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August 1, 2017 Circulation. 2017;136:e60–e122. DOI: 10.1161/CIR.0000000000000499 e92

Patients with ACHD are at risk for syncope as a result not only of the underlying structural disease, but also as a result of a previous palliative or corrective surgery. These patients may present with syncope of both hemodynamic and either bradycardic or tachycardic origin. Care by a physician with experience in management of CHD can be beneficial. The entire spectrum of arrhythmias may be seen in adults with CHD, including bradyarrhythmias secondary to sinus or AV nodal disease, atrial arrhythmias, and VA. By age 50 years, approximately 38% of patients with ACHD will develop an atrial arrhythmia, and by age 65 years, >50% of patients with severe CHD will develop atrial arrhythmias.660 The prevalence of VT after tetralogy of Fallot repair is 3% to 14%.661,662

10.3 Geriatric Patients: Recommendations

The management of syncope in older adults is particularly challenging: The incidence is high; the differential diagnosis is broad; the diagnosis is imprecise because of amnesia, falls, lack of witnesses, and polypharmacy; and secondary morbidity is high because of comorbidities, physical injury, and frailty.35,45,666–675 The vulnerability of older adults to syncope increases because of age-associated cardiovascular and autonomic changes, decreased fluid conservation,45,671,676–678 and an increased probability of developing multiple concurrent morbidities (with their associated pharmacological treatments) that can overwhelm homeostasis. In many instances, a syncopal event in an older adult is multifactorial, with many predisposing factors present simultaneously.

Older patients (>75 years of age) who present with syncope tend to have poor outcomes, both fatal and nonfatal.109,679,680 Although some of the risk is attributable to the aspects of syncope described in this guideline, among older adults such risks are usually compounded by multiple morbidities and frailty, which add to age-related vulnerability to syncope,671,681,682 and by the physical injuries associated with falls, collisions, or trauma, which more commonly result from syncope in old age.670 Furthermore, recurrent syncope can lead to nursing home admission and a devastating loss of independence.683 Given the multifactorial etiologies and high risks associated with syncope, a comprehensive and multidisciplinary approach is often necessary to assess for multiple morbidities, frailty, trauma, and other dimensions of health (including cognition and medications) pertinent to diagnosis and management.77,188,684,685 A thorough history and physical examination, including orthostatic vital signs, is particularly important in older patients.77

Recommendations for Geriatric Patients

COR LOE Recommendations IIa C-EO For the assessment and management of older adults with syncope, a comprehensive approach in collaboration with an expert in geriatric care can be beneficial.

N/A A multidisciplinary approach helps to facilitate diagnosis of frailty and other factors that predispose to syncope and poor outcome in older adults. The goal is to make management decisions in which older patients are well informed, therapeutic choices are tailored to each patient’s needs and goals of care, and decision making is successfully shared between patients and providers. Diagnostic and therapeutic approaches to syncope should incorporate considerations of age, comorbid illness, physical and cognitive functions, patient preferences, and severity of symptoms. Assessment is required of underlying cardiovascular and noncardiovascular diseases; use of medications (eg, polypharmacy, drug-drug interaction, age-related reduction in hepatic and renal clearance); the potential to reduce medications that might lower blood pressure; and circumstantial factors, such as dehydration, infection, or fever.

Consideration of frailty is particularly relevant. Characteristics of frailty include weight loss, weakness, exhaustion, reduced physical activity, physical slowing, and cognitive decline, with cumulative severity and impact that typically vary between patients and even in 1 patient over time.

IIa B-NR It is reasonable to consider syncope as a cause of nonaccidental falls in older adults.666–669,686

See Online Data Supplement 41. Approximately 30% of older adults who present with nonaccidental falls may have had syncope.687 Amnesia is commonly associated with both falls and loss of consciousness, which diminishes the effectiveness of the history. Cognitive impairment is also frequently present in older adults, even in those without a formal diagnosis of dementia,688–690 and this too can reduce the accuracy of recall of the clinical event.666–669,673,686

10.4 Driving and Syncope: Recommendation

The assessment of medical fitness to drive is a common issue for practitioners caring for patients with syncope. The main concern is the risk of causing injury or death to the driver or others as a result of recurrent syncope.691 Factors to consider in assessing the risk of syn- cope while driving are summarized in a formula developed by the Canadian Cardiovascular Society 25 years ago692 that estimates the risk that a driver will suddenly become incapacitated. The acceptable level of risk then becomes a societal decision.

Balancing the need to minimize risk from drivers fainting is the need for patients to drive to meet the demands of family and work. Society recognizes that

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