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........................................................... (2) In case of TLOC, is it of syncopal or non-syncopal origin? (3) In case of suspected syncope, is there a clear aetiological diagnosis (see section 4.1.1)? (4) Is there evidence to suggest a high risk of cardiovascular events or death (see section 4.1.2)?

TLOC has four specific characteristics: short duration, abnormal motor control, loss of responsiveness, and amnesia for the period of LOC (for an explanation of the clinical features of TLOC see Web Table 4 in section 4.1 of the Web Practical Instructions). TLOC is probably syncope when: (i) there are signs and symptoms specific for reflex syncope, syncope due to OH, or cardiac syncope, and (ii) signs and symptoms specific for other forms of TLOC (head trauma, epileptic seizures, psychogenic TLOC, and/or rare causes) are absent. Practical instructions for history taking are given in sections 3 and 4 of the Web Practical Instructions. When epileptic seizures or psychogenic attacks are likely, appropriate steps should be taken. By using a detailed clinical history, physicians can differentiate syncope from other forms of TLOC in approximately 60% of cases.12 For non-syncopal TLOC, refer to sections 7 and 8.

4.1.1 Diagnosis of syncope The starting point of the diagnostic evaluation of TLOC of suspected syncopal nature is the initial syncope evaluation, which consists of: • Careful history taking concerning present and previous attacks, as well as eyewitness accounts, in person or through a telephone interview. • Physical examination, including supine and standing BP measurements. • Electrocardiogram (ECG). Based on these findings, additional examinations may be performed when needed (see section 4.2): • Immediate ECG monitoring when there is a suspicion of arrhythmic syncope. • Echocardiogram when there is previous known heart disease, data suggestive of structural heart disease, or syncope secondary to cardiovascular cause.

Figure 4 Flow diagram for the initial evaluation and risk stratification of patients with syncope. BP = blood pressure; ECG = electrocardiogram; H&P exam = history and physical examination; TLOC = transient loss of consciousness. Downloaded from academic.oup.com/eurheartj/article/39/21/1883/4939241 by guest on 07 October 2026