Updated Recommendations

Document Overview

Design and created by Guideline Central in participation with the American Heart Association.

First Aid: Presyncope

American Heart Association

Publication Date: Nov 14, 2019

Page Last Updated: May 5, 2026

Class of Recommendations and Level of Evidence

Class (Strength) of Recommendation
CLASS I (STRONG)Benefit >>> Risk
Suggested phrases for writing recommendations: Is recommended Is indicated/useful/effective/beneficial Should be performed/administered/other Comparative-Effectiveness Phrases^†: Treatment/strategy A is recommended/indicated in preference to treatment B Treatment A should be chosen over treatment B
CLASS IIa (MODERATE) Benefit >> Risk
Suggested phrases for writing recommendations: Is reasonable Can be useful/effective/beneficial Comparative-Effectiveness Phrases^†: Treatment/strategy A is probably recommended/indicated in preference to treatment B It is reasonable to choose treatment A over treatment B
CLASS IIb (WEAK) Benefit ≥ Risk
Suggested phrases for writing recommendations: May/might be reasonable May/might be considered Usefulness/effectiveness is unknown/unclear/uncertain or not well established
CLASS III: No Benefit (MODERATE) (Generally, LOE A or B use only) Benefit = Risk
Suggested phrases for writing recommendations: Is not recommended Is not indicated/useful/effective/beneficial Should not be performed/administered/other
CLASS III: Harm (STRONG) Risk > Benefit
Suggested phrases for writing recommendations: Potentially harmful Causes harm Associated with excess morbidity/mortality Should not be performed/administered/other

Level (Quality) of Evidence^‡
LEVEL A
High-quality evidence^‡ from more than 1 RCT Meta-analyses of high-quality RCTs One or more RCTs corroborated by high-quality registry studies
LEVEL B-R (Randomized)
Moderate-quality evidence^‡ from 1 or more RCTs Meta-analyses of moderate-quality RCTs
LEVEL B-NR (Nonrandomized)
Moderate-quality evidence^‡ from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies Meta-analyses of such studies
LEVEL B
Limited populations evaluated Data derived from a single randomized trial or nonrandomized studies
LEVEL C-LD (Limited Data)
Randomized or nonrandomized observational or registry studies with limitations of design or execution Meta-analyses of such studies Physiological or mechanistic studies in human subjects
LEVEL C-EO (Expert Opinion)
Consensus of expert opinion based on clinical experience
LEVEL C
Very limited populations evaluated Only consensus opinion of experts, case studies, or standards of care

COR and LOE are determined independently (any COR may be paired with any LOE).

A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).
^† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
^‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.

COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; RCT, randomized controlled trial.

Document Overview

Document Title: First Aid: Presyncope

Authoring Society: American Heart Association

Document Publication Date: Nov 14, 2019

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: www.ahajournals.org/doi/10.1161/CIR.0000000000000730

Source Citation: 2019 American Heart Association and American Red Cross Focused Update for First Aid: Presyncope: An Update to the American Heart Association and American Red Cross Guidelines for First Aid
Nathan P. Charlton, MD, Co-Chair, Jeffrey L. Pellegrino, PhD, MPH, Co-Chair, Amy Kule, MD, Tammy M. Slater, DNP, MS, ACNP-BC, Jonathan L. Epstein, MEMS, NRP, Gustavo E. Flores, MD, Craig A. Goolsby, MD, MEd, Aaron M. Orkin, MD, MSc, MPH, Eunice M. Singletary, MD, Janel M. Swain, ACP

Document Scope, Criteria, and Use Cases

Document Objectives: This focused update highlights the evidence supporting specific interventions for presyncope of orthostatic or vasovagal origin and recommends the use of physical counterpressure maneuvers.

Scope: Treatment

Diseases/Conditions (MeSH)

D013575 - Syncope

Keywords: Syncope, neurocardiogenic syncope, presyncope

Inclusion Criteria: Male, Female, Adolescent, Adult, Child, Older Adult

Health Care Settings: Ambulatory, Childcare Center, Correctional Facility, Emergency Care, Hospital, Medical Transportation, School

Intended Users: Nurse, Nurse Practitioner, Paramedic/EMT, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Number of Source Documents: 29

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: No