1 , INTRODUCTION: Vasovagal syncope has been with humanity for countless millennia but has only been a target of active clinical research since the first seminal reports on tilt testing in the late 20th century. Investigators first focused on its optimal diagnostic strategies, impact on injury, quality of life, physiologic cascade, and biomedical treatments. Many of these approaches continue to be active and fruitful. We now understand the pivotal role of decreasing preload in triggering the vasovagal reflex, and the key role of bradycardia in causing terminal hypotension. Physical maneuvers, drugs, and pacemakers target these steps. Indeed current hotspots of investigations include ablating epicardial autonomic ganglia and implanting permanent pacemakers in otherwise healthy young and middle-aged people. There is a drive to increasingly aggressive treatments.
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