Evaluation and Management of Patients With Syncope

Publication Date: March 9, 2017


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.
Note: The numbering of the following tables and figures differs from that of the Clinical Practice Guideline.

Table 1. Relevant Terms and Definitionsa

...able 1. Relevant Terms and DefinitionsaH...

Diagnosis

...gnosis...

...igure 1. Syncope Initial...


...ry and Physical ExaminationA detail...


ElectrocardiographyIn the initial eval...


...Assessment...

...e cause and assessment for the short- and...

...stratification scores may be reasonable in...


...istorical Characteristics Associate...


...t- and Long-Term Risk FactorsaHaving trouble viewi...


...lood Testing

Targeted blood tests are reasonable in the eva...

...s of brain natriuretic peptide and...

...rehensive laboratory testing is not...

...TestingExercise stress testing can be useful...


...iac Monitoring...

...hoice of a specific cardiac monitor should...

...evaluate selected ambulatory patien...

...e selected ambulatory patients with synco...


...elemetryContinuous ECG monitoring is useful for h...


...igure 2. Patient Disposition After...


...ophysiological Study...

...ogical study (EPS) can be useful for evaluation...

...recommended for syncope evaluation in patients...


...able Testing...

...f the diagnosis is unclear after init...

...able testing can be useful for patients wi...


...ples of Serious Medical Conditions...


...ationReferral for autonomic evaluation c...


...urological Diagnostics

...aneous monitoring of an electroence...

...nd CT of the head are not recommended...

...artery imaging is not recommended in the routine...

...g of an EEG is not recommended in th...

Figure 3. Additional Evaluation an...


Treatment

...reatment

...atients with syncope associated with bradycardia...


Supraventricular Tachyc...

...s with syncope and SVT, GDMT is recommended. (I,...

...ients with AF, GDMT is recommended. (I, C-E...


...lar ArrhythmiaIn patients with syncope a...


...chemic and Nonischemic CardiomyopathyIn patie...


...lvular Heart DiseaseIn patients with...


...trophic CardiomyopathyIn patients with syncope as...


...c Right Ventricular Cardiomyopathy...

...mplantation is recommended in patients w...

...tion is reasonable in patients with AR...


...ardiac Sarcoidos...

ICD implantation is recommended in patients wit...

...h cardiac sarcoidosis presenting with s...

...lantation is reasonable in patients wit...

...S is reasonable in patients with cardi...


...gada ECG Pattern and Syncope...

ICD implantation is reasonable in pa...

...may be considered in patients with Brugada...

...implantation is not recommended in patients...


...opeICD implantation may be considered in...


Long-QT synd...

...-blocker therapy, in the absence of contraindica...

...ntation is reasonable in patients with LQTS...

...cardiac sympathetic denervation (LCSD)...


...gic Polymorphic Ventricular Tachycardia...

...riction is recommended in patients w...

...lockers lacking intrinsic sympathomimetic activity...

...e is reasonable in patients with CPVT who contin...

...is reasonable in patients with CP...

...ents with CPVT who continue to experience sy...

...y be reasonable in patients with CPVT,...


...olaminergic Polymorphic Ventricular Tach...

...ise restriction is recommended in pati...

...lockers lacking intrinsic sympathomimetic activit...

...inide is reasonable in patients with...

...therapy is reasonable in patients with...

...CPVT who continue to experience syncope o...

...easonable in patients with CPVT, sy...


...rly Repolarization...

...ion may be considered in patients with EPS and s...

...ould not be performed in patients with e...


...vagal Syncope

...nt education on the diagnosis and prognosis...

...al counter-pressure maneuvers can be useful in pa...

...idodrine is reasonable in patients with recurrent...

...s of orthostatic training is uncertain in...

...ortisone might be reasonable for pat...

...lockers might be reasonable in patients...

...g increased salt and fluid intake may be r...

...elected patients with VVS, it may be reasonable...

...with recurrent VVS, a selective serotonin...


...in VVSDual-chamber pacing might be reaso...


...id Sinus Syndro...

...rdiac pacing is reasonable in patients with ca...

It may be reasonable to implant a dual-chamber p...


...re 4. Vasvagal Synco...


...enic Orthostatic Hypotension...

...r ingestion is recommended in patients with sync...

...nter-pressure maneuvers can be beneficial...

...ments can be beneficial in patients with...

...e beneficial in patients with syncope due t...

...roxidopa can be beneficial in patients wi...

...rocortisone can be beneficial in patients w...

...ncreased salt and fluid intake may be r...

...yridostigmine may be beneficial in pati...

...y be beneficial in patients with sync...


...ydration and Dru...

...scitation via oral or intravenous bo...

...ithdrawing medications that may cause hypotensio...

...patients with syncope due to dehydration,...


...seudosyncop...

...ients with suspected pseudosyncope, a...

...ehavioral therapy may be beneficial in patients...


...tric Syncope...

...on, including a detailed medical history,...

...agnostic testing should be performed...

...on symptom awareness of prodromes and reass...

...ing can be useful for pediatric pati...

...pediatric patients with VVS not respon...

...ing increased salt and fluid intake may be reasona...

...ness of fludrocortisone is uncertain in pedi...

...ardiac pacing may be considered in...

...kers are not beneficial in pediatric patients wit...


Adult Congenital Heart Diseas...

...on of patients with adult congenital hea...

...le in patients with moderate or sever...


...re 5. Orthostatic Hypotensi...


...tric Patient...

...nt and management of older adults with...

...e to consider syncope as a cause o...

...ving and SyncopeIt can be beneficial for health...


Athlete...

...rdiovascular assessment by a care provider experie...

...essment by a specialist with disease-specif...

...nded monitoring can be beneficial for athle...

...ticipation in competitive sports is not recomm...

...ance of Private Driving After an Episode of Sy...