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Drager syndrome, and beta blockers (propranolol or pindolol) and indomethacin (25 to 50 mg tid) in others These and other approaches that have proved useful in treating orthostatic hypotension are reviewed by Mathias and Kimber Neurally mediated syncope (neurocardiogenic or vasodepressor syncope), identi ed largely by the clinical circumstances and by upright tilt-table testing, may be prevented by the use of betaadrenergic blocking agents Our colleagues in cardiology have favored, and we endorse from experience, acebutolol 400 mg daily, in part because of its partial alpha-adrenergic activity, which raises baseline blood pressure, but atenolol 50 mg may be as effective The anticholinergic agent disopyramide has also been used (Milstein et al) Several other drugs (eg, ephedrine, metoclopramide, dihydroergotamine) have been variably successful in individual patients, but their utility as standard medications remains to be established; the beta-blocking agents are generally preferred The treatment of carotid sinus syncope involves, rst of all, instructing the patient in measures that minimize the hazards of a fall (see below) A loose collar should be worn, and the patient should learn to turn his whole body, rather than the head alone, when looking to one side Atropine or one of the sympathomimetic group of drugs should be used, respectively, in patients with pronounced bradycardia or hypotension during attacks If atropine is

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not successful and the syncopal attacks are incapacitating, the insertion of a dual-chamber pacemaker should be considered Radiation or surgical denervation of the carotid sinus has apparently yielded favorable results in some patients, but it is rarely necessary Vagovagal attacks usually respond well to an anticholinergic agent (propantheline, 15 mg tid) Treatment of the hyperventilation syndrome and of hysteria are considered in Chap 56 For a discussion of the treatment of hypoglycemia and the various cardiac arrhythmias that may induce syncope, the reader is referred to Harrison s Principles of Internal Medicine In the elderly person, a faint carries the additional hazard of a fracture or other trauma due to the fall Therefore the patient subject to recurrent syncope should cover the bathroom oor and bathtub with mats and have as much of his home carpeted as is feasible Especially important is the oor space between the bed and the bathroom, because this is the route along which faints in elderly persons most commonly occur Outdoor walking should be on soft ground rather than hard surfaces, and the patient should avoid standing still for prolonged periods, which is more likely than walking to induce an attack Padded hip protectors, now available as a commercial product, should be considered in elderly patients at risk of recurrent falls of any kind

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