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Haemodynamic effects of fludrocortisone and midodrine in patients with symptoms due to hypotension

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Abstract

Aim

The study aimed to assess the haemodynamic effects of fludrocortisone and midodrine, alone or combined, in patients with recurrent syncope and/or symptoms due to hypotension and ≥ 1 daytime systolic blood pressure (SBP) drop < 90 mmHg or ≥ 2 daytime SBP drops < 100 mmHg recorded by 24-h ambulatory blood pressure monitoring (ABPM1).

Method

A total of 53 patients (mean age, 40.9 ± 18.5 years, 37 female) were treated with fludrocortisone (0.05–0.2 mg per day) and/or midodrine (2.5–10 mg two or three times per day). A second ABPM (ABPM2) was performed within 6 months and the results of ABPM1 AND ABPM2 were compared to assess the effects of BP-rising drugs.

Results

In 32 patients assigned to fludrocortisone, 24-h SBP increased from 107.1 ± 9.9 mmHg to 116.3 ± 14.9 (p = 0.0001), the number of daily SBP drops < 90 mmHg decreased by 73% (p = 0.0001) and that of drops < 100 mmHg decreased by 41% (p = 0.0005). In 14 patients assigned to midodrine, 24-h SBP increased from 112.7 ± 7.4 mmHg to 115.0 ± 9.1 (p = 0.12), the number of daily SBP drops < 90 mmHg decreased by 52% (p = 0.04) and that of drops < 100 mmHg decreased by 34% (p = 0.007). In the seven patients taking both fludrocortisone and midodrine, 24-h SBP increased from 110.1 ± 11.5 mmHg to 114.0 ± 12.4 (p = 0.002), the number of daily SBP drops < 90 mmHg decreased by 69% (p = 0.22) and that of drops < 100 mmHg decreased by 44% (p = 0.04).

Conclusions

Both fludrocortisone and midodrine effectively increased 24-h SBP and reduced SBP drops on ABPM but fludrocortisone seemed to be more effective than midodrine. Further randomised studies are needed to confirm these observations.

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Fig. 1

Data availability

The data underlying this article are available in the article and in its online supplementary material.

References

  1. Brignole M, Rivasi G (2021) New insights in diagnostics and therapies in syncope: a novel approach to non-cardiac syncope. Heart 107(11):864–873. https://doi.org/10.1136/heartjnl-2020-318261

    Article  PubMed  CAS  Google Scholar 

  2. Duschek S, Schandry R (2007) Reduced brain perfusion and cognitive performance due to constitutional hypotension. Clin Auton Res 17(2):69–76. https://doi.org/10.1007/s10286-006-0379-7

    Article  PubMed  Google Scholar 

  3. Rivasi G, Groppelli A, Brignole M, Soranna D, Zambon A, Bilo G et al. (2022) Association between hypotension during 24 h ambulatory blood pressure monitoring and reflex syncope: the SynABPM 1 study. Eur Heart J 43(38):3765–3776. https://doi.org/10.1093/eurheartj/ehac347

    Article  PubMed  PubMed Central  Google Scholar 

  4. Sharad B, Rivasi G, Hamrefors V, Johansson M, Ungar A, Sutton R et al. (2023) Twenty-four-hour ambulatory blood pressure profile in patients with reflex syncope and matched controls. J Am Heart Assoc 12(8):e028704. https://doi.org/10.1161/JAHA.122.028704

    Article  PubMed  PubMed Central  Google Scholar 

  5. Groppelli A, Rivasi G, Fedorowski A, de Lange F, Russo V, Maggi R et al. (2024) Interventions aimed to increase average 24-hour systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance. Europace. https://doi.org/10.1093/europace/euae026

    Article  PubMed  PubMed Central  Google Scholar 

  6. Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A et al. (2018) 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 39(21):1883–1948. https://doi.org/10.1093/eurheartj/ehy037

    Article  PubMed  Google Scholar 

  7. Russo V, Parente E, Tomaino M, Comune A, Sabatini A, Laezza N et al. (2023) Short-duration head-up tilt test potentiated with sublingual nitroglycerin in suspected vasovagal syncope: the fast Italian protocol. Eur Heart J 44(27):2473–2479. https://doi.org/10.1093/eurheartj/ehad322

    Article  PubMed  CAS  Google Scholar 

  8. Sheldon R, Raj SR, Rose MS, Morillo CA, Krahn AD, Medina E et al. (2016) Fludrocortisone for the prevention of vasovagal syncope: a randomized. Placebo-Controlled Trial J Am Coll Cardiol 68(1):1–9. https://doi.org/10.1016/j.jacc.2016.04.030

    Article  PubMed  CAS  Google Scholar 

  9. Sheldon R, Faris P, Tang A, Ayala-Paredes F, Guzman J, Marquez M et al. (2021) Midodrine for the prevention of vasovagal syncope : a randomized clinical trial. Ann Intern Med 174(10):1349–1356. https://doi.org/10.7326/M20-5415

    Article  PubMed  Google Scholar 

  10. Lei LY, Raj SR, Sheldon RS (2022) Midodrine for the prevention of vasovagal syncope: a systematic review and meta-analysis. Europace 24(7):1171–1178. https://doi.org/10.1093/europace/euab323

    Article  PubMed  PubMed Central  Google Scholar 

  11. Sutton R, Brignole M (2014) Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis. Eur Heart J 35(33):2211–2212. https://doi.org/10.1093/eurheartj/ehu255

    Article  PubMed  Google Scholar 

  12. Veazie S, Peterson K, Ansari Y, Chung KA, Gibbons CH, Raj SR et al. (2021) Fludrocortisone for orthostatic hypotension. Cochrane Database Syst Rev 5(5):CD012868

    PubMed  Google Scholar 

  13. Ward CR, Gray JC, Gilroy JJ, Kenny RA (1998) Midodrine: a role in the management of neurocardiogenic syncope. Heart 79(1):45–49. https://doi.org/10.1136/hrt.79.1.45

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  14. Kaufmann H, Saadia D, Voustianiouk A (2002) Midodrine in neurally mediated syncope: a double-blind, randomized, crossover study. Ann Neurol 52(3):342–345. https://doi.org/10.1002/ana.10293

    Article  PubMed  CAS  Google Scholar 

  15. Behnoush AH, Yazdani K, Khalaji A, Tavolinejad H, Aminorroaya A, Jalali A et al. (2023) Pharmacologic prevention of recurrent vasovagal syncope: a systematic review and network meta-analysis of randomized controlled trials. Heart Rhythm 20(3):448–460. https://doi.org/10.1016/j.hrthm.2022.12.010

    Article  PubMed  Google Scholar 

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Acknowledgements

Research partially funded by the Italian Ministry of Health.

Funding

Agenzia Italiana del Farmaco, Ministero della Salute, NCT05729724, Michele Brignole.

Author information

Authors and Affiliations

  1. Amsterdam UMC, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands

    Frederik J. de Lange

  2. Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy

    Giulia Rivasi, Marco Capacci & Andrea Ungar

  3. Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149, Milano, Italy

    Antonella Groppelli & Michele Brignole

  4. Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Piazzale E. Ruggeri, 80126, Naples, Italy

    Vincenzo Russo & Angelo Comune

  5. Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy

    Roberto Maggi

  6. Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden

    Sara Nawaz & Artur Fedorowski

  7. Department of Cardiology, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy

    Gianfranco Parati

  8. Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy

    Gianfranco Parati

  9. Reinier de Graaf Gasthuis, Department of Cardiology, Cardiology and Syncope Unit, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands

    Steven van Zanten

  10. Department of Medicine, Karolinska Institute, Stockholm, Sweden

    Sara Nawaz & Artur Fedorowski

Authors
  1. Frederik J. de Lange
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  2. Steven van Zanten
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  3. Giulia Rivasi
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  4. Antonella Groppelli
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  5. Vincenzo Russo
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  6. Roberto Maggi
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  7. Marco Capacci
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  8. Sara Nawaz
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  9. Angelo Comune
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  10. Andrea Ungar
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  11. Gianfranco Parati
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  12. Michele Brignole
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  13. Artur Fedorowski
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Corresponding author

Correspondence to Artur Fedorowski.

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Conflict of interest

The authors declare no competing interests. Frederik J. de Lange, Giulia Rivasi, Antonella Groppelli, Vincenzo Russo, Roberto Maggi, Marco Capacci, Sara Nawaz, Gianfranco Parati, Michele Brignole and Artur Fedorowski this authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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de Lange, F.J., van Zanten, S., Rivasi, G. et al. Haemodynamic effects of fludrocortisone and midodrine in patients with symptoms due to hypotension. Clin Auton Res (2024). https://doi.org/10.1007/s10286-024-01096-3

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  • DOI: https://doi.org/10.1007/s10286-024-01096-3

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