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LETTER
Management of Refractory Neurocardiogenic Syncope
Kenneth A. Ellenbogen, MD;
Mark A. Wood, MD; and
Hermes A. Kontos, MD, PhD
1 January 1998 | Volume 128 Issue 1 | Page 73
TO THE EDITOR:
Therapy for neurally mediated syncope and related syndromes has recently received considerable attention. Few randomized trials of any specific therapeutic agents have been performed. ß-blockers, mineralocorticoids, theophylline, serotonin receptor blockers, disopyramide, and peripheral vasoconstrictors (
-agonists) have all been used with some success [1]. There still remains, however, a group of patients whose condition is refractory to medical and pacing therapy. We describe four patients with refractory, disabling neurocardiogenic syncope whose symptoms improved markedly after therapy with diphenylhydantoin and carbamazepine after drug or pacemaker therapy had failed.
The clinical characteristics and drug levels associated with suppression of recurrent syncope are summarized in the (Table 1). Three patients had a tumor of the neck region, and one had previously undergone neck surgery. We hypothesize that the glossopharyngeal nerve or carotid body may act as a trigger for activation of vagal afferents to the brainstem, leading to a mixed vasodepressor and vasoinhibitory response similar to that seen in patients with neurally mediated syncope and its variants. We speculate that these agents may be effective because of the inhibitory effect of carbamazepine and diphenylhydantoin on brainstem activity, although the actual level of the reflex arc affected by these drugs is not known [2, 3]. The exact mechanism by which these agents suppress the autonomic reflex involving syncope is unknown.
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Author and Article Information
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Medical College of Virginia; Richmond, VA 23298
1. Morillo CA, Brignole M, Wood MA, Ellenbogen KA. Management of head-up tilt induced neurocardiogenic (vasovagal) syncope. Pacing Clin Electrophysiol. [In press].
2. Ellenbogen KA, Morillo CA, Smith ML, Wood MA, Gilligan DM, Eckberg DL, et al. Neural monitoring of vasovagal syncope. Pacing Clin Electrophysiol. 1997; 20:788-94.
3. Taylor PH, Gray K, Bicknell PG, Rees JR. Glossopharyngeal neuralgia with syncope. J Laryngol Otol. 1977; 91:859-68.
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