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
...ble 1. Relevant Terms and Definitio...
Diagnosis
Diagno...
...yncope Initial Evaluation...
...d Physical ExaminationA detailed hi...
...aphyIn the initial evaluation of p...
...Assessment...
...the cause and assessment for the short- an...
...sk stratification scores may be reasonabl...
...torical Characteristics Associated W...
...ble 3. Short- and Long-Term Risk FactorsaHaving t...
...lood Test...
...d blood tests are reasonable in the evaluatio...
...rain natriuretic peptide and high-sensitiv...
...and comprehensive laboratory testing is n...
...tress TestingExercise stress testing can be us...
...rdiac Monitor...
...f a specific cardiac monitor should be det...
...te selected ambulatory patients with syncope...
...valuate selected ambulatory patients with sync...
...tal TelemetryContinuous ECG monitoring i...
...t Disposition After Initial Evaluation for Sy...
...trophysiological St...
Electrophysiological study (EPS) can b...
...not recommended for syncope evaluation in patie...
...ilt-Table Testin...
...e diagnosis is unclear after initial evaluation,...
...table testing can be useful for patien...
...ples of Serious Medical Conditions That Migh...
...ic EvaluationReferral for autonomic evaluat...
...eurological Diagn...
...nitoring of an electroencephalogram (...
...e head are not recommended in the routine ev...
...artery imaging is not recommended in the r...
...outine recording of an EEG is not recommended...
...itional Evaluation and Diagnosis for...
Treatment
...reatment
...iaIn patients with syncope associate...
...upraventricular Tac...
...syncope and SVT, GDMT is recommended. (I, C-EO)57...
...ith AF, GDMT is recommended. (I, C-EO)573...
...lar ArrhythmiaIn patients with sync...
...mic and Nonischemic CardiomyopathyIn p...
...lvular Heart DiseaseIn patients with syncope assoc...
...hic CardiomyopathyIn patients with...
...hythmogenic Right Ventricular Cardiomyopathy...
...D implantation is recommended in patients with a...
...CD implantation is reasonable in patients...
...ac Sarcoidosi...
...D implantation is recommended in patients...
In patients with cardiac sarcoidosis pr...
...is reasonable in patients with cardia...
...s reasonable in patients with cardi...
...CG Pattern and Syncop...
...is reasonable in patients with Brugada ECG patte...
...y be considered in patients with Brugada ECG pa...
...implantation is not recommended in pat...
...ort-QT SyncopeICD implantation may...
...g-QT syndrom...
Beta-blocker therapy, in the absence of contrain...
...ntation is reasonable in patients with LQTS an...
...ac sympathetic denervation (LCSD)...
...holaminergic Polymorphic Ventricular Tach...
...tion is recommended in patients with cat...
...lockers lacking intrinsic sympathomimetic...
...is reasonable in patients with CPV...
...is reasonable in patients with CPVT and a...
...atients with CPVT who continue to experien...
...be reasonable in patients with CPVT, sync...
...c Polymorphic Ventricular Tachycardia...
...striction is recommended in patients with catechol...
...rs lacking intrinsic sympathomimetic...
...lecainide is reasonable in patients w...
...y is reasonable in patients with CPVT and a...
...atients with CPVT who continue to ex...
...reasonable in patients with CPVT, sync...
...Repolarization Patte...
...mplantation may be considered in pa...
...not be performed in patients with ear...
Vasovagal Syn...
...nt education on the diagnosis and prognosis o...
...sical counter-pressure maneuvers can be usef...
...ne is reasonable in patients with recurrent VVS wi...
...ness of orthostatic training is uncertain in pa...
...tisone might be reasonable for pati...
...ta blockers might be reasonable in patients 42 y...
...uraging increased salt and fluid intake may b...
...patients with VVS, it may be reasonabl...
...h recurrent VVS, a selective serotonin reuptake...
...SDual-chamber pacing might be reasonable...
...id Sinus Syndrome...
...nt cardiac pacing is reasonable in p...
It may be reasonable to implant a dual-chamber...
...re 4. Vasvagal Syncope...
Neurogenic Orthostatic Hypo...
Acute water ingestion is recommended in...
...-pressure maneuvers can be beneficia...
...garments can be beneficial in patient...
...rine can be beneficial in patients...
...can be beneficial in patients with sync...
...tisone can be beneficial in patients wi...
...ncouraging increased salt and fluid i...
...e may be beneficial in patients with syncope due t...
...ide may be beneficial in patients with synco...
...ation and Drugs
...resuscitation via oral or intravenous bolus is...
...ducing or withdrawing medications that ma...
...ted patients with syncope due to dehydration,...
...eudosynco...
...s with suspected pseudosyncope, a candi...
...avioral therapy may be beneficial in patien...
...iatric Syncope...
...aluation, including a detailed medi...
...ninvasive diagnostic testing should be perform...
...mptom awareness of prodromes and reassurance ar...
...testing can be useful for pediatric patien...
...c patients with VVS not responding to lifestyle me...
...creased salt and fluid intake may be rea...
...e effectiveness of fludrocortisone is uncert...
...ac pacing may be considered in pediatric patient...
...kers are not beneficial in pediatric patients...
...ongenital Heart Disease...
...uation of patients with adult congen...
...PS is reasonable in patients with mo...
...ure 5. Orthostatic Hypotensi...
...ric Patients
...he assessment and management of older...
...ble to consider syncope as a cause of nonaccidenta...
...and SyncopeIt can be beneficial for healthcar...
...thletes...
...ssessment by a care provider experienced in treati...
...sessment by a specialist with diseas...
...d monitoring can be beneficial for at...
...icipation in competitive sports is not...
...e 5. Avoidance of Private Driving Af...