Evaluation and Management of Patients With Syncope

Publication Date: March 9, 2017
Last Updated: December 16, 2022

Diagnosis

History and Physical Examination

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

In the initial evaluation of patients with syncope, a resting 12-lead ECG is useful. (I, B-NR)
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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)
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Use of risk stratification scores may be reasonable in the management of patients with syncope. (IIb, B-NR)
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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)
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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)
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Routine and comprehensive laboratory testing is not useful in the evaluation of patients with syncope. (III - No Benefit, B-NR)
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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)
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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)
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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)
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To evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, an implantable cardiac monitor (ICM) can be useful. (IIa, B-R)
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In-Hospital Telemetry

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

Electrophysiological study (EPS) can be useful for evaluation of selected patients with syncope of suspected arrhythmic etiology. (IIa, B-NR)
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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)
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Tilt-Table Testing

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

Bradycardia

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

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

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

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

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

In patients with syncope associated with HCM, GDMT is recommended. (I, C-EO)
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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)
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ICD implantation is reasonable in patients with ARVC who present with syncope of suspected arrhythmic etiology. (IIa, B-NR)
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Cardiac Sarcoidosis

ICD implantation is recommended in patients with cardiac sarcoidosis presenting with syncope and documented spontaneous sustained VA. (I, B-NR)
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In patients with cardiac sarcoidosis presenting with syncope and conduction abnormalities, GDMT is recommended. (I, C-EO)
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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)
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EPS is reasonable in patients with cardiac sarcoidosis and syncope of suspected arrhythmic etiology. (IIa, B-NR)
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Brugada ECG Pattern and Syncope

ICD implantation is reasonable in patients with Brugada ECG pattern and syncope of suspected arrhythmic etiology. (IIa, B-NR)
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Invasive EPS may be considered in patients with Brugada ECG pattern and syncope of suspected arrhythmic etiology. (IIb, B-NR)
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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)
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Short-QT Syncope

ICD implantation may be considered in patients with short-QT pattern and syncope of suspected arrhythmic etiology. (IIb, C-EO)
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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)
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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)
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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)
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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)
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Beta blockers lacking intrinsic sympathomimetic activity are recommended in patients with CPVT and stress-induced syncope. (I, C-LD)
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Flecainide is reasonable in patients with CPVT who continue to have syncope of suspected VA despite beta-blocker therapy. (IIa, C-LD)
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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)
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In patients with CPVT who continue to experience syncope or VA, verapamil with or without beta-blocker therapy may be considered. (IIb, C-LD)
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LCSD may be reasonable in patients with CPVT, syncope, and symptomatic VA despite optimal medical therapy. (IIb, C-LD)
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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)
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Beta blockers lacking intrinsic sympathomimetic activity are recommended in patients with CPVT and stress-induced syncope. (I, C-LD)
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Flecainide is reasonable in patients with CPVT who continue to have syncope of suspected VA despite beta-blocker therapy. (IIa, C-LD)
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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)
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In patients with CPVT who continue to experience syncope or VA, verapamil with or without beta-blocker therapy may be considered. (IIb, C-LD)
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LCSD may be reasonable in patients with CPVT, syncope, and symptomatic VA despite optimal medical therapy. (IIb, C-LD)
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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)
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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)
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Vasovagal Syncope

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

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

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

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

In patients with suspected pseudosyncope, a candid discussion with the patient about the diagnosis may be reasonable. (IIb, C-LD)
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Cognitive behavioral therapy may be beneficial in patients with pseudosyncope. (IIb, C-LD)
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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)
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Noninvasive diagnostic testing should be performed in pediatric patients presenting with syncope and suspected CHD, cardiomyopathy, or primary rhythm disorder. (I, C-LD)
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Education on symptom awareness of prodromes and reassurance are indicated in pediatric patients with VVS. (I, C-EO)
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Tilt-table testing can be useful for pediatric patients with suspected VVS when the diagnosis is unclear. (IIa, C-LD)
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In pediatric patients with VVS not responding to lifestyle measures, it is reasonable to prescribe midodrine. (IIa, B-R)
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Encouraging increased salt and fluid intake may be reasonable in selected pediatric patients with VVS. (IIb, B-R)
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The effectiveness of fludrocortisone is uncertain in pediatric patients with OH associated with syncope. (IIb, C-LD)
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Cardiac pacing may be considered in pediatric patients with severe neurally mediated syncope secondary to pallid breath-holding spells. (IIb, B-NR)
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Beta blockers are not beneficial in pediatric patients with VVS. (III - No Benefit, B-R)
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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)
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EPS is reasonable in patients with moderate or severe ACHD and unexplained syncope. (IIa, B-NR)
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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)
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It is reasonable to consider syncope as a cause of nonaccidental falls in older adults. (IIa, B-NR)
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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)
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Athletes

Cardiovascular assessment by a care provider experienced in treating athletes with syncope is recommended prior to resuming competitive sports. (I, C-EO)
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Assessment by a specialist with disease-specific expertise is reasonable for athletes with syncope and high-risk markers. (IIa, C-LD)
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Extended monitoring can be beneficial for athletes with unexplained exertional syncope after an initial cardiovascular evaluation. (IIa, C-LD)
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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)
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Recommendation Grading

Disclaimer

Overview

Title

Evaluation and Management of Patients With Syncope

Authoring Organizations

Endorsing Organization

Publication Month/Year

March 9, 2017

Last Updated Month/Year

November 3, 2022

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