Evaluation and Management of Patients With Syncope
Key Points
Key Points
- Studies of syncope report prevalence rates as high as 41%, with recurrent syncope occurring in 13.5%.
- Estimates may be inaccurate due to inconsistent data collection or improper diagnosis.
- The incidence follows a trimodal distribution in both sexes, with the first episode common around 20, 60, or 80 years of age and the third peak occurring 5 to 7 years earlier in males.
- Syncope has many causes and clinical presentations.
- Reflex syncope was most common (21%), followed by cardiac syncope (9%) and orthostatic hypotension (OH) (9%). The cause of syncope is unknown in 37%.
- In patients with New York Heart Association class III–IV heart failure (HF), syncope is present in 12% to 14% of patients.
- Predictors of recurrent syncope in older adults are aortic stenosis, impaired renal function, atrioventricular (AV) or left bundle-branch block, male sex, chronic obstructive pulmonary disorder, HF, atrial fibrillation (AF), advancing age, and orthostatic medications.
- Older institutionalized patients have a 7% annual incidence of syncope, a 23% overall prevalence, and a 30% 2-year recurrence rate.
- The incidence of syncope in older adults may overlap with falls, so it may be difficult to distinguish one from the other.
Table 1. Relevant Terms and Definitionsa
...levant Terms and DefinitionsaHaving trouble vie...
Diagnosis
...gnosis
...re 1. Syncope Initial Evaluation...
...ical ExaminationA detailed history and phys...
...ocardiographyIn the initial evaluation of pa...
...sk Assessment...
...f the cause and assessment for the short- and lo...
...f risk stratification scores may be reasona...
...cal Characteristics Associated With Increased Pro...
...Short- and Long-Term Risk FactorsaHaving troubl...
...lood Testing...
...argeted blood tests are reasonable in the evaluat...
...ness of brain natriuretic peptide and...
...comprehensive laboratory testing is not us...
...TestingExercise stress testing can be useful to es...
...rdiac Monito...
...hoice of a specific cardiac monitor should...
...lected ambulatory patients with syncope of...
...e selected ambulatory patients wit...
...n-Hospital TelemetryContinuous ECG monitoring is...
...Patient Disposition After Initial E...
...lectrophysiological Study
...iological study (EPS) can be useful fo...
...PS is not recommended for syncope eva...
...Table Testing
If the diagnosis is unclear after in...
...table testing can be useful for patients with sy...
...Examples of Serious Medical Conditions Th...
...EvaluationReferral for autonomic evaluation c...
Neurological Diagn...
...nitoring of an electroencephalogram (EEG) and h...
...e head are not recommended in the routi...
Carotid artery imaging is not recommende...
...rding of an EEG is not recommended in the eva...
...re 3. Additional Evaluation and Diagnosis for Syn...
Treatment
...eatmen...
...ardiaIn patients with syncope associa...
...upraventricular Tachycardia...
...h syncope and SVT, GDMT is recommended. (I, C-EO)5...
...ents with AF, GDMT is recommended. (I, C-EO)573...
...ular ArrhythmiaIn patients with syncope and...
...and Nonischemic CardiomyopathyIn pati...
...art DiseaseIn patients with syncope...
...ardiomyopathyIn patients with syncope as...
...genic Right Ventricular Cardiomyopathy...
...CD implantation is recommended in...
...is reasonable in patients with ARVC who pr...
...rdiac Sarcoidosis...
...ntation is recommended in patients with cardiac s...
...ts with cardiac sarcoidosis presenting with...
...ation is reasonable in patients with cardi...
...asonable in patients with cardiac sarcoidosis...
...CG Pattern and Syncope...
...n is reasonable in patients with Brugada ECG patt...
...vasive EPS may be considered in patients with B...
...plantation is not recommended in patients with Br...
...opeICD implantation may be considered in pat...
...-QT syndrome...
...ta-blocker therapy, in the absence of contraindica...
...is reasonable in patients with LQ...
...pathetic denervation (LCSD) is reasonable...
...gic Polymorphic Ventricular Tachycardia...
...estriction is recommended in patients with...
...rs lacking intrinsic sympathomimetic act...
...is reasonable in patients with CPVT...
...is reasonable in patients with CPVT and a history...
...th CPVT who continue to experience syn...
...y be reasonable in patients with CPVT, syncope,...
...laminergic Polymorphic Ventricular Tachyca...
...estriction is recommended in patie...
...lockers lacking intrinsic sympathomime...
...inide is reasonable in patients with CP...
...therapy is reasonable in patients with C...
...ts with CPVT who continue to experience syncop...
...onable in patients with CPVT, sync...
Early Repolarization Patte...
...antation may be considered in patients with E...
...hould not be performed in patients with...
...sovagal Syncope
...ion on the diagnosis and prognosis of VVS i...
...counter-pressure maneuvers can be useful in p...
...idodrine is reasonable in patients with recurr...
...usefulness of orthostatic training is uncertain...
...tisone might be reasonable for patients with r...
...kers might be reasonable in patients 42 years...
...increased salt and fluid intake may be...
...ents with VVS, it may be reasonable to reduce...
...n patients with recurrent VVS, a sele...
...ers in VVSDual-chamber pacing might be...
Carotid Sinus S...
...rmanent cardiac pacing is reasonable in pa...
It may be reasonable to implant a...
...e 4. Vasvagal Syncope...
...c Orthostatic Hypotension
...water ingestion is recommended in patient...
...er-pressure maneuvers can be beneficial in...
...ompression garments can be beneficial in...
...be beneficial in patients with syncop...
...a can be beneficial in patients with syncope due t...
...isone can be beneficial in patients with s...
...uraging increased salt and fluid intake...
...ne may be beneficial in patients wit...
...reotide may be beneficial in patients with sy...
...ehydration and...
...tation via oral or intravenous bolus is rec...
...ucing or withdrawing medications that may cause hy...
...ients with syncope due to dehydration, it is...
...eudosyncope...
...ts with suspected pseudosyncope, a candid discuss...
...ioral therapy may be beneficial in patient...
...tric Syncope...
...uation, including a detailed medical h...
...sive diagnostic testing should be per...
...ucation on symptom awareness of pro...
...esting can be useful for pediatric patients...
...ediatric patients with VVS not responding to lifes...
Encouraging increased salt and fluid intake may...
...iveness of fludrocortisone is uncertain in pedi...
...c pacing may be considered in pediatr...
...ckers are not beneficial in pediatric patien...
...Congenital Heart Disea...
...evaluation of patients with adult congenital...
...is reasonable in patients with mod...
...e 5. Orthostatic Hypotensio...
...iatric Patients
...e assessment and management of older adults...
It is reasonable to consider syncope as a ca...
...copeIt can be beneficial for healthcare...
...hletes...
Cardiovascular assessment by a care p...
...sessment by a specialist with disease-specific ex...
...onitoring can be beneficial for athletes with une...
...competitive sports is not recommended for ath...
...nce of Private Driving After an Episode...