Sandbox: Syncope
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Recommendation for History and Physical Examination
| COR | LOE | RECOMMENDATION |
|---|---|---|
| I | B-NR | A detailed history and physical examination should be performed in patients with syncope. |
| I | B-NR | In the initial evaluation of patients with syncope, a resting 12-lead electrocardiogram (ECG) is useful. |
| I | B-NR | Evaluation of the cause and assessment for the short- and long-term morbidity and mortality risk of syncope are recommended. |
| IIb | B-NR | Use of risk stratification scores may be reasonable in the management of patients with syncope. |
| Recommendations for Disposition After Initial Evaluation | ||
| I | B-NR | Hospital evaluation and treatment are recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. |
| IIa | C-LD | It is reasonable to manage patients with presumptive reflex-mediated syncope in the outpatient setting in the absence of serious medical conditions. |
| IIa | B-R | In intermediate-risk patients with an unclear cause of syncope, use of a structured ED observation protocol can be effective in reducing hospital admission. |
| IIb | C-LD | It may be reasonable to manage selected patients with suspected cardiac syncope in the outpatient setting in the absence of serious medical conditions. |
| Recommendations for Blood Testing | ||
| IIa | B-NR | Targeted blood tests are reasonable in the evaluation of selected patients with syncope identified on the basis of clinical assessment from history, physical examination, and ECG. |
| IIb | C-LD | Usefulness of brain natriuretic peptide and high-sensitivity troponin measurement is uncertain in patients for whom a cardiac cause of syncope is suspected. |
| III-No Benefit | B-NR | Targeted blood tests are reasonable in the evaluation of selected patients with syncope identified on the basis of clinical assessment from history, physical examination, and ECG. |
| Recommendations for Cardiac Imaging | ||
| IIa | B-NR | Transthoracic echocardiography can be useful in selected patients presenting with syncope if structural heart disease is suspected. |
| IIb | B-NR | Computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in selected patients presenting with syncope of suspected cardiac etiology. |
| III-No Benefit | B-NR | Routine cardiac imaging is not useful in the evaluation of patients with syncope unless cardiac etiology is suspected on the basis of an initial evaluation, including history, physical examination, or ECG. |
| Recommendation for Stress Testing | ||
| IIa | C-LD | Exercise stress testing can be useful to establish the cause of syncope in selected patients who experience syncope or presyncope during exertion. |
| Recommendations for Cardiac Monitoring | ||
| I | C-EO (N/A) | The choice of a specific cardiac monitor should be determined on the basis of the frequency and nature of syncope events. |
| IIa | B-NR | To evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, the following external cardiac monitoring approaches can be useful:
1. Holter monitor 2. Transtelephonic monitor 3. External loop recorder 4. Patch recorder 5. Mobile cardiac outpatient telemetry |
| IIa | B-R | To evaluate selected ambulatory patients with syncope of suspected arrhythmic etiology, an ICM can be useful. |
| Recommendation for In-Hospital Telemetry | ||
| I | B-NR | Continuous ECG monitoring is useful for hospitalized patients admitted for syncope evaluation with suspected cardiac etiology. |
| Recommendations for EPS | ||
| IIa | B-NR | Continuous ECG monitoring is useful for hospitalized patients admitted for syncope evaluation with suspected cardiac etiology. |
| III-No Benefit | B-NR | EPS is not recommended for syncope evaluation in patients with a normal ECG and normal cardiac structure and function, unless an arrhythmic etiology is suspected. |
| Recommendations for Tilt-Table Testing | ||
| IIa | B-R | If the diagnosis is unclear after initial evaluation, tilt-table testing can be useful for patients with suspected VVS. |
| IIa | B-NR | Tilt-table testing can be useful for patients with syncope and suspected delayed OH when initial evaluation is not diagnostic. |
| IIa | B-NR | Tilt-table testing is reasonable to distinguish convulsive syncope from epilepsy in selected patients. |
| IIa | B-NR | Tilt-table testing is reasonable to establish a diagnosis of pseudo syncope. |
| III-No Benefit | B-R | Tilt-table testing is not recommended to predict a response to medical treatments for VVS. |