Vasovagal Syncope: A Review of Current and Emerging Therapies for a Common Cardiology Condition
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Abstract
Vasovagal syncope (VVS), characterized by transient loss of consciousness, is among the most prevalent reasons for emergency visits worldwide. Although benign in nature, VVS can be accompanied by traumatic injury, leading to morbidity and decreased quality of life, especially in those with VVS recurrence. The management includes non-pharmacologic and pharmacologic therapies (if resistant), patient education and reassurance, salt and fluid intake increase, and physical counter-pressure maneuvers. Among medications, midodrine has shown promising results in reducing VVS recurrence and positive head-up tilt tests. Fluoxetine and atomoxetine also might be suitable candidates for VVS therapy. Permanent pacemakers, such as closed-loop stimulation, are under research and can be effective in cases unresponsive to medical treatment. In summary, while data are scarce regarding the definite treatment of VVS, there is a need for further research with novel, easy-to-use and cost-effective therapeutic methods to enhance quality of life and prevent traumatic injury.
1. Deveau AP, Sheldon R, Maxey C, Ritchie D, Doucette S, Parkash R. Sex Differences in Vasovagal Syncope: A Post Hoc Analysis of the Prevention of Syncope Trials (POST) I and II. Can J Cardiol 2020;36:79-83.
2. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, MartÃn A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG; ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018;39:1883-1948.
3. Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017;136:e25-e59.
4. Tajdini M, Khalaji A, Behnoush AH, Tavolinejad H, Jalali A, Sadeghian S, Vasheghani-Farahani A, Yadangi S, Masoudkabir F, Bozorgi A. Brain MRI and EEG overemployment in patients with vasovagal syncope: results from a tertiary syncope unit. BMC Cardiovasc Disord 2023;23:576.
5. Sun BC. Quality-of-life, health service use, and costs associated with syncope. Prog Cardiovasc Dis 2013;55:370-375.
6. van Dijk N, Sprangers MA, Boer KR, Colman N, Wieling W, Linzer M. Quality of life within one year following presentation after transient loss of consciousness. Am J Cardiol 2007;100:672-676.
7. Jorge JG, Raj SR, Teixeira PS, Teixeira JAC, Sheldon RS. Likelihood of injury due to vasovagal syncope: a systematic review and meta-analysis. Europace 2021;23:1092-1099.
8. Tajdini M, Tavolinejad H, Aminorroaya A, Aryan Z, Jalali A, Alaeddini F, Sadeghian S, Yadangi S, Vasheghani-Farahani A, Kalhor P, Bozorgi A. Clinical Associations of Injuries Caused by Vasovagal Syncope: A Cohort Study From a Tertiary Syncope Unit. J Am Heart Assoc 2023;12:e027272.
9. Sun BC, Emond JA, Camargo CA Jr. Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol 2005;95:668-671.
10. Farwell DJ, Sulke AN. Does the use of a syncope diagnostic protocol improve the investigation and management of syncope? Heart 2004;90:52-58.
11. Solbiati M, Casazza G, Dipaola F, Rusconi AM, Cernuschi G, Barbic F, Montano N, Sheldon RS, Furlan R, Costantino G. Syncope recurrence and mortality: a systematic review. Europace 2015;17:300-308.
12. Raj SR, Coffin ST. Medical therapy and physical maneuvers in the treatment of the vasovagal syncope and orthostatic hypotension. Prog Cardiovasc Dis 2013;55:425-433.
13. Sharma G, Ramakumar V, Sharique M, Bhatia R, Naik N, Mohanty S, Agarwal A, Meti M, Shukla A, Deepti S, Bansal R, Gupta A, Ahmed AS, Pandey RM, Narang R, Mishra S, Saxena A, Juneja R; LIVE-Yoga Investigators. Effect of Yoga on Clinical Outcomes and Quality of Life in Patients With Vasovagal Syncope (LIVE-Yoga). JACC Clin Electrophysiol 2022;8:141-149.
14. Aghajani F, Tavolinejad H, Sadeghian S, Bozorgi A, Jalali A, Vasheghani-Farahani A, Yadangi S, Niazi S, Poopak A, Tajdini M. Implementation of supervised physical training to reduce vasovagal syncope recurrence: A randomized controlled trial. J Cardiovasc Electrophysiol 2022;33:1863-1870.
15. Brignole M, Ammirati F, Arabia F, Quartieri F, Tomaino M, Ungar A, Lunati M, Russo V, Del Rosso A, Gaggioli G; Syncope Unit Project (SUP) Two Investigators. Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes. Eur Heart J 2015;36:1529-1535.
16. Behnoush AH, Yazdani K, Khalaji A, Tavolinejad H, Aminorroaya A, Jalali A, Tajdini M. Pharmacologic prevention of recurrent vasovagal syncope: A systematic review and network meta-analysis of randomized controlled trials. Heart Rhythm 2023;20:448-460.
17. Lei LY, Raj SR, Sheldon RS. Midodrine for the prevention of vasovagal syncope: a systematic review and meta-analysis. Europace 2022;24:1171-1178.
18. Ng J, Sheldon RS, Ritchie D, Raj V, Raj SR. Reduced quality of life and greater psychological distress in vasovagal syncope patients compared to healthy individuals. Pacing Clin Electrophysiol 2019;42:180-188.
19. Sheldon RS, Lei L, Guzman JC, Kus T, Ayala-Paredes FA, Angihan J, Safdar S, Maxey C, Bennett G, Raj SR. A proof of principle study of atomoxetine for the prevention of vasovagal syncope: the Prevention of Syncope Trial VI. Europace 2019;21:1733-1741.
20. Tajdini M, Aminorroaya A, Tavolinejad H, Tofighi S, Jalali A, Sadeghian S, Vasheghani-Farahani A, Yadangi S, Shahmansouri N, Akhondzadeh S, Bozorgi A. Atomoxetine as an adjunct to nonpharmacological treatments for preventing vasovagal attacks in patients with recurrent vasovagal syncope: A pilot randomized-controlled trial. Int J Cardiol Heart Vasc 2021;34:100789.
21. Sandhu RK, Raj SR, Hamzeh R, Sheldon RS; POST 7 Investigators. The Seventh Prevention of Syncope Trial (POST VII)-A randomized clinical trial of atomoxetine for the prevention of vasovagal syncope: Rationale and study design. Am Heart J 2023;262:49-54.
22. Sheldon R, Raj SR, Rose MS, Morillo CA, Krahn AD, Medina E, Talajic M, Kus T, Seifer CM, Lelonek M, Klingenheben T, Parkash R, Ritchie D, McRae M; POST 2 Investigators. Fludrocortisone for the Prevention of Vasovagal Syncope: A Randomized, Placebo-Controlled Trial. J Am Coll Cardiol 2016;68:1-9.
23. Olgar S, Omeroglu RE. Prolonged supine hypertension due to midodrine use in an orthostatic hypotensive child. Pediatr Cardiol 2007;28:309-310.
24. Shibao C, Raj SR, Gamboa A, Diedrich A, Choi L, Black BK, Robertson D, Biaggioni I. Norepinephrine transporter blockade with atomoxetine induces hypertension in patients with impaired autonomic function. Hypertension 2007;50:47-53.
25. Aminorroaya A, Tavolinejad H, Sadeghian S, Jalali A, Alaeddini F, Emkanjoo Z, Mollazadeh R, Bozorgi A, Oraii S, Kiarsi M, Shahabi J, Akbarzadeh MA, Rahimi B, Joharimoghadam A, Mohsenizade A, Mohammadi R, Oraii A, Ariannejad H, Apakuppakul S, Ngarmukos T, Tajdini M. Comparison of Outcomes with Midodrine and Fludrocortisone for Objective Recurrence in Treating Syncope (COMFORTS trial): Rationale and design for a multi-center randomized controlled trial. Am Heart J 2021;237:5-12.
26. Aksu T, Mandrola J, Raj SR. Permanent pacing for recurrent vasovagal syncope: New answers or just more questions? J Electrocardiol 2021;65:88-90.
27. Connolly SJ, Sheldon R, Roberts RS, Gent M. The North American Vasovagal Pacemaker Study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope. J Am Coll Cardiol 1999;33:16-20.
28. Sutton R, Brignole M, Menozzi C, Raviele A, Alboni P, Giani P, Moya A. Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope : pacemaker versus no therapy: a multicenter randomized study. The Vasovagal Syncope International Study (VASIS) Investigators. Circulation 2000;102:294-299.
29. Connolly SJ, Sheldon R, Thorpe KE, Roberts RS, Ellenbogen KA, Wilkoff BL, Morillo C, Gent M; VPS II Investigators. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial. JAMA 2003;289:2224-2229.
30. Raviele A, Giada F, Menozzi C, Speca G, Orazi S, Gasparini G, Sutton R, Brignole M; Vasovagal Syncope and Pacing Trial Investigators. A randomized, double-blind, placebo-controlled study of permanent cardiac pacing for the treatment of recurrent tilt-induced vasovagal syncope. The vasovagal syncope and pacing trial (SYNPACE). Eur Heart J 2004;25:1741-1748.
31. Baron-Esquivias G, Morillo CA, Moya-Mitjans A, Martinez-Alday J, Ruiz-Granell R, Lacunza-Ruiz J, Garcia-Civera R, Gutierrez-Carretero E, Romero-Garrido R. Dual-Chamber Pacing With Closed Loop Stimulation in Recurrent Reflex Vasovagal Syncope: The SPAIN Study. J Am Coll Cardiol 2017;70:1720-1728.
32. Brignole M, Russo V, Arabia F, Oliveira M, Pedrote A, Aerts A, Rapacciuolo A, Boveda S, Deharo JC, Maglia G, Nigro G, Giacopelli D, Gargaro A, Tomaino M; BioSync CLS trial Investigators. Cardiac pacing in severe recurrent reflex syncope and tilt-induced asystole. Eur Heart J 2021;42:508-516.
33. Podoleanu C, Maggi R, Brignole M, Croci F, Incze A, Solano A, Puggioni E, Carasca E. Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: a randomized single-blind controlled study. J Am Coll Cardiol 2006;48:1425-1432.
34. Ibegbuna V, Delis KT, Nicolaides AN, Aina O. Effect of elastic compression stockings on venous hemodynamics during walking. J Vasc Surg 2003;37:420-425.
35. Protheroe CL, Dikareva A, Menon C, Claydon VE. Are compression stockings an effective treatment for orthostatic presyncope? PLoS One 2011;6:e28193.
36. Tavolinejad H, Poopak A, Sadeghian S, Bozorgi A, Oraii A, Mollazadeh R, Emkanjoo Z, Kiarsi M, Shahabi J, Jalali A, Alaeddini F, Ariannejad H, Yadangi S, Oraii S, Kheirkhah J, Assadianrad M, Aminorroaya A, Tajdini M. Compression stockings for treating vasovagal syncope (COMFORTS-II) trial: Rationale and design of a triple-blind, multi-center, randomized controlled trial. Am Heart J 2022;249:57-65.
37. Vandenberk B, Lei LY, Ballantyne B, Vickers D, Liang Z, Sheldon RS, Chew DS, Aksu T, Raj SR, Morillo CA. Cardioneuroablation for vasovagal syncope: A systematic review and meta-analysis. Heart Rhythm 2022;19:1804-1812.
38. Sadeghian S, Aminorroaya A, Tajdini M. The Syncope Unit of Tehran Heart Center. Eur Heart J 2021;42:148-150.
39. Firouzbakht T, Shen ML, Groppelli A, Brignole M, Shen WK. Step-by-step guide to creating the best syncope units: From combined United States and European experiences. Auton Neurosci 2022;239:102950.
2. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, MartÃn A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG; ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018;39:1883-1948.
3. Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017;136:e25-e59.
4. Tajdini M, Khalaji A, Behnoush AH, Tavolinejad H, Jalali A, Sadeghian S, Vasheghani-Farahani A, Yadangi S, Masoudkabir F, Bozorgi A. Brain MRI and EEG overemployment in patients with vasovagal syncope: results from a tertiary syncope unit. BMC Cardiovasc Disord 2023;23:576.
5. Sun BC. Quality-of-life, health service use, and costs associated with syncope. Prog Cardiovasc Dis 2013;55:370-375.
6. van Dijk N, Sprangers MA, Boer KR, Colman N, Wieling W, Linzer M. Quality of life within one year following presentation after transient loss of consciousness. Am J Cardiol 2007;100:672-676.
7. Jorge JG, Raj SR, Teixeira PS, Teixeira JAC, Sheldon RS. Likelihood of injury due to vasovagal syncope: a systematic review and meta-analysis. Europace 2021;23:1092-1099.
8. Tajdini M, Tavolinejad H, Aminorroaya A, Aryan Z, Jalali A, Alaeddini F, Sadeghian S, Yadangi S, Vasheghani-Farahani A, Kalhor P, Bozorgi A. Clinical Associations of Injuries Caused by Vasovagal Syncope: A Cohort Study From a Tertiary Syncope Unit. J Am Heart Assoc 2023;12:e027272.
9. Sun BC, Emond JA, Camargo CA Jr. Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol 2005;95:668-671.
10. Farwell DJ, Sulke AN. Does the use of a syncope diagnostic protocol improve the investigation and management of syncope? Heart 2004;90:52-58.
11. Solbiati M, Casazza G, Dipaola F, Rusconi AM, Cernuschi G, Barbic F, Montano N, Sheldon RS, Furlan R, Costantino G. Syncope recurrence and mortality: a systematic review. Europace 2015;17:300-308.
12. Raj SR, Coffin ST. Medical therapy and physical maneuvers in the treatment of the vasovagal syncope and orthostatic hypotension. Prog Cardiovasc Dis 2013;55:425-433.
13. Sharma G, Ramakumar V, Sharique M, Bhatia R, Naik N, Mohanty S, Agarwal A, Meti M, Shukla A, Deepti S, Bansal R, Gupta A, Ahmed AS, Pandey RM, Narang R, Mishra S, Saxena A, Juneja R; LIVE-Yoga Investigators. Effect of Yoga on Clinical Outcomes and Quality of Life in Patients With Vasovagal Syncope (LIVE-Yoga). JACC Clin Electrophysiol 2022;8:141-149.
14. Aghajani F, Tavolinejad H, Sadeghian S, Bozorgi A, Jalali A, Vasheghani-Farahani A, Yadangi S, Niazi S, Poopak A, Tajdini M. Implementation of supervised physical training to reduce vasovagal syncope recurrence: A randomized controlled trial. J Cardiovasc Electrophysiol 2022;33:1863-1870.
15. Brignole M, Ammirati F, Arabia F, Quartieri F, Tomaino M, Ungar A, Lunati M, Russo V, Del Rosso A, Gaggioli G; Syncope Unit Project (SUP) Two Investigators. Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes. Eur Heart J 2015;36:1529-1535.
16. Behnoush AH, Yazdani K, Khalaji A, Tavolinejad H, Aminorroaya A, Jalali A, Tajdini M. Pharmacologic prevention of recurrent vasovagal syncope: A systematic review and network meta-analysis of randomized controlled trials. Heart Rhythm 2023;20:448-460.
17. Lei LY, Raj SR, Sheldon RS. Midodrine for the prevention of vasovagal syncope: a systematic review and meta-analysis. Europace 2022;24:1171-1178.
18. Ng J, Sheldon RS, Ritchie D, Raj V, Raj SR. Reduced quality of life and greater psychological distress in vasovagal syncope patients compared to healthy individuals. Pacing Clin Electrophysiol 2019;42:180-188.
19. Sheldon RS, Lei L, Guzman JC, Kus T, Ayala-Paredes FA, Angihan J, Safdar S, Maxey C, Bennett G, Raj SR. A proof of principle study of atomoxetine for the prevention of vasovagal syncope: the Prevention of Syncope Trial VI. Europace 2019;21:1733-1741.
20. Tajdini M, Aminorroaya A, Tavolinejad H, Tofighi S, Jalali A, Sadeghian S, Vasheghani-Farahani A, Yadangi S, Shahmansouri N, Akhondzadeh S, Bozorgi A. Atomoxetine as an adjunct to nonpharmacological treatments for preventing vasovagal attacks in patients with recurrent vasovagal syncope: A pilot randomized-controlled trial. Int J Cardiol Heart Vasc 2021;34:100789.
21. Sandhu RK, Raj SR, Hamzeh R, Sheldon RS; POST 7 Investigators. The Seventh Prevention of Syncope Trial (POST VII)-A randomized clinical trial of atomoxetine for the prevention of vasovagal syncope: Rationale and study design. Am Heart J 2023;262:49-54.
22. Sheldon R, Raj SR, Rose MS, Morillo CA, Krahn AD, Medina E, Talajic M, Kus T, Seifer CM, Lelonek M, Klingenheben T, Parkash R, Ritchie D, McRae M; POST 2 Investigators. Fludrocortisone for the Prevention of Vasovagal Syncope: A Randomized, Placebo-Controlled Trial. J Am Coll Cardiol 2016;68:1-9.
23. Olgar S, Omeroglu RE. Prolonged supine hypertension due to midodrine use in an orthostatic hypotensive child. Pediatr Cardiol 2007;28:309-310.
24. Shibao C, Raj SR, Gamboa A, Diedrich A, Choi L, Black BK, Robertson D, Biaggioni I. Norepinephrine transporter blockade with atomoxetine induces hypertension in patients with impaired autonomic function. Hypertension 2007;50:47-53.
25. Aminorroaya A, Tavolinejad H, Sadeghian S, Jalali A, Alaeddini F, Emkanjoo Z, Mollazadeh R, Bozorgi A, Oraii S, Kiarsi M, Shahabi J, Akbarzadeh MA, Rahimi B, Joharimoghadam A, Mohsenizade A, Mohammadi R, Oraii A, Ariannejad H, Apakuppakul S, Ngarmukos T, Tajdini M. Comparison of Outcomes with Midodrine and Fludrocortisone for Objective Recurrence in Treating Syncope (COMFORTS trial): Rationale and design for a multi-center randomized controlled trial. Am Heart J 2021;237:5-12.
26. Aksu T, Mandrola J, Raj SR. Permanent pacing for recurrent vasovagal syncope: New answers or just more questions? J Electrocardiol 2021;65:88-90.
27. Connolly SJ, Sheldon R, Roberts RS, Gent M. The North American Vasovagal Pacemaker Study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope. J Am Coll Cardiol 1999;33:16-20.
28. Sutton R, Brignole M, Menozzi C, Raviele A, Alboni P, Giani P, Moya A. Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope : pacemaker versus no therapy: a multicenter randomized study. The Vasovagal Syncope International Study (VASIS) Investigators. Circulation 2000;102:294-299.
29. Connolly SJ, Sheldon R, Thorpe KE, Roberts RS, Ellenbogen KA, Wilkoff BL, Morillo C, Gent M; VPS II Investigators. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial. JAMA 2003;289:2224-2229.
30. Raviele A, Giada F, Menozzi C, Speca G, Orazi S, Gasparini G, Sutton R, Brignole M; Vasovagal Syncope and Pacing Trial Investigators. A randomized, double-blind, placebo-controlled study of permanent cardiac pacing for the treatment of recurrent tilt-induced vasovagal syncope. The vasovagal syncope and pacing trial (SYNPACE). Eur Heart J 2004;25:1741-1748.
31. Baron-Esquivias G, Morillo CA, Moya-Mitjans A, Martinez-Alday J, Ruiz-Granell R, Lacunza-Ruiz J, Garcia-Civera R, Gutierrez-Carretero E, Romero-Garrido R. Dual-Chamber Pacing With Closed Loop Stimulation in Recurrent Reflex Vasovagal Syncope: The SPAIN Study. J Am Coll Cardiol 2017;70:1720-1728.
32. Brignole M, Russo V, Arabia F, Oliveira M, Pedrote A, Aerts A, Rapacciuolo A, Boveda S, Deharo JC, Maglia G, Nigro G, Giacopelli D, Gargaro A, Tomaino M; BioSync CLS trial Investigators. Cardiac pacing in severe recurrent reflex syncope and tilt-induced asystole. Eur Heart J 2021;42:508-516.
33. Podoleanu C, Maggi R, Brignole M, Croci F, Incze A, Solano A, Puggioni E, Carasca E. Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: a randomized single-blind controlled study. J Am Coll Cardiol 2006;48:1425-1432.
34. Ibegbuna V, Delis KT, Nicolaides AN, Aina O. Effect of elastic compression stockings on venous hemodynamics during walking. J Vasc Surg 2003;37:420-425.
35. Protheroe CL, Dikareva A, Menon C, Claydon VE. Are compression stockings an effective treatment for orthostatic presyncope? PLoS One 2011;6:e28193.
36. Tavolinejad H, Poopak A, Sadeghian S, Bozorgi A, Oraii A, Mollazadeh R, Emkanjoo Z, Kiarsi M, Shahabi J, Jalali A, Alaeddini F, Ariannejad H, Yadangi S, Oraii S, Kheirkhah J, Assadianrad M, Aminorroaya A, Tajdini M. Compression stockings for treating vasovagal syncope (COMFORTS-II) trial: Rationale and design of a triple-blind, multi-center, randomized controlled trial. Am Heart J 2022;249:57-65.
37. Vandenberk B, Lei LY, Ballantyne B, Vickers D, Liang Z, Sheldon RS, Chew DS, Aksu T, Raj SR, Morillo CA. Cardioneuroablation for vasovagal syncope: A systematic review and meta-analysis. Heart Rhythm 2022;19:1804-1812.
38. Sadeghian S, Aminorroaya A, Tajdini M. The Syncope Unit of Tehran Heart Center. Eur Heart J 2021;42:148-150.
39. Firouzbakht T, Shen ML, Groppelli A, Brignole M, Shen WK. Step-by-step guide to creating the best syncope units: From combined United States and European experiences. Auton Neurosci 2022;239:102950.
| Files | ||
| Issue | Vol 19 No 1 (2024): J Teh Univ Heart Ctr | |
| Section | Editorial | |
| DOI | https://doi.org/10.18502/jthc.v19i1.15529 | |
| Keywords | ||
| Vasovagal Syncope Diagnosis Syncope Therapeutics | ||
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How to Cite
1.
Tajdini M, Behnoush AH, Khalaji A, Raj S. Vasovagal Syncope: A Review of Current and Emerging Therapies for a Common Cardiology Condition. J Tehran Heart Cent. 2024;19(1):1-5.
