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Key challenges in the current management of syncope

Nature Reviews Cardiology volume 9, pages 590–598 (2012)Cite this article

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Abstract

Patients commonly present with syncope at emergency departments and other facilities for urgent care. Syncope is understood by physicians to be a transient, self-terminating period of cerebral hypoperfusion that usually results from systemic hypotension, and clinical guidelines for the care of patients with presumed syncope are available. However, the diagnosis and management of such patients continue to pose important diagnostic, therapeutic, and economic challenges, which are the focus of this Review. First, we discuss how to improve symptom characterization to distinguish syncope from other forms of transient loss of consciousness and syncope mimics. Second, we compare methods of risk stratification in patients with suspected syncope, and recommend the introduction of syncope clinics with enhanced interdisciplinary collaboration to optimize patient care at reduced expense. Third, we highlight the importance of the appropriate selection of diagnostic tools and treatment strategies in these syncope clinics. Finally, we address the difficulties associated with therapy for the most-common form of syncope—vasovagal or reflex syncope.

Key Points

  • The most-common cause of syncope is reflex in origin (vasovagal); cardiac syncope is less common, but potentially lethal

  • Risk stratification, although mandatory, is not yet sufficiently discriminating; syncope units, where a structured approach to diagnosis and treatment can be practised, might improve the situation

  • Syncope has multiple causes that overlap with various medical disciplines; bringing consensus to this disparate group of physicians is a major challenge

  • Diagnostic testing strategies should include the early use of implantable electrocardiographic loop recorders and the appropriate application of tilt-table testing

  • A lack of effective drugs to treat reflex syncope exists, and pacing to combat reflex cardioinhibition has been shown to be beneficial only in patients aged >40 years

  • The ultimate challenge is to minimize the number of patients in whom syncope remains unexplained

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Figure 1: Evaluation and risk stratification of patients with suspected syncope.
Figure 2: Results from ISSUE 3.68

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Article 10 October 2019

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Authors and Affiliations

  1. ICCH Building, 59–61 North Wharf Road, London, W2 1LA, UK

    Richard Sutton

  2. Department of Cardiology, Arrhythmologic Center and Syncope Unit, Ospedali del Tigullio, via don Bobbio 24, Lavagna, GE, 16033, Italy

    Michele Brignole

  3. University of Minnesota, Arrhythmia Center, Mail Code 508, 420 Delaware Street SE, Minneapolis, 55455, MN, USA

    David G. Benditt

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All the authors researched data for the article, contributed substantially to discussion of its content, and reviewed/edited the manuscript before submission. R. Sutton and D. Benditt wrote the article.

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Correspondence to Richard Sutton.

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Competing interests

R. Sutton is or has been a consultant, a member of the speakers' bureau, a patent holder or applicant, and a recipient of grant or research support for Medtronic. Additionally, he is a member of the speakers' bureau for St Jude Medical. M. Brignole is or has been a consultant for Medtronic, and a stockholder or director for F2 Solutions. D. G. Benditt is or has been a consultant, a recipient of grant or research support, and a stockholder or director for Medtronic. Additionally, he is or has been a consultant, and a stockholder or director for St Jude Medical.

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Sutton, R., Brignole, M. & Benditt, D. Key challenges in the current management of syncope. Nat Rev Cardiol 9, 590–598 (2012). https://doi.org/10.1038/nrcardio.2012.102

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