The guidelines provide recommendations on how to prevent syncope and include the use for an implantable loop recorder in diagnosis of patients with unexplained falls, suspected epilepsy, or recurrent episodes of unexplained syncope and a low risk of sudden cardiac death (SCD). The new pathway avoids costly hospitalizations while ensuring the patient is properly diagnosed and treated. A new section has been added to the guidelines, as an addendum, with practical instructions for doctors on how to perform and interpret diagnostic tests. The Task Force that prepared the guidelines was truly multidisciplinary. A minority of cardiologists were joined by experts in emergency medicine, internal medicine and physiology, neurology and autonomic diseases, geriatric medicine, and nursing. Diagnosis: initial evaluation 1. At the initial evaluation answer the following four key questions: Was the event a transient loss of consciousness (TLOC)? In case of TLOC, is it of syncopal or non-syncopal origin? In case of suspected syncope, is there a clear aetiological diagnosis? Is there evidence to suggest a high risk of cardiovascular events or death? 2. At evaluation of TLOC in the emergency department (ED) answer the following three key questions: Is there a serious underlying cause that can be identified? If the cause is uncertain, what is the risk of a serious outcome? Should the patient be admitted to hospital? 3. Perform immediate ECG monitoring (in bed or telemetry) in high-risk patients when there is a suspicion of arrhythmic syncope. 4. Perform carotid sinus massage (CSM) in patients >40 years of age with syncope of unknown origin compatible with a reflex mechanism. 5. Perform tilt testing if there is suspicion of syncope due to reflex or an orthostatic cause. Diagnosis: subsequent investigations 6. Perform prolonged ECG monitoring (external or implantable) in patients with recurrent severe unexplained syncope who: have clinical or ECG features suggesting arrhythmic syncope; and have a high probability of recurrence of syncope in a reasonable time; and may benefit with a specific therapy if a cause for syncope is found. Perform electrophysiology studies (EPS) in patients with unexplained syncope and bifascicular BBB (impending high-degree AV block) or suspected tachycardia. Consider video recording (at home or in hospital) of TLOC suspected of non-syncopal nature. Treatment 7. To all patients with reflex syncope and orthostatic hypotension (OH), explain the diagnosis, reassure, explain the risk of recurrence, and give advice on how to avoid triggers and situations. These measures are the cornerstone of treatment and have a high impact in reducing the recurrence of syncope. In patients with OH, select one or more of the following additional specific treatments according to clinical severity: Education regarding lifestyle manoeuvres; Adequate hydration and salt intake; Discontinuation/reduction of hypotensive therapy; Counter-pressure manoeuvres; Abdominal binders and/or support stockings; Head-up tilt sleeping; Midodrine or fludrocortisone. 8. In patients with severe forms of reflex syncope, select one or more of the following additional specific treatments according to the clinical features: Midodrine or fludrocortisone in young patients with low BP phenotype; Counter-pressure manoeuvres (including tilt training if needed) in young patients with prodromes; Implantable loop recorder-guided management strategy in selected patients with or without short prodromes; Discontinue/reduction of hypotensive therapy targeting a systolic BP of 140 mmHg in old hypertensive patients; Pacemaker implantation in older patients with dominant cardioinhibitory forms. 9. Balance benefit and harm of an ICD implantation in patients with unexplained syncope at high risk of SCD [e.g. those affected by left ventricle systolic dysfunction, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, or inheritable arrhythmogenic disorders]. In this situation, unexplained syncope is defined as syncope that does not meet any Class I diagnostic criterion defined in the tables of recommendations of the 2018 ESC Guidelines on syncope and is considered a suspected arrhythmic syncope. 10. Ensure that all patients with cardiac syncope receive the specific therapy for the culprit arrhythmia and/or the underlying disease. Re-evaluate the diagnostic process and consider alternative therapies if the above rules fail or are not applicable to an individual patient. Bear in mind that guidelines are only advisory. Even though they are based on the best available scientific evidence, treatment should be tailored to an individual patient’s need. Conflict of interest: none declared. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: firstname.lastname@example.org. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Heart Journal – Oxford University Press
Published: May 31, 2018
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