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............................................... of external and internal loop and Holter monitors and ABPM63

(Table 14). The clinical nurse specialist should be key in developing and delivering communication strategies and processes for the syncope unit for all stakeholders—patients and practitioners—and play a pivotal role in education and training together with the syncope specialist. The clinical nurse specialist should be involved in regular auditing and collection of data to inform quality indicators. See the video in Web Practical Instructions section 11.

Although the skill mix of a clinical nurse specialist has not been exposed to rigorous scientific or economic scrutiny, the consensus is that the clinical nurse specialist should have the necessary skills to deliver assessment and treatment for syncope and TLOC. Further research is required to establish the benefits. 10 Key messages

The ESC Task Force has selected 19 simple rules to guide the diagnosis and management of syncope patients with TLOC according to the 2018 ESC Guidelines on syncope: Diagnosis: initial evaluation (1) At the initial evaluation answer the following four key questions:  Was the event TLOC?  In cases of TLOC, are they of syncopal or non-syncopal origin?  In cases of suspected syncope, is there a clear aetiological diagnosis?  Is there evidence to suggest a high risk of cardiovascular events or death? (2) At the evaluation of TLOC in the ED, answer the following three key questions:  Is there a serious underlying cause that can be identified?

Table 14 The role of physicians and staff in performing procedures and tests

Procedure or test Syncope unit

physician Syncope

unit staff Non-syncope

unit personnel

History taking X

Structured history taking (e.g. application of software technologies and algorithms) X

12-lead ECG X

Blood tests X

Echocardiogram and imaging X

CSM X

Active standing test X Tilt testing (X)a X

Basic autonomic function test X

ECG monitoring (Holter, external loop recorder): administration and interpretation X X ILR X (X)b

Remote monitoring X

Other cardiac tests (stress test, EPS, angiograms) X

Neurological tests (computed tomography, magnetic resonance imaging, EEG, video-EEG) X

Pacemaker and ICD implantation, catheter ablation X Patient education, biofeedback training,c and instruction sheet on PCM X X

Final report and clinic note X

Communication with patients, referring physicians, and stakeholders. X X

Follow-up X X

BP = blood pressure; CSM = carotid sinus massage; ECG = electrocardiogram; EEG = electroencephalogram; EPS = electrophysiological study; ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; PCM = physical counter-pressure manoeuvres. aPhysician need not be in the room, but a physician adequately trained in resuscitation needs to be in the vicinity of the test. bCurrent practice limited to a few countries. cBiofeedback means that the PCM training session consists of biofeedback training using a continuous BP monitor. Each manoeuvre is demonstrated and explained. The manoeuvres are practised under supervision, with immediate feedback of the recordings to gain optimal performance. Downloaded from academic.oup.com/eurheartj/article/39/21/1883/4939241 by guest on 07 October 2026