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2018 Guidelines for Diagnosis/Management of Syncope

ESC Clinical Practice Guidelines

The 2018 ESC Guidelines for Syncope consist of a full text, supplementary data giving further explanation on specific points, and web-practical instructions. Advice is given on how to evaluate patients with loss of consciousness (LOC) and how to perform and interpret tests properly: tracings, videos, flow charts, and checklists are provided. While the full text gives formal, evidence-based recommendations according to the standard rules of the ESC, the new supplementary data allow expansion of the content into practical issues, filling the gap between the best available scientific evidence and the need for dissemination of these concepts into clinical practice. ('We have the knowledge: we need to teach it'.)

Syncope and Bradycardia
Arrhythmias and Device Therapy
Guidelines version available to download
Published in 2018
Reference Full Text and Supplementary Data -European Heart Journal doi:10.1093/eurheartj/ehy037
Published in 2018
Published in 2018
Reference Practical Instructions - European Heart Journal doi:10.1093/eurheartj/ehy071
Published in 2019
Reference SYNCOP
Published in 2018
Reference Sessions on Syncope at EHRA Congress
Published in 2018
Reference Abridged version on Syncope
Published in 2018
Reference 2018 Press release
Published in 2018
Reference Essential-Messages-Syncope
Published in 2018
Reference Download the ESC Pocket Guidelines App
Table of contents: Full Text (ESC Clinical Practice Guidelines)

1. Preamble

2. Introduction

3. Definitions, Classifications and Pathophysiology

3.1 Definitions 

3.2 Classification and pathophysiology of syncope and transient loss of consciousness 

3.2.1 Syncope 

3.2.2 Nonsyncopal forms of (real or apparent) transient loss of consciousness

4. Diagnostic Evaluation and Management, according to Risk Stratification                    

4.1 Initial evaluation    

4.1.1. Diagnosis of syncope     

4.1.2 Management of syncope in the emergency department based on risk stratification           

4.2 Diagnostic tests     

4.2.1 Carotid sinus massage    

4.2.2 Orthostatic challenge      

4.2.3 Basic autonomic function tests    

4.2.4 Electrocardiographic monitoring (noninvasive and invasive)       

4.2.5 Video recording in suspected syncope     

4.2.6 Electrophysiological study

4.2.7 Endogenous adenosine and other biomarkers      

4.2.8 Echocardiography

4.2.9 Exercise stress testing    

4.2.10 Coronary angiography

5. Treatment   

5.1 General principles of syncope treatment 

5.2 Treatment of reflex syncope          

5.2.1 Education and lifestyle modifications       

5.2.2 Discontinuation/reduction of hypotensive therapy

5.2.3 Physical counterpressure manoeuvres   

5.2.4 Tilt training         

5.2.5 Pharmacological therapy 

5.2.6 Cardiac pacing    

5.3 Treatment of orthostatic hypotension and orthostatic intolerance syndromes          

5.3.1 Education and lifestyle measures

5.3.2 Adequate hydration and salt intake         

5.3.3 Discontinuation/reduction of vasoactive drugs     

5.3.4 Counterpressure manoeuvres    

5.3.5 Abdominal binders and/or support stockings       

5.3.6 Head-up tilt sleeping       

5.3.7 Midodrine

5.3.8 Fludrocortisone   

5.3.9 Additional therapies        

5.3.10 Emerging new pharmacological therapy in specific subgroups    

5.4 Cardiac arrhythmias as the primary cause  

5.4.1 Syncope due to intrinsic sinoatrial or atrioventricular conduction system disease 

5.4.2 Syncope due to intrinsic cardiac tachyarrhythmias          

5.5 Treatment of syncope secondary to structural cardiac, cardiopulmonary, and great vessel disease

5.6 Treatment of unexplained syncope in patients at high risk of sudden cardiac death

5.6.1 Definition

5.6.2 Left ventricular systolic dysfunction        

5.6.3 Hypertrophic cardiomyopathy     

5.6.4 Arrhythmogenic right ventricular cardiomyopathy

5.6.5 Patients with inheritable arrhythmogenic disorders          

6. Special Issues

6.1 Syncope in patients with comorbidity and frailty     

6.1.1 Comorbidity and polypharmacy   

6.1.2 Falls       

6.1.3 Cognitive assessment and physical performance tests     

6.2 Syncope in paediatric patients       

6.2.1 Diagnostic evaluation      

6.2.2. Therapy 

7. Psychogenic Transient Loss of Consciousness and its Evaluation

7.1 Diagnosis  

7.1.1 Historical criteria for attacks       

7.1.2 Documentation of key features during an attack  

8.Neurological Causes and Mimics of Syncope

8.1 Clinical conditions  

8.1.1. Autonomic failure          

8.1.2 Epilepsy and ictal asystole          

8.1.3 Cerebrovascular disorders           

8.1.4 Migraine 

8.1.5 Cataplexy

8.1.6 Drop attacks       

8.2 Neurological tests  

8.2.1 Electroencephalography  

8.2.2 Brain-computed tomography and magnetic resonance imaging    

8.2.3 Neurovascular studies    

8.2.4 Blood tests         

9. Organizational Aspects

9.1 Syncope (transient loss of consciousness) management unit          

9.1.1 Definition of a syncope unit        

9.1.2 Definition of a syncope specialist    

9.1.3 Goal of a syncope unit    

9.1.4 Model of a syncope unit  

9.1.5 Access and referrals to a syncope unit       

9.1.6 Outcomes and quality indicators 

9.2 The clinical nurse specialist in the syncope unit      

9.2.1 Definition

9.2.2 Role and skills of a clinical nurse specialist 

10. Key Messages

11. Gaps in Evidence and Areas for Future Research

12. 'What To Do' and 'What Not To Do' Messages from the Guidelines

13. Supplementary Data and Web-Practical Instructions

14. Appendix of CPG Members and National Cardiac Societies Reviewers

15. References


Previous version available to download
Published in 2009
Reference European Heart Journal (2009) 30, 2631–2671; doi:10.1093/eurheartj/ehp298