Abstract
This review aims to provide a practical and up-to-date description on the relevance
and classification of syncope in adults as well as a guidance on the optimal evaluation,
management and treatment of this very common clinical and socioeconomic medical problem.
We have summarized recent active research and emphasized the value for physicians
to adhere current guidelines. A modern management of syncope should take into account
1) use of risk stratification algorithms and implementation of syncope management
units to increase the diagnostic yield and reduce costs; 2) early implantable loop
recorders rather than late in the evaluation of unexplained syncope; and 3) isometric
physical counter-pressure maneuvers as first-line treatment for patients with neurally-mediated
reflex syncope and prodromal symptoms.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to International Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- A prospective evaluation and follow-up of patients with syncope.N Engl J Med. 1983; 309: 197-204
- Epidemiologic features of isolated syncope.Stroke. 1985; 16: 626-629
- Incidence and prognosis of syncope.N Engl J Med. 2002; 347: 878-885
- Prospective evaluation of patients with syncope: a population-based study.Am J Med. 2001; 111: 177-184
- Direct medical costs of syncope-related hospitalizations in the United States.Am J Cardiol. 2005; 95: 668-671
- Task Force on Syncope, European Society of Cardiology. Guidelines on management (diagnosis and treatment) of syncope—update 2004.Europace. 2004; 6: 467-537
- The economic burden of unrecognized vasodepressor syncope.Am J Med. 1993; 95: 473-479
- On behalf of the PICTURE study investigators. Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry.Europace. 2011; 13: 262-269
- Indications for the use of diagnostic implantable and external ECG loop recorders.Europace. 2009; 11: 671-687
- Impairment of physical and psychosocial function in recurrent syncope.J Clin Epidemiol. 1991; 44: 1037-1043
- Clinical factors associated with quality of life in patients with transient loss of consciousness.J Cardiovasc Electrophysiol. 2006; 17: 998-1003
- Physical injuries caused by a transient loss of consciousness: main clinical characteristics of patients and diagnostic contribution of carotid sinus massage.Eur Heart J. 2008; 29: 618-624
- Falls in old age: a study of frequency and related clinical factors.Age Ageing. 1981; 110: 264-270
- Falls presenting to the accident and emergency department: types of presentation and risk factor profile.Age Ageing. 1996; 25: 362-366
- Clinical practice: neurocardiogenic syncope.N Engl J Med. 2005; 352: 1004-1010
- Task Force on Syncope, European Society of Cardiology. Guidelines on management (diagnosis and treatment) of syncope—update 2004. Executive summary.Eur Heart J. 2004; 25: 2054-2072
- Recording ambulatory blood pressure in the syncope and TLOC evaluation.in: Benditt D.G. Brignole M. Wieling W. Syncope and transient loss of consciousness: multidisciplinary management. Blackwell Futura, Malden, MA2007: 56-60
- Consensus statement on the definition of orthostatic hypotension pure autonomic failure, and multiple system atrophy.J Neurol Sci. 1996; 144: 218-219
- Sudden cardiac arrest associated with early repolarization.N Engl J Med. 2008; 358: 2016-2023
- Long-term outcome associated with early repolarization on electrocardiography.N Engl J Med. 2009; 361: 2529-2537
- The early repolarization pattern in the general population. Clinical correlates and heritability.J Am Coll Cardiol. 2011; 57: 2284-2289
- For the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure.N Engl J Med. 2005; 352: 225-237
- Cardiovascular causes of loss of consciousness in patients with presumed epilepsy: a cause of the increased sudden death rate in people with epilepsy?.Am J Med. 1994; 96: 146-154
- Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause.J Am Coll Cardiol. 2000; 36: 181-184
- Cardiac arrhythmias in focal epilepsy: a prospective long-term study.Lancet. 2004; : 2212-2219
- Seizure versus syncope.Lancet Neurol. 2006; 5: 171-180
- Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC).Eur Heart J. 2009; 30: 2631-2671
- Synopsis of the national institute for health and clinical excellence guideline for management of transient loss of consciousness.Ann Intern Med. 2011; 155: 543-549
- Risk stratification of patients with syncope in an accident and emergency department.Emerg Med J. 2002; 19: 23-27
- The application of a standardized strategy of evaluation in patients with syncope referred to three syncope units.Europace. 2002; 4: 351-356
- Diagnosing syncope. Part 2: unexplained syncope. Clinical efficacy assessment project of the American College of Physician.Ann Intern Med. 1997; 127: 76-86
- Arrhythmias detected by ambulatory monitoring: lack of correlation with symptoms of dizziness and syncope.Chest. 1980; 77: 722-725
- Evaluation of arrhythmic causes of syncope: correlation between Holter monitoring, electrophysiologic testing, and body surface potential mapping.Am Heart J. 1991; 122: 1346-1354
- Head-up tilt: a useful test for investigating unexplained syncope.Lancet. 1986; 327: 1352-1355
- The Bezold–Jarisch reflex revisited: clinical implications of inhibitory reflexes originating in the heart.J Am Coll Cardiol. 1983; 1: 90-102
- Recurrent vasovagal syncope: comparison between clomipramine and nitroglycerin as drug challenges during head-up tilt testing.Eur Heart J. 2009; 30: 2249-2253
- Tilt testing: on the road to obsolescence?.J Cardiovasc Electrophysiol. 2003; 14: 925-926
- Tilt testing and neurally mediated syncope: too many protocols for one condition or specific protocols for different situations.Eur Heart J. 2009; 30: 2174-2176
- Evaluation and management of the patient with syncope.JAMA. 1992; 268: 2553-2560
- Mechanism of syncope in patients with isolated syncope and in patients with tilt-positive syncope.Circulation. 2001; 104: 1261-1267
- An implantable loop recorder study of highly symptomatic vasovagal patients.J Am Coll Cardiol. 2006; 47: 587-593
- A prospective randomized comparison of loop recorders versus Holter monitors in patients with syncope or presyncope.Am J Med. 2003; 115: 1-5
- Effectiveness of remote monitoring in the management of syncope and palpitations.Europace. 2011; 13: 431-437
- Clinical utility of a novel wireless implantable loop recorder in the evaluation of patients with unexplained syncope.Heart Rhythm. 2011; 8: 858-863
- Randomized assessment of syncope trial: conventional diagnostic testing versus a prolonged monitoring strategy.Circulation. 2001; 104: 46-51
- Cost implications of testing strategy in patients with syncope: randomized assessment of syncope trial.J Am Coll Cardiol. 2003; 42: 495-501
- The clinical impact of implantable loop recorders in patients with syncope.Eur Heart J. 2006; 27: 351-356
- International Study on Syncope of Uncertain Etiology 2 (ISSUE 2) Group. Lack of correlation between the responses to tilt testing and adenosine triphosphate test and the mechanism of spontaneous neurally-mediated syncope.Eur Heart J. 2006; 27: 2232-2239
- Electrophysiological testing: the court of final appeal for the diagnosis of syncope?.Circulation. 1995; 92: 1332-1335
- Evaluation of Guidelines in Syncope Study 2 (EGSYS-2) GROUP. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals.Europace. 2006; 8: 644-650
- International Study on Syncope of Uncertain Etiology (ISSUE) investigators. Mechanism of syncope in patients with heart disease and negative electrophysiologic test.Circulation. 2002; 105: 2741-2745
- International Study on Syncope of Uncertain Etiology (ISSUE) investigators. Mechanism of syncope in patients with bundle branch block and negative electrophysiological test.Circulation. 2001; 104: 2045-2050
- The diagnostic sensitivity of electrophysiologic testing in patients with syncope caused by transient bradycardia.N Engl J Med. 1989; 332: 1703-1707
- Are nonsustained ventricular tachycardias predictive of major arrhythmias in patients with dilated cardiomyopathy on optimal medical treatment?.Pacing Clin Electrophysiol. 2008; 31: 290-299
- Non-sustained ventricular tachycardia as a predictor of sudden cardiac death in patients with left ventricular dysfunction: a meta-analysis.Eur J Heart Fail. 2008; 10: 1007-1014
- Usefulness of QRS prolongation in predicting risk of inducible monomorphic ventricular tachycardia in patients referred for electrophysiologic studies.Am J Cardiol. 2003; 92: 804-809
- Native QRS duration predicts the occurrence of arrhythmic events in ICD recipients.Europace. 2006; 8: 859-862
- ACC/AHA/ESC Guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death—executive summary.Circulation. 2006; 114: 1088-1132
- AHA/ACCF scientific statement on the evaluation of syncope.Circulation. 2006; 113: 316-327
- Use of electrophysiology studies in syncope: practical aspects for diagnosis and treatment.in: Grubb B.P. Olshansky B. Syncope, mechanisms and management. Second edition. Blackwell Futura, Malden, MA2005: 126-158
- ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities.J Am Coll Cardiol. 2008; 51: 1-62
- Rationale for a rapid access blackouts triage clinic.Br J Cardiac Nursing. 2008; 10: 468-474
- Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management.Circulation. 2004; 110: 3636-3645
- Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score.Eur Heart J. 2003; 24: 811-819
- Failure to validate the San Francisco Syncope Rule in an independent emergency department population.Ann Emerg Med. 2008; 52: 151-159
- Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes.Ann Emerg Med. 2004; 43: 224-232
- Short- and long-term prognosis of syncope, risk factors, and role of hospital admission: results from the STePS (Short-Term Prognosis of Syncope) study.J Am Coll Cardiol. 2008; 51: 276-283
- Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: the EGSYS score.Heart. 2008; 94: 1620-1626
- The ROSE (Risk stratification Of Syncope in the Emergency department) study.J Am Coll Cardiol. 2010; 55: 713-721
- Implantable loop recorder in unexplained syncope: classification, mechanism, transient loss of consciousness and role of major depressive disorder in patients with and without structural heart disease.Heart. 2008; 94: e17
- Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope.J Am Coll Cardiol. 2002; 40: 2053-2059
- Management of vasovagal syncope: controlling or aborting faints by leg crossing and muscle tensing.Circulation. 2002; 106: 1684-1689
- PC-Trial investigators. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the Physical Counterpressure Maneuvers Trial (PC-Trial).J Am Coll Cardiol. 2006; 48: 1652-1657
- Usefulness of a tilt training program for the prevention of refractory neurocardiogenic syncope in adolescents: a controlled study.Circulation. 1999; 100: 1798-1801
- Long-term follow-up results of tilt training therapy in patients with recurrent neurocardiogenic syncope.Pacing Clin Electrophysiol. 2002; 25: 1441-1446
- Tilt training: does it have a role in preventing vasovagal syncope?.Pacing Clin Electrophysiol. 2007; 30: 1499-1505
- Efficay of tilt training in the treatment of neurally mediated syncope. A randomized study.Europace. 2004; 6: 199-204
- The role of tilt training in preventing syncope in patients with vasovagal syncope: a prospective and randomized study.Pacing Clin Electrophysiol. 2008; 31: 592-596
- Salt supplement increases plasma volume and orthostatic tolerance in patients with unexplained syncope.Heart. 1996; 75: 134-140
- Randomized comparison of atenolol and fludrocortisone acetate in the treatment of pediatric neurally mediated syncope.Am J Cardiol. 1995; 76: 400-402
- Effectiveness of fludrocortisone and salt in preventing syncope recurrence in children: a double-blind, placebo-controlled, randomized trial.J Am Coll Cardiol. 2005; 45: 484-488
- POST II Investigators The Second Prevention of Syncope Trial (POST II)—a randomized clinical trial of fludrocortisone for the prevention of neurally mediated syncope: rationale and study design.Am Heart J. 2006; 151: 1186.e1-1186.e7
- Usefulness of metoprolol for unexplained syncope and positive response to tilt testing in young persons.Am J Cardiol. 1993; 71: 592-595
- Usefulness of pindolol in neurocardiogenic syncope.Am J Cardiol. 1998; 82: 1121-1124
- Randomized double-blind, placebo-controlled trial of oral atenolol in patients with unexplained syncope and positive upright tilt table test results.Am Heart J. 1995; 130: 1250-1253
- Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope.Circulation. 2006; 113: 1164-1170
- Effectiveness of paroxetine in the treatment of refractory vasovagal syncope in young patients.G Ital Cardiol. 1999; 29: 1472-1477
- Serotonin reuptake inhibitor (Paxil) does not prevent the vasovagal reaction associated with carotid sinus massage and/or lower body negative pressure in healthy volunteers.Circulation. 2002; 106: 1500-1504
- Midodrine: a role in the management of neurocardiogenic syncope.Heart. 1998; 79: 45-49
- Efficacy and safety of midodrine hydrochloride in patients with refractory vasovagal syncope.Am J Cardiol. 2001; 88: 80-83
- Usefulness of midodrine in patients with severely symptomatic neurocardiogenic syncope: a randomized control study.J Cardiovasc Electrophysiol. 2001; 12: 935-938
- Long-term outcome of paced and non paced patients with severe carotid sinus syndrome.Am J Cardiol. 1992; 69: 1039-1043
- Less syncope and milder symptoms in patients treated with pacing for induced cardioinhibitory carotid sinus syndrome: a randomized study.Europace. 2007; 9: 932-936
- The North American Vasovagal Pacemaker Study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope.J Am Coll Cardiol. 1999; 33: 16-20
- Vasovagal Syncope International Study (VASIS) investigators dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope: pacemaker versus no therapy.Circulation. 2000; 102: 294-299
- Permanent cardiac pacing versus medical treatment for the prevention of recurrent vasovagal syncope: a multicenter, randomized, controlled trial.Circulation. 2001; 104: 52-57
- Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS-II): a randomized trial.JAMA. 2003; 289: 2224-2229
- A randomized, double-blind, placebo-controlled study of permanent cardiac pacing for the treatment of recurrent tilt-induced vasovagal syncope. The vasovagal syncope and pacing trial (SYNPACE).Eur Heart J. 2004; 25: 1741-1748
- The expectation effect and cardiac pacing for refractory vasovagal syncope.Am J Med. 2007; 120: 54-62
- International study on syncope of uncertain aetiology 3 (ISSUE 3): pacemaker therapy for patients with asystolic neurally-mediated syncope: rationale and study design.Europace. 2007; 9: 25-30
Article info
Publication history
Published online: December 22, 2011
Accepted:
November 24,
2011
Received in revised form:
October 28,
2011
Received:
June 19,
2011
Identification
Copyright
Published by Elsevier Inc.
