Table 1.

Management of Swallow Syncope

Identify and treat underlying causes—neurological, gastrointestinal, and cardiac conduction abnormalities.

Identify and advise avoiding specific triggers.

Modify swallow technique—advise smaller mouthfuls of food and chewing before swallowing.

If a vasovagal tendency is present, educate on conservative strategies to minimize this—increase fluid and salt intake (if the patient has low to low normal blood pressure).

Assess the risk of significant injury, including presence and duration of warning, frequency of symptoms, and resulting injuries.

Identify cardioinhibition, by assessing electrocardiograph/Holter or implantable loop recorder during provocation with typical triggering foods.

Even if cardioinhibition is confirmed, consider conservative strategies initially to avoid pacemaker insertion.

Pharmacotherapy may be trialed for symptom control—atropine before meal intake has been effective in case reports.

If recurrent symptoms occur despite conservative strategies, consider cardioneuroablation if the patient is young or if there is strong patient preference to avoid pacing.∗ Otherwise, consider pacemaker.

^∗Cardioneuroablation is not currently recommended by the syncope guidelines (1). However, the authors are of the opinion that in (particularly) young patients with debilitating symptoms, it should be explored.