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Angelo Auricchio
Fondazione Cardiocentro
Ticino Lugano, Switzerland
Member of ESC Practice
Guidelines Committee
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There are two main features to distinguish this document from its predecessors. First is an emphasis on the two distinct reasons for evaluating patients with syncope: the need to identify the precise cause of syncope in order to address an effective mechanism-specific treatment; and identification of patient-specific risk, which frequently depends on the underlying disease rather than on the mechanism of syncope itself. The 2009 Guidelines provide extensive background for physicians to avoid confounding these two concepts. And second, the new Guidelines represent a comprehensive document which concerns not only cardiologists but all physicians interested in the field.
The most important introduction with respect to diagnostic tests relates to the role of implantable loop recorders (ILR). Pooled data from nine recent studies in patients with unexplained syncope showed that a correlation between syncope and ECG was found in about one-third at the end of a complete conventional investigation; of these, 56% had asystole, 11% tachycardia and 33% no arrhythmia. Other studies have shown that the presence of a significant arrhythmia can be considered a diagnostic finding even in absence of syncope. The new Guidelines discuss the role of ILR in the diagnostic flowchart of patients with syncope of unknown origin is discussed. When an arrhythmic cause of syncope is suspected but not sufficiently proven to allow treatment based on aetiology, it appears that early use of ILR in the diagnostic work-up may become the standard of reference.
One of the most relevant introductions on the treatment of patients with reflex syncope preceded by prodrome is the effectiveness of physical counter-pressure manoeuvres.
Other unanswered questions covered in the document include the role of pacing in patients with cardio-inhibitory reflex syncope. Data coming from controlled studies, in which patients were selected according to the response to tilt testing, have provided conflicting results. Two non-randomised studies, which evaluated the efficacy of pacing by selecting patients with documented asystole during spontaneous syncope by ILR, showed a striking reduction in recurrence of syncope compared with patients with non-ILR guided therapy. These data suggest that pacing can play a role in therapy for reflex syncope, when spontaneous bradycardia is detected during prolonged monitoring. This hypothesis, however, should be confirmed by ongoing controlled trials.
Finally, this document outlines the structure of a “Syncope Management Unit”. The establishment of such a unit, aimed at patient continuity of care, may determine a reduction of inappropriate admissions and thus set standards of clinical excellence.
(ESC Guidelines for the management of syncope. Sunday 30 August 08:30-10:00, Barcelona – Zone 2 (FPN 174))