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

...vant Terms and DefinitionsaHaving trouble viewi...

Diagnosis

...iagnosis...

...igure 1. Syncope Initial...


...story and Physical ExaminationA detai...


...ographyIn the initial evaluation of...


...k Assessment...

...ion of the cause and assessment for the short- an...

...k stratification scores may be reasonable in th...


...le 2. Historical Characteristics Associated...


...ort- and Long-Term Risk FactorsaHaving...


...ood Testi...

...argeted blood tests are reasonable in the ev...

...of brain natriuretic peptide and high-se...

...e and comprehensive laboratory testin...

...TestingExercise stress testing can b...


...ardiac Monitori...

The choice of a specific cardiac m...

...cted ambulatory patients with syncope...

To evaluate selected ambulatory patients with sy...


...Hospital TelemetryContinuous ECG monitoring is us...


...2. Patient Disposition After Initial...


...ctrophysiological Study...

...ophysiological study (EPS) can be us...

EPS is not recommended for syncope evalu...


...Table Testing

...s is unclear after initial evaluation, tilt...

...sting can be useful for patients with syncope...


.... Examples of Serious Medical Conditions That Migh...


...EvaluationReferral for autonomic evalua...


...gical Diagnostics

...monitoring of an electroencephalogra...

...e head are not recommended in the routine evaluati...

Carotid artery imaging is not recommended in th...

...ing of an EEG is not recommended in the evalua...

...itional Evaluation and Diagnosis for...


Treatment

...reatment

...ardiaIn patients with syncope associated with...


...ntricular Tachycardia...

...h syncope and SVT, GDMT is recommended....

...n patients with AF, GDMT is recommend...


...entricular ArrhythmiaIn patients with s...


...schemic and Nonischemic Cardiomyopa...


...DiseaseIn patients with syncope associated with v...


Hypertrophic CardiomyopathyIn patients...


...genic Right Ventricular Cardiomyopath...

...implantation is recommended in patie...

...plantation is reasonable in patients with ARVC who...


Cardiac Sarco...

...implantation is recommended in patients wit...

...ts with cardiac sarcoidosis presenting with synco...

...implantation is reasonable in patients...

...is reasonable in patients with cardiac...


...ada ECG Pattern and Sy...

...ation is reasonable in patients with Brugad...

Invasive EPS may be considered in patients with Br...

...mplantation is not recommended in pati...


...peICD implantation may be considered...


...ong-QT syndr...

...locker therapy, in the absence of contra...

...is reasonable in patients with LQTS and suspe...

...sympathetic denervation (LCSD) is reasonable in p...


...ergic Polymorphic Ventricular Tachycardia...

...cise restriction is recommended in patients wit...

...rs lacking intrinsic sympathomimetic activi...

...de is reasonable in patients with CPVT who conti...

...apy is reasonable in patients with CPVT and a...

...CPVT who continue to experience syn...

...easonable in patients with CPVT, synco...


...cholaminergic Polymorphic Ventricular...

...e restriction is recommended in patients...

...ckers lacking intrinsic sympathomimetic acti...

...s reasonable in patients with CPVT w...

...is reasonable in patients with CPVT and a histor...

...patients with CPVT who continue to experience sync...

...CSD may be reasonable in patients with...


...epolarization Pattern...

...plantation may be considered in patien...

...ot be performed in patients with e...


...ovagal Syncope...

...ion on the diagnosis and prognosis of VVS is reco...

...sical counter-pressure maneuvers can be...

...e is reasonable in patients with recurrent VVS w...

...ness of orthostatic training is un...

...might be reasonable for patients...

Beta blockers might be reasonable in patients...

...eased salt and fluid intake may be reasonable...

...cted patients with VVS, it may be reasonabl...

...patients with recurrent VVS, a selective serotoni...


...VVSDual-chamber pacing might be rea...


...rotid Sinus Syndrome

...nt cardiac pacing is reasonable in patients...

...t may be reasonable to implant a dual-chamber pac...


...4. Vasvagal Syncope...


...eurogenic Orthostatic H...

...estion is recommended in patients...

...r-pressure maneuvers can be benefici...

...arments can be beneficial in patients with sy...

...be beneficial in patients with syncope due to n...

...a can be beneficial in patients with syncope...

...sone can be beneficial in patients with...

...ouraging increased salt and fluid intake may...

Pyridostigmine may be beneficial in pa...

...eotide may be beneficial in patients with...


...ation and Drug...

...tation via oral or intravenous bol...

...or withdrawing medications that may cause hypot...

In selected patients with syncope due t...


...dosyncope

...with suspected pseudosyncope, a candi...

...e behavioral therapy may be beneficial in...


...ediatric Sync...

...VS evaluation, including a detailed medica...

...ive diagnostic testing should be performed i...

...n symptom awareness of prodromes and reassura...

Tilt-table testing can be useful for pedi...

...atients with VVS not responding to lifes...

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

...he effectiveness of fludrocortisone is u...

...ing may be considered in pediatric patients wi...

...eta blockers are not beneficial in p...


...dult Congenital Heart Disea...

...ion of patients with adult congenital heart...

...s reasonable in patients with moderate or sev...


Figure 5. Orthostatic H...


...atric Patients...

...or the assessment and management of older adul...

...reasonable to consider syncope as a caus...

...SyncopeIt can be beneficial for h...


...hletes...

...ovascular assessment by a care provider experien...

...nt by a specialist with disease-sp...

...ended monitoring can be beneficial f...

...n competitive sports is not recommen...

...ce of Private Driving After an Episode of Synco...