Managing Fatigue in the Syncope Unit

Julia L. Newton


Europace. 2012;14(12):1696-1699. 

In This Article

Managing Fatigue

When seeing patients in the clinic who describe symptoms of fatigue, the first thing to consider is whether this is a primary or, a secondary phenomenon. In doing so, it is important to focus on ruling out and treating simple, potentially reversible secondary causes such as anaemia, hypothyroidism, coeliac disease, liver disease, or cancer. A good starting point to aid with this differential diagnosis are the National Institute for Health and Clinical Excellence (NICE) guidelines for the management of CFS as these provide a comprehensive summary of potential alternative causes for fatigue in patients.[30]

Frequently in the syncope unit we find that the medications that patients are taking may be contributing to their fatigue symptoms, particularly medications such as anti-histamines or sedatives, so reviewing and changing medications is an important step in the successful management of all patients with fatigue.

When you are seeing a fatigued patient in a syncope unit it is important not to immediately despair but to recognize that fatigue is a critical factor in quality of life, so, if you get it right you have a real opportunity to make a difference to the patient you are seeing. As a consequence, managing an individual's fatigue appropriately can be clinically extremely rewarding. It is also important to recognize that it is not nearly as daunting as it first appears in terms of management opportunities and that if you take a structured approach, teasing out the symptoms experienced by a patient and managing these symptoms, it can be an extremely positive clinical encounter.

The approach we generally take in the clinic is that of TRACE. We Treat the underlying cause, Ameliorate the effects of the fatigue, help the individual Cope with the effects that the fatigue has on their life, and perhaps most importantly, Empathize and understand. In terms of the first two of these—Treating the underlying cause and Ameliorating the effects of fatigue, it is important to remember that fatigue is almost always multi-factorial in origin, so reviewing all potential causes for fatigue and managing these will gain the most for that individual in terms of improvement in their symptoms. Where there is a secondary cause for fatigue such as hypothyroidism or anaemia it is important to adequately treat this, withdraw or rationalize any medications that could be aggravating the symptoms and optimally manage the syncopal symptoms. Our cross-sectional prevalence study suggested that where patients continued to experience syncope that fatigue levels were higher.[12] However, a longitudinal study is required with symptoms such as fatigue as a primary endpoint in order to determine whether some pharmacological and non-pharmacological interventions used routinely in our clinical practice for neurally medicated syncope and POTS are more effective than others.

The following take-home messages might help and our local management strategies for fatigue and POTS are outlined in Figures 1 and 2:

Figure 1.

Managing fatigue in the syncope unit.

Figure 2.

Managing positional orthostatic tachycardia syndrome.

  1. Fatigue is usually real in chronic disease so treat it as such.

  2. It is normally multi-factorial with different patients with the same symptom having different causes (and different responses to treatment).

  3. Treat the treatable, ameliorate the amelioratable but always support and understand (do not fail before you start).

  4. Take a structured approach.

  5. Quantification is key.