Sandbox: Syncope

2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope

Recommendation for History and Physical Examination

COR	LOE	RECOMMENDATION
I	B-NR	A detailed history and physical examination should be performed in patients with syncope.
I	B-NR	In the initial evaluation of patients with syncope, a resting 12-lead electrocardiogram (ECG) is useful.
I	B-NR	Evaluation of the cause and assessment for the short- and long-term morbidity and mortality risk of syncope are recommended.
IIb	B-NR	Use of risk stratification scores may be reasonable in the management of patients with syncope.
Recommendations for Disposition After Initial Evaluation
I	B-NR	Hospital evaluation and treatment are recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation.
IIa	C-LD	It is reasonable to manage patients with presumptive reflex-mediated syncope in the outpatient setting in the absence of serious medical conditions.
IIa	B-R	In intermediate-risk patients with an unclear cause of syncope, use of a structured ED observation protocol can be effective in reducing hospital admission.
IIb	C-LD	It may be reasonable to manage selected patients with suspected cardiac syncope in the outpatient setting in the absence of serious medical conditions.
Recommendations for Blood Testing
IIa	B-NR	Targeted blood tests are reasonable in the evaluation of selected patients with syncope identified on the basis of clinical assessment from history, physical examination, and ECG.
IIb	C-LD	Usefulness of brain natriuretic peptide and high-sensitivity troponin measurement is uncertain in patients for whom a cardiac cause of syncope is suspected.
III-No Benefit	B-NR	Targeted blood tests are reasonable in the evaluation of selected patients with syncope identified on the basis of clinical assessment from history, physical examination, and ECG.
Recommendations for Cardiac Imaging
IIa	B-NR	Transthoracic echocardiography can be useful in selected patients presenting with syncope if structural heart disease is suspected.
IIb	B-NR	Computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in selected patients presenting with syncope of suspected cardiac etiology.
III-No Benefit	B-NR	Routine cardiac imaging is not useful in the evaluation of patients with syncope unless cardiac etiology is suspected on the basis of an initial evaluation, including history, physical examination, or ECG.
Recommendation for Stress Testing
IIa	C-LD	Exercise stress testing can be useful to establish the cause of syncope in selected patients who experience syncope or presyncope during exertion.
Recommendations for Cardiac Monitoring
I	C-EO (N/A)	The choice of a specific cardiac monitor should be determined on the basis of the frequency and nature of syncope events.
IIa	B-NR	To evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, the following external cardiac monitoring approaches can be useful: 1. Holter monitor 2. Transtelephonic monitor 3. External loop recorder 4. Patch recorder 5. Mobile cardiac outpatient telemetry
IIa	B-R	To evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, an ICM can be useful.
Recommendation for In-Hospital Telemetry
I	B-NR	Continuous ECG monitoring is useful for hospitalized patients admitted for syncope evaluation with suspected cardiac etiology.
Recommendations for Electrophysiological Study (EPS)
IIa	B-NR	Continuous ECG monitoring is useful for hospitalized patients admitted for syncope evaluation with suspected cardiac etiology.
III-No Benefit	B-NR	EPS is not recommended for syncope evaluation in patients with a normal ECG and normal cardiac structure and function, unless an arrhythmic etiology is suspected.
Recommendations for Tilt-Table Testing
IIa	B-R	If the diagnosis is unclear after initial evaluation, tilt-table testing can be useful for patients with suspected VVS.
IIa	B-NR	Tilt-table testing can be useful for patients with syncope and suspected delayed OH when initial evaluation is not diagnostic.
IIa	B-NR	Tilt-table testing is reasonable to distinguish convulsive syncope from epilepsy in selected patients.
IIa	B-NR	Tilt-table testing is reasonable to establish a diagnosis of pseudo syncope.
III-No Benefit	B-R	Tilt-table testing is not recommended to predict a response to medical treatments for VVS.
Recommendation for Autonomic Evaluation
IIa	C-LD	Referral for autonomic evaluation can be useful to improve diagnostic and prognostic accuracy in selected patients with syncope and known or suspected neurodegenerative disease.
Recommendations for Neurological Diagnostics
IIa	C-LD	Simultaneous monitoring of an EEG and hemodynamic parameters during tilt-table testing can be useful to distinguish among syncope, pseudosyncope, and epilepsy.
III-No Benefit	B-NR	MRI and CT of the head are not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings or head injury that support further evaluation.
III-No Benefit	B-NR	Carotid artery imaging is not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings that support further evaluation.
III-No Benefit	B-NR	Routine recording of an EEG is not recommended in the evaluation of patients with syncope in the absence of specific neurological features suggestive of a seizure.
Recommendation for Bradycardia
I	C-EO (N/A)	In patients with syncope associated with bradycardia, GDMT is recommended.
Recommendations for Supraventricular Tachycardia (SVT)
I	C-EO (N/A)	In patients with syncope and SVT, GDMT is recommended.
I	C-EO (N/A)	In patients with AF, GDMT is recommended.
Recommendation for Ventricular Arrhythmia (VA)
I	C-EO (N/A)	In patients with syncope and VA, GDMT is recommended.
Recommendation for Ischemic and Nonischemic Cardiomyopathy
I	C-EO (N/A)	In patients with syncope associated with ischemic and nonischemic cardiomyopathy, GDMT is recommended.
Recommendation for Valvular Heart Disease
I	C-EO (N/A)	In patients with syncope associated with valvular heart disease, GDMT is recommended.
Recommendation for Hypertrophic Cardiomyopathy (HCM)
I	C-EO (N/A)	In patients with syncope associated with HCM, GDMT is recommended.
Recommendation for Arrhythmogenic Right Ventricular Cardiomyopathy
I	B-NR	ICD implantation is recommended in patients with ARVC who present with syncope and have a documented sustained VA.
IIa	B-NR	ICD implantation is reasonable in patients with ARVC who present with syncope of suspected arrhythmic ethology.
Recommendations for Cardiac Sarcoidosis
I	B-NR	ICD implantation is recommended in patients with cardiac sarcoidosis presenting with syncope and documented spontaneous sustained VA.
I	C-EO	In patients with cardiac sarcoidosis presenting with syncope and conduction abnormalities, GDMT is recommended.
IIa	B-NR	ICD implantation is reasonable in patients with cardiac sarcoidosis and syncope of suspected arrhythmic origin, particularly with LV dysfunction or pacing indication.
IIa	B-NR	EPS is reasonable in patients with cardiac sarcoidosis and syncope of suspected arrhythmic ethology.
Recommendations for Brugada ECG Pattern and Syncope
IIa	B-NR	ICD implantation is reasonable in patients with Brugada ECG pattern and syncope of suspected arrhythmic ethology.
IIb	B-NR	Invasive EPS may be considered in patients with Brugada ECG pattern and syncope of suspected arrhythmic ethology.
III-No Benefit	B-NR	ICD implantation is not recommended in patients with Brugada ECG pattern and reflex-mediated syncope in the absence of other risk factors.
Recommendation for Short-QT Syndrome
IIb	C-EO	ICD implantation may be considered in patients with short-QT pattern and syncope of suspected arrhythmic ethology.
Recommendation for Long-QT Syndrome
I	B-NR	Beta-blocker therapy, in the absence of contraindications, is indicated as a first-line therapy in patients with LQTS and suspected arrhythmic syncope.
IIa	B-NR	ICD implantation is reasonable in patients with LQTS and suspected arrhythmic syncope who are on beta-blocker therapy or are intolerant to beta-blocker therapy.
IIa	C-LD	Left cardiac sympathetic denervation (LCSD) is reasonable in patients with LQTS and recurrent syncope of suspected arrhythmic mechanism who are intolerant to beta-blocker therapy or for whom beta-blocker therapy has failed.
Recommendation for Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
I	C-LD	Exercise restriction is recommended in patients with CPVT presenting with syncope of suspected arrhythmic ethology.
I	C-LD	Beta blockers lacking intrinsic sympathomimetic activity are recommended in patients with CPVT and stress- induced syncope.
IIa	C-LD	Flecainide is reasonable in patients with CPVT who continue to have syncope of suspected VA despite beta-blocker therapy.
IIa	B-NR	ICD therapy is reasonable in patients with CPVT and a history of exercise- or stress-induced syncope despite use of optimal medical therapy or LCSD.
IIb	C-LD	In patients with CPVT who continue to experience syncope or VA, verapamil with or without beta-blocker therapy may be considered.
IIb	C-LD	LCSD may be reasonable in patients with CPVT, syncope, and symptomatic VA despite optimal medical therapy.
Recommendations for Early Repolarization Pattern
IIb	C-EO	ICD implantation may be considered in patients with early repolarization pattern and suspected arrhythmic syncope in the presence of a family history of early repolarization pattern with cardiac arrest.
III-Harm	B-NR	EPS should not be performed in patients with early repolarization pattern and history of syncope in the absence of other indications.
Recommendations for Vasovagal Syncope (VVS)
I	C-EO	Patient education on the diagnosis and prognosis of VVS is recommended.
IIa	B-R	Physical counter-pressure maneuvers can be useful in patients with VVS who have a sufficiently long prodromal period.
IIa	B-R	Midodrine is reasonable in patients with recurrent VVS with no history of hypertension, HF, or urinary retention.
IIb	B-R	The usefulness of orthostatic training is uncertain in patients with frequent VVS.
IIb	B-R	Fludrocortisone might be reasonable for patients with recurrent VVS and inadequate response to salt and fluid intake, unless contraindicated.
IIb	B-NR	Beta blockers might be reasonable in patients 42 years of age or older with recurrent VVS.
IIb	C-LD	Encouraging increased salt and fluid intake may be reasonable in selected patients with VVS, unless contraindicated.
IIb	C-LD	In selected patients with VVS, it may be reasonable to reduce or withdraw medications that cause hypotension when appropriate.
IIb	C-LD	In patients with recurrent VVS, a selective serotonin reuptake inhibitor might be considered.
Recommendation for Pacemakers in VVS
IIb	B-R	Dual-chamber pacing might be reasonable in a select population of patients 40 years of age or older with recurrent VVS and prolonged spontaneous pauses.
Recommendations for Carotid Sinus Syndrome
IIa	B-R	Permanent cardiac pacing is reasonable in patients with carotid sinus syndrome that is cardioinhibitory or mixed.
IIb	B-R	It may be reasonable to implant a dual- chamber pacemaker in patients with carotid sinus syndrome who require permanent pacing.
Recommendation for Neurogenic Orthostatic Hypotension (OH)
I	B-R	Acute water ingestion is recommended in patients with syncope caused by neurogenic OH for occasional, temporary relief.
IIa	C-LD	Physical counter-pressure maneuvers can be beneficial in patients with neurogenic OH with syncope.
IIa	C-LD	Compression garments can be beneficial in patients with syncope and OH.
IIa	B-R	Midodrine can be beneficial in patients with syncope due to neurogenic OH.
IIa	B-R	Droxidopa can be beneficial in patients with syncope due to neurogenic OH.
IIa	C-LD	Fludrocortisone can be beneficial in patients with syncope due to neurogenic OH.
IIb	C-LD	Encouraging increased salt and fluid intake may be reasonable in selected patients with neurogenic OH.
IIb	C-LD	Pyridostigmine may be beneficial in patients with syncope due to neurogenic OH who are refractory to other treatments.
IIb	C-LD	Octreotide may be beneficial in patients with syncope and refractory recurrent postprandial or neurogenic OH.
Recommendations for Dehydration and Drugs
I	C-LD	Fluid resuscitation via oral or intravenous bolus is recommended in patients with syncope due to acute dehydration.
IIa	B-NR	Reducing or withdrawing medications that may cause hypotension can be beneficial in selected patients with syncope.
IIa	C-LD	In selected patients with syncope due to dehydration, it is reasonable to encourage increased salt and fluid intake.
Recommendations for he Treatment of Pseudosyncope
IIb	C-LD	In patients with suspected pseudosyncope, a candid discussion with the patient about the diagnosis may be reasonable.
IIb	C-LD	Cognitive behavioral therapy may be beneficial in patients with pseudo syncope.
Recommendations for Pediatric Syncope
I	C-LD	VVS evaluation, including a detailed medical history, physical examination, family history, and a 12-lead ECG, should be performed in all pediatric patients presenting with syncope.
I	C-LD	Noninvasive diagnostic testing should be performed in pediatric patients presenting with syncope and suspected CHD, cardiomyopathy, or primary rhythm disorder.
I	C-EO	Education on symptom awareness of prodromes and reassurance are indicated in pediatric patients with VVS.
IIa	C-LD	Tilt-table testing can be useful for pediatric patients with suspected VVS when the diagnosis is unclear.
IIa	B-R	In pediatric patients with VVS not responding to lifestyle measures, it is reasonable to prescribe midodrine.
IIb	B-R	Encouraging increased salt and fluid intake may be reasonable in selected pediatric patients with VVS.
IIb	C-LD	The effectiveness of fludrocortisone is uncertain in pediatric patients with OH associated with syncope.
IIb	B-NR	Cardiac pacing may be considered in pediatric patients with severe neurally mediated syncope secondary to pallid breath-holding spells.
III-No Benefit	B-R	Beta blockers are not beneficial in pediatric patients with VVS.
Recommendations for Adult Congenital Heart Disease
IIa	C-EO	For evaluation of patients with ACHD and syncope, referral to a specialist with expertise in ACHD can be beneficial.
IIa	B-NR	EPS is reasonable in patients with moderate or severe ACHD and unexplained syncope.
Recommendations for Geriatric Patients
IIa	C-EO	For the assessment and management of older adults with syncope, a comprehensive approach in collaboration with an expert in geriatric care can be beneficial.
IIa	B-NR	It is reasonable to consider syncope as a cause of nonaccidental falls in older adults.
Recommendation for Driving and Syncope
IIa	C-EO	For evaluation of patients with ACHD and syncope, referral to a specialist with expertise in ACHD can be beneficial.
Recommendations for Athletes
I	C-EO	Cardiovascular assessment by a care provider experienced in treating athletes with syncope is recommended prior to resuming competitive sports.
IIa	C-LD	Assessment by a specialist with disease-specific expertise is reasonable for athletes with syncope and high-risk markers.
IIa	C-LD	Extended monitoring can be beneficial for athletes with unexplained exertional syncope after an initial cardiovascular evaluation.
III-Harm	B-R	Participation in competitive sports is not recommended for athletes with syncope and phenotype-positive HCM, CPVT, LQTS1, or ARVC before evaluation by a specialist.