Efficacy of fludrocortisone for symptom relief in patients with autonomic syncope and hypotensive phenotype

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ID: 338505
2026
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Abstract
AIM: To assess the efficacy of fludrocortisone therapy in patients with autonomic syncope and hypotensive phenotype. METHODS AND RESULTS: Multicentre, prospective, non-randomized study. Fludrocortisone therapy was guided by clinician experience and supported by two 24-hour ambulatory blood pressure monitoring (ABPM) assessments-one before treatment start (ABPM 1) and one after drug optimization (ABPM 2). Primary endpoint: reduction of the syncope burden and presyncopal symptoms based on validated semi structured questionnaires. Secondary endpoint: hypotensive episodes on ABPM. In a cohort of 94 patients treated with fludrocortisone (median age 38 [IQR 21-57]) years, 83% females), 16 patients stopped therapy due to side effects, occurring during optimization (#11) or follow-up (#5). A total of 83 patients were analysed. The average 24-hour systolic blood pressure (SBP) increased from 106.3 ± 8.2 mmHg at ABPM 1 to 112.3 ± 9.3 at ABPM 2 (p = 0.0001). The number of daytime SBP drops <90 mmHg and <100 mmHg decreased by 61%, and 45% respectively (p < 0.001 for both). The annual syncope burden was reduced by 50.2%, from 2.0 (IQR 1.0-4.0) before therapy to 0.0 (IQR 0.0-1.8) episodes during a median follow-up of 12.9 months (p = 0.0001). Subjective symptom improvement was reported by 85.6% of patients. The frequency of syncope/presyncope decreased significantly, p = 0.009. The outcome was similar in 42 younger (23 ± 6 yrs) and in 41 older (56 ± 12 yrs) patients. CONCLUSION: Fludrocortisone therapy was associated with reduced hypotension and the burden of symptoms both in younger and in older patients. Side effects lead to discontinuation of therapy in 17% of cases.
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Authors Rose Anne Kenny, Ciara P. Rice, Vincenzo Russo, Erika Parente, Frederik J. de Lange, Thomas T. Boel, Antonella Groppelli, Jean‐Claude Deharo, Baptiste Maille, Artur Fedorowski, Maria Juszczyk, Roberto Maggi, Jaume Francisco Pascual, Giulia Rivasi, Mattia Laffi, Michele Brignole
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Journal EP Europace
Year 2026
DOI
10.1093/europace/euag304
URL
https://doi.org/10.1093/europace/euag304
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