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Syncope

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of syncope are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the European Society of Cardiology (ESC 2022,2021,2018,2014), the American College of Radiology (ACR 2021), the American Heart Association (AHA/HRS/ACC 2019,2018,2017), and the Canadian Pediatric Cardiology Association (CPCA/CCS 2017).
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Screening and diagnosis

Diagnostic criteria, situational syncope
As per ESC 2018 guidelines:
Suspect situational reflex syncope with high probability in patients with syncope occurring during or immediately after specific triggers.
B
Confirm reflex syncope when syncope is reproduced immediately after exercise in the presence of severe hypotension.
B
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  • Diagnostic criteria (vasovagal syncope)

  • Diagnostic criteria (carotid sinus syndrome)

  • Diagnostic criteria (orthostatic hypotension-induced syncope)

  • Diagnostic criteria (cardiac syncope, arrhythmic)

  • Diagnostic criteria (cardiac syncope, structural)

Classification and risk stratification

Risk assessment: as per AAFP 2023 guidelines, consider using risk stratification scores in the management of patients with syncope, although they have not been shown to be superior to physician judgment.
C
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Diagnostic investigations

History and physical examination: as per AAFP 2023 guidelines, elicit history and perform a physical examination, including orthostatic BP assessment, in patients presenting with syncope.
B
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  • Home video recording

  • Initial ECG

  • Cardiac monitoring (noninvasive techniques)

  • Cardiac monitoring (implantable loop recorder)

  • Carotid sinus massage

  • Orthostatic challenge (active standing)

  • Orthostatic challenge (tilt testing)

  • Autonomic function tests (indications)

  • Autonomic function tests (Valsalva maneuver)

  • Autonomic function tests (deep-breathing test)

  • Autonomic function tests (other tests)

  • Ambulatory BP monitoring

  • Cardiac imaging (echocardiography)

  • Cardiac imaging (CT/MRI)

  • Exercise stress testing

  • Chest imaging

  • Neurological evaluation

  • Cerebrovascular imaging

  • EEG

  • Laboratory testing

  • Genetic testing

Diagnostic procedures

Electrophysiological studies: as per ESC 2022 guidelines, consider obtaining electrophysiological evaluation when syncope remains unexplained after noninvasive evaluation in patients with dilated cardiomyopathy/hypokinetic non-dilated cardiomyopathy.
C
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  • Coronary angiography

Medical management

Setting of care
As per AAFP 2023 guidelines:
Manage patients with low-risk features suggestive of reflex or orthostatic syncope without hospital admission.
B
Admit patients with high-risk features suggestive of cardiac syncope to the hospital or observation unit.
B
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  • Management of reflex syncope (general principles)

  • Management of reflex syncope (nonpharmacological management)

  • Management of reflex syncope (pharmacotherapy)

  • Management of reflex syncope (cardiac pacing)

  • Management of carotid sinus syndrome

  • Management of vasovagal syncope (general principles)

  • Management of vasovagal syncope (nonpharmacological management)

  • Management of vasovagal syncope (pharmacotherapy)

  • Management of vasovagal syncope (cardiac pacing)

  • Management of OH-induced syncope (general principles)

  • Management of OH-induced syncope (nonpharmacological management)

  • Management of OH-induced syncope (pharmacotherapy)

  • Management of cardiac arrhythmia-induced syncope (general principles)

  • Management of cardiac arrhythmia-induced syncope (bradycardia)

  • Management of cardiac arrhythmia-induced syncope (bundle branch block)

  • Management of cardiac arrhythmia-induced syncope (long QT syndrome)

  • Management of cardiac arrhythmia-induced syncope (short QT syndrome)

  • Management of cardiac arrhythmia-induced syncope (Brugada syndrome)

  • Management of cardiac arrhythmia-induced syncope (early repolarization pattern)

  • Management of cardiac arrhythmia-induced syncope (SVT and VT)

  • Management of cardiac arrhythmia-induced syncope (catecholaminergic polymorphic VT)

  • Management of syncope due to cardiac structure disease (general principles)

  • Management of syncope due to cardiac structure disease (LV systolic dysfunction)

  • Management of syncope due to cardiac structure disease (HCM)

  • Management of syncope due to cardiac structure disease (ARVC)

  • Management of syncope due to cardiac structure disease (cardiac sarcoidosis)

  • Management of syncope due to cardiac structure disease (coronary anomalies)

  • Management of psychogenic pseudosyncope

  • Management of unexplained syncope

Specific circumstances

Pediatric patients, evaluation: as per ACC/AHA/HRS 2017 guidelines, elicit a detailed medical history and family history, perform a physical examination, and obtain a 12-lead ECG to evaluate for vasovagal syncope in all pediatric patients presenting with syncope.
B
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  • Pediatric patients (management)

  • Elderly patients

  • Athletes

Quality improvement

Driving restrictions: as per ACC/AHA/HRS 2017 guidelines, consider ensuring that healthcare providers managing patients with syncope know the driving laws and restrictions in their regions and discuss implications with the patient.
C
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