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The National Institute of Clinical Excellence (NICE), in August 2010, published the Transient Loss of Consciousness guideline1 which dealt with the assessment, diagnosis and specialist referral of adults and young people (aged 16 and older), who had experienced transient loss of consciousness (TLoC), also commonly described in the UK as a ‘blackout’. The guideline defines TLoC as spontaneous loss of consciousness with complete recovery, implying full recovery of consciousness without any residual neurological deficit. This first ever to be published guideline in the UK dealt with a very common condition which has a lifetime incidence of up to 50%.2 Transient loss of consciousness is a symptom with several causes, with cardiovascular causes (syncope) being the most common. Other common causes of TLoC include neurological conditions, principally epilepsy and psychogenic attacks. Syncope, in turn, has many causes, ranging from those with a benign prognosis, for example, vasovagal syncope, to those which can be life threatening and hence associated with an adverse long term prognosis, for example, cardiac syncope.3
There were a number of reasons why it was felt that such guidance was necessary. Review of the scientific literature suggested that the diagnosis of the underlying cause of TLoC is often inaccurate, inefficient and delayed. There is huge variation in the management of TLoC. Some people have expensive and inappropriate tests or inappropriate specialist referral; others with potentially dangerous conditions may not receive appropriate assessment, diagnosis and treatment. People experiencing TLoC may be treated by a range of clinicians—general physicians, care of the elderly physicians, cardiologists, neurologists etc and the lack of a clear pathway may contribute to misdiagnosis and inappropriate treatment. While there was some existing guidance related to TLoC, for example epilepsy,4 falls,5 dual chamber pacemakers6 and implantable cardioverter defibrillators,7 guidelines which defined …
Contributors All the authors of this manuscript were NICE guideline development group members. In addition, SD has conducted a health economic analysis on the role of implantable loop recorders in investigating patients with arrhythmic and syncope of unknown cause (cited in references).
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.