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The new ESC Clinical Practice Guidelines for the diagnosis and management of syncope

The new ESC Clinical Practice Guidelines for the diagnosis and management of syncope were published a few minutes ago.

The guidelines provide recommendations on how to prevent syncope; to extend its use for diagnosis in patients with unexplained falls, suspected epilepsy, or recurrent episodes of unexplained syncope and a low risk of sudden cardiac death. An addendum has been added too, with practical instructions for doctors on how to perform and interpret diagnostic tests.

In Brief

Here are the main messages summarised for you by Professor Michele Brignole, FESC, Chair of the Syncope Guidelines Task Force:

Diagnosis: initial evaluation

• At the initial evaluation answer the following 4 key questions:
o Was the event TLOC?
o In case of TLOC, is it of syncopal or non-syncopal origin?
o In case of suspected syncope, is there a clear aetiological diagnosis?
o Is there evidence to suggest a high risk of cardiovascular events or death?
• At the evaluation of TLOC in the ED answer the following 3 key questions:
o Is there a serious underlying cause that can be identified?
o If the cause is uncertain, what is the risk of a serious outcome?
o Should the patient be admitted to hospital?

Diagnosis: subsequent investigations

• Perform prolonged ECG monitoring (external or implantable) in patients with recurrent severe unexplained syncope who:
o Have clinical or ECG features suggesting arrhythmic syncope; and
o Have a high probability of recurrence of syncope in a reasonable time; and
o May benefit a specific therapy if a cause for syncope is found.
• Perform EPS in patients with unexplained syncope and bifascicular BBB (impending high-degree AV block) or suspected tachycardia.
• Consider video recording (at home or in hospital) of TLOC suspected of non-syncopal nature.


• 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.
• In patients with severe forms of reflex syncope, select one or more of the following additional specific treatments according to the clinical features:
o Midodrine or fludrocortisone in young patients with low BP phenotype;
o Counter-pressure manoeuvres (including tilt training if needed) in young patients with prodromes;
o ILR-guided management strategy in selected patients without or with short prodromes;
o Discontinuation/reduction of hypotensive therapy targeting a systolic BP of 140 mmHg in old hypertensive patients;
o Pacemaker implantation in old patients with dominant cardioinhibitory forms.
• In patients with OH, select one or more of the following additional specific treatments according to clinical severity:
o Education regarding lifestyle manoeuvres;
o Adequate hydration and salt intake;
o Discontinuation/reduction of hypotensive therapy;
o Counter-pressure manoeuvres;
o Abdominal binders and/or support stockings;
o Head-up tilt sleeping;
o Midodrine or fludrocortisone.
• Ensure that all patients with cardiac syncope receive the specific therapy of the culprit arrhythmia and/or of the underlying disease.
• Balance benefit and harm of an ICD implantation in patients with unexplained syncope at high risk of SCD (e.g. those affected by left ventricle systolic dysfunction, HCM, arrhythmogenic right ventricular cardiomyopathy, 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.
• 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 needs.