Midodrine for Neurocardiogenic Syncope?

Question

has anyone else been treated for NCS with midodrine?
How long does it take for your body to get used to it?
I'm not having much success :( my dizziness / fainting spells aren't decreasing and the side effects of the drug are actually making me feel worse.

I have another tilt table test scheduled in 2 weeks, what happens if I test positive again? will they put me on a different medicine? I read pace makers are a possibility and that's kinda scary.

Answer 1

I think 'Loving Heart' may have misunderstood your question, as his advice is flat wrong (it may apply to ventricular tachycardia and hypertrophic cardiomyopathy, but definitely not to neurocardiogenic syncope). Furthermore, despite the fact that beta blockers have been prescribed for years for this problem, if there's one thing we know about it, it's that they do *not* work in the average patient.

If you've given midodrine a two week or so trial, and it's not helping or you have intolerable side effects, it's time to try something else. I *will* say that I'm not quite sure why you're scheduled to have another tilt - it's pretty clear that the response of that test to medication doesn't mean much of anything. Unfortunately, the medical therapy of NCS is unsatisfactory - there's a long list of things that *might* work, which generally means that none of them work particularly well. The best evidence is actually for SSRI's (a class of antidepressant) like Paxil (paroxetine), but fludrocortisone and anticholinergics have been tried as well. It's important to make sure you've done all the nonpharmacologic things - avoiding triggers like heat, dehydration, and standing for long periods of time as well as stopping any medicines or supplements that can contribute to the problem. Make sure you know the 'counterpressure maneuvers' that can stop a vasovagal event in its tracks for about 50% of people. Don't avoid salt - in fact, you might even want to add salt to your diet to stay well hydrated. Some people find that caffeine helps them a lot. Finally, although they're annoying, support stockings help some people a great deal (you have to get the kind that go up to the groin, though - the kind that stop at the knee do nothing).

If all of that fails, a pacemaker may indeed be beneficial - probably not *necessary* in the sense of saving your life (unless it prevents you from passing out while driving), but I've treated patients who had their lives dramatically improved after I put in a pacemaker. I know it sounds scary to have a piece of metal in your body, and yes, there are risks - but really, they're pretty small and it's not that big a surgery. And, in case you were wondering, if the only problem is NCS, nothing bad will happen if the pacemaker suddenly stops working or malfunctions (your heart won't stop or anything) - you'll just be back where you started.

Answer 2

Maybe they'll switch you to beta-blockers like metoprolol or atenolol. But they normally start you on those before they give you midodrine. Or they might start you on Fludrocortisone, which retains fluids by acting on your kidneys and increases blood volume, thus raising your blood pressure.

They would probably resort to a pacemaker only if you have a low heart rate and run out of solutions with medication. But I haven't heard of pacemaker treatment for this illness so I don't know the limitations for it.

Answer 3

Briefly answering your question:

Beta-blockers have proven efficacy for approximately 60% of individuals, and the remaining 40% of individuals in whom exercise stress testing does not demonstrate adequate control of arrhythmias with the highest tolerated dose of beta-blockers may benefit from an ICD.