(1) syncope in paced patients with SSS has multiple etiologies and may be multifactorial; (2) the only predictor of syncope after pacemaker implant is the occurrence of preimplant syncope as the main indication for pacing; (3) extensive Holter monitoring is not useful to document bradycardiac origin of syncope nor to predict its recurrence; (4) SSS probably overlaps with other entities such as autonomic dysfunction, vasovagal syncope, carotid sinus hypersensitivity, and venous pooling, which would provide an explanation for recurrent syncope in patients with normal pacemaker function.

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Orthostatic hypotension in patients with supine hypertension may have multiple etiologies. Hemodynamic assessment with determination of cardiopulmonary volume and systemic vascular resistance differentiated between venous pooling and autonomic insufficiency in these patients; head-up tilt and plasma catecholamine levels did not. These findings may have important therapeutic implications.

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is a common clinical disorder that often escapes diagnosis; if the syncope is recurrent and severe (malignant vasovagal syncope), it can be a source of morbidity and possibly mortality. The authors report a 39-year-old patient with recurrent, unexplained syncope who underwent provocative head-up tilt testing that resulted in asystole for 73 seconds. In addition to vasovagal syncope, head-up tilt test also aids in the diagnosis and management of disorders of blood pressure and heart rate regulation. Management of recurrent vasovagal syncope is based upon the underlying pathophysiology and includes transdermal scopolamine, volume expansion, biofeedback, support stockings, and pacemakers (preferably AV sequential).

Because clinically significant complications can be detected with in-hospital monitoring in one of five patients starting sotalol therapy, hospital admission is warranted for initiation of sotalol. Patients without pacemakers are at higher risk for these complications.