Evaluation and Management of Patients With Syncope

Publication Date: March 9, 2017

Diagnosis

History and Physical Examination

A detailed history and physical examination should be performed in patients with syncope. (I, B-NR)
573

Electrocardiography

In the initial evaluation of patients with syncope, a resting 12-lead ECG is useful. (I, B-NR)
573

Risk Assessment

Evaluation of the cause and assessment for the short- and longterm morbidity and mortality risk of syncope are recommended (Table 3). (I, B-NR)
573
Use of risk stratification scores may be reasonable in the management of patients with syncope. (IIb, B-NR)
573

Blood Testing

Targeted blood tests are reasonable in the evaluation of selected patients with syncope identified on the basis of clinical assessment from history, physical examination, and ECG. (IIa, B-NR)
573
Usefulness of brain natriuretic peptide and high-sensitivity troponin measurement is uncertain in patients for whom a cardiac cause of syncope is suspected. (IIb, C-LD)
573
Routine and comprehensive laboratory testing is not useful in the evaluation of patients with syncope. (III - No Benefit, B-NR)
573

Stress Testing

Exercise stress testing can be useful to establish the cause of syncope in selected patients who experience syncope or presyncope during exertion. (IIa, C-LD)
573

Cardiac Monitoring

The choice of a specific cardiac monitor should be determined on the basis of the frequency and nature of syncope events. (I, C-EO)
573
To evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, the following external cardiac monitoring approaches can be useful:
  1. Holter monitor
  2. Transtelephonic monitor
  3. External loop recorder
  4. Patch recorder
  5. Mobile cardiac outpatient telemetry
(IIa, B-NR)
573
To evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, an implantable cardiac monitor (ICM) can be useful. (IIa, B-R)
573

In-Hospital Telemetry

Continuous ECG monitoring is useful for hospitalized patients admitted for syncope evaluation with suspected cardiac etiology. (I, B-NR)
573

Electrophysiological Study

Electrophysiological study (EPS) can be useful for evaluation of selected patients with syncope of suspected arrhythmic etiology. (IIa, B-NR)
573
EPS is not recommended for syncope evaluation in patients with a normal ECG and normal cardiac structure and function, unless an arrhythmic etiology is suspected. (III - No Benefit, B-NR)
573

Tilt-Table Testing

If the diagnosis is unclear after initial evaluation, tilt-table testing can be useful for patients with VVS. (IIa, B-R)
573
Tilt-table testing can be useful for patients with syncope and suspected delayed OH when initial evaluation is not diagnostic. (IIa, B-R)
573

Autonomic Evaluation

Referral for autonomic evaluation can be useful to improve diagnostic and prognostic accuracy in selected patients with syncope and known or suspected neurodegenerative disease. (IIa, C-LD)
573

Neurological Diagnostics

Simultaneous monitoring of an electroencephalogram (EEG) and hemodynamic parameters during tilt-table testing can be useful to distinguish among syncope, pseudosyncope, and epilepsy. (IIa, C-LD)
573
MRI and CT of the head are not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings or head injury that support further evaluation. (III - No Benefit, B-NR)
573
Carotid artery imaging is not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings that support further evaluation. (III - No Benefit, B-NR)
573
Routine recording of an EEG is not recommended in the evaluation of patients with syncope in the absence of specific neurological features suggestive of a seizure. (III - No Benefit, B-NR)
573

Treatment

Bradycardia

In patients with syncope associated with bradycardia, guideline-directed management and therapy (GDMT) is recommended. (I, C-EO)
573

Supraventricular Tachycardia

In patients with syncope and SVT, GDMT is recommended. (I, C-EO)
573
In patients with AF, GDMT is recommended. (I, C-EO)
573

Ventricular Arrhythmia

In patients with syncope and VA, GDMT is recommended. (I, C-EO)
573

Ischemic and Nonischemic Cardiomyopathy

In patients with syncope associated with ischemic and nonischemic cardiomyopathy, GDMT is recommended. (I, C-EO)
573

Valvular Heart Disease

In patients with syncope associated with valvular heart disease, GDMT is recommended. (I, C-EO)
573

Hypertrophic Cardiomyopathy

In patients with syncope associated with HCM, GDMT is recommended. (I, C-EO)
573

Arrhythmogenic Right Ventricular Cardiomyopathy

ICD implantation is recommended in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) who present with syncope and have a documented sustained VA. (I, B-NR)
573
ICD implantation is reasonable in patients with ARVC who present with syncope of suspected arrhythmic etiology. (IIa, B-NR)
573

Cardiac Sarcoidosis

ICD implantation is recommended in patients with cardiac sarcoidosis presenting with syncope and documented spontaneous sustained VA. (I, B-NR)
573
In patients with cardiac sarcoidosis presenting with syncope and conduction abnormalities, GDMT is recommended. (I, C-EO)
573
ICD implantation is reasonable in patients with cardiac sarcoidosis and syncope of suspected arrhythmic origin, particularly with LV dysfunction or pacing indication. (IIa, B-NR)
573
EPS is reasonable in patients with cardiac sarcoidosis and syncope of suspected arrhythmic etiology. (IIa, B-NR)
573

Brugada ECG Pattern and Syncope

ICD implantation is reasonable in patients with Brugada ECG pattern and syncope of suspected arrhythmic etiology. (IIa, B-NR)
573
Invasive EPS may be considered in patients with Brugada ECG pattern and syncope of suspected arrhythmic etiology. (IIb, B-NR)
573
ICD implantation is not recommended in patients with Brugada ECG pattern and reflex-mediated syncope in the absence of other risk factors. (III - No Benefit, B-NR)
573

Short-QT Syncope

ICD implantation may be considered in patients with short-QT pattern and syncope of suspected arrhythmic etiology. (IIb, C-EO)
573

Long-QT syndrome

Beta-blocker therapy, in the absence of contraindications, is indicated as a first-line therapy in patients with long-QT syndrome (LQTS) and suspected arrhythmic syncope. (I, B-NR)
573
ICD implantation is reasonable in patients with LQTS and suspected arrhythmic syncope who are on beta-blocker therapy or are intolerant to beta-blocker therapy. (IIa, B-NR)
573
Left cardiac sympathetic denervation (LCSD) is reasonable in patients with LQTS and recurrent syncope of suspected arrhythmic mechanism who are intolerant to beta-blocker therapy or for whom beta-blocker therapy has failed. (IIa, C-LD)
573

Catecholaminergic Polymorphic Ventricular Tachycardia

Exercise restriction is recommended in patients with catecholaminergic polymorphic ventricular tachycardia (CPVT) presenting with syncope of suspected arrhythmic etiology. (I, C-LD)
573
Beta blockers lacking intrinsic sympathomimetic activity are recommended in patients with CPVT and stress-induced syncope. (I, C-LD)
573
Flecainide is reasonable in patients with CPVT who continue to have syncope of suspected VA despite beta-blocker therapy. (IIa, C-LD)
573
ICD therapy is reasonable in patients with CPVT and a history of exercise- or stress-induced syncope despite use of optimal medical therapy or LCSD. (IIa, B-NR)
573
In patients with CPVT who continue to experience syncope or VA, verapamil with or without beta-blocker therapy may be considered. (IIb, C-LD)
573
LCSD may be reasonable in patients with CPVT, syncope, and symptomatic VA despite optimal medical therapy. (IIb, C-LD)
573

Catecholaminergic Polymorphic Ventricular Tachycardia

Exercise restriction is recommended in patients with catecholaminergic polymorphic ventricular tachycardia (CPVT) presenting with syncope of suspected arrhythmic etiology. (I, C-LD)
573
Beta blockers lacking intrinsic sympathomimetic activity are recommended in patients with CPVT and stress-induced syncope. (I, C-LD)
573
Flecainide is reasonable in patients with CPVT who continue to have syncope of suspected VA despite beta-blocker therapy. (IIa, C-LD)
573
ICD therapy is reasonable in patients with CPVT and a history of exercise- or stress-induced syncope despite use of optimal medical therapy or LCSD. (IIa, B-NR)
573
In patients with CPVT who continue to experience syncope or VA, verapamil with or without beta-blocker therapy may be considered. (IIb, C-LD)
573
LCSD may be reasonable in patients with CPVT, syncope, and symptomatic VA despite optimal medical therapy. (IIb, C-LD)
573

Early Repolarization Pattern

ICD implantation may be considered in patients with EPS and suspected arrhythmic syncope in the presence of a family history of early repolarization pattern with cardiac arrest. (IIb, C-EO)
573
EPS should not be performed in patients with early repolarization pattern and history of syncope in the absence of other indications. (III - Harm, B-NR)
573

Vasovagal Syncope

Patient education on the diagnosis and prognosis of VVS is recommended. (I, C-EO)
573
Physical counter-pressure maneuvers can be useful in patients with VVS who have a sufficiently long prodromal period. (IIa, B-R)
573
Midodrine is reasonable in patients with recurrent VVS with no history of hypertension, HF, or urinary retention. (IIa, B-R)
573
The usefulness of orthostatic training is uncertain in patients with frequent VVS. (IIb, B-R)
573
Fludrocortisone might be reasonable for patients with recurrent VVS and inadequate response to salt and fluid intake, unless contraindicated. (IIb, B-R)
573
Beta blockers might be reasonable in patients 42 years of age or older with recurrent VVS. (IIb, B-NR)
573
Encouraging increased salt and fluid intake may be reasonable in selected patients with VVS, unless contraindicated. (IIb, C-LD)
573
In selected patients with VVS, it may be reasonable to reduce or withdraw medications that cause hypotension when appropriate. (IIb, C-LD)
573
In patients with recurrent VVS, a selective serotonin reuptake inhibitor might be considered. (IIb, C-LD)
573

Pacemakers in VVS

Dual-chamber pacing might be reasonable in a select population of patients 40 years of age or older with recurrent VVS and prolonged spontaneous pauses. (IIb, B-R)
573

Carotid Sinus Syndrome

Permanent cardiac pacing is reasonable in patients with carotid sinus syndrome that is cardioinhibitory or mixed. (IIa, B-R)
573
It may be reasonable to implant a dual-chamber pacemaker in patients with carotid sinus syndrome who require permanent pacing. (IIb, B-R)
573

Neurogenic Orthostatic Hypotension

Acute water ingestion is recommended in patients with syncope caused by neurogenic OH for occasional, temporary relief. (I, B-R)
573
Physical counter-pressure maneuvers can be beneficial in patients with neurogenic OH with syncope. (IIa, C-LD)
573
Compression garments can be beneficial in patients with syncope and OH. (IIa, C-LD)
573
Midodrine can be beneficial in patients with syncope due to neurogenic OH. (IIa, B-R)
573
Droxidopa can be beneficial in patients with syncope due to neurogenic OH. (IIa, B-R)
573
Fludrocortisone can be beneficial in patients with syncope due to neurogenic OH. (IIa, C-LD)
573
Encouraging increased salt and fluid intake may be reasonable in selected patients with neurogenic OH. (IIb, C-LD)
573
Pyridostigmine may be beneficial in patients with syncope due to neurogenic OH who are refractory to other treatments. (IIb, C-LD)
573
Octreotide may be beneficial in patients with syncope and refractory recurrent postprandial or neurogenic OH. (IIb, C-LD)
573

Dehydration and Drugs

Fluid resuscitation via oral or intravenous bolus is recommended in patients with syncope due to acute dehydration. (I, C-LD)
573
Reducing or withdrawing medications that may cause hypotension can be beneficial in selected patients with syncope. (IIa, B-NR)
573
In selected patients with syncope due to dehydration, it is reasonable to encourage increased salt and fluid intake. (IIa, C-LD)
573

Pseudosyncope

In patients with suspected pseudosyncope, a candid discussion with the patient about the diagnosis may be reasonable. (IIb, C-LD)
573
Cognitive behavioral therapy may be beneficial in patients with pseudosyncope. (IIb, C-LD)
573

Pediatric Syncope

VVS evaluation, including a detailed medical history, physical examination, family history, and a 12-lead ECG, should be performed in all pediatric patients presenting with syncope. (I, C-LD)
573
Noninvasive diagnostic testing should be performed in pediatric patients presenting with syncope and suspected CHD, cardiomyopathy, or primary rhythm disorder. (I, C-LD)
573
Education on symptom awareness of prodromes and reassurance are indicated in pediatric patients with VVS. (I, C-EO)
573
Tilt-table testing can be useful for pediatric patients with suspected VVS when the diagnosis is unclear. (IIa, C-LD)
573
In pediatric patients with VVS not responding to lifestyle measures, it is reasonable to prescribe midodrine. (IIa, B-R)
573
Encouraging increased salt and fluid intake may be reasonable in selected pediatric patients with VVS. (IIb, B-R)
573
The effectiveness of fludrocortisone is uncertain in pediatric patients with OH associated with syncope. (IIb, C-LD)
573
Cardiac pacing may be considered in pediatric patients with severe neurally mediated syncope secondary to pallid breath-holding spells. (IIb, B-NR)
573
Beta blockers are not beneficial in pediatric patients with VVS. (III - No Benefit, B-R)
573

Adult Congenital Heart Disease

For evaluation of patients with adult congenital heart disease (ACHD) and syncope, referral to a specialist with expertise in ACHD can be beneficial. (IIa, C-EO)
573
EPS is reasonable in patients with moderate or severe ACHD and unexplained syncope. (IIa, B-NR)
573

Geriatric Patients

For the assessment and management of older adults with syncope, a comprehensive approach in collaboration with an expert in geriatric care can be beneficial. (IIa, C-EO)
573
It is reasonable to consider syncope as a cause of nonaccidental falls in older adults. (IIa, B-NR)
573

Driving and Syncope

It can be beneficial for healthcare providers managing patients with syncope to know the driving laws and restrictions in their regions and discuss implications with the patient. (IIa, C-EO)
573

Athletes

Cardiovascular assessment by a care provider experienced in treating athletes with syncope is recommended prior to resuming competitive sports. (I, C-EO)
573
Assessment by a specialist with disease-specific expertise is reasonable for athletes with syncope and high-risk markers. (IIa, C-LD)
573
Extended monitoring can be beneficial for athletes with unexplained exertional syncope after an initial cardiovascular evaluation. (IIa, C-LD)
573
Participation in competitive sports is not recommended for athletes with syncope and phenotype-positive HCM, CPVT, LQTS1, or ARVC before evaluation by a specialist. (III - Harm, B-NR)
573

Recommendation Grading

Disclaimer

Overview

Title

Evaluation and Management of Patients With Syncope

Authoring Organizations

Endorsing Organization

Publication Month/Year

March 9, 2017

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this ACC/AHA/HRS guideline is to provide contemporary, accessible, and succinct guidance on the management of adult and pediatric patients with suspected syncope.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Management

Diseases/Conditions (MeSH)

D013575 - Syncope, D019462 - Syncope, Vasovagal

Keywords

Syncope, consciousness, fainting

Source Citation

Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e25-e59. doi: 10.1161/CIR.0000000000000498. Epub 2017 Mar 9. Erratum in: Circulation. 2017 Oct 17;136(16):e269-e270. PMID: 28280232.

Methodology

Number of Source Documents
738
Literature Search Start Date
July 1, 2015
Literature Search End Date
October 31, 2015
Specialties Involved
Cardiology, Emergency Medicine, Geriatric Medicine, Neurology, Pediatrics, Sports Medicine, Electrophysiology, Pediatric Cardiology, Cardiology, Pediatrics
Percentage of Authors Reporting COI
100