Introduction

Vasovagal syncope (VVS) is a clinical consequence of abnormal interaction of increased vagal activity and vascular tonus. Typical manifestation of vasovagal syncope is loss of consciousness and syncope triggered by one of those mechanisms, bradycardia, hypotension, or mixed of them. Although the prodromal symptoms of dizziness, sweating and nausea may classically precede the syncope or fainting, signs and symptoms and also frequency of syncope may vary among patients. We presented an atypical presentation of a patient who differed from the typical scene of VVS with ECG indicating abnormally increased vagal activity accompanied with prolonged and persistent hypotension despite volume replacement. A 24-year-old male patient was admitted to emergency room with dizziness and pre-syncope. Arterial blood pressure was 90/60 mmHg and the heart rate was 78 beat per minute. Physical examination was normal except slight pallor skin. ECG revealed low atrial rhythm characterized with negative P-waves in precordial (V1-V6) and inferior leads (II, III, aVF) (Panel A). On echocardiographic examination, ventricular dimension and functions, and also valvular structures were normal. On the contrary of vasovagal syncope which generally improves and gains loss shortly after the fainting, patient’s hypotension and dizziness prolonged and continued for several hours despite the parenterally infusion of serum saline at 100 ml/hour. Improvement of patient’s hypotension and low atrial rhythm on ECG had been co-existingly provided after four of five hours (Panel B). Cardiac biomarkers, routine biochemistry tests, and complete blood count were normal. Patient was discharged and planned a tilt table test for further evaluation. One week after the index event, head-up tilt table test was planned. Vasodepressor type vasovagal syncope occurred in the test and the patient was advised and informed about the measures including diet with additional sodium chloride, avoidance of dehydration, and prolonged standing, and etc. to prevent the recurrence of similar signs and symptoms.