Syncope Clinical Practice Guidelines (ESC, 2018)

European Society of Cardiology

Reviewed and summarized by Medscape editors

October 31, 2018

The recommendations on the diagnosis and management of syncope were released in June 2018 by the European Society of Cardiology (ESC).[1,2]


Initial evaluation

Key questions

  • Was the event a transient loss of consciousness (TLOC)? If yes, is the origin syncopal or nonsyncopal?

  • In case of suspected syncope, is there a clear etiologic diagnosis?

  • Is there evidence to suggest a high risk of cardiovascular events or death?

Emergency department (ED) evaluation of suspected syncopal TLOC

  • 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?

Perform immediate bedside/telemetric electrocardiographic (ECG) monitoring in high-risk patients when arrhythmic syncope is suspected.

Perform carotid sinus massage in patients older than 40 years with syncope of unknown origin that is compatible with a reflex mechanism.

Perform tilt testing if syncope is suspected as secondary to a reflex or an orthostatic cause.

Subsequent investigations

Perform prolonged ECG monitoring (external or implantable) in patients with recurrent severe unexplained syncope who have all of the following characteristics:

  • Clinical or ECG features suggesting arrhythmic syncope

  • A high probability of recurrence of syncope in a reasonable time

  • Potentially benefit from a specific therapy if a cause for syncope is found

Perform electrophysiology studies in patients with unexplained syncope and bifascicular bundle branch block (impending high-degree atrioventricular block) or suspected tachycardia.

Consider at-home/in-hospital video recording of suspected nonsyncopal TLOC.


Reflex syncope and orthostatic hypotension

Explain the diagnosis and risk of recurrence to the patient, as well as provide reassurance and 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.

Orthostatic hypotension

Add one or more of the following specific treatments based on the clinical severity:

  • Education regarding lifestyle manoeuvers

  • Adequate hydration and salt intake

  • Discontinuation/reduction of hypotensive therapy

  • Counter-pressure manoeuvers

  • Abdominal binders and/or support stockings

  • Head-up tilt sleeping

  • Midodrine or fludrocortisone

Severe forms of reflex syncope

Add one or more of the following specific treatments based on clinical features:

  • Midodrine or fludrocortisone in young patients with low blood pressure (BP) phenotype

  • Counter-pressure manoeuvers (including tilt training if needed) in young patients with prodromes

  • Implantable loop recorder-guided management strategy in selected patients with or without short prodromes

  • Discontinue/reduction of hypotensive therapy targeting a systolic BP of 140 mmHg in elderly hypertensive patients

  • Pacemaker implantation in older patients with dominant cardioinhibitory forms of reflex syncope

Unexplained syncope and high risk sudden cardiac death

Balance the benefit and harm of placing an implantable cardioverter-defibrillator (ICD) in these patients (eg, unexplained syncope and those affected by left ventricle systolic dysfunction, hypertrophic cardiomyopathy, 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.

General Considerations

Ensure that all patients with cardiac syncope receive the specific therapy for the causative arrhythmia and/or the underlying disease.

Reevaluate the diagnostic process and consider alternative therapies if the above rules fail or do not apply to an individual patient.

Note that guidelines are only advisory, so always individualize treatment.

For more information, please go to Syncope.

For more Clinical Practice Guidelines, please go to Guidelines.


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