Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association Position Statement on the Approach to Syncope in the Pediatric Patient

Abstract

Pediatric syncope is a common problem that peaks in adolescence, for which there are few data or evidence-based consensus on investigation and management. This document offers guidance for practical evaluation/management of pediatric patients (age < 19 years) with syncope encountered in the acute or primary care setting. The writing committee used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Most syncope is vasovagal, which is benign and does not require extensive investigation. This Position Statement presents recommendations to encourage an efficient and cost-effective disposition for the many patients with a benign cause of syncope, and highlights atypical or concerning clinical findings associated with other causes of transient loss of consciousness. The prodrome and the circumstances around which the event occurred are the most important aspects of the history. Syncope occurring midexertion suggests a cardiac etiology. A family history, which includes sudden death in the young or from unknown causes or causes that might be suspected to be other than natural can be a red flag. The electrocardiogram is the most frequently ordered test, but the yield is low and the test is not cost-effective when applied broadly to a population of patients with syncope. We recommend an electrocardiogram when the history is not suggestive of vasovagal syncope and there are features suggestive of a cardiac cause like absence of a prodrome, midexertional event, family history of early-life sudden death or heart disease, abnormal physical examination, or new medication with potential cardiotoxicity. For most patients with syncope, medical testing is not required and lifestyle modifications without medications suffice to prevent recurrences.

2018 Chinese Pediatric Cardiology Society (CPCS) guideline for diagnosis and treatment of syncope in children and adolescents

“…Pacemaker therapy should be considered carefully. For recurrent syncope accompanied by a long cardiac arrest (>4 s), a pacemaker should be considered under the advice of pediatric cardiovascular specialists [41,42] (IIa; C).…”

Polymorphic ventricular tachycardia associated with an episode of reflex syncope: Is this the needle in the haystack?

“…The most informative diagnostic test is an accurate, detailed history, ideally from the patient. 1 Confirming typical triggers 2 for the syncope is reassuring and implies a benign prognosis. Recurrence is predicted primarily by the frequency of recent syncopal episodes.…”

“…Syncope is common, occurring in approximately 30%–40% of the population by age 60 years. 1 Reflex syncope presents as loss of consciousness and postural tone with spontaneous recovery. The ultimate cause is cerebral hypoperfusion, although the underlying mechanism(s) is not completely understood.…”

Predictors of abnormal electrocardiograms in the pediatric emergency department

“…The authors concluded that ECGs are not necessary for diagnosing cardiac causes of syncope; only five of 480 pediatric patients with syncope were found to have a cardiac cause. [ 7 ] Similar to chest pain, a detailed history and physical examination without an ECG are sufficient to determine if syncope can be diagnosed as vasovagal or requires follow-up with a cardiologist or neurologist. [ 7 ]…”

“…[ 7 ] Similar to chest pain, a detailed history and physical examination without an ECG are sufficient to determine if syncope can be diagnosed as vasovagal or requires follow-up with a cardiologist or neurologist. [ 7 ]…”