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Guideline Summary
Guideline Title
Guidelines for the diagnosis and management of syncope (version 2009).
Bibliographic Source(s)
Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, Deharo JC, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Granell RR, Sarasin F, Ungar A, van Dijk JG, Walma EP, Wieling W, Abe H, Benditt DG, Decker WW, Grubb BP, Kaufmann H, Morillo C, Olshansky B, Parry SW, Sheldon R, Shen WK, ESC Committee for Practice Guidelines (CPG), Vahanian A, Auricchio A, Bax J, Ceconi C, Dean V, Filippatos G, Funck-Brentano C, Hobbs R, Kearney P, McDonagh T, McGregor K, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Vardas P, Widimsky P. Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009 Nov;30(21):2631-71. [213 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ, Bloch Thomsen PE, van Dijk JG, Fitzpatrick A, Hohnloser S, Janousek J, Kapoor W, Kenny RA, Kulakowski P, Masotti G, Moya A, Raviele A, Sutton R, Theodorakis G, Ungar A, Wieling W. Guidelines on management (diagnosis and treatment) of syncope--update 2004. Europace 2004 Nov;6(6):467-537. [399 references]

Scope

Disease/Condition(s)

Syncope

Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Treatment
Clinical Specialty
Cardiology
Emergency Medicine
Family Practice
Geriatrics
Internal Medicine
Neurology
Pediatrics
Intended Users
Physicians
Guideline Objective(s)
  • To provide specific recommendations on the diagnostic evaluation and management of syncope
  • To update the 2004 guidelines on management of syncope
Target Population

Patients presenting with transient loss of consciousness suggestive of syncope

Interventions and Practices Considered

Diagnosis/Evaluation/Risk Assessment

  1. Initial evaluation, including history, physical examination with orthostatic blood pressure measurements, and electrocardiogram
  2. Risk stratification
  3. Diagnostic tests
    • Carotid sinus massage
    • Orthostatic challenge (active standing, tilt testing)
    • Electrocardiographic monitoring
    • Electrophysiological study
    • Adenosine triphosphate test
    • Echocardiography and other imaging techniques
    • Exercise stress testing
    • Cardiac catheterization
    • Psychiatric evaluation
    • Neurological evaluation

Treatment/Management

  1. Physical counterpressure manoeuvre
  2. Tilt training
  3. Pharmacological therapy (midodrine, fludrocortisone, antiarrhythmic drugs)
  4. Cardiac pacing
  5. Catheter ablation
  6. Implantable cardioverter defibrillator
  7. Surgery, including revascularization or angioplasty
  8. Consideration for elderly, paediatric patients, and drivers
Major Outcomes Considered
  • Accuracy, sensitivity, specificity, and prognostic value of diagnostic tests and procedures
  • Syncopal recurrences
  • Mortality risk
  • Symptom recurrence and associated injuries
  • Quality of life
  • Complications and adverse effects of diagnostic procedures

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

For the guideline update, Pub Med was searched from 2003 to 2009 to supplement database searches from previous versions of the guideline (2001, 2004). Clinical trials, meta-analyses, practice guidelines, randomized controlled trials, and review articles were included in the search. Editorials and letters were excluded. Only English language articles were included.

Specific search terms included syncope, tilt testing or head up tilt testing, carotid sinus massage, carotid sinus syndrome, carotid sinus hypersensitivity, transient loss of consciousness, orthostatic hypotension, orthostatic intolerance, electrocardiographic monitoring, implantable loop recorder, external loop recorder, adenosine triphosphate test, syncope AND bundle branch block, syncope AND hypertrophic syncope AND cardiomyopathy, syncope AND dilated cardiomyopathy, syncope AND right ventricular dysplasia/cardiomyopathy, Brugada syndrome, short QT syndrome, long QT syndrome, Syncope Unit.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level A: Data derived from multiple randomized clinical trials or meta-analyses.

Level B: Data derived from a single randomized clinical trial or large non-randomized studies.

Level C: Consensus of opinion of the experts and/or small studies, retrospective studies, registries.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk/benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The first European Society of Cardiology (ESC) Guidelines for the management of syncope were published in 2001 and reviewed in 2004. In March 2008, the Committee for Practice Guidelines (CPG) considered that there were enough new data to justify production of new guidelines.

There are two main aspects of this document that differentiate it from its predecessors.

The first is to stress the concept that there are two distinct reasons for evaluating patients with syncope: one is to identify the precise cause in order to address an effective mechanism-specific treatment; the other is to identify the specific risk to the patient, which frequently depends on the underlying disease rather than on the mechanism of syncope itself. The background is provided for physicians to avoid confounding these two concepts.

The second aspect is to produce a comprehensive document which is addressed not only to cardiologists but to all physicians who are interested in the field. In order to achieve this aim a great number of other specialists were involved, as either full members, external contributors, or reviewers nominated by international societies of neurology, autonomic disease, internal medicine, emergency medicine, geriatrics, and general medicine. In total 76 specialists from different disciplines participated in this project.

The literature on syncope investigation and treatment is largely composed of case series, cohort studies, or retrospective analyses of already existing data. The impact of these approaches on guiding therapy and reducing syncope recurrences is difficult to discern without randomization and blinding. Because of these issues, the panel performed full reviews of the literature on diagnostic tests but did not use predefined criteria for selection of articles to be reviewed. This task force recognizes that for some of the recommendations related to diagnostic processes, controlled trials have never been performed. Consequently, some of these recommendations are based on brief observational studies, accepted clinical practice, expert consensus and sometimes common sense. In those cases, according to the current format of recommendations, a level of evidence C is given.

Rating Scheme for the Strength of the Recommendations

Classes of Recommendations

Class I: Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective.

Class II: Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure.

Class IIa: Weight of evidence/opinion is in favour of usefulness/efficacy.

Class IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Evidence or general agreement that the given treatment or procedure is not useful/effective and in some cases may be harmful.

Cost Analysis

The management of syncope is expensive for a number of reasons:

  1. As syncope is very frequent in the general population, it inevitably results in high direct clinical and indirect social costs. Approximately 1% of referrals to the emergency department (ED) are for syncope; of these, ~40% are hospitalized. In a large study the median in-hospital stay was 5.5 days (interquartile range 3–9). Hospitalization costs account for >75% of the total costs.
  2. A wide range of conditions may cause syncope. Consequently, without strict adherence to published management guidelines the evaluation of syncope patients has proved to be inefficient. The absence of a gold standard clinical test able to provide a certain, easy, and cheap diagnosis, and the widespread inappropriate use of multiple but inefficiently directed diagnostic tests ('shotgun approach') results in overuse of medical resources and increased costs. By following a well defined standardized care pathway a considerable improvement in diagnostic yield and cost-effectiveness (i.e., cost per reliable diagnosis) can be achieved (see section 5.3 of the original guideline document).

Although a comparison of costs between different studies is difficult, owing to differences in methods of calculation and between healthcare systems in different countries, it is generally believed that costs associated with syncope management are high. In the USA, estimated total annual costs for syncope-related admissions, derived from the Medicare database, were US$2.4 billion, with a mean cost of US$5400 per hospitalization. In the UK, the overall cost per patient was £611, with 74% attributed to the costs of hospital stay. Cost per diagnosis of patients admitted to hospital was £1080. In a multicentre study performed in Italy, 929 patients evaluated according to usual practice were compared with 725 patients evaluated using a standardized guideline-based approach. In the usual practice group, the cost per diagnosis was €1753±2326 per patient; it increased to €3506±2729 for hospitalized patients. When compared with the usual-care group, the standardized-care group had a 17% lower hospitalization rate, 24% fewer tests performed, and 11% shorter in-hospital stay. As a consequence, the mean cost per diagnosis was 29% lower (€1240±521 P = 0.0001).

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Once the document has been finalized and approved by all the experts involved in the Task Force, it is submitted to outside specialists for review. The document is revised, finally approved by the Committee for Practice Guidelines, and subsequently published.

Recommendations

Major Recommendations

The ratings for the class of recommendations (I-III) and level of evidence (A-C) are defined at the end of the "Major Recommendations" field.

Note from the National Guideline Clearinghouse and the European Society of Cardiology: The most relevant changes in this guideline update are as follows:

  • An update of the classification of syncope in the larger framework of transient loss of consciousness (T-LOC)
  • New data on epidemiology
  • A new diagnostic approach focusing on risk stratification of sudden cardiac death (SCD) and cardiovascular events after initial evaluation, including some recommendations for treatment in patients with unexplained syncope at high risk
  • Emphasis on the increasing role of a diagnostic strategy based on prolonged monitoring in contrast to the conventional strategy based on laboratory testing
  • An update of evidence-based therapy

Initial Evaluation, Diagnosis, and Risk Stratification

Initial Evaluation

The initial evaluation of a patient presenting with transient loss of consciousness (T-LOC) consists of careful history, physical examination, including orthostatic blood pressure (BP) measurements, and electrocardiogram (ECG). Based on these findings, additional examinations may be performed:

  • Carotid sinus massage (CSM) in patients <40 years.
  • Echocardiogram when there is previous known heart disease or data suggestive of structural heart disease or syncope secondary to cardiovascular cause.
  • Immediate ECG monitoring when there is a suspicion of arrhythmic syncope.
  • Orthostatic challenge (lying-to-standing orthostatic test and/or head-up tilt testing) when syncope is related to the standing position or there is a suspicion of a reflex mechanism.
  • Other less specific tests such as neurological evaluation or blood tests are only indicated when there is suspicion of nonsyncopal T-LOC.

The initial evaluation should answer three key questions:

  1. Is it a syncopal episode or not?
  2. Has the aetiological diagnosis been determined?
  3. Are there data suggestive of a high risk of cardiovascular events or death?

Diagnosis of Syncope

The differentiation between syncope and non-syncopal conditions with real or apparent LOC can be achieved in most cases with a detailed clinical history, but sometimes can be extremely difficult.

The following questions should be answered:

  • Was LOC complete?
  • Was LOC transient with rapid onset and short duration?
  • Did the patient recover spontaneously, completely and without sequelae?
  • Did the patient lose postural tone?

If the answers to these questions are positive, the episode has a high likelihood of being syncope. If the answer to one or more of these questions is negative, exclude other forms of LOC before proceeding with syncope evaluation.

Aetiological Diagnosis

Initial evaluation is able to define the cause of syncope in 23%–50% of patients. Table 9 in the original guideline document lists some of the most important questions that must be answered by the clinical history. There are some findings in the clinical history, physical examination, or ECG that can be considered diagnostic of the cause of syncope, permitting no further evaluation and institution of treatment.

In many other situations, the findings of initial evaluation do not permit a definite diagnosis to be made, but suggest some causes (see Table 10 in the original guideline document). In these cases, additional testing is usually needed.

Risk Stratification

When the cause of syncope remains uncertain after initial evaluation the next step is to assess the risk of major cardiovascular events or sudden cardiac death (SCD). Figure 7 in the original guideline document shows the diagnostic flow chart to be followed in these patients. The main high risk features, in accordance with recent guidelines on SCD and cardiac pacing, are listed in Table 11 of the original guideline document.

Recommendations: Diagnostic Criteria with Initial Evaluation
Recommendations Class Level
VVS is diagnosed if syncope is precipitated by emotional distress or orthostatic stress and is associated with typical prodrome. I C
Situational syncope is diagnosed if syncope occurs during or immediately after specific triggers listed in Table 4 of the original guideline document. I C
Orthostatic syncope is diagnosed when it occurs after standing up and there is documentation of OH. I C
Arrhythmia-related syncope is diagnosed by ECG when there is:
  • Persistent sinus bradycardia <40 bpm in awake or repetitive sinoatrial block or sinus pauses ≥3 s
  • Mobitz II second or third degree AV block
  • Alternating left and right BBB
  • VT or rapid paroxysmal SVT
  • Non-sustained episodes of polymorphic VT and long or short QT interval
  • Pacemaker or ICD malfunction with cardiac pauses
I C
Cardiac ischaemia-related syncope is diagnosed when syncope presents with ECG evidence of acute ischaemia with or without myocardial infarction. I C
Cardiovascular syncope is diagnosed when syncope presents in patients with prolapsing atrial myxoma, severe aortic stenosis, pulmonary hypertension, pulmonary embolus, or acute aortic dissection. I C

AV = atrioventricular; BBB = bundle branch block; ECG = electrocardiogram; ICD = implantable cardioverter defibrillator; OH = orthostatic hypotension; SVT = supraventricular tachycardia; VVS = vasovagal syncope; VT = ventricular tachycardia

Diagnostic Tests

Recommendations: Carotid Sinus Massage
Recommendations Class Level
Indications
CSM is indicated in patients >40 years with syncope of unknown aetiology after initial evaluation. I B
CSM should be avoided in patients with previous TIA or stroke within the past 3 months and in patients with carotid bruits (except is carotid Doppler studies excluded significant stenosis). III C
Diagnostic Criteria
CSM is diagnostic if syncope is reproduced in the presence of asystole longer than 3 s and/or a fall in systolic BP >50 mm Hg. I B

BP = blood pressure; CSM = carotid sinus massage; TIA = transient ischaemia attack

Recommendations: Active Standing
Recommendations Class Level
Indications
Manual intermittent determination with sphygmomanometer of BP supine and during active standing for 3 min is indicated as initial evaluation when OH is suspected. I B
Continuous beat-to-beat non-invasive pressure measurement may be helpful in cases of doubt. IIb C
Diagnostic Criteria
The test is diagnostic when there is a symptomatic fall in systolic BP from a baseline value ≥20 mmHg or diastolic BP ≥10 mmHg, or a decrease in systolic BP <90 mmHg. I C
The test should be considered diagnostic when there is an asymptomatic fall in systolic BP from baseline value ≥20 mmHg or diastolic BP ≥10 mmHg, or a decrease in systolic BP to <90 mmHg. IIa C

BP = blood pressure; OH = orthostatic hypotension

Recommendations: Tilt Testing
Recommendations Class Level
Methodology
Supine pre-tilt phase of at least 5 min, when no venous cannulation, and of at least 20 min, when cannulation is undertaken, is recommended. I C
Tilt angle between 60° and 70° is recommended. I B
Passive phase of a minimum of 20 min and a maximum of 45 min is recommended. I B
For nitroglycerine, a fixed dose of 300-400 µg sublingually administered in the upright position is recommended. I B
For isoproterenol, an incremental infusion rate from 1 up to 3 µg/min in order to increase average heart rate by ~20%-25% over baseline is recommended. I B
Indications
Tilt testing is indicated in the case of an unexplained single syncopal episode in high risk settings (e.g., occurrence of, or potential risk of physical injury or with occupational implications), or recurrent episodes in the absence of organic heart disease, or in the presence of organic heart disease, after cardiac causes of syncope have been excluded. I B
Tilt testing is indicated when it is of clinical value to demonstrate susceptibility to reflex syncope to the patient. I C
Tilt testing should be considered to discriminate between reflex and OH syncope. IIa C
Tilt testing may be considered for differentiating syncope with jerking movements from epilepsy. IIb C
Tilt testing may be indicated for evaluating patients with recurrent unexplained falls. IIb C
Tilt testing may be indicated for evaluating patients with frequent syncope and psychiatric disease. IIb C
Tilt testing is not recommended for assessment of treatment. III B
Isoproterenol tilt testing is contraindicated in patients with ischaemic heart disease. III C
Diagnostic Criteria
In patients without structural heart disease the induction of reflex hypotension/bradycardia with reproduction of syncope or progressive OH (with or without symptoms) are diagnostic of reflex syncope and OH, respectively. I B
In patients without structural heart disease the induction of reflex hypotension/bradycardia without reproduction of syncope may be diagnostic of reflex syncope. IIa B
In patients with structural heart disease, arrhythmia or other cardiovascular cause of syncope should be excluded prior to considering positive tilt test results as diagnostic. IIa C
Induction of LOC in absence of hypotension and/or bradycardia should be considered diagnostic of psychogenic pseudosyncope. IIa C

LOC = loss of consciousness; OH = orthostatic hypotension

Recommendations: Electrocardiographic Monitoring
Recommendations Class Level
Indications
ECG monitoring is indicated in patients who have clinical or ECG features suggesting arrhythmic syncope (listed in Table 10 of the original guideline document). The duration (and technology) of monitoring should be selected according to the risk and the predicted recurrence rate of syncope: I B

Immediate in-hospital monitoring (in bed or telemetric) is indicated in high risk patients defined in Table 11 of the original guideline document

I C

Holter monitoring is indicated in patients who have very frequent syncope or pre-syncope (≥1 per week)

I B

ILR is indicated in:

An early phase of evaluation in patients with recurrent syncope of uncertain origin, absence of high risk criteria listed in Table 11 of the original guideline and a high likelihood of recurrence within battery longevity of the device

I B

High risk patients in whom a comprehensive evaluation did not demonstrate a cause of syncope or lead to a specific treatment

I B

ILR should be considered to assess the contribution of bradycardia before embarking on cardiac pacing in patients with suspected or certain reflex syncope presenting with frequent or traumatic syncopal episodes.

IIa B

External loop reorders should be considered in patients who have an inter-symptom interval ≤4 weeks.

IIa B
Diagnostic Criteria
ECG monitoring is diagnostic when a correlation between syncope and an arrhythmia (brady- or tachyarrhythmia) is detected. I B
In the absence of such correlation, ECG monitoring is diagnostic when periods of Mobitz II or III degree AV block or a ventricular pause >3 s (with the possible exception of young trained persons, during sleep, medicated patients, or rate-controlled atrial fibrillation), or rapid prolonged paroxysmal SVT or VT are detected. The absence of arrhythmia during syncope excludes arrhythmic syncope. I C
The ECG documentation of pre-syncope without any relevant arrhythmia is not an accurate surrogate for syncope. III C
Asymptomatic arrhythmias (other than those listed above) are not an accurate surrogate for syncope. III C
Sinus bradycardia (in the absence of syncope) is not an accurate surrogate for syncope. III C

AV = atrioventricular; ECG = electrocardiogram; ILR = implantable loop recorder; SVT = supraventricular tachycardia; VT = ventricular tachycardia

Recommendations: Electrophysiological Study
Recommendations Class Level
Indications
In patients with ischaemic heart disease EPS is indicated when initial evaluation suggests an arrhythmic cause of syncope (listed in Table 10 of the original guideline document) unless there is already an established indication for ICD. I B
In patients with BBB, EPS should be considered when non-invasive tests have failed to make the diagnosis. IIa B
In patients with syncope preceded by sudden and brief palpitations, EPS may be performed when other non-invasive tests have failed to make the diagnosis. IIb B
In patients with Brugada syndrome, ARVC and hypertrophic cardiomyopathy, an EPS may be performed in selected cases. IIb C
In patients with high-risk occupations, in whom every effort to exclude a cardiovascular cause of syncope is warranted, an EPS may be performed in selected cases. IIb C
EPS is not recommended in patients with normal ECG, no heart disease, and no palpitations. III B
Diagnostic Criteria
EPS is diagnostic, and no additional tests are required, in the following cases:

Sinus bradycardia and prolonged CSNRT (>525 ms)

I B

BBB and either a baseline HV interval of ≥100 ms, or second or third degree His-Purkinje block is demonstrated during incremental atrial pacing, or with pharmacological challenge

I B

Induction of sustained monomorphic VT in patients with previous myocardial infarction

I B

Induction of rapid SVT which reproduces hypotensive or spontaneous symptoms

I B
An HV interval between 70 and 100 ms should be considered diagnostic. IIa B
The induction of polymorphic VT or ventricular fibrillation in patients with Brugada syndrome, ARVC, and patients resuscitated from cardiac arrest may be considered diagnostic. IIb B
The induction of polymorphic VT or ventricular fibrillation in patients with ischaemic cardiomyopathy or DCM cannot be considered a diagnostic finding. III B

ARVC = arrhythmogenic right ventricular cardiomyopathy; BBB = bundle branch block; CSNRT = corrected sinus node recovery time; DCM = dilated cardiomyopathy; EPS =electrophysiological study; ICD = implantable cardioverter defibrillator; HV = His-ventricle; SVT = supraventricular tachycardia; VT = ventricular tachycardia

Recommendations: Adenosine Triphosphate Test
Recommendations Class Level
Indications
Owing to lack of correlation with spontaneous syncope, ATP test cannot be used as a diagnostic test to select patients for cardiac pacing. III B

ATP = adenosine triphosphate test

Recommendations: Echocardiography
Recommendations Class Level
Indications
Echocardiography is indicated for diagnosis and risk stratification in patients who are suspected of having structural heart disease. I B
Diagnostic Criteria
Echocardiography alone is diagnostic of the cause of syncope in severe aortic stenosis, obstructive cardiac tumours or thrombi, pericardial tamponade, aortic dissection, and congenital anomalies of coronary arteries. I B

 

Recommendations: Exercise Testing
Recommendations Class Level
Indications
Exercise testing is indicated in patients who experience syncope during or shortly after exertion. I C
Diagnostic Criteria
Exercise testing is diagnostic when syncope is reproduced during or immediately after exercise in the presence of ECG abnormalities or severe hypotension. I C
Exercise testing is diagnostic if Mobitz II second degree or third degree AV block develops during exercise even without syncope. I C

AV = atrioventricular; ECG = electrocardiogram

Recommendations: Psychiatric Evaluation
Recommendations Class Level
Indications
Psychiatric evaluation is indicated in patients in whom T-LOC is suspected to be psychogenic pseudosyncope. I C
Tilt testing, preferably with concurrent EEG recording and video monitoring, may be considered for diagnosis of T-LOC mimicking syncope ('pseudosyncope') or epilepsy. IIb C

EEG = electroencephalogram; T-LOC = transient loss of consciousness

Recommendations: Neurological Evaluation
Recommendations Class Level
Indications
Neurological evaluation is indicated in patients in whom T-LOC is suspected to be epilepsy. I C
Neurological evaluation is indicated when syncope is due to ANF in order to evaluate the underlying disease. I C
EEG, ultrasound of neck arteries, and computed tomography or magnetic resonance imaging of the brain are not indicated, unless a non-syncopal cause of T-LOC is suspected. III B

ANF = autonomic failure; EEG = electroencephalogram; T-LOC = transient loss of consciousness

Treatment

General Principles of Treatment of Syncope

The principal goals of treatment for patients with syncope are to prolong survival, limit physical injuries, and prevent recurrences.

The importance and priority of these different goals are dependent on the cause of syncope. For example, in patients with ventricular tachycardia (VT) causing syncope, the mortality risk is clearly predominant, while in patients with reflex syncope it is the prevention of recurrences and/or limitation of injuries.

Knowledge of the cause of syncope has a key role in selection of treatment. Once the cause has been ascertained, the second goal is to assess the mechanism leading to syncope. For example, the mechanism is obvious in the case of atrioventricular (AV) block in the context of intraventricular conduction defects, but it could be more complex in the context of reflex syncope: is it cardioinhibitory, vasodepressor, or a mixed response?

Investigations of the cause and mechanism of syncope are generally performed at the same time and could lead to different treatments (or absence of treatment). For example, syncope during the acute phase of an inferior myocardial infarction is generally of reflex origin, and consequent severe bradycardia, hypotension, or both are just a part of the infarction and have to be treated as a complication of the infarct. On the other hand, recurrent reflex syncope due to severe bradycardia, hypotension, or both in the absence of an acute disease has to be treated for what it is. Finally, the optimal treatment of syncope must be directed to the responsible cause of the global cerebral hypoperfusion. However, to the extent that these causes are either unknown or not responsive to present therapy (e.g., there is no specific treatment for degenerative AV block) treatment is directed to the mechanisms leading to global cerebral hypoperfusion (pacing in the above-mentioned example). The general framework of treatment is based on risk stratification and the identification of specific mechanisms when possible, as summarized in Figure 8 of the original guideline document.

Treatment of Reflex Syncope and Orthostatic Intolerance

This section deals with measures and interventions for prevention of reflex syncope (vasovagal, situational, carotid sinus syndrome [CSS]) and syncope secondary to autonomic failure (ANF) with orthostatic hypotension (OH). Although there are many physiological mechanisms that lead to syncope, the strategies for prevention of syncope apply to the entire range of causes. The goal of therapy is primarily prevention of recurrence and associated injuries, and improvement in quality of life, but not to prolong survival.

Recommendations: Treatment of Reflex Syncope
Recommendations Class Level
Explanation of the diagnosis, provision of reassurance, and explanation of risk of recurrence are indicated in all patients. I C
Isometric PCMs are indicated in patients with prodrome. I B
Cardiac pacing should be considered in patients with dominant cardioinhibitory CSS. IIa B
Cardiac pacing should be considered in patients with frequent recurrent reflex syncope, age >40 years, and documented spontaneous cardioinhibitory response during monitoring. IIa B
Midodrine may be indicated in patients with VVS refractory to lifestyle measures. IIb B
Tilt training may be useful for education of patients but long-term benefit depends on compliance. IIb B
Cardiac pacing may be indicated in patients with tilt-induced cardioinhibitory response with recurrent frequent unpredictable syncope and age >40 after alternative therapy has failed. IIb C
Cardiac pacing is not indicated in the absence of a documented cardioinhibitory reflex. III C
β-adrenergic blocking drugs are not indicated. III A

CSS = carotid sinus syndrome; PCM = physical isometric counterpressure manoeuvre; VVS = vasovagal syncope

Recommendations: Treatment of Orthostatic Hypotension
Recommendations Class Level
Adequate hydration and salt intake must be maintained. I C
Midodrine should be administered as adjunctive therapy if needed. IIa B
Fludrocortisone should be administered as adjunctive therapy if needed. IIa C
PCMs may be indicated. IIb C
Abdominal binders and/or support stockings to reduce venous pooling may be indicated. IIb C
Head-up tilt sleeping (>10⁰) to increase fluid volume may be indicated. IIb C

PCM = physical isometric counterpressure manoeuvre

Cardiac Arrhythmias as Primary Cause

Treatment goals are prevention of symptom recurrence, improvement of quality of life, and prolongation of survival. The basis of syncope in these situations is multifactorial, and is influenced by the ventricular rate, left ventricular function, and the adequacy of vascular compensation (including the potential impact of neurally mediated reflex).

Recommendations: Treatment of Syncope Due to Cardiac Arrhythmias
Recommendations Class Level
Syncope due to cardiac arrhythmias must receive treatment appropriate to the cause. I B
Cardiac Pacing
Pacing is indicated in patients with sinus node disease in whom syncope is demonstrated to be due to sinus arrest (symptom-ECG correlation) without a correctable cause. I C
Pacing is indicated in sinus node disease patients with syncope and abnormal CSNRT. I C
Pacing is indicated in sinus node disease patients with syncope and asymptomatic pauses ≥3 s (with the possible exceptions of young trained persons, during sleep, and in medicated patients). I C
Pacing is indicated in patients with syncope and second degree Mobitz II, advanced or complete AV block. I B
Pacing is indicated in patients with syncope, BBB, and positive EPS. I B
Pacing should be considered in patients with unexplained syncope and BBB. IIa C
Pacing may be indicated in patients with unexplained syncope and sinus node disease with persistent sinus bradycardia itself asymptomatic. IIb C
Pacing is not indicated in patients with unexplained syncope without evidence of any conduction disturbance. III C
Catheter Ablation
Catheter ablation is indicated in patients with symptom-arrhythmia ECG correlation in both SVT and VT in the absence of structural heart disease (with the exception of atrial fibrillation). I C
Catheter ablation may be indicated in patients with syncope due to the onset of rapid atrial fibrillation. IIb C
Antiarrhythmic Drug Therapy
Antiarrhythmic drug therapy, including rate control drugs, is indicated in patients with syncope due to onset of rapid atrial fibrillation. I C
Drug therapy should be considered in patients with symptom-arrhythmia ECG correlation in both SVT and VT when catheter ablation cannot be undertaken or has failed. IIa C
Implantable Cardioverter Defibrillator
ICD is indicated in patients when documented VT and structural heart disease. I B
ICD is indicated when sustained monomorphic VT is induced at EPS in patients with previous myocardial infarction. I B
ICD should be considered in patients with documented VT and inherited cardiomyopathies or channelopathies. IIa B

AV = atrioventricular; BBB = bundle branch block; CSNRT = corrected sinus node recovery time; ECG = electrocardiogram; EPS = electrophysiological study; ICD = implantable cardioverter defibrillator; SVT = supraventricular tachycardia; VT = ventricular tachycardia

Syncope Secondary to Structural Cardiac or Cardiovascular Disease

In patients with syncope secondary to structural cardiac disease, including congenital heart malformations, or cardiopulmonary disease, the goal of treatment is not only to prevent syncopal recurrence, but also to treat the underlying disease and to decrease the risk of SCD.

Treatment of syncope associated with structural heart disease varies with the diagnosis. In patients with syncope secondary to severe aortic stenosis or to atrial myxoma, surgical treatment of the underlying disease is indicated. In patients with syncope secondary to acute cardiovascular disease, such as pulmonary embolism, myocardial infarction, or pericardial tamponade, treatment should be directed to the underlying process. In hypertrophic cardiomyopathy (with or without left ventricle outflow tract obstruction), specific treatment of the arrhythmia is usually warranted; in most of these patients, an ICD should be implanted to prevent SCD. There are no data on the effect of reducing the outflow gradient on relief of syncope. In syncope associated with myocardial ischaemia, pharmacological therapy and/or revascularization is clearly the appropriate strategy in most cases. On the other hand, when syncope is caused by primary pulmonary hypertension or restrictive cardiomyopathy, it is often impossible adequately to ameliorate the underlying problem. Other less common causes of syncope include left ventricular inflow tract obstruction in patients with mitral stenosis, right ventricular outflow tract obstruction, and right to left shunting secondary to pulmonary stenosis or pulmonary hypertension.

Unexplained Syncope in Patients with High Risk of Sudden Cardiac Death

In patients at high risk of SCD a disease-specific treatment is warranted in order to reduce the risk of death and of life-threatening events, even if the exact mechanism of syncope is still unknown or uncertain at the end of a complete work-up. In these patients the goal of treatment is primarily the reduction of mortality risk.

It is important to bear in mind, however, that even if an effective specific treatment of the underlying disease is found, patients may remain at risk of recurrence of syncope. For example, ICD-treated patients may remain at risk for fainting because only the SCD risk is being addressed and not the cause of syncope. An analysis of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) has shown that ICD did not protect patients against syncope recurrence compared with those treated with amiodarone or placebo. This implies the need for precise identification of the mechanism of syncope and specific treatment as far as possible.

Recommendations: Indications for ICD in Patients with Unexplained Syncope and a High Risk of SCD
Recommendations Class Level Comments
In patients with ischaemic cardiomyopathy with severely depressed LVEF or HF, ICD therapy is indicated according to current guidelines for ICD-cardiac resynchronization therapy implantation. I A  
In patients with non-ischaemic cardiomyopathy with severely depressed LVEF or HF, ICD therapy is indicated according to current guidelines for ICD-cardiac resynchronization therapy implantation. I A  
In hypertrophic cardiomyopathy ICD therapy should be considered in patients at high risk (see text in the original guideline document). IIa C In non-high risk, consider ILR
In right ventricular cardiomyopathy ICD therapy should be considered in patients at high risk (see text in the original guideline document). IIa C In non-high risk, consider ILR
In Brugada syndrome ICD therapy should be considered in patients with spontaneous type I ECG. IIa B In the absence of spontaneous type I pattern, consider ILR
In long QT syndrome, ICD therapy, in conjunction with β-blockers, should be considered in patients at risk. IIa B In non-high risk, consider ILR
In patients with ischaemic cardiomyopathy without severely depressed LVEF or HF and negative programmed electrical stimulation ICD therapy may be considered. IIb C Consider ILR to help define the nature of unexplained syncope
In patients with non-ischaemic cardiomyopathy without severely depressed LVEF or HF ICD therapy may be considered. IIb C Consider ILR to help define the nature of unexplained syncope

ECG = electrocardiogram; HF = heart failure; ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; LVEF = left ventricular ejection fraction; SCD = sudden cardiac death

Special Issues

Syncope in the Elderly

The most common causes of syncope in the elderly are OH, reflex syncope, especially CSS, and cardiac arrhythmias. Different forms may often co-exist in a patient, making diagnosis difficult.

Diagnostic Evaluation

Following a standardized algorithm a definite diagnosis may be obtained in >90% of older patients with syncope.

Evaluation of neurological and locomotor systems, including observation of gait and balance, is useful. If cognitive impairment is suspected, the Mini-Mental State Examination should be performed. Otherwise, the clinical examination and diagnostic work-up is the same as for younger adults with the exception of routine supine and upright CSM at the first assessment.

Some important aspects of diagnostic testing and use of devices in older patients are illustrated:

  • OH is not always reproducible in older adults (particularly medication- and age-related). Therefore, orthostatic blood pressure (BP) appraisal should be repeated, preferably in the morning and/or promptly after syncope.
  • CSM is particularly important to use even if non-specific carotid sinus hypersensitivity (CSH) is frequent without history of syncope.
  • In evaluation of reflex syncope in older patients, tilt testing is well tolerated and safe, with positivity rates similar to those observed in younger patients, particularly after nitroglycerine challenge.
  • Twenty-four hour ambulatory BP recordings may be helpful if instability of BP is suspected (e.g. medication or post-prandial).
  • Due to the high frequency of arrhythmias, an ILR may be especially useful in the elderly with unexplained syncope.

Evaluation of the Frail Elderly

Being old is not a contraindication to assessment and treatment. However, in frail patients, the rigour of assessment will depend on compliance with tests and on prognosis. Evaluation of mobile, independent, cognitively normal older adults must be performed as for younger individuals.

Orthostatic BP measurements, CSM, and tilt testing are well tolerated, even in the frail elderly with cognitive impairment.

Multiple risk factors are more common in the frail elderly and distinguishing falls from syncope may be difficult. In one recent study, symptomatic elderly patients with cognitive impairment had a median of five risk factors for syncope or falls. There is some evidence that modification of cardiovascular risk factors for falls/syncope reduces the incidence of subsequent events in community-dwelling frail elderly, even in those with dementia, but not in institutionalized elderly. The influence of hypotension or arrhythmia on cognitive decline in patients with dementia remains unknown.

Syncope in Paediatric Patients

Diagnostic Evaluation

Diagnostic evaluation in paediatric patients is similar to that in adults. Reflex syncope represents the vast majority of the aetiology, but in rare cases syncope is the manifestation of life-threatening cardiac arrhythmia or structural abnormalities. Syncope should also be differentiated from epilepsy and psychogenic pseudosyncope, which are rare but important causes of T-LOC in paediatric patients.

Two specific conditions occur in early childhood:

  1. Infantile reflex syncopal attacks (also called pallid breath-holding spells or reflex anoxic seizures), elicited by a brief unpleasant stimulus, are caused by vagally mediated cardiac inhibition.
  2. Apnoeic hypoxic T-LOC (also called cyanotic breath-holding spells), are characterized by an expiratory cessation of respiration during crying, leading to cyanosis and usually T-LOC.

Careful personal and family history and standard ECG are most important in distinguishing benign reflex syncope (also including reflex anoxic seizure or breath-holding spells) from other causes. If the family history is positive, genetic causes of electrical disease of the heart should be considered first. Some children with reflex syncope also have a positive family history, the genetics of which are not understood. In patients with a typical history of reflex syncope, normal physical examination and ECG are usually sufficient to cease investigation. Tilt testing seems to have high false-negative and false-positive rates and should be used with caution for primary identification of patients with reflex syncope.

Therapy

The therapeutic approach is the same as in adults. However, it should be stressed that effectiveness of pharmacological agents and tilt training for recurrent syncope is undetermined in the absence of well-designed paediatric trials. Furthermore, even in the presence of VVS with prolonged asystole, pacemakers should be avoided due to the relatively transient and benign nature of the syndrome.

In summary, the key points for the evaluation of syncope in paediatrics are as follows:

  • Syncope in childhood is common, the vast majority being of reflex origin, with only a minority having a potentially life-threatening cause.
  • Discrimination between benign and serious causes is made primarily by history, physical examination, and ECG.
  • The cornerstone of therapy for young patients with reflex syncope includes education and reassurance.

Driving and Syncope

Recommendations Concerning Driving in Patients with Syncope
Diagnosis Group 1 (private drivers) Group 2 (professional drivers)
Cardiac Arrhythmias
Cardiac arrhythmia, medical treatment After successful treatment is established After successful treatment is established
Pacemaker implant After 1 week After appropriate function is established
Successful catheter ablation After successful treatment is established After long-term success is confirmed
ICD implant In general low risk, restriction according current recommendations Permanent restriction
Reflex Syncope
Single/mild No restrictions No restriction unless it occurred during high risk activity*
Recurrent and severe* After symptoms are controlled Permanent restriction unless effective treatment has been established
Unexplained syncope No restriction unless absence of prodrome, occurrence during driving, or presence of severe structural heart disease After diagnosis and appropriate therapy is established

Group 1: private drivers of motorcycles, cars, and other small vehicles with and without a trailer. Group 2: professional drivers of vehicles over 3.5 tons or passenger-carrying vehicles exceeding eight seats excluding the driver. Drivers of taxicabs, small ambulances, and other vehicles form an intermediate category between the ordinary private driver and the vocational driver and should follow local legislation.
*Neutrally medicated syncope is defined as severe if it is very frequent, or occurring during the prosecution of a "high risk" activity, or recurrent or unpredictable in "high risk" patients (see Part 3, Treatment, in the original guideline document)

Organizational Aspects

Refer to the original guideline document for discussion of the following organizational aspects of care:

  • Management of syncope in general practice
  • Management of syncope in the Emergency Department
  • Syncope (T-LOC) Management Unit

Definitions:

Classes of Recommendations

Class I: Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective.

Class II: Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure.

Class IIa: Weight of evidence/opinion is in favour of usefulness/efficacy.

Class IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Evidence or general agreement that the given treatment or procedure is not useful/effective and in some cases may be harmful.

Levels of Evidence

Level A: Data derived from multiple randomized clinical trials or meta-analyses.

Level B: Data derived from a single randomized clinical trial or large non-randomized studies.

Level C: Consensus of opinion of the experts and/or small studies, retrospective studies, registries.

Clinical Algorithm(s)

Algorithms are provided in the original guideline document for:

  • Context of transient loss of consciousness (T-LOC)
  • Diagnostic flowchart in patients with suspected T-LOC
  • Treatment of syncope

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for most recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Accurate diagnosis of syncope
  • In general, treatment of syncope may result in prevention of syncopal recurrences, reduction of mortality risk, prevention of symptom recurrence and associated injuries, and an improved quality of life.
Potential Harms

Tilt-Testing

Tilt-testing is safe. There have been no reported deaths during the test. However, some rare life-threatening ventricular arrhythmias with isoproterenol in the presence of ischaemic heart disease or sick sinus syndrome have been reported. No complications have been published with the use of nitroglycerine. Minor side effects are common and include palpitations with isoproterenol and headache with nitroglycerine. Atrial fibrillation can be induced during or after a positive tilt test and is usually self-limited. Despite the low risk, it is recommended that resuscitation equipment should available.

Midodrine

The major limitation of midodrine is frequent dosing, limiting long-term compliance. Caution in its use in older males is necessary because of adverse effects on urinary outflow.

Carotid Sinus Massage (CSM)

The main complications of CSM are neurological. Pooling the data of three studies in which 7319 patients were analysed, neurological complications were observed in 21 (0.29%). CSM should be avoided in patients with previous transient ischemic attack (TIA), stroke within the past 3 months, or with carotid bruits, except if carotid Doppler studies excluded significant stenosis.

Implanted Pacing Systems

Infrequently, implantable pacing systems have been associated with provoking near-syncope or syncope. When syncope is attributable to the implanted device, it may occur as a result of pulse generator battery depletion or failure, or lead failure. Device/lead replacement is indicated and eliminates the problem. Alternatively, some patients may experience syncope due to pacemaker syndrome, a condition, which incorporates many possible mechanisms of hypotension. In pacemaker syndrome with retrograde atrioventricular conduction, device re-programming to eliminate the problem is usually feasible, although replacement is occasionally needed (e.g., replace a single-chamber ventricular with a dual chamber-pacing system). Implantable cardioverter defibrillators (ICDs) may also be associated with syncope most commonly because even appropriate intervention is too late to prevent loss of consciousness. Re-programming of the device (more aggressive antitachycardia pacing and/or earlier shock) is only seldom able to solve the problem. In those patients, antiarrhythmic drugs or catheter ablation may be helpful.

Contraindications

Contraindications
  • Contraindications to the administration of isoproterenol include ischaemic heart disease, uncontrolled hypertension, left ventricular outflow tract obstruction, and significant aortic stenosis. Caution should be used in patients with known arrhythmias.
  • Carotid sinus massage should be avoided in patients with previous transient ischemic attack (TIA), stroke within the past 3 months, or with carotid bruits, except if carotid Doppler studies excluded significant stenosis.
  • Computed tomography or magnetic resonance imaging in uncomplicated syncope should be avoided.

Qualifying Statements

Qualifying Statements
  • The European Society of Cardiology (ESC) Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient's guardian or carer. It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.
  • The literature on syncope investigation and treatment is largely composed of case series, cohort studies, or retrospective analyses of already existing data. The impact of these approaches on guiding therapy and reducing syncope recurrences is difficult to discern without randomization and blinding. Because of these issues, the panel performed full reviews of the literature on diagnostic tests but did not use predefined criteria for selection of articles to be reviewed. The Task Force recognizes that for some of the recommendations related to diagnostic processes, controlled trials have never been performed. Consequently, some of these recommendations are based on brief observational studies, accepted clinical practice, expert consensus and sometimes common sense. In those cases, according to the current format of recommendations, a level of evidence C is given.

Implementation of the Guideline

Description of Implementation Strategy

After publication, dissemination of the message is of paramount importance. Pocket-sized versions and personal digital assistant (PDA)-downloadable versions are useful at the point of care. Some surveys have shown that the intended end-users are sometimes not aware of the existence of the guidelines, or simply do not translate them into practice; this is why implementation programmes for new guidelines form an important component of the dissemination of knowledge. Meetings are organized by the European Society of Cardiology (ESC) and are directed towards its member national societies and key opinion leaders in Europe. Implementation meetings can also be undertaken at national levels, once the guidelines have been endorsed by ESC member societies and translated into the national language. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by thorough application of clinical recommendations.

Thus, the task of writing Guidelines or Expert Consensus Documents covers not only the integration of the most recent research, but also the creation of educational tools and implementation programmes for the recommendations. The loop between clinical research, the writing of guidelines, and implementing them into clinical practice can then only be completed if surveys and registries are performed to verify that real-life daily practice is in keeping with what is recommended in the guidelines. Such surveys and registries also make it possible to evaluate the impact of implementation of the guidelines on patient outcomes. Guidelines and recommendations should help physicians to make decisions in their clinical practice; however, the ultimate judgement regarding the care of an individual patient must be made by the physician in charge of that patient.

Organizational Aspects

Section 5 of the original guideline document discusses organizational aspects of syncope management and includes a proposed model of care.

Key points for standardized care delivery include the following:

  • A cohesive, structured care pathway—delivered either within a single syncope facility or as a more multifaceted service—is recommended for global assessment of patients with transient loss of consciousness (T-LOC) (suspected syncope).
  • Referral can be directly from family practitioners, emergency department, acute hospital inpatients, institutional settings.
  • Objectives are to give the patient continuity of care, reduce inappropriate hospitalizations, and set standards of clinical excellence.
  • Experience and training in key components of cardiology, neurology, emergency and geriatric medicine are pertinent.
Implementation Tools
Clinical Algorithm
Foreign Language Translations
Mobile Device Resources
Pocket Guide/Reference Cards
Quick Reference Guides/Physician Guides
Slide Presentation
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, Deharo JC, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Granell RR, Sarasin F, Ungar A, van Dijk JG, Walma EP, Wieling W, Abe H, Benditt DG, Decker WW, Grubb BP, Kaufmann H, Morillo C, Olshansky B, Parry SW, Sheldon R, Shen WK, ESC Committee for Practice Guidelines (CPG), Vahanian A, Auricchio A, Bax J, Ceconi C, Dean V, Filippatos G, Funck-Brentano C, Hobbs R, Kearney P, McDonagh T, McGregor K, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Vardas P, Widimsky P. Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009 Nov;30(21):2631-71. [213 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2001 Aug (revised 2009 Nov)
Guideline Developer(s)
European Heart Rhythm Association - Professional Association
European Society of Cardiology - Medical Specialty Society
Heart Failure Association of the ESC - Disease Specific Society
Heart Rhythm Society - Professional Association
Source(s) of Funding

The Task Force report was entirely supported financially by the ESC and was developed without any involvement of industry.

Guideline Committee

Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)

European Society of Cardiology (ESC) Committee for Practice Guidelines

Composition of Group That Authored the Guideline

Task Force Members: Angel Moya (Chairperson) (Spain), Richard Sutton (Co-Chairperson) (UK), Fabrizio Ammirati (Italy), Jean-Jacques Blanc (France), Michele Brignole (Italy), Johannes B. Dahm (Germany), Jean-Claude Deharo (France), Jacek Gajek (Poland), Knut Gjesdal (Norway), Andrew Krahn (Canada), Martial Massin (Belgium), Mauro Pepi (Italy), Thomas Pezawas (Austria), Ricardo Ruiz Granell (Spain), Francois Sarasin (Switzerland), Andrea Ungar (Italy), J. Gert van Dijk (The Netherlands), Edmond P. Walma (The Netherlands), Wouter Wieling (The Netherlands)

External Contributors: Haruhiko Abe (Japan), David G. Benditt (USA), Wyatt W. Decker (USA), Blair P. Grubb (USA), Horacio Kaufmann (USA), Carlos Morillo (Canada), Brian Olshansky (USA), Steve W. Parry (UK), Robert Sheldon (Canada), Win K. Shen (USA)

European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG) Members: Alec Vahanian (Chairperson) (France), Angelo Auricchio (Switzerland), Jeroen Bax (The Netherlands), Claudio Ceconi (Italy), Veronica Dean (France), Gerasimos Filippatos (Greece), Christian Funck-Brentano (France), Richard Hobbs (UK), Peter Kearney (Ireland), Theresa McDonagh (UK), Keith McGregor (France), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Michal Tendera (Poland), Panos Vardas (Greece), Petr Widimsky (Czech Republic)

Financial Disclosures/Conflicts of Interest

The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House Headquarters of the European Society of Cardiology (ESC). Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report was entirely supported financially by the ESC and was developed without any involvement of industry.

The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines External Web Site Policy.

Guideline Endorser(s)
American Autonomic Society - Professional Association
American Geriatrics Society - Medical Specialty Society
Austrian Society of Cardiology - Medical Specialty Society
Belgian Society of Cardiology - Medical Specialty Society
Belorussian Scientific Society of Cardiologists - Medical Specialty Society
Bulgarian Society of Cardiology - Medical Specialty Society
Croatian Cardiac Society - Medical Specialty Society
Danish Society of Cardiology - Medical Specialty Society
European Federation of Autonomic Societies - Professional Association
European Federation of Internal Medicine - Medical Specialty Society
European Neurological Society - Medical Specialty Society
European Society of Emergency Medicine - Medical Specialty Society
European Union Geriatric Medicine Society - Medical Specialty Society
Finnish Cardiac Society - Medical Specialty Society
French Society of Cardiology - Medical Specialty Society
German Cardiac Society - Medical Specialty Society
Israel Heart Society - Medical Specialty Society
Italian Federation of Cardiology - Medical Specialty Society
Lithuanian Society of Cardiology - Medical Specialty Society
Luxembourg Society of Cardiology - Medical Specialty Society
Netherlands Society of Cardiology - Medical Specialty Society
Polish Cardiac Society - Medical Specialty Society
Portuguese Society of Cardiology - Medical Specialty Society
Romanian Society of Cardiology - Medical Specialty Society
Slovak Society of Cardiology - Medical Specialty Society
Society of Cardiology of the Russian Federation - Medical Specialty Society
Spanish Society of Cardiology - Medical Specialty Society
Turkish Society of Cardiology - Medical Specialty Society
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ, Bloch Thomsen PE, van Dijk JG, Fitzpatrick A, Hohnloser S, Janousek J, Kapoor W, Kenny RA, Kulakowski P, Masotti G, Moya A, Raviele A, Sutton R, Theodorakis G, Ungar A, Wieling W. Guidelines on management (diagnosis and treatment) of syncope--update 2004. Europace 2004 Nov;6(6):467-537. [399 references]

Guideline Availability

Electronic copies: Available from the European Society of Cardiology (ESC) Web site External Web Site Policy.

Print copies: Available from Oxford University Press, Great Clarendon Street, Oxford, OX2 6DP, UK, Tel: +44 (0) 1865 353263, Fax: +44 (0) 1865 353774, Web site: http://www.eurheartj.oxfordjournals.org/ External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Essential messages from ESC guidelines. Syncope. 2009. 7 p. Available in Portable Document Format (PDF) from the European Society of Cardiology (ESC) Web site External Web Site Policy
  • Diagnosis and management of syncope. Pocket guidelines. 2009. Available in English, Spanish, and Turkish. Order form available from the ESC Web site External Web Site Policy. Also available for PDA download from the ESC Web site External Web Site Policy.
  • Guidelines for the diagnosis and management of syncope (version 2009). Slide set. Available from the ESC Web site. External Web Site Policy

Additionally, continuing medical education (CME) credit is available online at the ESC Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on April 2, 2002. This NGC summary was updated by ECRI on March 4, 2005. The updated information was verified by the guideline developer on July 20, 2005. This NGC summary was updated by ECRI Institute on August 2, 2011.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's restrictions.

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