What are the three types of syncope?

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Drug treatment in syncope: summary of clinical trials*

Investigators	Drug	Study design	Sample	Results
Ventura et al (2002)w1	β blocker (metoprolol, propranolol, or no treatment)	Prospective randomised controlled clinical trial	n=56 (36 female, 20 male); mean (SD) age 44 (18) years	β blocker group had fewer recurrent episodes of syncope v no treatment
Madrid et al (2002)16	β blocker (atenolol)	Prospective randomised double blind placebo controlled clinical trial	n=50 (26 on atenolol, 24 on placebo)	Atenolol group had similar No of recurrent syncope episodes to placebo group, with no difference in time to first syncopal recurrence
Flevari et al (2002)17	β blocker (propranolol, nadolol, or placebo)	Randomised crossover controlled clinical trial	n=30 consecutive patients with vasovagal syncope and positive tilt test (all were serially and randomly assigned to propranolol, nadolol, or placebo for three months each, with crossover)	After nine month follow up: no difference in recurrence of syncope or presyncope among the three groups; all three treatments were equally effective in treating vasovagal syncope
Mahanonda et al (1995)w2	β blocker (oral atenolol) v placebo for one month	Randomised controlled clinical trial	n=42 (21 on atenolol, 21 on placebo); all had at least one syncopal episode or two presyncopal episodes occurring one month before presentation and had positive isoproterenol tilt test	After one month: 62% of atenolol group v 5% of placebo group had negative tilt test (P=0.0004), and 71% of atenolol group v 29% of placebo group reported symptomatic improvement (P=0.02)
Takata et al (2002)w2	Selective serotonin reuptake inhibitors (paroxetine/paxil) 20 mg/day v placebo for six weeks	Randomised double blind controlled trial	n=25 (19 completed the study: 9 on paroxetine, 10 on placebo)	Paroxetine did not attenuate sympathoinhibition or vagotonia (did not prevent syncope)
DiGirolamo et al (1999)21	Selective serotonin reuptake inhibitors (paroxetine/paxil) 20 mg/day v placebo for one month	Randomised controlled clinical trial	n=68 (42 female, 26 male); mean (SD) age 44.7 (16.5) years	61.8% of paroxetine group v 38.2% of placebo group had negative tilt test; 17.6% of paroxetine group v 52.9% of placebo group had spontaneous syncope (P<0.0001); paroxetine improved symptoms of vasovagal syncope
Kaufmann et al (2002)18	Selective α1 adrenergic agonist (midodrine) v placebo	Randomised double blind crossover placebo controlled trial	n=12 (with recurrent neurally mediated syncope)	Midodrine significantly improved orthostatic tolerance during tilt test in patients with neurally mediated syncope (P<0.02)
Perez-Lugones et al (2001)19	Selective α1 adrenergic agonist (midodrine) v fluid and salt tablets for six months	Prospective randomised controlled trial	n=61 (31 on midodrine, 30 on fluid and salt tablet)	81% of midodine v 13% of fluid and salt tablet group remained asymptomatic (P<0.001); midodrine was beneficial in treating neurally mediated syncope
Ward et al (1998)20	Selective α1 adrenergic agonist (midodrine) v placebo for one month	Randomised double blind placebo controlled trial	n=16 (11 female, 5 male); mean (SD) age 56 (18) years	Midodrine group had more symptom-free days and fewer positive tilt tests v placebo group; midodrine reduced symptom frequency and symptoms during tilt test
Mitro et al (1999)w4	Selective α1 adrenergic agonist (midodrine)	Prospective non-randomised clinical trial	n=41 (23 female, 18 male); mean age 34 years; with recurrent syncope and positive tilt test	95% had no inducible presyncope or syncope during repeat tilt test; the effective dose was 2.5 mg po bid in 25 patients, and 5 mg po bid in 16 patients; on mean (SD) follow up of 19 (9) months, 97% with negative repeat tilt test remained free of syncope recurrence
Yu and Sung (1997)w5	Anticholinergic (propantheline bromide), mean (SD) 64.3 (21) mg/day for seven days	Prospective non-randomised clinical trial	n=16 (5 female, 11 male); mean (SD) age 48.8 (15.1) years	81% of patients had no inducible presyncope or syncope on repeat tilt test; on mean (SD) follow up of 15.2 (7.4) months in 12 patients, 33% had clinical recurrence of symptoms
Da Costa et al (1993)22	Salt retaining mineralocorticoid (fludrocortisone) for two weeks	Prospective non-randomised clinical trial	n=11; mean (SD) age 83 (5) years; all patients had daily dizziness and had vasodepressor carotid sinus syndrome	Fludrocortisone effectively reduced vaspdepressor response and relieved symptoms of vasodepressor carotid sinus syndrome

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