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..................... the burden of syncope decreases by >70% compared with the preceding period. The effect of education and reassurance is probably the most likely reason for the decrease in syncope (see Supplementary Data Table 10). An example of a patient instruction sheet can be found in the Web Practical Instructions section 9.1: European Society of Cardiology information sheet for patients affected by reflex syncope. Despite the lack of controlled studies, there is strong consensus that education and lifestyle modifications have a high impact in reducing recurrence of syncope.

5.2.2 Discontinuation/reduction of hypotensive therapy Careful avoidance of agents that lower BP, i.e. any antihypertensive agents, nitrates, diuretics, neuroleptic antidepressants, or

Figure 9 Schematic practical decision pathway for the first-line management of reflex syncope (based on patient’s history and tests) according to age, severity of syncope, and clinical forms. Younger patients are those aged <40 years while older patients are >60 years, with an overlap between 40 and 60 years. Severity of reflex syncope is defined in the text. The duration of prodrome is largely subjective and imprecise. A value of <_5 s distinguishes arrhythmic from reflex syncope49; in patients without structural heart disease, a duration >10 s can distinguish reflex syncope from cardiac syncope.38 In practice, the prodrome is ‘absent or very short’ if it does not allow patients enough time to act, such as to sit or lie down. The heading’ low BP phenotype’ identifies patients with chronic low BP values (in general, systolic around 110 mmHg, who have a clear history of orthostatic intolerance and orthostatic VVS). The group ‘dominant cardioinhibition‘ identifies patients in whom clinical features and results of tests suggest that sudden cardioinhibition is mainly responsible for syncope. One such clue is lack of prodrome, so patients without prodromes may, after analysis, fall into this category. Remark:  Overlap between subgroups is expected.  In selected cases, pacing may be used in patients aged <40 years. This Task Force cannot give recommendations due to the lack of sufficient evidence from studies.  In selected cases, fludrocortisone may be used in patients aged >60 years. This Task Force cannot give recommendations due to the lack of sufficient evidence from studies.  Midodrine can be used at any age even if existing studies were performed in young patients.  Patients with short or no prodrome should continue investigations to identify the underlying mechanism and guide subsequent therapy.  Sometimes an ILR strategy should also be considered in patients aged <40 years. BP = blood pressure; ILR = implantable loop recorder; VVS = vasovagal syncope. aSpontaneous or provoked by, sequentially, carotid sinus massage, tilt testing, or ILR. Downloaded from academic.oup.com/eurheartj/article/39/21/1883/4939241 by guest on 07 October 2026