It includes tilt testing, carotid sinus massage, and ECG monitoring, and often further requires implantation of an implantable loop recorder (ILR). If cardiac evaluation does not show evidence of arrhythmia as a cause of syncope, evaluation for neurally‐mediated syndromes is recommended only in those with recurrent or severe syncope. In these patients, cardiac evaluation (echocardiography, stress testing, electrophysiological study and prolonged ECG monitoring including loop recorder) is recommended. The presence of suspected or certain heart disease is associated with a higher risk of arrhythmias and mortality at one year. TIA, transient cerebral ischaemic attack. BP, blood pressure ECG, electrocardiogram. Once the evaluation, as outlined, is completed and no cause of syncope is determined, reappraisal of the work‐up may be needed. When a cardiac diagnosis cannot be confirmed, neurally‐mediated tests are usually performed. Among neurally‐mediated investigations, tilt test, carotid sinus massage and implantable loop recorder are most useful. Among cardiac investigations, echocardiography, prolonged electrocardiographic monitoring, stress test, electrophysiological study and implantable loop recorder are most useful. The features which suggest a cardiac or a neurally‐mediated cause of syncope are listed in tables 3 and 4. The conditions in which the results of the initial evaluation are diagnostic of the cause of syncope and no further evaluation is required are listed as recommendations in the section “The diagnostic strategy based on the initial evaluation”. For the classification of syncope refer to table 1 1 and for the classification of non‐syncopal attack refer to table 2 2. Differentiating true syncope from other “non‐syncopal” conditions associated with real or apparent transient loss of consciousness is generally the first diagnostic step and influences the subsequent diagnostic strategy. Examples of non‐classical vasovagal syncope include episodes without clear triggering events or premonitory symptoms.įigure 1 Flow diagram outlining an approach to the evaluation of loss of consciousness based on the initial evaluation, proposed by the Task Force on Syncope of the European Society of Cardiology 1, 2. These forms are diagnosed by minor clinical criteria, exclusion of other causes for syncope (absence of structural heart disease) and positive response to tilt testing or carotid sinus massage. Often, however, neurally‐mediated reflex syncopes have “non‐classical” presentations. “Situational syncope” refers to those forms of neurally‐mediated syncope associated with specific scenarios (for example, micturition, coughing, defaecating, etc). “Carotid sinus syncope” is defined as syncope which, by history, seems to occur in close relationship to accidental mechanical manipulation of the carotid sinuses, and which can be reproduced by carotid sinus massage. The “classical vasovagal syncope” is mediated by emotional or orthostatic stress and can be diagnosed by history taking. The triggering events might vary considerably in individual patients. “Neurally‐mediated (reflex) syncope” refers to a reflex response that, when triggered, gives rise to vasodilatation and/or bradycardia however the contribution of each of these two factors to systemic hypotension and cerebral hypoperfusion may differ considerably. Pulmonary embolus/pulmonary hypertension.Structural cardiac or cardiopulmonary disease Implanted device (pacemaker, implantable cardioverter‐defibrillator) malfunction.Inherited syndromes (eg, long QT syndrome, Brugada syndrome).Paroxysmal supraventricular and ventricular tachycardias.Atrioventricular conduction system disease.Sinus node dysfunction (including bradycardia/tachycardia syndrome).haemorrhage, diarrhoea, Addison's disease secondary autonomic failure syndromes (eg, diabetic neuropathy, amyloid neuropathy) primary autonomic failure syndromes (eg, pure autonomic failure, multiple system atrophy, Parkinson's disease with autonomic failure) others (eg, brass instrument playing, weightlifting) gastrointestinal stimulation (swallow, defaecation, visceral pain)
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