Syncope: new solutions for an old problem

Rationale and design of SAN.OK randomized clinical trial and registry: Comparison of the effects of evidence-based pacemaker therapy and cardioneuroablation in sinus node dysfunction

“…The autonomic nervous system plays a distinctive role in the pathophysiology of bradyarrhythmia [8]. Neuraxial modulation of vagal nerve is an important avenue of scientific inquiry and novel therapeutic intervention [5][6][7][8][9][10][11][12][13][14][15][16][17]. Treatment of SND by ablation technique seems a very attractive method, especially in young patients in whom a prosthesis is highly undesirable.…”

Improving the approach to non-cardiac syncope in the emergency department observation unit

“…The latest update of the European Society of Cardiology guidelines on syncope (ESC GL), [3] as the previous ones, [7] states that the first step of the diagnostic work-up should aim at recognizing patients with a likely high-risk cardiovascular condition requiring urgent investigation and admission. The approach to other forms of syncope has been recently implemented according to a new classification, based on the underlying mechanism, [8] which defines two main syncope phenotypes with different predominant mechanisms: [9] the hypotensive phenotype, where hypotension or vasodepression prevails, and the bradycardic phenotype, where cardioinhibition prevails, whose typical pattern are, classical OH and adenosine syncope due to paroxysmal atrioventricular (AV) block, respectively. Once a cardiac form has been excluded, diagnostic investigations are therefore aimed at discovering the underlying mechanism leading to syncope.…”

“…Once a cardiac form has been excluded, diagnostic investigations are therefore aimed at discovering the underlying mechanism leading to syncope. [8,9] Table 1 shows the clinical features, main causes and the diagnostic tests useful for the diagnosis of the two World J Emerg Med, Vol 14, No 2, 2023 phenotypes.…”

“…Although the identification of hypotensive and bradycardic phenotypes, in a non-cardiac syncope, can exceed the resources of the ED, in terms of timing and instrumental equipment, the authors believe that the recent advances in the management of non-cardiac syncope could be applied in an EDOU, leading to an improvement in the ED management of patients with TLOC. These acquisitions may, in fact, help define the diagnostic protocol to be used in patients with syncope managed in EDOU, so that it includes the following points: i) clinical reassessment, also aimed at pointing out suggestive features for hypotensive (advanced age and frailty; vasoactive drugs; comorbidities with fluid loss; relationship with orthostatic stress, postprandial or post exercise) [9] or bradycardic phenotypes (younger age; absence of hypotensive drugs; shortness or absence of prodromes [typical premonitory symptoms preceding syncope, such as pallor, sweating and/or nausea]) and at stratifying cardiovascular and syncopal risk, to define appropriate therapeutic targets in the case of hypertensive patients with syncope.…”