Syncope (Fainting): Symptoms, Causes, and Treatment

Syncope is a medical condition where you experience sudden loss of consciousness and return to normal spontaneously after a short time. It is also known as fainting among the public. When you experience syncope, blood flow to the brain temporarily decreases and you lose consciousness briefly. This condition usually lasts between a few seconds to a few minutes, after which you return completely to normal. When you come to, you may experience confusion for a short time.

80% of syncope causes stem from harmless conditions. Daily life factors such as suddenly standing up, standing for long periods, being in a hot environment, experiencing stress can cause syncope. In syncope caused by heart diseases, additional symptoms usually accompany. By learning triggering factors, making lifestyle changes, and receiving medical treatment when necessary, you can largely prevent syncope recurrence.

What is syncope?

Syncope is sudden and temporary loss of consciousness that occurs when adequate blood flow to the brain cannot be provided. In this condition, the amount of oxygen and nutrients going to your brain temporarily decreases, you lose consciousness and fall to the ground.

Under normal conditions, your heart pumps 4-6 liters of blood per minute and a significant portion of this blood goes to your brain. During syncope, this blood flow drops below critical levels. The brain is very sensitive to oxygen deficiency; interruption for 3-4 seconds can cause dizziness, blackouts, or drowsiness. When blood flow is cut off for 6-8 seconds, loss of consciousness can begin.

There is no difference between syncope and fainting; both terms refer to the same condition. The term syncope is preferred in medical literature because it is more specific and descriptive.

During syncope, you lose muscle strength and fall to the ground. This condition is actually a protective mechanism of your body because blood flow to the brain is restored in horizontal position. In most cases, your consciousness is completely restored within 1-2 minutes.

What are the types of syncope?

Vasovagal syncope is the most common type of syncope and constitutes 60-70% of cases. This type of syncope develops as a result of the nervous system’s overreaction. Situations such as standing for long periods, hot environment, pain, stress, seeing blood, fear of needles can trigger it. The large nerve called the vagus nerve is overstimulated and heart rate drops, vessels dilate.

Vasovagal syncope usually starts with warning symptoms. You may experience nausea, sweating, dizziness, blurred vision. These symptoms can last for several minutes and can be prevented by sitting or lying down.

Orthostatic syncope occurs with position change. When you suddenly stand up, your blood pressure drops and not enough blood goes to the brain. This condition is common in elderly people, patients who have been bedridden for long periods, and people using certain medications. It is also known as orthostatic hypotension.

Under normal conditions, your body balances blood pressure when you stand up. In orthostatic syncope, this mechanism is disrupted. Fluid loss, blood loss, certain blood pressure medications can trigger this condition.

Cardiac syncope occurs due to heart problems and is the most serious type of syncope. Conditions such as arrhythmias, heart valve diseases, coronary artery disease disrupt the heart’s pumping capacity. This type of syncope usually develops suddenly without warning.

Cardiac syncope constitutes 10-15% of cases but can carry the risk of sudden death. Heart symptoms such as chest pain, shortness of breath, palpitations may accompany. This type of syncope requires emergency evaluation.

Neurogenic syncope is a type of fainting that occurs due to the effects of nervous system diseases. Conditions such as Parkinson’s disease, multiple sclerosis, or nerve damage due to diabetes affect the autonomic nervous system in your body.

The autonomic nervous system automatically controls vital functions such as your heart rate and blood pressure. Disruption of this system leads to sudden drops in blood pressure or heart rate and thus brief interruption of blood flow to the brain. As a result, neurogenic syncope develops.

What are the symptoms of syncope?

Syncope symptoms manifest differently before, during, and after fainting. Recognizing these symptoms is important for determining the type of syncope and taking precautions.

Pre-syncope symptoms are called presyncope and can last minutes or seconds.

• You may experience dizziness and feel your surroundings spinning. This condition occurs due to the inner ear system that controls balance being affected, called vertigo.
• Visual disturbances may develop. You may experience blackouts, blurred vision, tunnel vision in your eyes. You may feel as if you’re seeing the environment from a distance. These symptoms are related to decreased blood flow in the retina.
• You may experience nausea and sweating. Your palms may sweat and you may break out in cold sweats. Your face color may pale and you may hear people around you say “you’ve gone pale.” These symptoms develop with nervous system activation.
• There may be ear ringing and hearing reduction. You may feel as if you’re hearing surrounding sounds from a distance. You may have difficulty speaking and may not find words.

Symptoms during syncope are characterized by loss of consciousness.

• You lose muscle strength and fall to the ground uncontrollably.
• Eyelids may flutter or eyes may roll upward.
• Breathing may become irregular.
• Brief muscle contractions may occur.
• This condition can be confused with epileptic seizures, but muscle contractions in syncope usually last less than 10-15 seconds. Urinary or fecal incontinence is rarely seen.

Post-syncope symptoms are usually mild. You may feel tired and weak. You may experience mild headache. When you move suddenly, you may have dizziness again. You usually don’t have problems recognizing your surroundings. You remember where you are, who you are. You usually remember events before fainting. This condition helps distinguish syncope from other causes of loss of consciousness.

What causes syncope?

The basic mechanism of syncope development is inadequate blood flow to the brain. Under normal conditions, while your brain constitutes 2% of your body weight, it uses 15-20% of the blood your heart sends to the body per minute. This intense blood need is due to the brain’s high energy requirement.

For syncope to develop, blood flow to the brain needs to drop below 100 ml per minute. Normal brain blood flow is 50-60 ml/100 grams of brain tissue per minute. When this flow decreases by 40-50%, consciousness disorders begin; when it decreases by 60-70%, complete loss of consciousness occurs.

What are the risk factors for syncope?

Syncope risk depends on many factors such as your age, gender, general health condition, and lifestyle. Knowing these risk factors helps you take preventive measures.

Age factor is one of the factors that most affects syncope risk. At young ages, especially between 15-25 years, vasovagal syncope is more common. During this period, hormonal changes, stress, and lifestyle effects increase risk; it is often not serious.

After age 65, the risk increases again. At advanced ages, cardiovascular diseases, medication use, and autonomic nervous system disorders increase syncope risk. In this age group, fainting may usually be due to more serious causes.

The autonomic nervous system is a system that automatically regulates vital functions such as your heart rate, blood pressure, and digestion without your awareness. Disruptions in this system can increase the risk of fainting by causing sudden drops in blood pressure and heart rate.

Gender difference is also important. Vasovagal syncope is seen 2-3 times more in women than men; pregnancy, menstrual period, and hormonal fluctuations can be effective. In men, cardiogenic syncope is more common.

Family predisposition is a significant risk factor, especially for vasovagal syncope. Risk increases 3-4 times in those with a family history of fainting. Genetic structure can affect the sensitivity of the autonomic nervous system.

Cardiovascular diseases seriously increase syncope risk. Coronary artery disease, heart failure, valve diseases, and arrhythmias can cause cardiac syncope. Additionally, some medications used in hypertension treatment can increase orthostatic syncope risk, especially in elderly people.

Medication use is another important factor. Diuretics can increase fainting risk by causing fluid loss (dehydration), vasodilators by lowering blood pressure, and antidepressants by affecting the autonomic nervous system.

Lifestyle factors also play a role. Inadequate fluid intake, unbalanced nutrition, excessive alcohol consumption, and inactivity increase risk. Additionally, stressful life can trigger vasovagal syncope.

Metabolic diseases should not be forgotten. For example, diabetes can damage nerve endings, leading to sudden drops in blood pressure. Low blood sugar (hypoglycemia) can directly cause fainting by reducing energy going to the brain. Thyroid diseases can also increase risk by disrupting heart rhythm.

How is syncope diagnosed?

Syncope diagnosis is made with detailed history taking, physical examination, and necessary tests. The diagnostic process aims to determine the cause of syncope and perform risk assessment.

• Detailed history taking is the most important step of the diagnostic process. Your doctor questions in detail when, where, and under what circumstances syncope was experienced. Pre-syncope symptoms, duration, and awakening pattern are evaluated.
• Triggering factors are investigated. Situations such as suddenly standing up, standing for long periods, hot environment, stress, pain suggest vasovagal syncope. Syncope during exercise is important for cardiac causes.
• Electrocardiography is the basic test performed in all syncope patients. ECG shows heart rhythm, conduction disorders, and ischemia findings. Bradycardia, tachycardia, block types are evaluated.
• Laboratory tests are performed to evaluate general condition. Blood count, electrolyte levels, kidney and liver functions are measured. Blood sugar is checked to rule out hypoglycemia.
• Thyroid function tests are important for hyperthyroidism. Natriuretic peptide is helpful in heart failure diagnosis. Troponin level rules out myocardial infarction.
• Advanced tests are performed when indicated. Holter monitoring is used to investigate arrhythmias. Echocardiography evaluates heart structure and function.
• Tilt table test can be used in vasovagal syncope diagnosis. This test attempts to trigger syncope by making position changes on a special table. Electrophysiological study may be needed in complex arrhythmias.

Not all tests listed here are performed on every patient. Your doctor decides which test is necessary for you by evaluating your history, examination findings, and risk status.

How is syncope treated?

Syncope treatment is personalized according to the cause of your fainting. In harmless types such as vasovagal syncope, lifestyle changes and simple measures are usually sufficient. In syncope situations caused by heart diseases, advanced treatment methods such as drug therapy, pacemaker, or ablation may be needed. Your treatment plan is determined according to your syncope type, age, and general health condition.

Lifestyle changes

Lifestyle arrangements are the basic treatment approach in all syncope types and are sufficient alone in a significant portion of cases.

• Increasing fluid intake is critical especially in vasovagal and orthostatic syncope. You should aim to drink 2-3 liters of water daily. Fluid deficiency reduces blood volume and increases syncope risk. You should increase fluid intake even more in hot weather and after exercise.
• Increasing salt intake helps increase blood volume. 6-10 grams of daily salt intake is recommended. This amount corresponds to approximately 1-2 teaspoons. If you don’t have hypertension problems, you can increase salt intake under doctor control.
• Avoiding triggering factors is the most important measure in vasovagal syncope. Avoid standing for long periods, hot and crowded environments. Move gradually instead of suddenly standing up. Learn stress management techniques.
• Physical counter-maneuvers help prevent fainting when applied when pre-fainting (syncope) symptoms appear. For example, movements such as contracting leg muscles or joining hands and pulling improve blood flow to the brain by increasing blood return to the heart and blood pressure. Thus, fainting risk decreases.

Drug therapy

Drug therapy is applied when lifestyle changes are insufficient and in the presence of specific indications.

• Fludrocortisone is the first choice drug used in vasovagal syncope. This drug provides salt and water retention from the kidneys, increasing blood volume. It is used at a daily dose of 0.1-0.2 mg. Potassium level and blood pressure should be monitored regularly.
• Beta blockers may be effective especially in young people with vasovagal syncope. Drugs such as metoprolol and atenolol suppress vasovagal reflex. They should be used carefully in elderly people due to hypotension risk.
• Midodrine is a drug with alpha agonist effect. It increases blood pressure by increasing vascular resistance. It is especially effective in orthostatic hypotension. It can be used at a dose of 2.5-10 mg three times a day.
• SSRI-type antidepressants may be an alternative option in vasovagal syncope treatment. Drugs such as sertraline and fluoxetine help reduce fainting attacks by regulating control of vasovagal reflex by increasing serotonin levels in the brain.

Pacemaker therapy

Pacemaker is an effective treatment for syncope that occurs when heart rate slows down too much (bradycardia). Modern pacemakers activate only when needed.

• Traditional pacemakers become active when heart rate slows down too much. Dual chamber pacemakers provide a more harmonious rhythm by stimulating both the upper chamber (atrium) and lower chamber (ventricle) of the heart. These devices can usually work for 8-15 years.
• CRT pacemaker (Cardiac Resynchronization Therapy) is especially used in patients with heart failure. CRT improves both syncope and heart failure symptoms by enabling the heart muscle to work more synchronized.

Advanced treatment methods

• Implantable defibrillator (ICD) can be life-saving in cardiac syncope (heart-related fainting). ICD detects dangerous arrhythmias and automatically gives electric shock to correct heart rhythm. It is preferred in patients at high risk of sudden cardiac death.
• If syncope is related to arrhythmias, ablation therapy can be applied. Additionally, in vasovagal syncope, cardioneurablation method can be performed as an option.

What are the complications of syncope?

Syncope complications range from falls and injuries experienced during fainting to serious conditions related to heart diseases. The most common complications are head trauma, bone fractures, and soft tissue injuries caused by uncontrolled falls. In heart-related syncope situations, vital dangers such as sudden cardiac arrest risk may be involved.

• Physical injuries are the most common complications in syncope. You may experience head trauma due to uncontrolled falls. Serious injuries such as skull fractures and brain hemorrhage may develop. Hip fracture risk is especially high in elderly people.
• Soft tissue injuries are common. Bruises and cuts may occur in arms, legs, and face area. Although these injuries are usually mild, they can cause cosmetic problems. Tooth fractures and jaw injuries can also be seen.
• Psychological effects can significantly affect quality of life after syncope. Fear of experiencing syncope again may develop and this condition may restrict your daily activities. You may withdraw from social life and experience decreased work performance.
• Anxiety disorders may develop. You may constantly worry “I will faint again” and this condition may cause panic attack-like symptoms. Depression risk may increase and quality of life may decrease.
• Heart and vascular problems can reach serious dimensions if there is underlying heart disease. Cardiac syncope may increase sudden cardiac arrest risk. Recurring fainting attacks may accelerate worsening of heart disease.
• In people with coronary artery blockage (coronary artery disease), fainting may increase heart attack risk. Arrhythmias may worsen over time and lead to more frequent fainting attacks.
• Neurological complications may develop in recurrent syncope. Frequent interruption of blood flow to the brain may affect cognitive functions. You may experience memory problems and attention deficit.
• Dementia risk may increase in elderly people. Recurring oxygen deficiency attacks (hypoxia) may damage brain cells. This condition is even more important especially in people with risk factors such as vascular disease.
• Restrictions may be imposed on sports activities. Especially competitive sports and high-risk activities may be prohibited. This condition may significantly change lifestyle, especially in young people.

What is good for fainting?

Your eating habits and exercise program can significantly affect syncope frequency. You can minimize syncope risk with correct approaches.

• Nutritional arrangements are critical for blood sugar and blood pressure balance. Regular meal times prevent blood sugar fluctuations. Consuming 5-6 small meals per day keeps blood sugar stable.
• You should not extend fasting periods. You must have breakfast because your body, which has been fasting overnight, has low blood sugar in the morning. Skipping meals increases syncope risk.
• You should prefer complex carbohydrates. Whole grain products, vegetables, legumes slowly increase blood sugar and keep it stable for a long time. Simple carbohydrates like sugar and white bread quickly raise and lower blood sugar.
• You should keep fluid and salt balance at optimum level. Daily 2.5-3 liter fluid intake preserves blood volume. Water is the best choice, but electrolyte-containing drinks are also beneficial.
• If you don’t have salt restriction, you can take 6-10 grams of salt daily. This amount increases blood volume and reduces orthostatic syncope risk. Check the salt content of processed foods.
• Caffeine can be beneficial when taken in limited amounts. For example, 1-2 cups of coffee per day can slightly increase blood pressure. However, excessive caffeine consumption can lead to water loss (dehydration) in the body and trigger arrhythmias in some people.
• You should avoid sudden and intense exercises. You must do warm-up movements because sudden exercise can trigger syncope.
• Aerobic exercises improve your cardiovascular condition. Walking, swimming, cycling are safe options. Aim for 150 minutes of moderate-intensity exercise per week.
• Resistance training is also beneficial, but avoid lifting excessive weights. Holding breath increases syncope risk. Pay attention to breathing regularly during exercise.
• You should take precautions during exercise. You should consume plenty of fluids. You should avoid exercising in hot environments. You should rest when you feel tired.
• Instead of stopping suddenly after exercise, you should do cool-down movements. Lower your heart rate gradually with slow walking. Don’t shower immediately after exercise.

When should you consult a doctor?

Knowing when you need to make emergency applications when you experience syncope is vitally important. Some symptoms may indicate serious heart problems.

• If you experience chest pain with syncope, there is a possibility of heart attack. Especially if chest pain radiates to arm, jaw, or back, call emergency services.
• If your consciousness does not fully return after syncope, if there is difficulty speaking, facial asymmetry, arm-leg weakness, stroke possibility should be considered. In this case, apply to emergency room without delay.
• If severe shortness of breath is seen with syncope, there may be pulmonary embolism or heart failure. If your lips are blue, if you have difficulty breathing, emergency intervention is needed.

Situations requiring rapid application require evaluation within 24 hours.

• If you experienced syncope during exercise, the possibility of cardiac cause is high. This condition may indicate serious heart diseases, especially in young people.
• If you experience syncope with palpitations, there may be arrhythmias. Especially if palpitations are very fast or irregular, close follow-up is needed. If there is a feeling of tightness in your chest before fainting, evaluation is important.
• If you are experiencing recurring syncope attacks, there may be a serious underlying cause. Especially if frequency is increasing or warning symptoms are decreasing, doctor control is essential.

Situations requiring routine control can be done with planned evaluation.

• If you experienced syncope for the first time, you should go for control to investigate the cause. Especially first syncope over age 40 should definitely be evaluated.
• If there is sudden cardiac death in your family history, you should take your syncope complaint seriously. Genetic heart diseases can be prevented with early diagnosis. In this case, cardiology consultation is recommended.
• If you experienced injury due to syncope, evaluation is needed both for trauma and syncope cause. Brain imaging may be performed in cases with head trauma.

Experiencing syncope can be frightening, but with correct diagnosis and treatment, it can be successfully managed in most cases. What’s important is adopting the correct approach without panicking and getting expert support. With early diagnosis and appropriate treatment, you can safely continue your normal life.

Reference: Syncope