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Guidelines on management (diagnosis and treatment) of syncope – Update 2004
The task force on Syncope, European Society of Cardiology

Michele Brignole, Paolo Alboni, David G. Benditt, Lennart Bergfeldt, Jean-Jacques Blanc, Poul Erik Bloch Thomsen, J. Gert van Dijk, Adam Fitzpatrick, Stefan Hohnloser, Jan Janousek, Wishwa Kapoor, Rose Anne Kenny, Piotr Kulakowski, Giulio Masotti, Angel Moya, Antonio Raviele, Richard Sutton, George Theodorakis, Andrea Ungar, Wouter Wieling
DOI: http://dx.doi.org/10.1016/j.ehj.2004.09.004 2054-2072 First published online: 2 November 2004

Executive Summary

ESC Committee for Practice Guidelines (CPG): Silvia G. Priori (Chairperson) (Italy), Maria Angeles Alonso Garcia (Spain), Jean-Jacques Blanc (France), Andrzej Budaj (Poland), Martin Cowie (UK), Jaap Deckers (The Netherlands), Enrique Fernandez Burgos (Spain), John Lekakis (Greece), Bertil Lindhal (Sweden), Gianfranco Mazzotta (Italy), João Morais (Portugal), Ali Oto (Turkey), Otto Smiseth (Norway)

Document reviewers: Silvia G. Priori (CPG Review Coordinator) (Italy), Martin Cowie (UK), Carlo Menozzi (Italy), Hugo Ector (Belgium), Ali Oto (Turkey), Panos Vardas (Greece)

Preamble

Guidelines and Expert Consensus documents aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and by different organisations and other related societies. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents.

In spite of the fact that standards for issuing good quality Guidelines and Expert Consensus Documents are well defined, recent surveys of Guidelines and Expert Consensus Documents published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilization of health resources.

The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by Task Forces, expert groups or consensus panels. The chosen experts in these writing panels are asked to provide disclosure statements of all relationships they may have which might be perceived as real or potential conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. The Committee is also responsible for the endorsement of these Guidelines and Expert Consensus Documents or statements.

The Task Force has classified and ranked the usefulness or efficacy of the recommended procedure and/or treatments and the Level of Evidence as indicated in the tables below:

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. Classes of recommendations

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Levels of evidence

Introduction

The European Society of Cardiology guidelines for the management (diagnosis and treatment) of syncope were published in August 2001.1 Since then, more clinical trials and observational studies have been published, some of which alter the recommendations made in that document. The panel reconvened in September 2003, made revisions where appropriate and developed the consensus recommendations. This executive summary reports the most important changes.

Furthermore, since the strategies for the assessment of syncope vary widely among physicians and among hospitals in Europe, we recognised the need to coordinate the evaluation of syncope. The panel sought to define ESC standards for the management of syncope and proposed a model of organisation for the evaluation of the syncope patient. A new section was thus added to the document on this topic.

The full revised text, including all references, of this document is available on the website of the European Society of Cardiology (www.escardio.org) in the section 'Knowledge Centre', Guidelines and Scientific Statements and it was published in Europace 2004;6:467–537.

Part 1. The initial evaluation

The diagnostic strategy based on the initial evaluation

The 'Initial evaluation' of a patient presenting with syncope consists of: careful history, physical examination including orthostatic blood pressure measurements and standard electrocardiogram (ECG).2–9

Differentiating true syncope from 'non-syncopal' conditions associated with real or apparent transient loss of consciousness is generally the first diagnostic challenge and influences the subsequent diagnostic strategy (Fig. 1).

Table 1 provides a clinical classification of the principal known causes of transient loss of consciousness (TLOC). The subdivision of syncope is based on pathophysiology as follows:

  • •'Neurally-mediated (reflex) syncope' refers to a reflex response that, when triggered, gives rise to vasodilatation and bradycardia; however, the contribution of each of these two factors to systemic hypotension and cerebral hypoperfusion may differ considerably. The triggering events might vary considerably over time in any individual patient. The 'classical vasovagal syncope' is mediated by emotional or orthostatic stress and can be diagnosed by history taking. 'Carotid sinus syncope' is defined as syncope which, by history, seems to occur in close relationship with accidental mechanical manipulation of the carotid sinuses, and which can be reproduced by carotid sinus massage. 'Situational syncope' refers to those forms of neurally-mediated syncope associated with specific scenarios (e.g., micturition, coughing, defecating, etc.). Often, however, neurally-mediated syncopes have a 'non-classical' presentation. These forms are diagnosed by minor clinical criteria, exclusion of other causes for syncope (absence of structural heart disease) and the positive response to tilt testing or carotid sinus massage. Examples of non-classical vasovagal syncope include episodes without clear triggering events or premonitory symptoms.

  • •'Orthostatic hypotension' refers to syncope in which the upright position (most often the movement from sitting or lying to an upright position) causes arterial hypotension. This occurs when the autonomic nervous system is incapacitated and fails to respond to the challenges imposed by upright position. A second major cause is 'volume depletion' in which the autonomic nervous system is itself not deranged, but is unable to maintain blood pressure due to decreased circulating volume. Note that vasovagal syncope can also be provoked by standing (e.g., soldiers fainting on parade), but these events are grouped under 'neurally-mediated (reflex) syncope'.

  • •'Cardiac arrhythmias' can cause a decrease in cardiac output, which usually occurs irrespective of circulatory demands.

  • •'Structural heart disease' can cause syncope when circulatory demands outweigh the impaired ability of the heart to increase its output.

  • •'Steal' syndromes can cause syncope when a blood vessel has to supply both part of the brain and an arm.

Non-syncopal conditions

Several disorders may resemble syncope in two different ways. In some, consciousness is truly lost, but the mechanism is something other than cerebral hypoperfusion. Examples are epilepsy, several metabolic disorders (including hypoxia and, hypoglycaemia) and intoxications. In several other disorders, consciousness is only apparently lost; this is the case in 'psychogenic pseudo-syncope', cataplexy and drop attacks. Table 2 lists the most common conditions misdiagnosed as the cause of syncope. A differentiation such as this is important because the clinician is usually confronted with patients with sudden loss of consciousness, which may be due to causes not associated with decreased cerebral blood flow such as seizure and/or conversion reaction.

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Recommendations. Neurological and psychiatric investigations

The initial evaluation may lead to certain or suspected diagnosis or no diagnosis (here termed as unexplained syncope) (Fig. 2).

Certain diagnosis

Initial evaluation may lead to a certain diagnosis based on symptoms, signs or ECG findings. Under such circumstances, no further evaluation of the disease or disorder may be needed and treatment, if any, can be planned. This is the case in the following recommendations:

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Recommendations. Diagnostic criteria based on the initial evaluation

Suspected diagnosis

More commonly, the initial evaluation leads to a suspected diagnosis, when one or more of the features listed in Tables 3 and 4 are present. A suspected diagnosis needs to be confirmed by directed testing. If a diagnosis is confirmed by specific testing, treatment may be initiated. On the other hand, if the diagnosis is not confirmed, then patients are considered to have unexplained syncope and are evaluated as follows.

Unexplained syncope

The initial evaluation may lead to no diagnosis (here termed as unexplained syncope). The strategy of evaluation varies according to the severity and frequency of the episodes. In patients with unexplained syncope the likely diagnosis is neurally-mediated. The tests for neurally mediated syncope consist of tilt testing and carotid massage. The majority of patients with single or rare episodes in this category probably have neurally mediated syncope and tests for confirmation are usually not necessary. If it is not clear that it was syncope, the term 'transient loss of consciousness (TLOC) is preferable and reappraisal is warranted.

Re-appraisal

Once the evaluation, as outlined, is completed and no cause of syncope is determined, re-appraisal of the work-up is needed since subtle findings or new historical information may change the entire differential diagnosis. Re-appraisal may consist of obtaining details of history and re-examining patients as well as review of the entire work-up. If unexplored clues to possible cardiac or neurological disease are apparent, further cardiac and neurological assessment is recommended. In these circumstances, consultation with appropriate speciality services may be needed. An additional consideration is psychiatric illness. Psychiatric assessment is recommended in patients with frequent recurrent syncope who have multiple other somatic complaints and initial evaluation raises concerns for stress, anxiety and possible other psychiatric disorders.

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Recommendations. Diagnostic work-up based on the initial evaluation

Part 2. Diagnostic tests

Electrocardiographic monitoring (non-invasive and invasive)

As a general rule ECG monitoring is indicated only when there is a high pre-test probability of identifying an arrhythmia responsible for syncope. These conditions are those listed in Tables 3 and 4.

In-hospital monitoring (in bed or telemetric) is warranted only when the patient is at high risk of life-threatening arrhythmias. A few days of ECG monitoring may be of value, especially if the monitoring is applied immediately after a syncopal attack.

In a recent study,10 external loop recorder was not useful for diagnosis of syncope in patients with 3±4 episodes (⩾2) of syncope during the previous 6 months, no overt heart disease and a negative tilt testing.

In the initial clinical experience Implantable Loop Recorder was used for diagnosis in patients with unexplained syncope after a comprehensive conventional work-up. Pooled data from 4 studies11–14 for a total of 247 patients showed that a correlation between syncope and ECG was found in 84 patients (34%); of these 52% had a bradycardia or asystole at the time of the recorded event, 11% had tachycardia and 37% had no rhythm variation. One study15 randomized 60 patients with unexplained syncope to "conventional" testing with external loop recorder, tilt and electrophysiological testing or to prolonged monitoring with the Implantable Loop Recorder. The results showed that a strategy of implantation of the Loop recorder in an initial phase of the work-up is more likely to provide a diagnosis than conventional testing (52% vs. 20%) (level B). There are several areas of interest that merit further clarification:

  • •patients in whom epilepsy was suspected but the treatment has proven ineffective;16

  • •patients with recurrent unexplained syncope without structural heart disease when the understanding of the exact mechanism of spontaneous syncope may alter the therapeutic approach;11

  • •patients who have a diagnosis of neurally-mediated syncope when the understanding of the exact mechanism of spontaneous syncope may alter the therapeutic approach;11

  • •patients with bundle branch block in whom a paroxysmal AV block is suspected despite a complete negative electrophysiological evaluation;17

  • •patients with definite structural heart disease and/or non-sustained ventricular tachyarrhythmias in whom a ventricular tachyarrhythmia is suspected despite a completely negative electrophysiological study;17

  • •patients with unexplained falls.18

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Recommendations. Electrocardiographic monitoring

Electrophysiological testing

Suspected ventricular tachycardia

The outcome largely depends on the clinical features of the patients. It seems that only the inducibility of sustained ventricular tachycardia and/or very depressed systolic function can predict a life-threatening arrhythmic syncope and, conversely, their absence suggests a more favourable outcome.

The specificity of the induction of polymorphic ventricular tachycardia and ventricular fibrillation probably depends on the clinical setting. On one hand, in coronary artery disease and syncope, the follow-up of patients with and without inducible ventricular fibrillation did not demonstrate any difference in survival between the two groups.19 On the other hand, the induction of polymorphic ventricular arrhythmias seems to have a predictive value in patients with the Brugada syndrome,20,21 in survivors of cardiac arrest with significant coronary artery disease undergoing coronary by-pass surgery and in idiopathic ventricular fibrillation.22–24

Programmed ventricular stimulation has a low predictive value in patients with nonischaemic dilated cardiomyopathy. In a study25 of selected patients affected by idiopathic dilated cardiomyopathy who received an ICD, there was a high incidence of appropriate shocks both in the inducible and in non-inducible sustained monomorphic ventricular tachycardia groups. In another study26 the induction of polymorphic ventricular tachycardia or fibrillation during electrophysiological study was of no value for predicting syncopal events or ventricular tachyarrhythmias.

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Recommendations. Electrophysiological testing

ATP test

Endogenous adenosine release may be involved in the triggering mechanism of syncope induced during tilt testing.27 In a prospective follow-up study,28 using an Implantable Loop Recorder for arrhythmia detection, the mechanism of syncope was heterogeneous and ATP-induced AV block predicted AV block as the mechanism of the spontaneous syncope only in a few patients; the overall outcome was benign and there were no complications.

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Recommendations. ATP test

Part 3. Treatment

Neurally-mediated (reflex) syncope

Non-pharmacological "physical" treatments are emerging as a new front line treatment of vasovagal syncope. In highly motivated patients with recurrent vasovagal symptoms, the prescription of progressively prolonged periods of enforced upright posture (so-called 'tilt-training') may reduce syncope recurrence. However, this treatment is hampered by the low compliance of patients to continue the training programme for a long period29–32 (Level B). Two recent clinical trials33,34 have shown that isometric counter-pressure manoeuvres of the legs (leg crossing) or of the arms (hand grip and arm tensing) are able to induce a significant blood pressure increase during the phase of impending vasovagal syncope, which allow the patient to avoid or delay losing consciousness in most cases (level B).

Pacing for vasovagal syncope has been the subject of five major multicentre randomised controlled trials:35–39 three gave positive and two negative results. Putting together the results of the 5 trials, 318 patients were evaluated; syncope recurred in 21% (33/156) of the paced patients and in 44% (72/162) of not paced patients (p<0.001). However, all the studies have weaknesses and further follow-up studies addressing many of these limitations (particularly the pre-implant selection criteria of the patients who might benefit from pacemaker therapy) need to be completed before pacing can considered an established therapy.

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Recommendations. Treatment of neurally – mediated (reflex) syncope

Part 4. Special issues

Syncope in paediatric patients

Careful personal and family history and standard ECG is most important in distinguishing the benign neurally-mediated syncopes (also called reflex anoxic seizure or breath holding spells in infants and children). There are numerous warning signs from the history that should indicate a potentially life-threatening cause.40 These are:

  • •syncope in response to loud noise, fright, or extreme emotional stress

  • •syncope during exercise including swimming (near drowning)

  • •syncope while supine

  • •family history of sudden death in young person <30 years old

Probably the most important investigation is ECG, primarily to exclude inherited syndromes.

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Recommendations. Syncope in paediatric patients

Syncope management facilities

Syncope is a common symptom in the community and in emergency medicine. In one study,41 syncope and collapse were the sixth commonest reason for admission of adults aged over 65 years to acute medical hospital beds. The average length of stay for these admissions was 5–17 days – emphasising the diversity of syncope management strategies and availability of existing investigations. Hospital admission alone accounted for 74% of the cost of investigating syncope.41 In a study, based on administrative data from Medicare, there were estimated to be 193,164 syncope hospital discharges in 1993 in the USA.42 The cost per discharge was calculated to $4,132 and increased to $5,281 for those patients who were readmitted for recurrent syncope. In UK the 41 the overall cost per patient was £611, with 74% attributed to the costs of hospital stay alone. Cost per diagnosis of patients admitted to hospital was £1080.

Currently, the strategies for assessment of syncope vary widely among physicians and among hospitals and clinics. More often than not, the evaluation and treatment of syncope is haphazard and not stratified. The result is a wide variation in the diagnostic tests applied, the proportion and types of attributable diagnoses and the proportion of syncope patients in whom the diagnosis remains unexplained.41,43–45 For example, in a prospective registry43 enrolling patients referred to the emergency department from 28 general hospitals in Italy, carotid sinus massage was performed in 0–58% and head up tilt tests in from 0% to 50% of the syncope patients. Consequently the final diagnosis for neurally-mediated syncope ranged from 10% to 79%. These disparate patterns of assessment can explain why pacing rates for carotid sinus syndrome vary, even within countries, from 1% to 25% of implants, depending on whether carotid sinus hypersensitivity is systematically assessed in the investigation profile. If the evaluation of syncope remains unchanged, diagnostic and treatment effectiveness is unlikely to improve substantially. Furthermore, the implementation of the published syncope management guidelines will be diverse and incomplete. Thus, to maximise implementation of the guidelines it is recommended that models of care for assessment and management of syncope are in place and that information about the models within each organisation is adequately communicated to all parties involved with syncope patients.

It is the view of the European Society of Cardiology Syncope Task Force that a cohesive, structured care pathway – either delivered within a single syncope facility or as a more multi-faceted service – is the optimal for quality service delivery (Fig. 3).

Professional skill mix for the syncope evaluation facility

It is probably not appropriate to be dogmatic regarding the training needs of personnel responsible for a dedicated syncope facility. These skills will depend on the pre-determined requirements of local professional bodies, the level of screening evaluation provided prior to referral, and the nature of the patient population typically encountered in a given setting. In general, experience and training in key components of cardiology, neurology, emergency and geriatric medicine are pertinent to the assessment and diagnosis of syncope. In addition, access to other specialties such as psychiatry, physiotherapy, occupational therapy, Ear Nose and Throat specialties and clinical psychology is important.

Core medical and support personnel should be involved full time or most of the time in the management of the Unit and should interact with all other stakeholders in the hospital and in the community.

Staff responsible for the clinical management of the facility should be conversant with the recent syncope guidelines. A structured approach to the management of syncope also expedites clinical audit, patient information systems, service developments, and continuous professional training.

Equipment

Core equipment for the syncope evaluation facility include: surface ECG recording, phasic blood pressure monitoring, tilt table testing equipment, external and internal (implantable) ECG loop recorder systems, 24 h ambulatory blood pressure monitoring, 24 h ambulatory ECG monitoring, and autonomic function testing. The facility should also have access to echocardiography, invasive electrophysiological testing, stress testing, cardiac imaging, computed tomography and magnetic resonance imaging and electroencephalography.

Patients should have preferential access to hospitalisation and to any eventual therapy for syncope, namely pacemaker and ICD implantation, catheter ablation of arrhythmias, etc.

Dedicated rooms for assessment and investigation are required.

Setting

The majority of syncope patients can be investigated as out-patients or day cases. Indications for hospital admission are defined in another section (see part 4 "Need for hospitalisation").

The role of a local integrated syncope service is to set standards for the following in keeping with the objectives of the Guidelines on Syncope of the European Society of Cardiology and other appropriate guideline publications:

  • •The diagnostic criteria for causes of syncope

  • •The preferred approach to the diagnostic work-up in subgroups of patients with syncope

  • •Risk stratification of the patient with syncope

  • •Treatments to prevent syncopal recurrences

A major objective of the syncope facility is to reduce the number of hospitalisations by offering the patient a well defined, quick, alternative evaluation pathway.

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Recommendations. Syncope managment facilities

Driving and syncope

An ESC Task Force report on driving and heart disease was published in 1998 which is the present reference standard for Europe46 (Table 5). Two groups of drivers are defined. Group one comprises drivers of motorcycles, cars and other small vehicles with and without a trailer. Group two includes drivers of vehicles over 3.5 metric tonnes (3,500 kilos) or passengers 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.

This Task force has the benefit of further publications that are relevant. Data suggest that the risk for car accident related to syncope is low.46–49 Repeat tilt testing to assess any therapy probably has no predictive value. There is no evidence that allowing three asymptomatic months to elapse provides any confirmation that attack will not recur. To date, the evidence in favour of drug therapy remains unconvincing. Neurological review in syncopal patients is of little value. Modified disqualifying criteria according to 2004 Syncope Task Force are also reported in Table 5.

Appendix A: ESC Task Force on Guidelines on management (diagnosis and treatment) of syncope

Michele Brignole, MD, FESC, Department of Cardiology and Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy (Chair)

Paolo Alboni, MD, Divisione di Cardiologia, Ospedale Civile, Cento, Italy

David Benditt, MD, Cardiac Arrhythmia Service, Cardiovascular Division, University of Minnesota, Minneapolis, USA

Lennart Bergfeldt, MD, FESC, Electrophysiology & Arrhythmia Service, Department of Cardiology, Thoracic Clinics, Karolinska Hospital Stockholm, Sweden

Jean Jacques Blanc, MD, FESC, Departement de Cardiologie, Hôpital de la Cavale Blanche, CHU de Brest, France

Poul Erik Bloch Thomsen, MD, Department of Cardiology, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark

J. Gert van Dijk, MD, Department of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands

Adam Fitzpatrick, MD, Manchester Heart Centre, Manchester, Royal Infirmary, Manchester, UK

Stefan Hohnloser, MD, FESC, Medizinische Klinik IV, Kardiologie Klinicum der JW Goethe University, Frankfurt, Germany

Jan Janousek, MD, Kardiocentrum, University Hospital Motol, Prague, Czech Republic

Wishwa Kapoor, MD, Department of Medicine, University of Pittsburg, Pittsburg, Pennsylvania, USA

Rose-Anne Kenny, MD, Institute for the Health of the Elderly, University of Newcastle Upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne, UK

Piotr Kulakowski, MD, FESC, Department of Cardiology, Med. Centre of Postgraduate Education, Grochowski Hospital, Warsaw, Poland

Giulio Masotti, MD, Unit of Geriatric Medicine, University of Firenze and Azienda Ospedaliera Careggi, Firenze, Italy

Angel Moya, MD, FESC, Department of Cardiology, Hospital General Vall d'Hebron, Barcelona, Spain

Antonio Raviele, MD, FESC, Divisione di Cardiologia, Ospedale Umberto I, Mestre-Venice, Italy

Richard Sutton, DScMed, FESC, Department of Cardiology, Royal Brompton Hospital, London, UK

George Theodorakis, MD, FESC, 2° Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece

Andrea Ungar, MD, Unit of Geriatric Medicine, University of Firenze and Azienda Ospedaliera Careggi, Firenze, Italy

Wouter Wieling, MD, Academic Medical Centre, University of Amsterdam, Department of Internal Medicine, Amsterdam, The Netherlands

Fig. 1

Classification of transient loss of consciousness.

Fig. 2

The flow diagram proposed by the Task Force on Syncope of an approach to the evaluation of loss of consciousness based on the Initial Evaluation. Instructions for the use of the flow diagram. Differentiating true syncope from other 'non-syncopal' conditions associated with real or apparent transient loss of consciousness is generally the first diagnostic step and influences the subsequent diagnostic strategy. For the classification of syncope refer to Table 1 and for the classification of non-syncopal attack refer to Table 2. The conditions in which the results of the initial evaluation are diagnostic of the cause of syncope and no further evaluation is required are listed as recommendations in the section "The initial evaluation". The features which suggest a cardiac or a neurally-mediated cause of syncope are listed in Tables 3 and 4. Among cardiac investigations, echocardiography, prolonged electrocardiographic monitoring, stress test, electrophysiological study and implantable loop recorder are most useful. Among neurally-mediated investigations, tilt test, carotid sinus massage and implantable loop recorder are most useful. When a cardiac diagnosis cannot be confirmed, neurally-mediated tests are usually performed. Once the evaluation, as outlined, is completed and no cause of syncope is determined, re-appraisal of the work-up may be needed. BP: blood pressure; ECG: electrocardiogram.

Fig. 3

A proposed model of organisation for the evaluation of the syncope patient in a community.

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Table 1. Causes of syncope

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Table 2. Causes of non-syncopal attacks (commonly misdiagnosed as syncope)

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Table 3. Clinical features suggestive of specific causes of syncope

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Table 4. ECG abnormalities suggesting an arrhythmic syncope

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Table 5. Suggested recommendations for driving rules in patients suffering from syncope (modified after Task Force Report of the European Society of Cardiology on Driving and Heart Disease46)

Footnotes

  • The full text of this document is available on the website of the European Society of Cardiology (http://www.escardio.org) in the section 'Knowledge Centre', Guidelines and Scientific Statements and was published in Europace 2004;6: 467–537.

  • ☆☆ For affiliations of Task Force members see Appendix A.

  • 1 Corresponding author: Michele Brignole, MD FESC, Department of Cardiology and Arrhythmologic Centre, Ospedali del Tigullio, 16033 Lavagna, Italy. Tel.: +39 185 329569; fax: +39 185 306506. E-mail address: mbrignole@ASL4.liguria.it (M. Brignole)

  • 2 Representative of the European Union Geriatric Medicine Society.

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