EpistemisRecurrent lipothymia
Specialty: General.
Why it occurs
- Primary or secondary dysautonomia syndrome (diabetic polyneuropathy, amyloidosis or Parkinson's disease, causing sympathetic denervation and failure of vasoconstriction when standing)
- Severe bilateral carotid stenosis or vertebrobasilar insufficiency (drop in cerebral blood flow due to minimal positional changes of the head)
- Paroxysmal heart rhythm disorders (sinus node disease, nonsustained ventricular tachycardia, or paroxysmal atrial fibrillation with rapid ventricular response)
- Severe persistent chronic anemia (constant cerebral tissue hypoxia that lowers the threshold for syncope)
- Anxiety with repeated psychogenic hyperventilation (inducing hypocapnia, respiratory alkalosis and secondary cerebral vasoconstriction).
Initial workup
Holter recording of 24-hour electrocardiogram (ideally prolonged or long-term insertable Holter), transthoracic Doppler echocardiogram, Doppler ultrasound of carotid and vertebral arteries, tilt table test, and complete blood count.
red flags
Episodes of lipothymia that occur without prodromes (previous dizziness, sweating or paleness), that cause physical trauma due to free fall, associated with chest pain, previous palpitations, dyspnea or that occur in recumbency.
Standard management
- Midodrine — 2.5 to 5 mg orally every 8 hours, avoiding administration in the afternoon/night to prevent supine hypertension, indicated in dysautonomia with severe orthostatic hypotension
- Fludrocortisone — 0.1 mg orally daily, monitoring serum potassium and the appearance of peripheral edema
- Use of class II graduated lower limb compression stockings (20-30 mmHg) systematically during the day.
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- General
- Listed causes
- 5
- Treatment options
- 3