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| ==Overview==
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| ==FIRE: Focused Initial Rapid Evaluation==
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| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
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| <span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span>
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| <span style="font-size:85%">'''Abbreviations:''' </span>
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| {{Family tree/start}}
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| {{familytree | | | | | | | | | D01 | | | | | | | | | D01=<div style="text-align: center; width: 15em"> '''Identify cardinal findings that increase the pretest probability of chest pain'''</div> <br> <div style="text-align: left; width: 15em"> ❑ </div>}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | }}
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| {{familytree | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Does the patient have any of the findings that require urgent management?'''<br>
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| ❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ Severe [[dyspnea]]<br> ❑ <br> ❑ </div>}}
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| {{familytree | | | | | | |,|-|-|^|-|-|.| | | | |}}
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| {{familytree | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}} </div>| B02= '''No'''}}
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| {{familytree | | | | | | |!| | | | | |!| | | | }}
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| {{familytree | | | | | | C01 | | | | C02 | | | | C01=<div style=" background: #FA8072; text-align: left; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| ❑ Immediately order an [[ECG|<span style="color:white;">ECG</span>]]}}<br><br></div> | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Continue with the complete diagnostic approach below]]''' </div>}}
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| {{familytree | | | | | | |!| | | | | | | | | | }}
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| {{familytree | | | | | | G01 | | | | | | | | | G01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| '''[[ECG|<span style="color:white;">ECG</span>]] findings'''}}</div>}}
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| {{familytree | | |,|-|-|-|+|-|-|-|.| | | | |}}
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| {{Family tree/end}}
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| <br><br>
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| ==Complete Diagnostic Approach==
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| A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.
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| <span style="font-size:85%"> '''Abbreviations:''' </span>
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| {{familytree/start}}
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| {{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the symptoms:'''<br>
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| ❑ <br>
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| ❑ <br>
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| ❑ <br>
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| ❑ <br>
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| ❑ Activity prior to <br>
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| ❑ </div>}}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Inquire about past medical history:'''<br>
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| ❑ Previous episodes<br>
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| ❑ Cardiovascular disease
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| ❑ Neurological diseases </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Identify possible triggers:''' <br>
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| </div>}}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:'''
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| '''Vitals'''<br>
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| ❑ [[Heart rate]]
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| : ❑ Irregularly irregular rhythm (suggestive of [[AF]])
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| : ❑ [[Tachycardia]] (suggestive of [[orthostatic hypotension]], cardiovascular or reflex [[syncope]])
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| : ❑ [[Bradycardia]] (suggestive of cardiovascular [[syncope]])
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| ❑ [[Blood pressure]]<br>
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| : ❑ Measure in both arms, while standing and supine
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| :: ❑ [[Orthostatic hypotension]] (Fall in [[systolic BP]] ≥ 20 mmHg and/or in diastolic BP of at least≥ 10 mmHg between the [[supine]] and sitting BP reading)
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| :: ❑ [[Hypertension]] (suggestive of cardiovascular [[syncope]])
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| ❑ [[Respiratory rate]]
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| : ❑ [[Tachypnea]] (suggestive of reflex syncope)
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| '''Respiratory''' <br>
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| ❑ [[Rales]] (suggestive of [[HF]]) <br>
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| '''Cardiovascular'''<br>
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| ❑ [[Palpitations]] (suggestive of [[arrhythmia]]) <br> ❑ [[Carotid bruits]] (suggestive of cardiovascular syncope) <br> ❑ [[Murmurs]]
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| : ❑ [[Aortic stenosis]]: crescendo-decrecendo systolic ejection murmur best heard at the upper right sternal border
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| : ❑ [[Pulmonary stenosis]]: systolic ejection murmur best heard at the left second intercostal space <br>
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| ❑ [[Heart sounds]]
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| : ❑ Loud P2 (suggestive of [[pulmonary hypertension]])
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| '''Neurologic'''<br>
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| ❑ [[focal neurologic signs|Focal abnormalities]] (suggestive of [[stroke]] or [[cerebral mass]])
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| : ❑ [[Hemiparesis]]
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| : ❑ [[Vision loss]]
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| : ❑ [[Aphasia]]
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| : ❑ [[Hypertonia]]
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| ❑ [[Glasgow coma scale]] <br>
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| ❑ Signs suggestive of [[Parkinson's disease]]:
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| : ❑ [[Tremor]]
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| : ❑ [[Spasticity|Rigidity]]
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| : ❑ [[Bradykinesia]]/[[Akinesia]]
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| : ❑ [[Postural instability]]
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| : ❑ Shuffling gait </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)''
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| : ❑ [[Myocardial infarction]]
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| : ❑ [[Tachyarrhythmia]]
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| : ❑ [[Heart block]]
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| : ❑ [[Bradyarrhythmia]]
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| : ❑ [[long QT|Long]] or [[short QT syndrome|short QT]]
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| : ❑ [[Bradyarrhythmia]]
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| ❑ [[Electrolytes]]
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| : ❑ [[Hyponatremia]]
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| : ❑ [[Hypernatremia]]
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| : ❑ [[Hypokalemia]]
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| ❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]]
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| : ❑ [[Hypoxia]]
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| : ❑ [[Hypocapnea]] (suggestive of [[tachypnea]], rule out psychiatric disease)</div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | H01 | | H01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order imaging studies:'''<br> ❑ '''[[Echocardiography]]''' ''in case of:''
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| :: ❑ [[Structural heart disease]]
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| :: ❑ [[Myocardial infarction]]
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| :: ❑ [[Cardiac valve disease]]<br>
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| ❑ '''Head [[CT]]''' ''in case of:''
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| :: ❑ [[Head trauma]]
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| :: ❑ [[TIA]]</div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | U01 | | U01= '''Confirm diagnosis of syncope''' <br> ''Must have this 3 characteristics:'' <br> <div style="text-align: left"> ❑ Short duration, AND <br> ❑ Rapid onset, AND <br> ❑ Complete spontaneous recovery </div>}}
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| {{familytree | | | | |,|-|-|^|-|.| | | | }}
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| {{familytree | | | | C01 | | | | C02 | | C01= <div style=" width: 15em">'''Syncope'''</div>| C02= <div style=" width: 15em">'''Non-syncopal [[LOC]]''' </div>}}
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| {{familytree | |,|-|-|^|-|.| | | |!| | | }}
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| {{familytree | D01 | | | D02 | | D03 | | D01= '''Known etiology'''| D02= '''Unknown etiology''' | D03=<div style="text-align:left">'''Consider additional tests'''<br>
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| ❑ [[Stool guaiac test]] (rule out [[GI bleeding]]) <br> ❑ Blood and urine toxicology tests (rule out [[intoxication]]) </div> }}
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| {{familytree | |!| | | | |!| | | |!| | | }}
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| {{familytree | F01 | | | F02 | | F03 | | F01=<div style="text-align: left; width: 20em">'''Determine the etiology:'''<br> ❑ '''Cardiovascular'''
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| : ❑ [[Arrhythmia]]
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| : ❑ [[Ischemia|Cardiac ischemia]]
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| : ❑ [[Structural heart disease]]
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| ❑ '''[[Orthostatic hypotension]]'''
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| : ❑ [[Syncope]] after standing up and documentation of [[orthostatic hypotension]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br>
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| ❑ '''Reflex'''
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| : ❑ [[Vasovagal syncope]] precipitated by emotional distress and associated with typical [[prodome]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| : ❑ Situational [[syncope]] during or after specific [[Vasovagal syncope#Triggers|triggers]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) </div> | F02=<div style="float: left; text-align: left;"> '''Determine if there are any high risk criteria:''' <br> ❑ Severe [[structural heart disease]] <br> ❑ [[CAD]]<br> ❑ Clinical or [[ECG]] features suggesting arrhythmic syncope <br>
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| : ❑ [[Syncope]] during exertion or [[supine]]
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| : ❑ [[Palpitations]] at the time of [[syncope]]
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| : ❑ Family history of [[SCD]]
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| : ❑ Non-sustained [[VT]]
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| : ❑ Conduction abnormalities with [[QRS]] >120 ms
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| : ❑ [[Sinus bradycardia]]
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| : ❑ [[Preexcitation syndrome]]
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| : ❑ [[long QT|Long]] or [[short QT syndrome|short QT]]
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| : ❑ [[Brugada syndrome|Brugada pattern]]
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| : ❑ [[ARVC]]
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| ❑ Important comorbidities
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| : ❑ Severe [[anemia]]
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| : ❑ [[Electrolyte disturbance]] </div> | F03=<div style="float: left; text-align: left; width:20em">'''Consider alternative diagnoses:'''
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| <br>
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| ❑ '''With loss of consciousness''' <br>
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| : ❑ [[Epilepsy]]
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| :: ❑ Inquire about suggestive signs include [[aura]], prolonged [[confusion]], [[muscle ache]]
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| :: ❑ Inquire about past medical history
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| :: ❑ Perform neurological evaluation ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| :: ❑ Perform [[tilt test|tilt testing]] ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]), preferably with concurrent [[EEG]] and video monitoring if doubt of mimicking epilepsy <br>
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| : ❑ [[Intoxication]]
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| : ❑ Vertebrobasilar [[TIA]]
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| <br>
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| ❑ '''Without loss of consciousness'''
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| : ❑ [[Cataplexy]]
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| : ❑ [[Drop attack]]s
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| : ❑ Functional /psychogenic pseudosyncope
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| :: ❑ Perform a psychiatric evaluation ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| : ❑ [[TIA]] of [[carotid]] origin </div>}}
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| {{familytree | | | | | | |!| | | | | | |}}
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| {{familytree | |,|-|-|-|-|^|-|.| | | | | | }}
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| {{familytree | G01 | | | | | G02 | | | | | | | G01= '''High risk''' |G02= '''Low risk''' }}
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| {{familytree | |!| | | | | | |!| | | | | | }}
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| {{familytree | S01 | |,|-|-|-|^|-|-|.| | | | S01= <div style="float: left; text-align: left; width: 20em"> ❑ Immediate in-hospital monitoring (in bed or telemetry) to look for abnormalities suggestive of arrhythmic syncope ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) </div> | }}
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| {{familytree | | | | |!| | | | | | |!| | | | | }}
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| {{familytree | | | | H01 | | | | | H02 | | | | | H01= '''Recurrent episodes of syncope''' <br> <div style="float: left; text-align: left; width:20em"> ❑ Order a [[Holter]] if > 1 episode/week ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) <br> ❑ Order external loop recorder (ELR) if interval between episodes < 4 weeks ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])<br> ❑ Perform [[carotid sinus massage]] in patients > 40 years with uncertain syncopal etiology ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])<br>
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| : <span style="font-size:85%;color:red"> Contraindicated in patients with previous TIA or stroke in the past 3 months <br> Contraindicated in patients with carotid bruits </span></div> |H02= '''Single episode of syncope''' }}
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| {{familytree | | | | |!| | | | | | |!| | | }}
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| {{familytree | | | | I01 | | | | | I02 | | | I01= <div style="float: left; text-align: left; width: 20em">'''In case of suspicion of structural heart disease:''' <br> ❑ Order an [[echocardiography]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])</div> | I02= '''Is any of the following high risk setting present?''' <br> ❑ Potential risk of physical injury <br> ❑ Occupational implications }}
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| {{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| | }}
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| {{familytree | J01 | | J02 | | J03 | | J04 | | J01= Presence of [[structural heart disease]] | J02= Absence of [[structural heart disease]] | J03=<div style="width: 10em"> Yes </div> | J04=No}}
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| {{familytree | |!| | | | |!| |!| | | | |!| | }}
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| {{familytree | T00 | | | | T01 | | | | T02 | | T00= ❑ Treat accordingly| T01= '''Perform a [[tilt test]]''' ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])| T02= No further investigation}}
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| {{familytree | | | | | | | |!| | | | | | }}
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| {{familytree | | | | | | | U01 | | | | | U01= <div style="float: left; text-align: left"> ❑ No findings, OR <br> ❑ '''Reflex syncope''': induction of [[hypotension]] or [[bradycardia]] with reproduction of [[syncope]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]), OR<br> ❑ '''[[Orthostatic hypotension]]''': induction of progressive [[orthostatic hypotension]] with or without symptoms ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) </div>}}
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| {{familytree/end}}
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| ===Diagnostic Clues===
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| ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="3"| {{fontcolor|#FFF|Diagnostic clues for the etiologies of syncope}} | |
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| | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | '''''Cardiovascular syncope'''''|| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left|'''''Reflex syncope'''''|| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left|'''''Orthostatic hypotension''''' | | | style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | |
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| | | style="padding: 5px 5px; background: #F5F5F5;" | |
| | style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left | '''Diagnostic criteria'''<br> | | | style="padding: 5px 5px; background: #F5F5F5;" | |
| ❑ [[Arrhythmia]] and cardiac ischemia-related [[syncope]] diagnosed by [[ECG]] specific findings ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) <br>
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| ❑ Cardiovascular syncope due [[structural heart disease]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br>
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| ----
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| '''Additional findings'''<br>
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| ❑ Presence of definitive structural hearth disease
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| : ❑ [[Aortic stenosis]]
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| : ❑ [[Acute myocardial infarction]]
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| : ❑ [[Hypertrophic cardiomyopathy]]
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| : ❑ [[Pericardial disease]]
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| : ❑ [[Cardiac tumors]]
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| ❑ Family history of unexplained sudden death <br> ❑ Syncope during exertion or supine <br> ❑ Abnormal [[ECG]] findings<br> ❑ Sudden onset of [[palpitations]] before syncope <br>
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| ----
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| '''Abnormal [[ECG]] findings'''<br><div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| : ❑ [[Second degree AV block classification|Mobitz I second degree AV block]] <br> [[File:Wenckebach2.png|200px]]
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| : ❑ Non-sustained VT <br>[[File:Non-sustained VT.png|200px]]
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| : ❑ Premature QRS complexes <br>[[File:VPC 1.png|200px]]
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| : ❑ [[Wide QRS]](≥ 0.12 s)
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| : ❑ Long or short [[QT interval]]s <br>[[File:LQTS.png|200px]]
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| : ❑ Early repolarization <br>[[File:Benign early repolarization.jpg|200px]]
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| : ❑ [[Q waves]] ([[myocardial infarction]])<br> [[File:Q wave.jpg|200px]]
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| : ❑ Bifascicular block <br>[[File:Bifascicular block ECG.png|200px]]
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| | style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Diagnostic criteria'''<br> | |
| ❑ Syncope after standing up and documentation of [[orthostatic hypotension]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| ----
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| '''Additional findings''' <br> ❑ Syncope after prolonged standing <br> ❑ New [[antihypertensive]] drug or dosage change <br> ❑ Presence of [[autonomic neuropathy]] <br> ❑ Prolonged standing <br> ❑ Associated with crowd or hot spaces </div> </div>
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| | style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Diagnostic criteria'''<br>
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| ❑ [[Vasovagal syncope]] precipitated by emotional distress and is associated with typical prodome ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) <br>
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| ❑ Situational [[syncope]] during or after specific [[Vasovagal syncope#Triggers|triggers]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br>
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| ❑ [[Carotid sinus hypersensitivity]] if syncope is reproduced in the presence of [[asystole]] > 3 sec and/or fall in systolic blood pressure > 50 mmHg ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])
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| ----
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| '''Additional findings''' <br>
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| ❑ Absence of heart disease <br> ❑ History of recurrent [[syncope]] <br> ❑ After unpleasant [[sight]], [[smell]], [[sound]] or [[pain]] <br> ❑ Associated to [[nausea]] or [[vomit]] <br> ❑ Prolonged standing <br> ❑ Associated with crowd or hot spaces <br> ❑ Head rotation or pressure to [[carotid sinus]]<br> ❑ After exertion <br> ❑ Postprandial
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| |} | |
| |} | | |} |
|
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| <br>
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|
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| ==Treatment==
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|
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| Shown below is an algorithm summarizing the therapeutic approach to [[syncope]] based on the 2009 ESC Guidelines for the Diagnosis and Management of Syncope<ref name="pmid19713422">{{cite journal| author=Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A et al.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422 }} </ref> and the 2006 AHA/ACCF Scientific Statement on the Evaluation of Syncope.<ref name="Strickberger2006">{{cite journal|last1=Strickberger|first1=S. A.|title=AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: In Collaboration With the Heart Rhythm Society: Endorsed by the American Autonomic Society|journal=Circulation|volume=113|issue=2|year=2006|pages=316–327|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.170274}}</ref>
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| <span style="font-size:85%">'''Abbreviations:''' '''AF:''' Atrial fibrillation; '''SVT:''' Supraventricular tachycardia; '''VT:''' Ventricular tachycardia; '''MI:''' Myocardial infarction; '''BBB:''' Bundle branch block. </span>
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| {{familytree/start}}
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| {{familytree | | | | | A00 | | | | | | A00= '''Determine the etiology'''}}
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| {{familytree | |,|-|-|-|+|-|-|-|.| |}}
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| {{familytree | A01 | | A02 | | A03 | A01= '''Cardiovascular syncope'''| A02= '''Reflex Syncope'''| A03= '''[[Orthostatic hypotension]]'''}}
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| {{familytree | |!| | | |!| | | |!| | }}
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| {{familytree | D01 | | D02 | | D03 | | | D03= <div style="float: left; text-align: left; width: 24em"> ❑ Explain the diagnosis and provide reassurance ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> ❑ Explain the risk of recurrence and educate regarding avoidance of [[Vasovagal syncope#Triggers|triggers]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]) <br> ❑ Educate patients with prodrome about isometric physical counterpressure maneuvers (PCM) ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]):
| |
| : ❑ Hand grip and arm tensing
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| : ❑ Leg crossing <br>
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| ❑ Consider [[cardiac pacing]] in:
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| : ❑ Dominant cardioinhibitory [[carotid sinus syndrome]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])
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| : ❑ Recurrent reflex syncope, age >40 years and spontaneous cardioinhibitory response during monitoring ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])</div>
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|
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| | D02= <div style="float: left; text-align: left; width: 24em"> ❑ Provide adequate hydration and salt intake ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br> ❑ Provide additional therapy if needed:
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| : ❑ Administer [[midodrine]] 10 mg PO every 8 hours ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])
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| <span style="font-size:85%;color:red">Contraindicated in severe heart disease, acute renal failure, pheochromocytoma, severe hypertension or thyrotoxicosis </span> <br>OR<br>
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| : ❑ Administer [[fludrocortisone]]''' 0.1 mg/day PO ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]]) <br>
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| ❑ Educate patients about isometric physical counterpressure maneuvers (PCM) ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) <br> ❑ Position the patient in a head-up tilt sleeping position (>10°) to increase fluid volume ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]]) </div> | D01=<div style="float: left; text-align: left; width: 24em; padding:1em;"> ❑ Treat the [[arrhythmia]] according to the type <br>
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| ❑ Schedule for [[cardiac pacing]] surgery in patients with:
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| : ❑ [[Sinus node disease]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| : ❑ [[Second degree AV block classification|Mobitz II AV block]] or [[complete AV block]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])
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| : ❑ [[BBB]] with positive [[electrophysiological study]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]]) <br>
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| ❑ Schedule for [[catheter ablation]] in patients with:
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| : ❑ [[SVT]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| : ❑ [[VT]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])
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| : ''In absence of [[structural hearth disease]]'' <br>
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| ❑ Administer [[atrial fibrillation resident survival guide#Maintenance of Sinus Rhythm|antiarrhythmic drug therapy]] in patients with:
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| : ❑ [[AF]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]])
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| : ❑ Failed [[catheter ablation]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]])<br>
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| ❑ Schedule for [[implantable cardioverter defibrillator]] surgery in patients with:
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| : ❑ [[VT]] with [[heart disease]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])
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| : ❑ Electrophysiological study induced [[VT]] with previous [[MI]] ([[ESC#Classes of Recommendations|Class I; Level of Evidence: B]])
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| : ❑ [[VT]] with inherited [[cardiomyopathy]] or [[channelopathy]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: B]])</div>}}
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| {{familytree/end}}
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|
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| ==Do's==
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| * Consider a [[tilt test]]:
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| ** To differentiate between reflex [[syncope]] and [[orthostatic hypotension]] ([[ESC#Classes of Recommendations|Class IIa; Level of Evidence: C]])
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| ** If syncope is due to a [[psychiatric disease]] ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]])
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| ** To differenciate [[syncope]] with jerking movements from [[epilepsy]] ([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]])
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| ** If [[syncope]] happened after standing up from a seated position due to possible [[orthostatic hypotension]]([[ESC#Classes of Recommendations|Class IIb; Level of Evidence: C]])
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| * Consider implantable loop recorder before [[cardiac pacing]] in patients with suspected or confirmed reflex [[syncope]] presenting with frequent or traumatic syncopal episodes.
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| * Perform exercise testing in patients who experience syncope during or after exertion ([[ESC#Classes of Recommendations|Class I; Level of Evidence: C]]).
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|
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| ==Don'ts==
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| * Don't perform [[carotid sinus massage]] in patients with previous [[TIA]] or [[stroke]] within the past 3 months and in patients with [[carotid sinus]] bruits unless [[carotid sinus]] [[doppler]] studies excluded significant stenosis ([[ESC#Classes of Recommendations|Class III; Level of Evidence: C]]).
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| * Don't perform [[tilt test|tilt testing]] for the assessment of response to treatment. ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]).
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| * Don't perform [[tilt test|isoproterenol tilt test]] in patients with [[ischemic heart disease]] ([[ESC#Classes of Recommendations|Class III; Level of Evidence: C]]).
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| * Don't use [[adenosine]] [[stress test]] as a diagnostic test to select patients for [[cardiac pacing]] due to the lack of correlation with spontaneous [[syncope]] ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]).
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| * Don't perform [[electrophysiologic study]] if there is already indication for [[implantable cardioverter defibrillator]] in patients with [[ischemic heart disease]] with suspected [[arrhythmia|arrhythmic]] cause.
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| * Don't perform [[electrophysiologic study]] in patients with normal [[ECG]], no [[heart disease]] and no [[palpitations]] unless non-syncopal [[LOC]] is suspected ([[ESC#Classes of Recommendations|Class III; Level of Evidence: B]]).
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| * Don't give [[beta blockers]] for patients with reflex syncope ([[ESC#Classes of Recommendations|Class III; Level of Evidence: A]]).
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|
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| ==References==
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| {{Reflist|2}}
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|
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| [[Category:Cardiology]]
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| [[Category:Resident survival guide]]
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| [[Category:Up-To-Date]]
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| [[Category:Emergency]]
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| </div>
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