Fainting (Syncope)

I. Fainting also known as Syncope of "black out" is defined as a condition of sudden loss of consciousness followed by the return to full wakefulness in a short duration as a result of  abnormally low blood pressure. In most cases, it is caused by hypotension, with blood pressure that's lower than 90/60 mmHg.(1). Even though Low blood pressure has mainly been regarded as good health for people who exercise, but recent studies have indicated an association with depression in elderly people. there are epidemiological evidence for an association of low blood pressure with anxiety and depression, which is not caused by cardiovascular disease.(2). In some case, severely low blood pressure can seriously impair adequate blood flow to vital organs and a life-threatening condition called shock.

II. Symptoms
In the study of Medical Centre/University of Amsterdam, the research team of Wieling W found that Prior to loss of consciousness the affected individual tends to exhibit unclear thinking[1], followed by fixation of the eyes[2] in the midline and a 'frozen' appearance[3]. Narrowing of the field of vision with loss of colour vision[4] ('greying' out) and finally a complete loss of vision[5] (hence 'blacking' out) occurs. Hearing loss[6] may occur following loss of vision. This process may take as little as approximately 7 s in cases of sudden complete circulatory arrest[7] (e.g. abrupt asystole), but in other circumstances it may take longer depending on the rate and depth of cerebral hypoperfusion[8]. Complete loss of consciousness occurs with the 'turning up' of the eyeballs. Profound cerebral hypoperfusion may be accompanied by myoclonic jerks[9].(3)

III. Causes and risk factors
Causes of fainting may be a result of your heart rate and blood vessels can't react fast enough when your body's need for oxygen changes
1. History of any cardiovascular disease and and cardiac arrhythmias
 In  a study of consecutive patients evaluated for syncope from 1996 through 1998 at an academic medical center, we documented causes, clinical characteristics, and recurrence of syncope while driving. Of 3877 patients identified, 381 (9.8%) had syncope while driving (driving group). Compared with the 3496 patients (90.2%) who did not have syncope while driving, the driving group was younger (P=0.01) and had higher percentages of male patients (P<0.001) and patients with a history of any cardiovascular disease (P=0.01) and stroke (P=0.02). Syncope while driving was commonly caused by neurally mediated syncope (37.3%) and cardiac arrhythmias (11.8%). Long-term survival in the driving group was comparable to that of an age- and sex-matched cohort from the Minnesota population (P=0.15). Among the driving group, syncope recurred in 72 patients, 35 of whom (48.6%) had recurrence >6 months after the initial evaluation. Recurrences during driving happened in 10 patients in the driving group, 7 of which (70%) were >12 months after the initial evaluation.(4)

2. Low blood pressure 
researchers suggested that Syncope due to orthostatic hypotension (OH) refers to loss of consciousness caused by hypotension induced by the upright position; it is an important risk factor for fall-related physical injuries, especially in the elderly adults(5). Other report indicated that eventhough Low blood pressure has mainly been regarded as good health for people who exercise, but recent studies have indicated an association with depression in elderly people. there are epidemiological evidence for an association of low blood pressure with anxiety and depression, which is not caused by cardiovascular disease.

3.  Parkinson's disease and neurological comorbidity in olders
Low blood pressure is considered as a major cause of fainting of patient older than 65 years as a result of  Parkinson's disease and neurological comorbidity. (5)

4.  Medication
there is a report that in patients with AD treated with donepezil, a noninvasive evaluation identified a probable cause of syncope in over two-thirds of patients. Cardiovascular abnormalities were predominant. Noninvasive evaluation is recommended before discontinuing treatment with cholinesterase inhibitors in patients with AD and unexplained syncope.(6)

5. Hemodynamic ischemia 
There a report that a patient with convulsive syncope whose convulsive movements seemed to be associated with transient hemodynamic ischemia in the basal ganglia. In Single-photon emission computed tomography (SPECT, a significant decrease in blood flow was revealed in the anterior part of the left basal ganglia, bilateral frontal areas, and right cerebellar hemisphere. An alteration in the functional balance between the basal ganglia and the cerebral cortices may play a role in the generation of convulsive movements in patients with convulsive syncope.(7)

6. Vertebrobasilar disease
Vertebrobasilar disease is a broad classification describing the condition where there is an insufficient delivery of blood flow via the vertebral and/or basilar arteries to the brain.(8)

7. Vasovagal (situational) syncope
A vasovagal episode or vasovagal response or vasovagal attack (also called neurocardiogenic syncope) is a malaise mediated by the vagus nerve. When it leads to syncope or "fainting", it is called a vasovagal syncope, which is the most common type of fainting(9)

8. Deglutition syncope 
Deglutition suncope is defined as a  loss of consciousness on swallowing. There are report that a 49-year-old woman was referred to the ENT department with a 1.5-year history of dysphagia accompanied by globus sensation and regurgitation as well as recurrent syncopal attacks associated with swallowing solid foods(10) and a case of swallow syncope associated with cold beverage ingestion(11) and a woman who faints when she eats and drinks(12) may be as a result of an ambulatory electrocardiogram revealed atrial and ventricular asystoles immediately after swallowing (13)

9. Cardiac syncope
Structural cardiac abnormalities may cause syncope include cardiac obstructions, pulmonary hypertension, and myocardiopathy. Children with congenital heart disease who experienced syncope should always be referred to a specialist. Primary arrhythmias which are easily diagnosed on ECG are complete atrio-ventricular block and Wolff-Parkinson-White syndrome. "Channelopathies" such as the long OT syndrome and catecholaminergic ventricular tachycardia are increasingly recognized in children, carry a high risk of sudden death and deserve a complete work up, including familial screening and lifelong treatment with beta-blockers(14)

10. History of diaphoresis In the investigation of   whether the pattern of presyncopal prodromal symptoms can predict the recurrence probability of vasovagal syncope, fifty-four patients (68.4%) reported at least one of the four main prodromal symptoms. Median syncopal +/- presyncopal spells were 4 episodes. Forty-two patients (53.2%) experienced recurrence of syncope or presyncope during the follow-up period. In recurrent symptomatic patients, diaphoresis had been more significantly reported in their past medical history (p = 0.018) and they had more syncopal spells before TTT (p = 0.001). Age, gender and type of TTT response did not have any effect on the recurrence of VVS.(15)

11.  Prolonged exercise
Some researchers suggested that the magnitude of exercise-induced hypotension (post-exercise hypotension; PEH), and the hypotensive response to postural change (initial orthostatic hypotension; IOH) are predictors of syncope post-exercise, but research team from the University of Otago, found that endurance athletes who present with greater hypotension are not necessarily at a greater risk of syncope than those who present with lesser reductions in BP.(16)

12.  Chiari type I malformation (CMI)
Chiari type I malformation (CMI) is a congenital hindbrain anomaly characterized by downward displacement of the cerebellar tonsils through the foramen magnum. Chiari type I malformation often presents with a complex clinical picture and can be sporadic or linked to a variety of genetic conditions. (17)

13. Low blood sugar
In the study of Syncope and Hypoglycemia posted in International Journal of Clinical Medicine, 2011, 2, 129-132 doi:10.4236/ijcm.2011.22023 Published Online May 201, showed that hypoglycemic syncope should be sus-pected in older diabetic patients with preserved postural tone, usually but not always using insulin therapy, who show a slow recovery from transient loss of consciousness with persisting neurological impairment and low blood glucose levels.(18)

14. Dehydration 
Dehydration  is defined as a condition of  the excessive loss of body fluid. of which can lead to symptoms of decreased blood pressure (hypotension), and dizziness or fainting(19)

15. Family history
In the study conducted by Johns Hopkins Bloomberg School of Public Health, researchers showed that family history of fainting is not a risk factor for adult-onset NMH in fatigued veterans. Our findings may differ from other studies of familial aggregation in NMH because of study methods or because NMH-fatiguers may differ from NMH-fainters.(20)

16. Pregnancy
A 23-year-old woman at 34 weeks' gestation developed recurrent syncope due to profound sinus arrest captured on electrocardiography. Syncopal events occurred in the same sitting position. An echocardiogram revealed severe collapse of the inferior vena cava each time the patient changed her posture from a supine to a sitting position, which was related to the syncope.(21)

17. Etc.

IV. Diagnosis
In the Part 1 of two-part unit outlines. Dr. Meyer A. indicated that the various possible causes of transient loss of consciousness (blackouts), the importance of accurate diagnosis and the impact of misdiagnosis. It also discusses the establishment of specialist clinics in order to help with diagnosis and management.
(22) Other researchers suggested that Syncope is much more common than epilepsy and may present with symptoms akin to the latter. This fact is not well appreciated and often leads to misdiagnosis.(23)
A. Misdiagnosis
1. Seizure
Neurocardiogenic syncope (NCS) can be mistaken as a seizure. Scientists at the Capital Health Authority found that NCS is commonly misdiagnosed as epilepsy. Some patients had an incorrect diagnosis for > 10 years. Patients with this misdiagnosis are often excessively investigated, inappropriately treated, and have unnecessary restrictions placed on driving and employment(24)

2. Cardiac arrest
In the report of presents two patients, both known to have cardiac disease, with implanted cardiac devices, who presented with loss of consciousness, who were initially investigated for epilepsy, but were subsequently shown to have had a cardiac arrhythmia, diagnosed following device interrogation.(25)

3. Status cataplecticus 
A 76-year-old patient, since the age of 45, presented with frequent attacks often triggered by emotional stimuli and characterised by forward head drop and a fall to the ground without loss of consciousness. Status cataplecticus misdiagnosed as recurrent syncope(26)

4. Etc.

B. Diagnosis
1. According to the University of Wisconsin School of Medicine suggestion in Diagnosing syncope. Part 1, Dr. Linzer M,  and the team indicated that Despite the absence of a diagnostic gold standard and the paucity of data from randomized trials, several points emerge. First, history, physical examination, and electrocardiography are the core of the syncope workup (combined diagnostic yield, 50%). Second, neurologic testing is rarely helpful unless additional neurologic signs or symptoms are present (diagnostic yield of electroencephalography, computed tomography, and Doppler ultrasonography, 2% to 6%). Third, patients in whom heart disease is known or suspected or those with exertional syncope are at higher risk for adverse outcomes and should have cardiac testing, including echocardiography, stress testing. Holter monitoring, or intracardiac electrophysiologic studies, alone or in combination (diagnostic yields, 5% to 35%). Fourth, syncope in the elderly often results from polypharmacy and abnormal physiologic responses to daily events. Fifth, long-term loop electrocardiography (diagnostic yield, 25% to 35%) and tilt testing (diagnostic yield < or = 60%) are most useful in patients with recurrent syncope in whom heart disease is not suspected. Sixth, psychiatric evaluation can detect mental disorders associated with syncope in up to 25% of cases. Seventh, hospitalization may be indicated for patients at high risk for cardiac syncope (those with an abnormal electrocardiogram, organic heart disease, chest pain, history of arrhythmia, age > 70 years) or with acute neurologic signs and suggested that Many tests for syncope have a low diagnostic yield. A careful history, physical examination, and electrocardiography will provide a diagnosis or determine whether diagnostic testing is necessary in most patients.(27)

2. According to the University of Wisconsin School of Medicine suggestion in Diagnosing syncope. Part 2. Dr. Linzer M,  and the team indicated that after a thorough history, physical examination, and electrocardiography, the cause of syncope remains undiagnosed in 50% of patients. In such patients, information may be derived from the results of carefully selected diagnostic tests, especially 1) electrophysiologic studies in patients with organic heart disease, 2) Holter monitoring or telemetry in patients known to have or suspected of having heart disease, 3) loop monitoring in patients with frequent events and normal hearts, 4) psychiatric evaluation in patients with frequent events and no injury, and 5) tilt-table testing in patients who have infrequent events or in whom vasovagal syncope is suspected. Hospitalization is indicated for high-risk patients, especially those with known heart disease and elderly patients.(28)
 
V. Preventions

A. Do and do not list
1. Avoid fatigue
  It may be the result of the physiological mechanisms that regulate blood pressure and actually trigger neurally mediated hypotension, because of miscommunication between the heart and the brain which causes blood pressure to lower when it should rise.(29)

2. Anxiety, fear, pain, intense emotional stress, hunger, or use of alcohol or drug
Sometime, you may suffer a simple fainting spell as a result of anxiety, fear, pain, intense emotional stress, hunger, or use of alcohol or drugs. Most people who suffer from simple fainting have no underlying heart or neurological (nerve or brain) problem.(30)

3. Avoid changing positions quickly and standing for long periods of time, always getting up from a sitting or lying-down position slowly by preventing postural hypotension cause of fainting

4. Drink plenty of fluids
At least 8-10 glasses per day is necessary to enhance the blood volume.

5. Aerobic exercise
Aerobic exercise can also help prevent fainting, and strengthening the leg muscles can improve the circulation and helps avoid pooling of blood in the lower part of the body.

6. Sleep with the foot of your bed raised
The position will promote blood flow to the brain and allow the blood trapped in the legs to return to the heart.

7. Avoid Wearing elastic stockings 
As this may cause blood to be trapped in the leg of which reduce blood flow to the brain

8. Medication, such as diuretic, Vasodilators (hydralazine, nitrates, angiotensin-converting enzyme inhibitors may cause the drop of blood pressure excessively

9. Tight clothing around the neck can reduce blood flow to the brain

10. Avoid caffeine
Too much caffeine may cause an arrhythmia(31), a fast or irregular heartbeat of that can lead chest pain, fainting, dizziness, shortness of breath, etc.

11. Etc.
B. Diet against syncope 
1. Salmon
a. Cardiovascular disease
It contains high levels of Omega-3 Fatty Acids that helps to reduce the levels of bad cholesterol, thus reducing the risk of hardening of arteries and veins and damaging the functions of amino acids in repairing the cardiovascular tissues according to the study of "Fish oil for the treatment of cardiovascular disease" by Weitz D, Weintraub H, Fisher E, Schwartzbard AZ, posted in PubMed(32)

b. Antioxidants
In the research of the antioxidant effect of vitamin E after ingestion of salmon found that that megadoses of vitamin E, far from having pro-oxidative activity, actually increase the anti-oxidative capacity of the liver, especially after ingestion of salmon oil, according to "Effects of megadoses of dietary vitamin E on the antioxidant status of rats fed lard or salmon oil" by Flader D, Brandsch C, Hirche F, Eder K.(33) 


c. Omega 3 fatty acids
Omega 3 fatty acids is necessary to maintain the ratio of good and bad cholesterol, thus reducing the risk of cholesterol inflammation according to the study of "In vitro fatty acid enrichment of macrophages alters inflammatory response and net cholesterol accumulation" by Wang S, Wu D, Lamon-Fava S, Matthan NR, Honda KL, Lichtenstein AH., posted in PubMed (IV) and forming of free radical in the heart cells, leading to heart diseases. It also reduces the risk of plaque forming in the arterial wall, thus also decreasing the risk of stoke, according to the study of "N-3 vs. saturated fatty acids: effects on the arterial wall" by Sudheendran S, Chang CC, Deckelbaum RJ., posted in PubMed (34).

2. Flaxseed
a. Cardiovascular health
In the research of Flaxseed and its effect on cardiovascular risk found that flaxseed can modestly reduce serum total and low-density lipoprotein cholesterol concentrations, reduce postprandial glucose absorption, decrease some markers of inflammation, and raise serum levels of the omega-3 fatty acids, ALA and eicosapentaenoic acid. Data on the antiplatelet, antioxidant, and hypotensive effects of flaxseed, however, are inconclusive. More research is needed to define the role of this functional food in reducing cardiovascular risk, according to "Flaxseed and cardiovascular risk' by Bloedon LT, Szapary PO.(35)

b. Hypercholesterolemic atherosclerosis
In the evaluation of Flaxseed (Type I flaxseed) and CDC-flaxseed (Type II flaxseed) and theirs effect onhypercholesterolemic atherosclerosis found that Type II flaxseed reduced the development of atherosclerosis by 69%, according to "Reduction of hypercholesterolemic atherosclerosis by CDC-flaxseed with very low alpha-linolenic acid" by Prasad K, Mantha SV, Muir AD, Westcott ND.(36) 

c. Omega 3 fatty acids
Besides well known for its benefits for the maintenance of a healthy cardio-vascular system, according to the study of "Omega-3 Fatty acids for cardiovascular disease prevention" by Defilippis AP, Blaha MJ, Jacobson TA, posted in PubMed(37) and proper ratio of Omega 3 and 6 fatty acid and prevent blood clotting, it also extends the portion of your cycle in which you are fertile, by promoting natural ovulation, according tothe study of "Postpartum ovarian activity in multiparous Holstein cows treated with bovine somatotropin and fed n-3 fatty acids in early lactation" by Carriquiry M, Dahlen CR, Weber WJ, Lamb GC, Crooker BA., posted in pubMed (38)

3.  Garlic (39)
a, Garlic for VARICOSE VEINS. Garlic helps to keep your blood from clumping or becoming too sticky, helping your blood move through your blood vessels and reduces the risk of blood clots. One clove a day should do the trick. You can also take garlic capsules. CAUTION: Medication and Garlic could lead to uncontrolled bleeding and spell HEMORRHAGIC STROKES if it occurs in your brain. To avoid this, take caution against taking standardized garlic extract. Experts suggest eating no more than one clove of garlic a day.

b. Garlic For BLOOD FORTIFIER. Raw garlic is said to do a super job of blood fortifying. It also helps REJUVENATE the body. Eat raw garlic and garlic supplements daily.

c. Garlic For CHOLESTEROL: Eating 4 cloves of garlic a day can cut total CHOLESTEROL by 70%(Fresh or Supplement). The member of the allium family fights poor circulation.The sulfur compound in garlic keep your platelets from clumping together.

4. Black Beans
a. Nervous system
Protein is essential for the brain in transmitting information between themselves and cells in the other parts of the body, thus reducing the blood sugar levels from rising too rapidly after a meal, reducing the risk of nervous symptoms cause of anxiety, stress and depression, etc., according to the study of "The planar polarity protein Scribble1 is essential for neuronal plasticity and brain function" by Moreau MM, Piguel N, Papouin T, Koehl M, Durand CM, Rubio ME, Loll F, Richard EM, Mazzocco C, Racca C, Oliet SH, Abrous DN, Montcouquiol M, Sans N (40)


b. Antioxidant
Black bean contains flavoinoid, the powerful antioxidant (it contains more antioxidant than any bean in the same family with difference skin colors). It not only enhances the immune system in regulating cells in DNA replication and division, but also improves the immune system in fighting against the forming of free radical and protects our body from infection and inflammation. In a study of "Evaluation of Crocus sativus L. stigma phenolic and flavonoid compounds and its antioxidant activity" by Karimi E, Oskoueian E, Hendra R, Jaafar HZ., posted in Pubmed (41), researchers found that In summary, saffron stigmas showed antioxidant activity and methanol appeared to be the best solvent to extract the active components, among which the presence of gallic acid and pyrogallol might contribute towards the stigma's antioxidant properties.

c. Low-density lipoprotein
in the evaluation of fermentation on the contents of total phenolics and amino nitrogen pf balck bean and their lowering cholesterol effect found that the A. awamori-fermented black soybean prepared at 30 °C for 3 days exhibited the highest inhibitory effect on LDL oxidation. The bioactive principles related to the inhibitory effect on LDL oxidation in black soybeans, regardless of fermentation, could be most efficiently extracted with water rather than 80% methanol or 80% ethanol, according to "Fermentation with Aspergillus awamori enhanced contents of amino nitrogen and total phenolics as well as the low-density lipoprotein oxidation inhibitory activity of black soybeans" by Chen YF, Lee SL, Chou CC.(42)

5.  Broccoli
a. Potential heart health benefits
In the investigation of cruciferous vegetables which include broccoli, cabbage and cauliflower and theirs bioactive components in functional foods effect for the improvement of health found that the molecular basis of the biological activities of the chemicals present in broccoli potentially responsible for health promotion, from chemoprevention to cardio protection, are outlined based on in vitro and in vivo studies with a note on the structure activity relationship of sulforaphane and a few other isothiocyanates, according to "Potential health benefits of broccoli- a chemico-biological overview" by Vasanthi HR, Mukherjee S, Das DK.(43)

b. Free radicals 
Broccoli helps to fight against the forming of free radical by detoxificating and cleansing the toxins accumulated in the body, according to "Effect of broccoli (Brassica oleracea) and its phytochemical sulforaphane in balanced diets on the detoxification enzymes levels of tilapia (Oreochromis niloticus) exposed to a carcinogenic and mutagenic pollutant" by Villa-Cruz V, Davila J, Viana MT, Vazquez-Duhalt R.(44) 

6. Blueberries
a. Antioxidant Capacity
In the investigation of Blueberry and blackberry wines commercially available in Illinois and theirs potential health benefits, found that fruit wines made from blueberries and blackberries may have potential health applications and therefore could contribute to the economy of the wine industry. Practical Application: The majority of wines are produced from grapes, but wine can also be produced from other fruits including blueberries and blackberries, which contain phenolic compounds that may contribute to human health, according to "Comparison of Chemical Composition and Antioxidant Capacity of Commercially Available Blueberry and Blackberry Wines in Illinois" by Johnson MH, Gonzalez de Mejia E.(45)

b. Cardiovascular health
In the determination of polyphenols, especially anthocyanins, micronutrients, and fiber in berries, including to chokeberries, cranberries, blueberries, and strawberries found that purified anthocyanin extracts have demonstrated significant improvements in LDL oxidation, lipid peroxidation, total plasma antioxidant capacity, dyslipidemia, and glucose metabolism. Benefits were seen in healthy subjects and in those with existing metabolic risk factors. Underlying mechanisms for these beneficial effects are believed to include upregulation of endothelial nitric oxide synthase, decreased activities of carbohydrate digestive enzymes, decreased oxidative stress, and inhibition of inflammatory gene expression and foam cell formation. Though limited, these data support the recommendation of berries as an essential fruit group in a heart-healthy diet, according to " Berries: emerging impact on cardiovascular health" by Basu A, Rhone M, Lyons TJ.(46) 

8. Etc.

C. Nutritional supplement against syncope

1. Omega-3 fatty acids
a. Vascular smooth muscle tone
In the investigation of the comparative effects of omega-3, omega-6 and omega-9 fatty acids on vascular smooth muscle tone, showed that Docosahexaenoic acid (1-255 microM) and eicosapentaenoic acid (31-255 microM) inhibited phenylephrine-induced contractions, (8-63%) and (20-65%), respectively, which were not altered by indomethacin, NDGA, or by removal of the endothelium. Linoleic acid (18:2n6) and arachidonic acid (20:4n6) also induced significant relaxation. Therefore, fatty acid-induced relaxation of the rat aorta is specific to polyunsaturated fatty acids, 20:5n3, 22:6n3, 18:2n6 and 20:4n6, according to "Effects of omega-3, omega-6 and omega-9 fatty acids on vascular smooth muscle tone" by Engler MB.(47)

b. Systolic blood pressure, triglycerides and LDL cholesterol
In the ccomparison of the cardiovascular risk-reduction potential of three major polyunsaturated fatty acids in a double-blind study. showed that for the diet supplemented with EPA plus DHA compared with the linoleic acid diet systolic blood pressure fell 5.1 mm Hg (p = 0.01); plasma triglyceride and VLDL cholesterol fell by 39% (p = 0.001) and 49% (p = 0.01), respectively; and LDL cholesterol rose by 9% (p = 0.01). There were no significant changes with the diet supplemented with alpha-linolenic acid. The net effect on cardiovascular risk therefore is complex and the systolic blood pressure reduction was substantial, according to "n-3 fatty acids of marine origin lower systolic blood pressure and triglycerides but raise LDL cholesterol compared with n-3 and n-6 fatty acids from plants" by Kestin M, Clifton P, Belling GB, Nestel PJ.(48)

c. Cardiovascular effects
In the comparison of the effects of alpha-linolenic acid (ALA, C18:3n-3) to those of eicosapentaenoic acid (EPA, C20:5n-3) plus docosahexaenoic acid (DHA, C22:6n-3) on cardiovascular risk markers in healthy elderly subjects, found that Both n-3 fatty acid diets did not change concentrations of total-cholesterol, LDL-cholesterol, HDL-cholesterol, triacylglycerol and apoA-1 when compared with the oleic acid-rich diet. However, after the EPA/DHA-rich diet, LDL-cholesterol increased by 0.39 mmol/l (P = 0.0323, 95% CI (0.030, 0.780 mmol/l)) when compared with the ALA-rich diet. Intake of EPA/DHA also increased apoB concentrations by 14 mg/dl (P = 0.0031, 95% CI (4, 23 mg/dl)) and 12 mg/dl (P = 0.005, 95% CI (3, 21 mg/dl)) versus the oleic acid and ALA-rich diet, respectively. Except for an EPA/DHA-induced increase in tissue factor pathway inhibitor (TFPI) of 14.6% (P = 0.0184 versus ALA diet, 95% CI (1.5, 18.3%)), changes in markers of hemostasis and endothelial integrity did not reach statistical significance following consumption of the two n-3 fatty acid diets, according to "Effects of alpha-linolenic acid versus those of EPA/DHA on cardiovascular risk markers in healthy elderly subjects" by Goyens PL, Mensink RP.(49)

d. Cognitive effects
In the assessment of the cognitive effects of fish oil supplementation at college age, hypothesizing benefits on affect, executive control, inhibition, and verbal learning and memory. College-aged participants, indicated that the benefits of n-3 PUFA on RAVLT performance derived more from depreciated placebo performance than improved performance due to fish oil. The placebo gain on TMT performance likely derived from a learning effect. Together, these results present limited cognitive benefits of n-3 PUFA at college age; however, the treatment may have been subtherapeutic, with a larger sample needed to generalize these results, according to "Omega-3 polyunsaturated fatty acids and cognition in a college-aged population" by Karr JE, Grindstaff TR, Alexander JE.(50)

2. Antioxidant for heart health
2.1. Antioxidants and ischemia(51)
a. Nitric oxide (NO)
Nitric oxide (NO), one of the antioxidant and peroxynitrite can inhibit pathways of oxygen radical generation, and, in turn, oxidants can inhibit NO synthesis from NOS.

b. glutathione and vitamin E
Reduced form of glutathione may act as a first line of defense against oxidative stress during ischemia–reperfusion while vitamin E may act later on during severe oxidative stress by rendering resistance to the heart against the ischemic–reperfusion injury

c. 2-dithiole-3-thione (D3T)

Researcher found that in rat cardiac H9c2 cells, D3T and time-dependent induction of a number of cellular antioxidants and phase 2 enzymes, including catalase, reduced glutathione (GSH), GSH peroxidase, glutathione reductase (GR), GSH S-transferase (GST), and NADH:quinone oxidoreduc- tase-1 (NQO1) help to protect against H9c2 cell injury caused by various oxidants and simulated ischemia-reperfusion. D3T pretreatment also resulted in decreased intracellular accumulation of reactive oxygen in H9c2 cells after exposure to the oxidants as well as simulated ischemia-reperfusion.

d. Selenium
Deficeiency of of a co-enzyme selenium, which is required in maintaining the glutathione redox cycle, also promote more susceptible to oxidative injure.

e. Etc.

2.2. Antioxidants and Atherosclerosis(52)
a. Bioflavonoids or vitamin P
Discovered by Szent-Gyorgyi and his colleagues back in the 1930`s. In Laboratory tests, B
bioflavonoids help to reduce the fragility and “permeability” in capillaries and prevent the clotting up of arterial as a result of oxidation.

b. Vitamins C and E, beta-carotene
Recent research findings have suggested that antioxidants such as vitamin C, E and beta carotene play an important role in the prevention of atherosclerosis. Data from animal studies showed they are able to prevent oxidative modification of low density lipoproteins (LDL).

c. Alpha-tocopherol
Alpha-tocopherol, a antioxidant found abundant in vitamin E, helps to decrease lipid peroxidation and platelet aggregation, adhesion and inflammatory. Epidemiological studies suggest that low levels of antioxidants are associated with increased risk for cardiovascular disease.

d. Vitamin C and E
Studies showed in take of 500mg of vitamin C and 400 IU of vitamin E helps to retard the progression of coronary atherosclersis.

e. Chlorophyl
Antioxidant chorophyll in the green algae shows to inhibit the chemical cadmium of smoking, by preventing from oxidation that cause building up of plaque along the walls of arteries.

f. Etc.

3. Coenzyme Q10
 Lower CoQ10 is a risk factor to coronary artery disease and chronic heart failure (CHF) and mortality due to CHF suggest that low CoQ10 is another factor explaining the risk to cardiovascular disorder in depression.(53)

4. Acetyl-L-carnitine
a. Acetyl-L-carnitine prevented the marked cognitive decline otherwise observed in normal mice maintained on this challenge diet(54)

b. Many clinical trials have suggested Acetyl-L-carnitine (ALC) and propionyl-L-carnitine (PLC) as potential strategies in the management of peripheral arterial disease, heart and cerebral ischemia, and congestive heart failure(55)

5. Alpha-lipoic acid
Alpha-lipoic acid (LA) is highly effective in preventing the endotoxin-induced oxidative stress in the heart and in improving the glutathione redox system.(56)

6.  Allyl sulfides
a. Antioxidant against oxidation
According to the study of " Antioxidant Health Effects of Aged Garlic Extract" by Carmia Borek, posted in (Journal of Nutrition. 2001;131:1010S-1015S.)© 2001 The American Society for Nutritional Sciences, researcher found that AGE contains a wide range of antioxidants that can act in synergistic or additive fashion and protect cells against oxidative damage, thus helping to lower the risk of heart disease, stroke, cancer and Alzheimer’s disease and protect against toxic, tissue-damaging effects of ROS-producing radiation, including UV light, drugs used in therapy and chemicals in the environment and industry.(57)

b. Cholesterol, heart disease and stroke
In an article of "GARLICTHE BOUNTIFUL BULB" by Carmia Borek, Ph.D. posted in Life extension magazine, the author indicated that in the past 15 years, garlic supplementation studies have concentrated on the bulb's effects in reducing blood cholesterol and triglycerides (the form in which fat is transported in the blood). All studies did not agree with one another, given differences in the kind of garlic preparation, quality of standardization, doses and periods of treatment. But most findings showed that garlic slightly lowered blood cholesterol, LDL cholesterol and triglycerides with a consistent lowering of blood lipids seen in studies that used aged garlic extract as the supplement. For example, while a University of Oxford study showed that garlic powder, given to patients at 900 mg a day for six months, had no protective effects and did not lower cholesterol levels, a study at East Carolina University found that aged garlic extract given at 2.4-4.8 gm a day, for six months, lowered cholesterol by 5-7%, and reduced LDL, triglycerides and blood pressure in men with high cholesterol.(58)

c.  Blood circulation
In an article of "Onions, Garlic, and Scallions... Oh My!" By Dr. Leo Galland, M.D., and Jonathan Galland", posted in the Chritian Broacasting Network, the authors wrote that scientists believe the components in onions, garlic, and scallions called allyl sulfides and bioflavonoids are key to their powerful health benefits. For cardiovascular health, clinical experiments have shown regular consumption of garlic may help improve circulation and help decrease calcium deposits and the size of arterial plaque in coronary arteries. As for detoxification, one study found that eating fresh garlic and onions each day can help remove toxins from the body.(59)


7. Etc.

VI. Treatments
A. In conventional medicine perspective
1. Prehospital Care(60)
Acute care to someone faint must be taken to increase blood flow to the brain, such as with the legs raise, loosen all tight clothing, crossing the legs or squeezing the thighs together, etc. and call 911. The patient may require the below from the medical team.

a. Intravenous access

b. Oxygen administration
c. Advanced airway techniques
d. Glucose administration
e. Pharmacologic circulatory support
f. Pharmacologic or mechanical restraints
g. Defibrillation or temporary pacing
h. Etc


2. Medication
2.1. Beta blockers
a. Beta blockers or beta-adrenergic blocking agents, beta-adrenergic antagonists, beta-adrenoreceptor antagonists or beta antagonists are the most commonly used type of medication to prevent syncope, as a result of blunting of elevated catecholamine levels that precede vasovagal syncope. Dr. John R. Kapoor, MD, PhD at the Stanford University said "Notwithstanding the widespread use of beta-blockers in the past, some studies on chronic beta-blocker use have been less than encouraging and may suggest some benefit in older but not in younger patients, as mentioned in the recent article by Tan and Parry"(61). In other study group consisted of 62 patients (29 females, mean age 32.8+/-12.3 years and 33 males, mean age 35.9+/-18.2 years) with at least two syncopal episodes during the six months preceding positive tilt testing, propranolol administered intravenously prevents syncope during tilt testing in a significant proportion of patients. Both complete or partial efficacy of intravenous propranolol predict long-term efficacy of chronic beta blocker therapy in patients with vaso-vagal syncope.(62)

b. Side effects
Major cardiac effects caused by beta blockade include the precipitation or worsening of congestive heart failure, and significant negative chronotropy(62a) and severe and therapy-resistant rhinitis, sinusitis, and nasal polyp(62b)
and (62c)
* Nausea
* Diarrhea
* Bronchospasm
* Dyspnea
* Cold extremities
* Dizziness
* Hair loss
* Abnormal vision
* Insomnia
* Nightmares
* Sexual dysfunction
* Erectile dysfunction
* Etc.

2.2. Serotonin re-uptake inhibitor (SSRI)
a Antidepressants are commonly used in the treatment of depression, anxiety disorders, and some personality disorders. In the study to assess whether the well-tolerated serotonin re-uptake inhibitor paroxetine hydrochloride could prevent vasovagal syncope in young patients resistant to or intolerant of previous traditional therapies, Paroxetine significantly improved symptoms of young patients with recurrent vasovagal syncope unresponsive to or intolerant of traditional medications and was well tolerated by patients.(63). Other report indicated that the serotonin reuptake inhibitor sertraline hydrochloride can be effective in preventing recurrent neurocardiogenic syncope in selected patients unresponsive to or intolerant of other therapeutic modalities.(64)

b. Side effects (65)
Almost all SSRIs are known to cause one or more of these symptoms, including Sexual Dysfunction(66) and withdrawal syndrome(67), Suicide risk(68) and
* Nausea/vomiting
* Drowsiness or somnolence
* Headache (very common as a short-term side effect)
* Bruxism
*Tinnitus
* Extremely vivid or strange dreams
* Dizziness
* Fatigue
* Mydriasis (pupil dilation)
* Urinary retention
* Changes in appetite
* Insomnia
* Etc.
In rare case, SSRI antidepressants may cause cardiac effects, according to American Family Physician, 8/1/97 by Grace Brooke Huffman, but SSRIs are safe and do not have a high rate of cardiovascular adverse events. However, further study is needed to determine whether tricyclic antidepressants and SSRIs are equally efficacious in patients with cardiovascular disease.(69)


3. Surgical
Pacemaker implantation may be necessary for some patient because of either severity or do not respond to the medication to has been successful in decreasing the number of fainting episodes. Pacemaker implantation is a procedure to put a small battery-operated device into the chest to help the heart beating regularlyas it send out the regular electrical pulses. There is a report  on a patient with recurrent sleep syncope (with physical injury) in whom an asystolic pause was documented during one of her "sleep syncope" spells. Implantation of a dual chamber pacemaker (5-year follow-up) "cured" her of further syncope(70)

B. In herbal medicine perspective
1. Bilberry
a.  Antioxidants
Edible berries of bilberry contains high amounts of antioxidant of natural anthocyanin may be used to trigger genetic signaling in promoting human health and disease prevention, according to the study of "Berry anthocyanins as novel antioxidants in human health and disease prevention" by Zafra-Stone S, Yasmin T, Bagchi M, Chatterjee A, Vinson JA, Bagchi D., posted in PubMed(71)


b. Anti-angiogenic, antioxidant, and anti-carcinogenic properties
Anthocyanins, a natural compounds of pigmentation in bilberry is also considered as natural antioxidants have exerted the property of Anti-angiogenisis and genomic DNA repairment and protection in reducing the risk of cancers, according to the study of "Anti-angiogenic, antioxidant, and anti-carcinogenic properties of a novel anthocyanin-rich berry extract formula" by Bagchi D, Sen CK, Bagchi M, Atalay M., posted in PubMed(72)

c. Cardiotoxicity
Bilberry extract significantly inhibited DOX-provoked reduced glutathione depletion and accumulation of oxidized glutathione, malondialdehyde and protein carbonyls in cardiac tissues, according to the study of "Protective effect of bilberry (Vaccinium myrtillus) against doxorubicin-induced oxidative cardiotoxicity in rats" by Ashour OM, Elberry AA, Alahdal A, Al Mohamadi AM, Nagy AA, Abdel-Naim AB, Abdel-Sattar EA, Mohamadin AM., posted in PubMed(73)

d. Cholesterol
Oxidative modifications of low density lipoproteins (LDL) can be result of thickening of artery wall as a result of the accumulation of fatty, affecting arterial blood vessels. Vaccinium myrtillus contains high amount of antioxidants which help to block the oxidation of low density lipoproteins (LDL), according to the study of "Antioxidant action of Vaccinium myrtillus extract on human low density lipoproteins in vitro: initial observations" by Laplaud PM, Lelubre A, Chapman MJ., posted in PubMed(74)

2. Ginkbo Biloba
a. Cardiovascular tissues
Ginkgo biloba extract (EGb) has shown the protection of the cardiovascular tissues against HgCl(2)-induced oxidative damage, according to the study of "Protective effects of Ginkgo biloba extract against mercury(II)-induced cardiovascular oxidative damage in rats" by Tunali-Akbay T, Sener G, Salvarli H, Sehirli O, Yarat A., posted in PubMed(75)

b. Hyperlipidemia
Ginkgo biloba leaves (EGB) has demonstrated the activities of limitation of the absorption of cholesterol, inactivation of HMGCoA and favorable regulation of profiles of essential polyunsaturated fatty acid (EFA), according to the study of "Application of GC/MS-based metabonomic profiling in studying the lipid-regulating effects of Ginkgo biloba extract on diet-induced hyperlipidemia in rats" by Zhang Q, Wang GJ, A JY, Wu D, Zhu LL, Ma B, Du Y., posted in PubMed(76)

3. Peppermint
a. Cholesterol effects
In the investigation the choleretic effect and molecular mechanisms of action of peppermint oil (PO), the main component of Danshu capsules (Sichuan Jishengtang Pharmaceutical Co., Ltd., Pengzhou, Sichuan Province, China), found that PO might play a role in upregulating CYP7A1 and FXR mRNA levels, suggesting that the molecular mechanisms are related to gene expression involved in bile acid synthesis, according to "Preliminary experimental research on the mechanism of liver bile secretion stimulated by peppermint oil" by Zong L, Qu Y, Luo DX, Zhu ZY, Zhang S, Su Z, Shan JC, Gao XP, Lu LG.(77)

b. Cardiovascular effects
In the assessment of Cardiovascular effects of intravenous (i. v.) treatment with the essential oil of Mentha x villosa (EOMV) in pentobarbitone-anaesthetised rats, found that The present study shows for the first time that i. v. treatment with EOMV in pentobarbitone-anaesthetised rats induces hypotensive and bradycardic effects, which appear mostly attributed to the actions of the major constituent of EOMV, PO. These cardiovascular effects appear to be independent since EOMV-induced bradycardia appears dependent upon the presence of an intact and functional sympathetic nerve drive to the heart, while EOMV-induced hypotension appears independent of the presence of an operational sympathetic nervous system. This suggests that hypotensive activity of EOMV may result from its vasodilatory effects directly upon vascular smooth muscle, according to "Cardiovascular effects of the essential oil of Mentha x villosa and its main constituent, piperitenone oxide, in normotensive anaesthetised rats: role of the autonomic nervous system" by
Lahlou S, Carneiro-Leão RF, Leal-Cardoso JH, Toscano CF.(78)

c. Antimicrobial and antioxidant activities
In the observation of the antimicrobial activity and free radical scavenging capacity (RSC) of essential oils from Mentha aquatica L., Mentha longifolia L., and Mentha piperita L., found that The M. piperita essential oil also exhibited the highest OH radical scavenging activity, reducing OH radical generation in the Fenton reaction by 24 % (pure oil). According to GC-MS and TLC (dot-blot techniques), the most powerful scavenging compounds were monoterpene ketones (menthone and isomenthone) in the essential oils of M. longifolia and M. piperita and 1,8-cineole in the oil of M. aquatica, according to "Antimicrobial and antioxidant activities of three Mentha species essential oils" by Mimica-Dukić N, Bozin B, Soković M, Mihajlović B, Matavulj M.(79)

4. Rosemary
Rosemary contains high amount of carnosic acid, a natural benzenediol diterpene which has found to reduce the risk of free radical cause of cancers, according to "Inhibitory effects of rosemary extracts, carnosic acid and rosmarinic acid on the growth of various human cancer cell lines" by Yesil-Celiktas O, Sevimli C, Bedir E, Vardar-Sukan F.(80)

5. Lavender
a. Antioxidants
In the observation of total phenolics and total flavonoids for the extracts of three medicinal plants including oregano (Origanum vulgare L.), lavender (Lavandula angustifolia) and lemon balm (Melissa officinalis) found that Origanum vulgare and Melissa officinalis extracts present the most effective antioxidant capacity in scavenging DPPH radicals, while Lavandula angustifolia is less active. High performance liquid chromatography-mass spectrometry analysis was used to identify the components of extracts. Major phenolic acids identified in the analysed species were ferulic, rosmarinic, p-coumaric and caffeic, while predominant flavonoids were quercetin, apigenin kaempherol, which were present as glucosides, according to "Antioxidant capacity and total phenolic contents of oregano (Origanum vulgare), lavender (Lavandula angustifolia) and lemon balm (Melissa officinalis) from Romania"by Spiridon I, Colceru S, Anghel N, Teaca CA, Bodirlau R, Armatu A. (81)

b. Antidepressant-like effect
In the classification of the antidepressant effects of essential oils of Anthemis nobilis (chamomile), Salvia sclarea (clary sage; clary), Rosmarinus officinalis (rosemary), and Lavandula angustifolia (lavender)found that clary oil could be developed as a therapeutic agent for patients with depression and that the antidepressant-like effect of clary oil is closely associated with modulation of the DAnergic pathway, according to "Antidepressant-like effect of Salvia sclarea is explained by modulation of dopamine activities in rats" by Seol GH, Shim HS, Kim PJ, Moon HK, Lee KH, Shim I, Suh SH, Min SS.(82)

c. Cognition and mood
In the evaluation of Aromas of rosemary and lavender essential oils and theirs effect on cognition and mood found that rosemary produced a significant enhancement of performance for overall quality of memory and secondary memory factors, but also produced an impairment of speed of memory compared to controls. With regard to mood, comparisons of the change in ratings from baseline to post-test revealed that following the completion of the cognitive assessment battery, both the control and lavender groups were significantly less alert than the rosemary condition; however, the control group was significantly less content than both rosemary and lavender conditions. These findings indicate that the olfactory properties of these essential oils can produce objective effects on cognitive performance, as well as subjective effects on mood, according to "Aromas of rosemary and lavender essential oils differentially affect cognition and mood in healthy adults" by Moss M, Cook J, Wesnes K, Duckett P.(83)

d.  'Subsyndromal' anxiety disorder
In the investigation of orally administered Lavandula oil preparation and its effect on'subsyndromal' anxiety disorder, found that Lavandula oil preparation had a significant beneficial influence on quality and duration of sleep and improved general mental and physical health without causing any unwanted sedative or other drug specific effects. Lavandula oil preparation silexan is both efficacious and safe for the relief of anxiety disorder not otherwise specified. It has a clinically meaningful anxiolytic effect and alleviates anxiety related disturbed sleep, according to "Silexan, an orally administered Lavandula oil preparation, is effective in the treatment of 'subsyndromal' anxiety disorder: a randomized, double-blind, placebo controlled trial"by Kasper S, Gastpar M, Müller WE, Volz HP,
Möller HJ, Dienel A, Schläfke S.(84)

6. Etc.


C. In  Chinese medicine perspective
Depending to differentiation, some traditional Chinese TCM practitioners classify fainting (Syncope) as a result of (85)
C.1. Deficiency of the Heart yang and Kidney yang
1. Symptoms
a. Shortness of breath
b. Dizziness, occasional fainting,
c. Fatigue and weakness,
d. Tinnitus
e. Pain in the loins,
f. Aversion to cold,
g. Cold limbs,
h. Restlessness and insomnia
i. Pale thick or dark red tongue,
j. Thready,
l. Slow and uneven pulse
m. Etc.

2. Herbal treatment 
Modified prescriptions of Decoction for Protecting Primordial qi and Decoction of Ephedra, Aconite and Asarum. Prepared aconite root (Fu Zi) 6-20g, Red ginseng (Hong Seng) 10-30g, astragalus root (Huang Qi) 30g, Siberian solomonseal rhizome (Huang Jin) 30g, Cinnamon twig(Gui Zhi) 10g, Ephedra (Ma Huang) 6-12g, Asarum herb (Xi Xin) 3g, Prepared liquorice (Zhi Gan Cao) 6-30g

C.2. Deficiency of both qi and yin
1. Symptoms
a. Shortness of breath
b. Vague pain in the precordial region,
c. Dizziness
d. Blurred vision
c. Palpitation
f. Insomnia
g. Amnesia (memory loss
h. Dry mouth
i. Pale or dark red tongue with thin and white fur,
j. Slow or thready pulse
k. Etc.

2. Herbal treatment
Prescription/Formula: Modified Decoction of Prepared Licorice Prepared licorice root (Zhi Gan Cao) 30g, Dangshen (Dang Shen) 30g, Astragalus root (Huang Qi) 30g, Siberian solomonseal rhizome (Huang Jin) 30g, Dried rehmannia root Sheng Di Huang) 20g, Ophiopogon root (Mai Dong) 15g, Sesame kernel (Ma Ren)12g, Cinnamon twig (Gui Zhi) 10g, Chinese-date (Da Zao)10 pieces, Schisandra fruit (Wu Wei Zi) 10g

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