addition, they may cause the syncope by lowering the blood pressure and heart rate.[17][18]
Other medications which may be effective include: CNS stimulants[19] fludrocortisone, midodrine,
SSRIs[20] such as paroxetine or sertraline, disopyramide, and, in health-care settings where a
syncope is anticipated, atropine epinephrine (adrenaline).[21]
For people with the cardioinhibitory form of vasovagal syncope, implantation of a permanent pacemaker
may be beneficial or even curative.[22]
Types of Long-Term Therapy for Vasovagal Syncope include:[14]
Preload agents
Vasoconstrictors
Anticholinergic agents
Negative cardiac inotropes
Central agents
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Mechanical device

Prognosis
Brief periods of unconsciousness do no harm and are seldom symptoms of disease. The main danger of
vasovagal syncope (or dizzy spells from vertigo) is the risk of injury by falling while unconscious. Medication
therapy could possibly prevent future vasovagal responses; however, for some individuals medication is
ineffective and they will continue to have fainting episodes.[23]

See also
Roemheld Syndrome

References
1. "vasovagal attack
(http://web.archive.org/web/20090616022448/http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?
pg=/ppdocs/us/common/dorlands/dorland/nine/000958086.htm)" at Dorland's Medical Dictionary
2. "Vasovagal syncope" (http://www.mayoclinic.com/health/vasovagal-syncope/DS00806). MayoClinic.com. 2010-08-07.
Retrieved 2012-07-06.
3. "NEURO-CARDIOGENIC SYNCOPE" (http://www.nwocc.com/Pt%20Education/neuro_syncope.pdf) (PDF). NorthWest
Ohio Cardiology Consultants: 12. March 2001.
4. Ajamian, Paul C. "If patient faints, be laid back: what do you do when a patient passes out in your office? Lay the patient
back to restore blood and oxygen to the brain." Review of Optometry 143.7 (July 15, 2006): 85(2). Nursing Resource
Center. Gale. California State Univ East Bay. 13 Mar. 2013
5. "Vasovagal syncope: Causes" (http://www.mayoclinic.com/health/vasovagal-syncope/DS00806/DSECTION=causes).
MayoClinic.com. 2010-08-07. Retrieved 2012-07-06.
6. "Vasomotor and vasovagal syncope" (http://heartdisease.about.com/cs/arrhythmias/a/Syncope2_2.htm).
Heartdisease.about.com. Retrieved 2012-07-06.
7. Shalev, A., Yehuda, R., & McFarlane, A. (2000). International handbook of human response to trauma. (pp. 263-264).
New York: Kluwer Academic/Plenium Publishers.
8. Hilhorst, John. "Approach to syncope: Is it cardiac or not??" (http://learnpediatrics.com/bodysystems/cardiology/approach-to-syncope-is-it-cardiac-or-not/). Cardiology. Retrieved 7 October 2012.
9. Zervou EK, Ziciadis K, Karabini F, Xanthi E, Chrisostomou E, Tzolou A (2005). "Vasovagal reactions in blood donors
during or immediately after blood donation". Transfus Med 15 (5): 38994. doi:10.1111/j.1365-3148.2005.00600.x
(https://dx.doi.org/10.1111%2Fj.1365-3148.2005.00600.x). PMID 16202053
(https://www.ncbi.nlm.nih.gov/pubmed/16202053).
10. Low brain serotonin turnover rate (low CSF 5-HIAA) and impulsive violence. Virkkunen, Matti;Goldman,
David;Nielsen, David A.;Linnoila, Markku Journal of Psychiatry & Neuroscience, Vol 20(4), Jul 1995, 271-275.
11. Farb A, Valenti SA (1999). "Swallow syncope". Md Med J 48 (4): 1514. PMID 10461434
(https://www.ncbi.nlm.nih.gov/pubmed/10461434).
12. fainting. (2005). In The Crystal Reference Encyclopedia. Retrieved from
http://www.credoreference.com/entry/cre/fainting

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13. Rossi S, Hallett M, Rossini PM, Pascual-Leone A (2009). "Safety, ethical considerations, and application guidelines for
the use of transcranial magnetic stimulation in clinical practice and research"
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3260536). Clinical Neurophysiology 120 (12): 20082039.
doi:10.1016/j.clinph.2009.08.016 (https://dx.doi.org/10.1016%2Fj.clinph.2009.08.016). PMC 3260536
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3260536). PMID 19833552
(https://www.ncbi.nlm.nih.gov/pubmed/19833552).
14. Fenton AM, Hammill SC, Rea RF, Low PA, Shen WK (2000). "Vasovagal syncope". Ann. Intern. Med. 133 (9): 71425.
doi:10.7326/0003-4819-133-9-200011070-00014 (https://dx.doi.org/10.7326%2F0003-4819-133-9-200011070-00014).
PMID 11074905 (https://www.ncbi.nlm.nih.gov/pubmed/11074905).
15. Durand, VM, and DH Barlow. 2006. Essentials of Abnormal Psychology 4th Edition. pp. 150.
16. France CR, France JL, Patterson SM (January 2006). "Blood pressure and cerebral oxygenation responses to skeletal
muscle tension: a comparison of two physical maneuvers to prevent vasovagal reactions". Clin Physiol Funct Imaging 26
(1): 215. doi:10.1111/j.1475-097X.2005.00642.x (https://dx.doi.org/10.1111%2Fj.1475-097X.2005.00642.x).
PMID 16398666 (https://www.ncbi.nlm.nih.gov/pubmed/16398666).
17. Sheldon R, Connolly S, Rose S, Klingenheben T, Krahn A, Morillo C, Talajic M, Ku T, Fouad-Tarazi F, Ritchie D,
Koshman ML (March 2006). "Prevention of Syncope (POST): a randomized, placebo-controlled study of metoprolol in
the prevention of vasovagal syncope". Circulation 113 (9): 116470. doi:10.1161/CIRCULATIONAHA.105.535161
(https://dx.doi.org/10.1161%2FCIRCULATIONAHA.105.535161). PMID 16505178
(https://www.ncbi.nlm.nih.gov/pubmed/16505178).
18. Madrid AH, Ortega J, Rebollo JG, Manzano JG, Segovia JG, Snchez A, Pea G, Moro C (February 2001). "Lack of
efficacy of atenolol for the prevention of neurally mediated syncope in a highly symptomatic population: a prospective,
double-blind, randomized and placebo-controlled study". J. Am. Coll. Cardiol. 37 (2): 5549. doi:10.1016/S07351097(00)01155-4 (https://dx.doi.org/10.1016%2FS0735-1097%2800%2901155-4). PMID 11216978
(https://www.ncbi.nlm.nih.gov/pubmed/11216978).
19. "The use of methylphenidate in the... [Pacing Clin Electrophysiol. 1996] - PubMed - NCBI"
(http://www.ncbi.nlm.nih.gov/pubmed/8734752). Ncbi.nlm.nih.gov. 2012-05-24. Retrieved 2012-07-06.
20. Ali Aydin, Muhammet; Salukhe, Tushar; Wilkie, Iris; Willems, Stephan. "Management and therapy of vasovagal
syncope: A review" (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998831/). PubMed. World J Cardiol. Retrieved
7 November 2014.
21. [1] (http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/Nursing%20Drug%20Guide/mg/epinephrine.htm))
22. "Vasovagal Syncope: What is it?" (http://www.vasovagal-syncope.com/). Retrieved 7 October 2012.
23. Vasovagal Syncope Prognosis. MDGuidlines. (http://www.mdguidelines.com/vasovagal-syncope/prognosis) Retrieved
July 25, 2013.

External links
Dysautonomia International (http://www.dysautonomiainternational.org/)
Dysautonomia Information Network (http://www.dinet.org/NCS/ncs.htm)
Dysautonomia Youth Network of America, Inc. (http://www.dynainc.org/dysautonomia)
Seattle Community Network Autism (http://www.scn.org/autistics/syncope.html) Information regarding
syncope
Mik's Hidden Hearts Alliance for Dysautonomia (http://mikshiddenheartsalliance.wordpress.com/)
12 More Pages-Live & Cope with Dysautonomia (http://www.12morepages.com/)
Retrieved from "https://en.wikipedia.org/w/index.php?title=Vasovagal_response&oldid=669834457"
Categories: Cardiology Vagus nerve
Symptoms and signs: Cognition, perception, emotional state and behaviour

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