ESC 2018 2018 ESC Guidelines for the diagnosis and management of syncope
European Society of Cardiology｜循環器 / 不整脈 / 失神｜69 ページ｜チャンク 621｜推奨 124 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.12 | I | C | (pallor, sweating, and/or nausea).8,13–17 | |
| p.12 | I | C | Situational reflex syncope is highly probable if syncope occurs during or immediately after specific triggers, listed in Table 3.8,13–17 | |
| p.12 | I | C | Syncope due to OH is confirmed when syncope occurs while standing and there is concomitant significant OH.18–24 | |
| p.12 | I | C | Cardiac ischaemia-related syncope is confirmed when syncope presents with evidence of acute myocardial ischaemia with or without myocardial infarction.25–39 | |
| p.14 | I | B | It is recommended that patients with low-risk features, likely to have reflex or situational syncope, or syncope due to OH, are discharged from the ED.27,35,36,49–54,58,62,69 | |
| p.14 | I | B | in an ED observation unit (if available), or are hospitalized.26,27,35,36,44–46,50,55–57,59,60,70–76 | |
| p.14 | I | B | It is recommended that patients who have neither high- nor low-risk features are observed in the ED or in a syncope unit instead of being hospitalized.40,63–65,77 | |
| p.14 | IIb | B | Risk stratification scores may be considered for risk stratification in the ED.78–86 | |
| p.19 | I | B | CSM is indicated in patients >40 years of age with syncope of unknown origin compatible with a reflex mechanism.92–94 | |
| p.19 | I | B | patients have clinical features compatible with a reflex mechanism of syncope.89,90,92,93,98–102 | |
| p.20 | I | C | cated at initial syncope evaluation.20,103,104 | |
| p.20 | IIb | C | Continuous beat-to-beat non-invasive BP and HR measurement may be preferred when short-lived BP variations are suspected, such as in initial OH.20,103,104 | |
| p.20 | I | C | mmHg, or a decrease in systolic BP to <90 mmHg that reproduces spontaneous symptoms.6,20,103,104 | |
| p.20 | IIa | C | active standing) in the absence of OH that reproduces spontaneous symptoms.6,20,103,104 | |
| p.21 | IIa | B | Tilt testing should be considered in patients with suspected reflex syncope, OH, POTS, or PPS.23,24,105–109,111–117 | |
| p.21 | IIb | B | Tilt testing may be considered to educate patients to recognize symptoms and learn physical manoeuvres.119–121 | |
| p.21 | IIa | B | teristic circulatory pattern of these conditions.23,24,105–109,111–117 | |
| p.23 | IIb | C | Valsalva manoeuvre may be considered for confirming the hypotensive tendency induced by some forms of situational syncope, e.g. coughing, brass instrument playing, singing, and weightlifting.144 | |
| p.23 | IIa | B | OH.142,143,146,147 | |
| p.23 | IIb | C | Other autonomic function tests (30:15 ratio, cold pressure test, sustained hand grip test, and mental arithmetic test) may be considered for the assessment of autonomic function in patients with suspected neurogenic OH.13,142,143,147 | |
| p.23 | I | B | ABPM is recommended to detect nocturnal hypertension in patients with autonomic failure.140,148–151 | |
| p.23 | IIa | C | autonomic failure.152,153 | |
| p.25 | I | C | Immediate in-hospital monitoring (in bed or by telemetry) is indicated in high-risk patients (defined in Table 6). | |
| p.25 | IIa | B | Holter monitoring should be considered in patients who have frequent syncope or presyncope (>_1 episode per week).161 | |
| p.25 | IIa | B | weeks.162,166,168,201 | |
| p.25 | IIa | B | episodes.184–186 | |
| p.25 | IIb | B | ILR may be considered in patients with unexplained falls.191–194, Supplementary Data Table 8 | |
| p.25 | I | B | rhythmia) is detected.172,184–186,188,200 | |
| p.26 | IIa | C | Video recording in suspected syncope Home video recordings of spontaneous events should be considered. Physicians should encourage patients and their relatives to obtain home video recordings of spontaneous events.206,208 | |
| p.26 | IIb | C | Adding video recording to tilt testing may be considered in order to increase the reliability of clinical observation of induced events.9,116,117,205 aClass of recommendation. bLevel of evidence. 4.2.6 Electrophysiological study | |
| p.27 | I | B | cope remains unexplained after non-invasive evaluation.218 | |
| p.27 | IIa | B | In patients with syncope and bifascicular BBB, EPS should be considered when syncope remains unexplained after non-invasive evaluation.188,214–217,221 | |
| p.27 | IIb | B | tests (e.g. ECG monitoring) have failed to show a correlation between syncope and bradycardia.210–212 | |
| p.27 | I | B | In patients with unexplained syncope and previous myocardial infarction, or other scar-related conditions, it is recommended that induction of sustained monomorphic VT is managed according to the current ESC Guidelines for VA.46 | |
| p.27 | IIa | B | SNRT is present.210–212 | |
| p.28 | I | B | Echocardiography is indicated for diagnosis and risk stratification in patients with suspected structural heart disease.235,236 | |
| p.28 | I | C | able causes of syncope when the electrocardiogram shows the typical features of these conditions.237–244 | |
| p.29 | I | C | Exercise testing Indications Exercise testing is indicated in patients who experience syncope during or shortly after exertion. Diagnostic criteria | |
| p.29 | I | C | Syncope due to second- or third-degree AV block is confirmed when the AV block develops during exercise, even without syncope.253–257 | |
| p.29 | I | C | Reflex syncope is confirmed when syncope is reproduced immediately after exercise in the presence of severe hypotension.250–252 Additional advice and clinical perspectives with syncope. AV = atrioventricular. aClass of recommendation. bLevel of evidence. | |
| p.29 | IIa | C | Coronary angiography Indications In patients with syncope, the same indica- tions for coronary angiography should be considered as in patients without syncope.258 Additional advice and clinical perspectives aClass of recommendation. bLevel of evidence. 5 Treatment | |
| p.36 | IIa | B | Modification or discontinuation of hypotensive drug regimen should be considered in patients with vasodepressor syncope, if possible.260–262 | |
| p.36 | IIa | B | Isometric PCM should be considered in patients with prodromes who are <60 years of age.119–121,263,264 | |
| p.36 | IIb | B | Tilt training may be considered for the education of young patients.265–272 | |
| p.36 | IIb | B | and the absence of contraindication to the drug.275 | |
| p.36 | IIb | B | Midodrine may be considered in patients with the orthostatic form of VVS.278 | |
| p.36 | III | A | Beta-adrenergic blocking drugs are not indicated.279,280 | |
| p.36 | IIa | B | drome who are >40 years with recurrent frequent unpredictable syncope.90,292,293 | |
| p.36 | IIb | B | >40 years with recurrent frequent unpredictable syncope.292,297,298,303 | |
| p.36 | IIb | B | Cardiac pacing may be considered to reduce syncope recurrences in patients with the clinical features of adenosine-sensitive syncope.5,227,286 | |
| p.36 | III | B | Cardiac pacing is not indicated in the absence of a documented cardioinhibitory reflex.299,300 | |
| p.39 | I | C | indicated.310,311 | |
| p.39 | IIa | C | Isometric PCM should be considered.319 | |
| p.39 | IIa | B | toms persist.324–326 | |
| p.39 | IIa | C | symptoms persist.322,327,328 | |
| p.39 | I | C | Treatment of orthostatic hypotension Explanation of the diagnosis, the provision of reassurance, and explanation of the risk of recurrence and the avoidance of triggers and situations are indicated in all patients. Adequate hydration and salt intake are | |
| p.39 | IIa | B | Modification or discontinuation of hypotensive drug regimens should be considered.312–318 | |
| p.39 | IIa | B | Abdominal binders and/or support stockings to reduce venous pooling should be considered.23,320,321 | |
| p.39 | IIa | C | Head-up tilt sleeping (>10 degrees) to increase fluid volume should be considered.104,322,323 Midodrine should be considered if symp- Fludrocortisone should be considered if Additional advice and clinical perspectives | |
| p.42 | I | B | • Sick sinus syndrome.210–212,334–338 | |
| p.42 | I | B | • Intrinsic AV block.200,255,341 | |
| p.42 | IIa | C | Cardiac pacing should be considered when the relationship between syncope and asymptomatic sinus node dysfunction is less established.135,136,210–212,339,340 | |
| p.42 | III | C | Cardiac pacing is not indicated in patients when there are reversible causes for bradycardia. | |
| p.42 | I | B | Cardiac pacing is indicated in patients with syncope, BBB, and a positive EPS or ILR-documented AV block.188,217 | |
| p.42 | IIb | B | Cardiac pacing may be considered in patients with unexplained syncope and bifascicular BBB.217,255,344 | |
| p.42 | I | B | Catheter ablation is indicated in patients with syncope due to SVT or VT in order to prevent syncope recurrence.46 | |
| p.42 | I | A | An ICD is indicated in patients with syncope due to VT and an ejection fraction <_35%.46 | |
| p.42 | I | C | An ICD is indicated in patients with syncope and previous myocardial infarction who have VT induced during EPS.218 | |
| p.42 | IIa | C | ablation and pharmacological therapy have failed or could not be performed.46 | |
| p.42 | IIa | C | Antiarrhythmic drug therapy, including rate-control drugs, should be considered in patients with syncope due to SVT or VT. | |
| p.43 | I | A | ICD therapy is recommended to reduce SCD in patients with symptomatic heart fail- ure (NYHA class II–III) and LVEF <_35% after >_3 months of optimal medical therapy, who are expected to survive >_1 year with good functional status.46 | |
| p.43 | IIa | C | An ICD should be considered in patients with unexplained syncopea with systolic impairment, but without a current indication for ICD, to reduce the risk of sudden death.27,28,359,360 | |
| p.43 | IIb | C | Instead of an ICD, an ILR may be considered in patients with recurrent episodes of unexplained syncopea with systolic impairment, but without a current indication for ICD. for SCD. | |
| p.44 | I | B | It is recommended that decisions for ICD implantation in patients with unexplained syncopea are made according to the ESC HCM Risk-SCD score.d,245 | |
| p.44 | IIa | C | Instead of an ICD, an ILR should be consid- ered in patients with recurrent episodes of unexplained syncopea who are at low risk of SCD, according to the HCM Risk-SCD score.d,245 Additional advice and clinical perspectives | |
| p.44 | IIb | C | ICD implantation may be considered in patients with ARVC and a history of unexplained syncope.a,46 Instead of an ICD, an ILR should be consid- | |
| p.44 | IIa | C | ered in patients with recurrent episodes of unexplained syncope who are at low risk of SCD, based on a multiparametric analysis that takes into account the other known risk factors for SCD. | |
| p.45 | IIa | B | ICD implantation in addition to beta-blockers should be considered in LQTS patients who experience unexplained syncopea while receiving an adequate dose of beta-blockers.46 Left cardiac sympathetic denervation should | |
| p.45 | IIa | C | be considered in patients with symptomatic LQTS when: (1) beta-blockers are not effective, not tol- erated, or are contraindicated; (2) ICD therapy is contraindicated or refused; or (3) when patients on beta-blockers with an ICD experience multiple shocks.46 | |
| p.45 | IIa | C | Instead of an ICD, an ILR should be considered in patients with recurrent episodes of unexplained syncopea who are at low risk of SCD based on a multiparametric analysis that takes into account the other known risk factors for SCD. | |
| p.45 | IIa | C | ICD implantation should be considered in patients with a spontaneous diagnostic type 1 ECG pattern and a history of unexplained syncope.a,46,353,355,365,366 | |
| p.45 | IIa | C | Instead of an ICD, an ILR should be consid- ered in patients with recurrent episodes of unexplained syncopea who are at low risk of SCD, based on a multiparametric analysis that takes into account the other known risk factors for SCD. | |
| p.46 | I | B | Multifactorial evaluation and intervention is recommended in older patients because more than one possible cause for syncope and unex- plained fall may be present.33,372–374,376–380 | |
| p.46 | I | C | Cognitive assessment and physical perform- ance tests are indicated in older patients with syncope or unexplained fall.373,389,391–394 | |
| p.46 | IIa | B | Modification or discontinuation of possible culprit medications, particularly hypotensive drugs and psychotropic drugs, should be considered in older patients with syncope or unexplained fall.260,381–385 | |
| p.46 | IIa | C | In patients with unexplained fall, the same assessment as for unexplained syncope should be considered.191,194,387–390 Additional advice and clinical perspectives | |
| p.48 | IIa | C | the diagnosis of PPS to the patient.116,404 | |
| p.48 | IIa | C | Diagnosis The recording of spontaneous attacks with a video by an eyewitness should be consid- ered for diagnosis of PPS.116,154 | |
| p.48 | IIb | C | Tilt testing, preferably with concurrent EEG recording and video monitoring, may be considered for diagnosis of PPS.116,403,407 Management | |
| p.48 | IIb | C | Doctors who diagnose PPS should present Cognitive behavioural therapy may be considered in the treatment of PPS if attacks persist after explanation. | |
| p.50 | I | C | Neurological evaluation Neurological evaluation is indicated when syncope is due to autonomic fail- ure to evaluate the underlying disease. | |
| p.50 | I | C | Neurological evaluation is indicated in patients in whom TLOC is suspected to be epilepsy. TLOC = transient loss of consciousness. aClass of recommendation. bLevel of evidence. | |
| p.50 | I | C | Neurological tests Brain MRI is recommended if neurological examination indicates Parkinsonism, ataxia, or cognitive impairment. | |
| p.50 | I | B | Screening for paraneoplastic antibodies and antiganglionic acetylcholine receptor anti- bodies is recommended in cases of acute or subacute onset of multidomain autonomic failure.432,433 | |
| p.50 | III | B | EEG, ultrasound of neck arteries, and com- puted tomography or magnetic resonance imaging of the brain are not indicated in patients with syncope.178,435–440 Additional advice and clinical perspectives investigations for occult malignancy. 9 Organizational aspects | |
| p.56 | I | C | VVS is highly probable if syncope is precipitated by pain, fear, or standing, and is associated with typical progressive prodrome (pallor, sweating, and/or nausea).8,13–17 | |
| p.56 | I | C | Situational reflex syncope is highly probable if syncope occurs during or immediately after specific triggers listed in Table 3.8,13–17 | |
| p.56 | I | C | Syncope due to OH is confirmed when syncope occurs while standing and there is concomitant OH.18–24 | |
| p.57 | I | B | are discharged from the ED.27,35,36,49–54,58,62,69 | |
| p.57 | I | B | It is recommended that patients with high-risk features receive an early intensive prompt evaluation in a syncope unit or in an ED observation unit (if available), or are hospitalized.26,27,35,36,44–46,50,55–57,59,60,70–76 | |
| p.57 | I | B | instead of being hospitalized.40,63–65,77 | |
| p.57 | I | B | CSM is indicated in patients >40 years of age with syncope of unknown origin compatible with a reflex mechanism.92–94 | |
| p.57 | I | B | patients have clinical features compatible with a reflex mechanism of syncope.89,90,92,93,98–102 | |
| p.57 | I | C | cated at initial syncope evaluation.20,103,104 | |
| p.57 | I | C | mmHg, or a decrease in systolic BP to <90 mmHg that reproduces spontaneous symptoms.6,20,103,104 | |
| p.57 | I | C | Immediate in-hospital monitoring (in bed or by telemetry) is indicated in high-risk patients (defined in Table 6). | |
| p.57 | I | B | Arrhythmic syncope is confirmed when a correlation between syncope and an arrhythmia (bradyarrhythmia or tachyarrhythmia) is detected.172,184–186,188,200 | |
| p.57 | I | B | In patients with syncope and previous myocardial infarction or other scar-related conditions, EPS is indicated when syncope remains unexplained after non-invasive evaluation.218 | |
| p.57 | I | B | mended that induction of sustained monomorphic VT is managed according to the current ESC Guidelines for VA.46 | |
| p.57 | I | B | Echocardiography is indicated for diagnosis and risk stratification in patients with suspected structural heart disease.235,236 | |
| p.57 | I | C | Exercise testing is indicated in patients who experience syncope during or shortly after exertion. | |
| p.57 | I | C | syncope.253–257 | |
| p.57 | I | C | Reflex syncope is confirmed when syncope is reproduced immediately after exercise in the presence of severe hypotension.250–252 | |
| p.58 | III | A | Beta-adrenergic blocking drugs are not indicated.279,280 | |
| p.58 | III | B | Cardiac pacing is not indicated in the absence of a documented cardioinhibitory reflex.299,300 | |
| p.58 | I | C | Adequate hydration and salt intake are indicated.310,311 | |
| p.58 | I | B | bradycardia.200,210–212,255,334–338,341 | |
| p.58 | III | C | Cardiac pacing is not indicated in patients when there are reversible causes for bradycardia. | |
| p.58 | I | B | Cardiac pacing is indicated in patients with syncope, BBB, and a positive EPS or ILR-documented AV block.188,217 | |
| p.58 | I | C | Catheter ablation is indicated in patients with syncope due to SVT or VT in order to prevent syncope recurrence. | |
| p.58 | I | A | An ICD is indicated in patients with syncope due to VT and ejection fraction <_35%.46 | |
| p.58 | I | C | An ICD is indicated in patients with syncope and previous myocardial infarction who have VT induced during EPS.218 | |
| p.58 | I | B | A multifactorial evaluation and intervention is recommended in older patients because more than one possible cause for syncope and unexplained fall may be present.33,372–374,376–380 | |
| p.58 | I | C | underlying disease. |