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2018 ESC Clinical Practice Guidelines in the spotlight Syncope

ESC Congress News 2018 - Munich, Germany

The 2018 ESC Guidelines for the Diagnosis and Management of Syncope1 aim to focus on proper initial and subsequent evaluation, in order to help distinguish between benign and life-threatening causes, and describe available therapeutic options.

Syncope and Bradycardia
Arrhythmias and Device Therapy

Javier-2018-esc-congress-news.jpgDoctor Javier Moreno (Hospital Ramon y Cajal, Madrid, Spain), who together with Professor Adam Torbicki (European Health Centre Otwock, Otwock, Poland) moderated the review process of the new version of these guidelines, explains why they are so important and summarises the key updates since publication of the previous guidelines in 2009.

“The current guidelines provide a thorough state-of-the-art vision of the problem, dealing with both diagnostic and therapeutic considerations.”

“Syncope is one of the leading causes of Emergency Department admissions. The broad aetiological causes involved, ranging from absolutely benign—luckily in most cases—to serious conditions, make many physicians feel uncomfortable in dealing with them,” explains Prof. Moreno. The current ESC Guidelines have been produced with the contribution of the European Heart Rhythm Association and, in contrast to many standard textbooks, have been developed by many recognised experts—not only cardiologists but those from many other medical fields.

So, what are the most important changes? Dr. Moreno highlights that the new version emphasises a very systematic way of managing patients after transient loss of consciousness, both at the initial evaluation in the Emergency Department and at subsequent investigations either in hospital or on an ambulatory basis. “The guidelines state very clearly when the patient should be hospitalised according to the presence or absence of well-established high-risk features,” he says. “The authors have comprehensively reviewed all diagnostic and therapeutic measures regarding syncope and have scientifically redefined their present role in 2018, indicating how strong the evidence is for each of them. Tests and therapies have been reclassified following standard ESC classes of recommendation and, accordingly, new diagnostic and therapeutic algorithms and flowcharts have been created.”

There is particular emphasis that all patients with reflex syncope and orthostatic hypotension should receive clear and full explanation of their diagnosis and the risk of recurrence. The importance of giving reassurance and advice on how to avoid triggers is highlighted. “These measures are the cornerstone of treatment and have a high impact in reducing the recurrence of syncope,” says Dr. Moreno.

The current guidelines also cover some of the non-cardiovascular causes of transient loss of consciousness, which can be very useful for the cardiologist, and include the increased role of prolonged ECG monitoring. A further new aspect is the support of video recording at home, with mobile phones, of unclear episodes of syncope in order to provide more information to assist with aetiological analysis. The establishment and goals of Syncope Management Units are described in detail, in terms of structure, tests and assessments, access and referrals, the role of the Clinical Nurse Specialist, and outcome and quality indicators. Dr Moreno adds, “A new chapter is included that provides clear definitions of all the terms that may be related to syncope, in order to avoid frequent confusion—this will be very helpful for cardiologists.”

As to what these changes may mean for clinical practice, Dr Moreno is clear. “As most episodes of syncope occur away from the hospital and have fully ended by the time of consultation, a significant amount of speculation is always involved in the diagnostic process. Clinicians following the present guidelines should feel reassured in their daily work that they are complying with the highest standards of care according to the ESC.”

  1. Brignole, M et al. Eur Heart J 2018;39:1883–1948.


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Notes to editor

About the European Society of Cardiology

The European Society of Cardiology brings together healthcare professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

About ESC Congress 2018

ESC Congress is the world’s largest and most influential cardiovascular event contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2018 takes place 25 to 29 August at the Messe München in Munich, Germany. Explore the scientific programme