What is the approach to syncope according to European Society of Cardiology (ESC) guidelines?

Approach to Syncope According to ESC Guidelines

According to the European Society of Cardiology (ESC) guidelines, the approach to syncope should follow a structured pathway focused on risk stratification, with specialized syncope units being the optimal setting for evaluation and management of patients with syncope. 1

Initial Evaluation and Risk Stratification

Key Components of Initial Assessment

• Complete medical history focusing on:
  • Circumstances before the event (position, activity, predisposing factors)
  • Onset (presence of prodromal symptoms)
  • Event characteristics (witnessed information, duration, recovery pattern)
  • Age-specific considerations (older patients may have multiple causes) 1
• Physical examination including:
  • Vital signs with orthostatic blood pressure measurements
  • Cardiovascular examination
  • Neurological assessment
• 12-lead ECG to identify potential cardiac causes

High-Risk Features Requiring Immediate Attention

• Syncope during exertion or in supine position
• Absence of prodromal symptoms
• Family history of sudden cardiac death
• Presence of structural heart disease or heart failure
• Abnormal ECG findings (bifascicular block, QRS >120ms, arrhythmias) 2
• Age >60 years with structural heart disease 1, 2

Diagnostic Pathway

Reflex Syncope (Most Common)

• Characterized by prodromal symptoms (nausea, sweating, pallor)
• Triggered by emotional stress, prolonged standing, pain
• Diagnostic tests:
  • Tilt table testing (Class IIa recommendation) for suspected cases 1
  • Carotid sinus massage in patients >40 years 1

Cardiac Syncope

• Second most common cause, especially in older patients
• Diagnostic approach:
  • Echocardiography when structural heart disease is suspected
  • Electrophysiological study (EPS) is recommended for:
    • Patients with ischemic heart disease (Class I)
    • Syncope with bifascicular block (Class IIa)
    • Syncope with sinus bradycardia or palpitations (Class IIb) 1
  • Implantable loop recorder (ILR) recommended for:
    • Recurrent unexplained syncope
    • Patients with bifascicular block and negative EPS (Class I) 1

Orthostatic Hypotension

• Common in elderly patients
• Diagnostic approach:
  • Orthostatic BP measurements (repeat in morning or after syncope)
  • 24-hour ambulatory BP monitoring when instability is suspected 1

Management Based on Etiology

Reflex Syncope

• Non-pharmacological approaches:
  • Patient education (Class I, LOE: B)
  • Physical counter-pressure maneuvers for patients with prodrome (Class IIa, LOE: B) 1
  • Orthostatic training may be considered in young patients (Class IIb) 1
• Pharmacological therapy:
  • Midodrine may be considered for orthostatic form of vasovagal syncope (Class IIb)
  • Fludrocortisone may be considered in young patients with orthostatic form (Class IIb)
  • Beta-blockers are not indicated (Class III, LOE: A) 1

Cardiac Syncope

• Pacemaker implantation:
  • Recommended for documented high-grade AV block
  • EPS-guided pacemaker implantation for bifascicular block (Class I) 1
  • Consider empiric pacing in patients with syncope and bifascicular block when other causes excluded (Class IIb) 1
• ICD implantation for patients with life-threatening ventricular arrhythmias

Orthostatic Hypotension

• Non-pharmacological measures:
  • Avoid rapid position changes
  • Increase fluid and salt intake
  • Physical counter-maneuvers
• Medication review and adjustment of hypotensive drugs

Organizational Approach

Syncope Units

• ESC strongly recommends a cohesive, structured care pathway delivered through a syncope unit 1
• Benefits include:
  • Standardized assessment protocols
  • Reduced hospitalizations
  • Improved diagnostic yield
  • Better cost-effectiveness 1

Patient Disposition

• Hospitalization criteria:
  • Presence of high-risk features
  • Severe comorbidities
  • Need for immediate treatment
• Low-risk patients can be managed as outpatients with referral to specialized syncope units 1

Special Populations

Elderly Patients

• Multiple risk factors often present
• Cognitive assessment may be necessary
• Evaluation should include assessment of frailty and fall risk 1
• Orthostatic BP measurements, carotid sinus massage, and tilt testing are well-tolerated even in frail elderly 1

Driving Recommendations

• Restrictions based on syncope type and risk of recurrence
• More stringent for vocational drivers (Group 2) than private drivers (Group 1) 1

Common Pitfalls to Avoid

• Inadequate risk stratification leading to inappropriate disposition
• Overreliance on diagnostic tests without proper initial evaluation
• Failure to recognize multiple potential causes in elderly patients
• Dismissing single episodes without proper risk assessment 2

The ESC approach emphasizes the importance of structured evaluation pathways and specialized syncope units to improve diagnostic accuracy and patient outcomes.