New insights in diagnostics and therapies in syncope: a novel approach to non-cardiac syncope

Abstract

This article aims to give advice on how to identify and manage patients with syncope who are at risk of severe outcomes, that is, at risk of trauma, potentially life-threatening episodes or frequent recurrences reducing quality of life. The first step of syncope diagnostic assessment is to identify patients with cardiac syncope, and once established, these patients must receive the adequate mechanism-specific treatment. If cardiac syncope is unlikely, reflex (neurally mediated) syncope and orthostatic hypotension are the most frequent causes of transient loss of consciousness. For these presentations, efficacy of therapy is largely determined by the mechanism of syncope rather than its aetiology or clinical features. The identified mechanism of syncope should be carefully assessed and assigned either to hypotensive or bradycardic phenotype, which will determine the choice of therapy (counteracting hypotension or counteracting bradycardia). The results of recent trials indicate that ‘mechanism-specific therapy’ is highly effective in preventing recurrences. Established mechanism-specific treatment strategies include withdrawal of hypotensive drugs, applying fludrocortisone and midodrine for the hypotensive phenotype and cardiac pacing in the bradycardic phenotype.

Syncope: new solutions for an old problem

“…Consistently, lower resting systolic BP (≤128 mm Hg) and absence of hypertension have been identified as independent predictors of TT positivity, confirming that reflex syncope susceptibility is strongly related to hemodynamic reserve, which is reduced in presence of lower BP [19]. Therefore, three different hemodynamic profiles can be outlined, including (1) individuals with stable cardiovascular homeostasis; (2) individuals with a predisposition to syncope and well-functioning compensatory mechanisms, allowing for increased tolerance to orthostatic stress and TT; (3) individuals with a more pronounced predisposition to syncope due to the suboptimal compensatory capacity, making them more prone to develop reflex syncope during TT.…”

“…Although etiology is often benign, syncope is estimated to be severe in approximately 14% of cases, carrying a high risk of severe injuries and/or substantial impairment of the quality of life [1]. Even in the case of rare episodes, syncope may be responsible for serious fall-related complications, such as fractures and intracranial hemorrhage [2]. Moreover, recurrent syncope may cause patients' anxiety and restriction in social and working activities, thus affecting psychosocial functioning as in chronic diseases [3,4].…”

Syncope presenting to the emergency department

“…Syncope is much more challenging in older patients as they may have no memory of the episode and live alone, implying no witness. The likelihood of a serious cause of syncope is much greater including arrhythmias, structural cardiopulmonary disease and iatrogenic overtreatment of hypertension [1,6]. Presentation as an unexplained fall is common, and it is estimated that~20% of falls are really due to syncope [1,6].…”

“…The likelihood of a serious cause of syncope is much greater including arrhythmias, structural cardiopulmonary disease and iatrogenic overtreatment of hypertension [1,6]. Presentation as an unexplained fall is common, and it is estimated that~20% of falls are really due to syncope [1,6]. Patients are often admitted as inpatients unnecessarily and, when they are, they may languish for days in the hospital awaiting valueless investigations such as brain-scanning preceded or not by neurological consultations which may also be poorly informed about syncope.…”

Heartbeat: time to address sexism and sexual harassment in cardiology

“…Several algorithms provide a roadmap for patient management that will be of great value to clinicians. 8…”