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Management of Refractory Neurocardiogenic Syncope
- Kenneth A. Ellenbogen, MD;
- Mark A. Wood, MD; and
- Hermes A. Kontos, MD, PhD
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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. β-blockers, mineralocorticoids, theophylline, serotonin receptor blockers, disopyramide, and peripheral vasoconstrictors (α-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.
Kenneth A. Ellenbogen, MD
Mark A. Wood, MD
Hermes A. Kontos, MD, PhD
Medical College of Virginia; Richmond, VA 23298
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
