Hawkins Nathaniel M, Krahn Andrew D
Division of Cardiology, University of British Columbia, Vancouver, Canada.
Cardiol J. 2014;21(6):616-24. doi: 10.5603/CJ.2014.0094.
Effectiveness of a treatment for neurocardiogenic syncope can be defined in terms of symptom response, quality-of-life, healthcare utilization, treatment side effects and cost-effectiveness. Most trials have focused on syncope recurrence or burden, without assessing quality-of-life formally. Drug and device interventions are characterized by a dearth of randomized controlled trials, with those few of robust design demonstrating little impact on recurrence of syncope. General advice includes hydration, trigger recognition and counter pressure maneuvers to attenuate episodes. Lifestyle recommendations have limited comparative effectiveness evidence, but are favored due to lack of side effects and low cost. The frequency of syncope improves in many patients regardless of the intervention, although ultimate recurrence of syncope remains high. In the minority of patients seeking treatment due to recurrence, midodrine has reasonable supporting evidence for effectiveness with some evidence for beta-blockers in older age patients. Emerging evidence favors pacing in patients with asystole during spontaneous (as opposed to provoked) syncope. Combining long-term implantable cardiac monitoring, tilt and adenosine triphosphate testing may yet accurately define the optimal minority who benefit from pacing. In the remaining majority, pharmacologic and device interventions should be used sparingly until clear benefits are established. Better understanding of patient fears, beliefs and behaviors may help develop cognitive therapies and improve quality-of-life alongside the focus on physical symptoms.
神经心源性晕厥治疗的有效性可根据症状反应、生活质量、医疗资源利用、治疗副作用和成本效益来定义。大多数试验都集中在晕厥复发或负担上，而没有正式评估生活质量。药物和器械干预的特点是缺乏随机对照试验，少数设计严谨的试验对晕厥复发几乎没有影响。一般建议包括补充水分、识别诱因和采取对抗压力动作以减轻发作。生活方式建议的比较有效性证据有限，但由于没有副作用且成本低而受到青睐。无论采取何种干预措施，许多患者的晕厥频率都会有所改善，尽管晕厥最终复发率仍然很高。在少数因复发而寻求治疗的患者中，米多君有合理的有效性支持证据，老年患者使用β受体阻滞剂也有一些证据支持。新出现的证据表明，对于自发（而非诱发）晕厥时出现心搏停止的患者，起搏治疗有益。结合长期植入式心脏监测、直立倾斜试验和三磷酸腺苷试验，可能还能准确确定从起搏治疗中获益的少数最佳患者。在其余大多数患者中，在明确益处之前，应谨慎使用药物和器械干预。更好地了解患者的恐惧、信念和行为，可能有助于开发认知疗法，并在关注身体症状的同时提高生活质量。
