Blog | Thursday, June 21, 2018

What's new in syncope guidelines

The Europeans have published a thorough guideline for syncope. I have not had time to absorb the entire guideline. It is dense but seems very well done. There is enough material here for 5 days of short posts rather than one long post. Today, I have copied their key messages.

2018 ESC Guidelines for the diagnosis and management of syncope, European Heart Journal

10. Key messages

The ESC Task Force has selected 19 simple rules to guide the diagnosis and management of syncope patients with TLOC (total loss of consciousness) according to the 2018 ESC Guidelines on syncope:

Diagnosis: initial evaluation

At the initial evaluation answer the following four key questions:
• Was the event TLOC?
• In cases of TLOC, are they of syncopal or non-syncopal origin?
• In cases of suspected syncope, is there a clear aetiological diagnosis?
• Is there evidence to suggest a high risk of cardiovascular events or death?

At the evaluation of TLOC in the ED, answer the following three key questions:
• Is there a serious underlying cause that can be identified?
• If the cause is uncertain, what is the risk of a serious outcome?
• Should the patient be admitted to hospital?

In all patients, perform a complete history taking, physical examination (including standing BP measurement), and standard ECG.

Perform immediate ECG monitoring (in bed or telemetry) in high-risk patients when there is a suspicion of arrhythmic syncope.

Perform an echocardiogram when there is previous known heart disease, or data suggestive of structural heart disease or syncope secondary to cardiovascular cause.

Perform CSM (carotid sinus massage) in patients >40 years of age with syncope of unknown origin compatible with a reflex mechanism.

Perform tilt testing in cases where there is suspicion of syncope due to reflex or an orthostatic cause.

Perform blood tests when clinically indicated, e.g. haematocrit and cell blood count when haemorrhage is suspected, oxygen saturation and blood gas analysis when hypoxic syndromes are suspected, troponin when cardiac ischaemia-related syncope is suspected, and D-dimer when pulmonary embolism is suspected, etc.

Diagnosis: subsequent investigations
9. Perform prolonged ECG monitoring (external or implantable) in patients with recurrent severe unexplained syncope who have all of the following three features:
• Clinical or ECG features suggesting arrhythmic syncope.
• A high probability of recurrence of syncope in a reasonable time.
• Who may benefit from a specific therapy if a cause for syncope is found.
10. Perform EPS in patients with unexplained syncope and bifascicular BBB (impending high-degree AV block) or suspected tachycardia.
11. Perform an exercise stress test in patients who experience syncope during or shortly after exertion.
12. Consider basic autonomic function tests (Valsalva manoeuvre and deep-breathing test) and ABPM for the assessment of autonomic function in patients with suspected neurogenic OH.
13. Consider video recording (at home or in hospital) of TLOC suspected to be of non-syncopal nature.

14. To all patients with reflex syncope and OH, explain the diagnosis, reassure, explain the risk of recurrence, and give advice on how to avoid triggers and situations. These measures are the cornerstone of treatment and have a high impact in reducing the recurrence of syncope.
15. In patients with severe forms of reflex syncope, select one or more of the following additional specific treatments according to the clinical features:
• Midodrine or fludrocortisone in young patients with low BP phenotype.
• Counter-pressure manoeuvres (including tilt training if needed) in young patients with prodromes.
• ILR-guided management strategy in selected patients without or with short prodromes.
• Discontinuation/reduction of hypotensive therapy targeting a systolic BP of 140 mmHg in old hypertensive patients.
• Pacemaker implantation in old patients with dominant cardioinhibitory forms.
16. In patients with OH, select one or more of the following additional specific treatments according to clinical severity:
• Education regarding lifestyle manoeuvres.
• Adequate hydration and salt intake.
• Discontinuation/reduction of hypotensive therapy.
• Counter-pressure manoeuvres.
• Abdominal binders and/or support stockings.
• Head-up tilt sleeping.
• Midodrine or fludrocortisone.
17. Ensure that all patients with cardiac syncope receive the specific therapy of the culprit arrhythmia and/or of the underlying disease.
18. Balance the benefits and harm of ICD implantation in patients with unexplained syncope at high risk of SCD (e.g. those affected by left ventricle systolic dysfunction, HCM, ARVC, or inheritable arrhythmogenic disorders). In this situation, unexplained syncope is defined as syncope that does not meet any class I diagnostic criterion defined in the tables of recommendations of the 2018 ESC Guidelines on syncope and is considered a suspected arrhythmic syncope.
19. Re-evaluate the diagnostic process and consider alternative therapies if the above rules fail or are not applicable to an individual patient. Bear in mind that Guidelines are only advisory. Even though they are based on the best available scientific evidence, treatment should be tailored to an individual patient's need.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.