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 Definitionsa...
Diagnosis
...Diagnosis...
...re 1. Syncope Initial Evalu...
...and Physical ExaminationA detailed...
...cardiographyIn the initial evaluat...
...Risk Assessment...
...of the cause and assessment for the short- and...
...k stratification scores may be reasonable in the m...
.... Historical Characteristics Associated With I...
...ble 3. Short- and Long-Term Risk Fa...
...Blood Testi...
...eted blood tests are reasonable in the e...
...ss of brain natriuretic peptide and high-se...
...and comprehensive laboratory testing is not...
...tingExercise stress testing can be useful...
...ice of a specific cardiac monitor should be de...
...ate selected ambulatory patients w...
...cted ambulatory patients with syncope of susp...
...emetryContinuous ECG monitoring is useful...
...2. Patient Disposition After Initial...
...Electr...
...ctrophysiological study (EPS) can be use...
...mended for syncope evaluation in pati...
...Tilt-Table Testing...
...he diagnosis is unclear after initial e...
...testing can be useful for patients with syncop...
Table 4. Examples of Serious Medical C...
...luationReferral for autonomic evaluation...
...Neurol...
...us monitoring of an electroencephalogram (EEG)...
...I and CT of the head are not recommended in the r...
...id artery imaging is not recommended i...
...outine recording of an EEG is not r...
...Additional Evaluation and Diagnosis fo...
Treatment
...Treatment...
...tients with syncope associated with bradycardi...
...Suprav...
...patients with syncope and SVT, GDMT is re...
...with AF, GDMT is recommended. (I, C...
...tricular ArrhythmiaIn patients with synco...
...hemic and Nonischemic CardiomyopathyIn patient...
...t DiseaseIn patients with syncope ass...
...rophic CardiomyopathyIn patients wi...
...Arrhythmog...
...ion is recommended in patients with a...
...CD implantation is reasonable in patients w...
...Cardiac S...
...on is recommended in patients with car...
...s with cardiac sarcoidosis presenting wi...
...plantation is reasonable in patient...
...le in patients with cardiac sarcoidosis and syncop...
...Brug...
...D implantation is reasonable in patients with Brug...
...be considered in patients with Brugada...
...ation is not recommended in patients with Br...
...peICD implantation may be considered...
...ta-blocker therapy, in the absence...
...mplantation is reasonable in patie...
...ympathetic denervation (LCSD) is reasonable in pat...
...Cat...
...iction is recommended in patients with catechol...
...s lacking intrinsic sympathomimetic...
...e is reasonable in patients with CPVT who continu...
...therapy is reasonable in patients with CPVT an...
...s with CPVT who continue to experienc...
...reasonable in patients with CPVT, sy...
...Ca...
...restriction is recommended in patients with catech...
...blockers lacking intrinsic sympathomi...
...cainide is reasonable in patients with C...
...erapy is reasonable in patients with CPVT and a h...
...tients with CPVT who continue to experience...
...ay be reasonable in patients with CPVT, sync...
...Early...
...n may be considered in patients wi...
...S should not be performed in patients w...
...Vasovagal Syncope...
...ent education on the diagnosis and prognosis of VV...
...l counter-pressure maneuvers can be useful in pa...
...drine is reasonable in patients with...
The usefulness of orthostatic training is uncerta...
...udrocortisone might be reasonable for p...
...eta blockers might be reasonable in p...
...ncreased salt and fluid intake may be reasonable...
...ted patients with VVS, it may be reasonable to...
...h recurrent VVS, a selective serotonin reupta...
...in VVSDual-chamber pacing might be r...
...Carotid...
...anent cardiac pacing is reasonable in...
...reasonable to implant a dual-chamb...
...gure 4. Vasvagal Synco...
...Neurog...
...gestion is recommended in patients with synco...
...-pressure maneuvers can be beneficial...
...ssion garments can be beneficial in patients wi...
Midodrine can be beneficial in patie...
Droxidopa can be beneficial in patients with syn...
...ludrocortisone can be beneficial in patients wi...
...g increased salt and fluid intake may be reasona...
...dostigmine may be beneficial in patients w...
...treotide may be beneficial in patients with synco...
...Dehydration a...
...d resuscitation via oral or intravenous...
...ing or withdrawing medications that may cause hy...
...cted patients with syncope due to dehyd...
...Pseudosyncope...
...tients with suspected pseudosyncope, a candid dis...
...behavioral therapy may be beneficial in...
...n, including a detailed medical history...
...diagnostic testing should be performed in ped...
...on symptom awareness of prodromes and rea...
...testing can be useful for pediatric patients w...
...ients with VVS not responding to lifestyle measur...
...aging increased salt and fluid inta...
The effectiveness of fludrocortisone...
...pacing may be considered in pediatric patient...
...re not beneficial in pediatric patients with...
...Adult C...
...f patients with adult congenital heart disease...
...le in patients with moderate or severe ACHD and un...
...gure 5. Orthostatic Hypotensi...
...Geriatric...
...or the assessment and management of...
It is reasonable to consider syncope as a cause o...
...yncopeIt can be beneficial for healt...
...ar assessment by a care provider experienced in tr...
...specialist with disease-specific exp...
...ed monitoring can be beneficial for athletes wi...
...in competitive sports is not recommen...
Table 5. Avoidance of Private Driving After an E...