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Document Reviewers: Adam Torbicki (CPG Review Coordinator) (Poland), Javier Moreno (CPG Review Coordinator) (Spain), Victor Aboyans (France), Stefan Agewall (Norway), Riccardo Asteggiano (Italy), Jean-Jacques Blanc (France), Natan Bornstein1 (Israel), Serge Boveda (France), He ́ctor Bueno (Spain), Haran Burri (Switzerland), Antonio Coca (Spain), Jean-Philippe Collet (France), Giorgio Costantino2 (Italy), Ernesto Dıaz-Infante (Spain), Victoria Delgado (The Netherlands), Faas Dolmans (The Netherlands), Oliver Gaemperli (Switzerland), Jacek Gajek (Poland), Gerhard Hindricks (Germany), Josef Kautzner (Czech Replublic), Juhani Knuuti (Finland), Piotr Kulakowski (Poland), Ekaterini Lambrinou (Cyprus), Christophe Leclercq (France), Philippe Mabo (France), Carlos A. Morillo (Canada), Massimo Francesco Piepoli (Italy), Marco Roffi(Switzerland), Win K. Shen (USA), Iain A. Simpson (UK), Martin Stockburger (Germany), Peter Vanbrabant3 (Belgium), Stephan Windecker (Switzerland), and Jose Luis Zamorano (Spain) The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website http://www.escardio.org/guidelines. For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see https://academic.oup.com/eurheartj/article-lookup/doi/ 10.1093/eurheartj/ehy037#supplementary-data

Click here to access the corresponding chapter in ESC CardioMed - Section 39 Syncope Online publish-ahead-of-print 19 March 2018

................................................................................................................................................................................................... Keywords Guidelines • Syncope • Transient loss of consciousness • Vasovagal syncope • Reflex syncope • Orthostatic hypotension • Cardiac syncope • Sudden cardiac death • Electrophysiological study • Prolonged ECG monitoring • Tilt testing • Carotid sinus massage • Cardiac pacing • Implantable cardioverter defibrillator • Syncope unit • Emergency department

Table of Contents

1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1886 2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1887 2.1 What is new in the 2018 version? . . . . . . . . . . . . . . . . . . . . . . . . . . . 1889 3. Definitions, classification, and pathophysiology . . . . . . . . . . . . . . . . . . 1889 3.1 Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1889 3.2 Classification and pathophysiology of syncope and transient loss of consciousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1890 3.2.1 Syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1890 3.2.2 Non-syncopal forms of (real or apparent) transient loss of consciousness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1890 4. Diagnostic evaluation and management according to risk stratification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1892

4.1 Initial evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1892 4.1.1 Diagnosis of syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1893 4.1.2 Management of syncope in the emergency department based on risk stratification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1895 4.2 Diagnostic tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1900 4.2.1 Carotid sinus massage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1900 4.2.2 Orthostatic challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1901 4.2.2.1 Active standing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1901 4.2.2.2 Tilt testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1903 4.2.3 Basic autonomic function tests. . . . . . . . . . . . . . . . . . . . . . . . . 1904 4.2.3.1 Valsalva manoeuvre. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1904 4.2.3.2 Deep breathing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1904 4.2.3.3 Other autonomic function tests . . . . . . . . . . . . . . . . 1904 4.2.3.4 Twenty-four-hour ambulatory and home blood pressure monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1904 4.2.4 Electrocardiographic monitoring (non-invasive and invasive) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1905

4.2.4.1 In-hospital monitoring . . . . . . . . . . . . . . . . . . . . . . . . . 1905 4.2.4.2 Holter monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1905 4.2.4.3 Prospective external event recorders. . . . . . . . . . . 1905 4.2.4.4 Smartphone applications. . . . . . . . . . . . . . . . . . . . . . . 1906 4.2.4.5 External loop recorders. . . . . . . . . . . . . . . . . . . . . . . . 1906 4.2.4.6 Remote (at home) telemetry. . . . . . . . . . . . . . . . . . . 1906 4.2.4.7 Implantable loop recorders . . . . . . . . . . . . . . . . . . . . 1906 4.2.4.8 Diagnostic criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1906 4.2.5 Video recording in suspected syncope . . . . . . . . . . . . . . . . . 1907 4.2.5.1 In-hospital video recording. . . . . . . . . . . . . . . . . . . . . 1907 4.2.5.2 Home video recording. . . . . . . . . . . . . . . . . . . . . . . . . 1908 4.2.6 Electrophysiological study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1908 4.2.6.1 Asymptomatic sinus bradycardia – suspected sinus arrest causing syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . 1908 4.2.6.2 Syncope in bifascicular bundle branch block (impending high-degree atrioventricular block) . . . . . . . . . 1908 4.2.6.3 Suspected tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . 1908 4.2.7 Endogenous adenosine and other biomarkers. . . . . . . . . . 1909 4.2.7.1 Adenosine (triphosphate) test and plasma concentration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1909 4.2.7.2 Cardiovascular biomarkers. . . . . . . . . . . . . . . . . . . . . . 1910 4.2.7.3 Immunological biomarkers. . . . . . . . . . . . . . . . . . . . . . 1910 4.2.8 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1910 4.2.8.1 Exercise stress echocardiography . . . . . . . . . . . . . . . 1910 4.2.9 Exercise stress testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1911 4.2.10 Coronary angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1911 5. Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1911 Downloaded from academic.oup.com/eurheartj/article/39/21/1883/4939241 by guest on 07 October 2026