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........................................................................................................................................................................... If the cause is uncertain, what is the risk of a serious outcome? Should the patient be admitted to hospital? (3) In all patients, perform a complete history taking, physical examination (including standing BP measurement), and standard ECG. (4) Perform immediate ECG monitoring (in bed or telemetry) in highrisk patients when there is a suspicion of arrhythmic syncope. (5) Perform an echocardiogram when there is previous known heart disease, or data suggestive of structural heart disease or syncope secondary to cardiovascular cause. (6) Perform CSM in patients >40 years of age with syncope of unknown origin compatible with a reflex mechanism. (7) Perform tilt testing in cases where there is suspicion of syncope due to reflex or an orthostatic cause. (8) Perform blood tests when clinically indicated, e.g. haematocrit and cell blood count when haemorrhage is suspected, oxygen saturation and blood gas analysis when hypoxic syndromes are suspected, troponin when cardiac ischaemia-related syncope is suspected, and Ddimer when pulmonary embolism is suspected, etc. Diagnosis: subsequent investigations 9. Perform prolonged ECG monitoring (external or implantable) in patients with recurrent severe unexplained syncope who have all of the following three features: Clinical or ECG features suggesting arrhythmic syncope. A high probability of recurrence of syncope in a reasonable time. Who may benefit from a specific therapy if a cause for syncope is found. 10. Perform EPS in patients with unexplained syncope and bifascicular BBB (impending high-degree AV block) or suspected tachycardia. 11. Perform an exercise stress test in patients who experience syncope during or shortly after exertion. 12. Consider basic autonomic function tests (Valsalva manoeuvre and deep-breathing test) and ABPM for the assessment of autonomic function in patients with suspected neurogenic OH. 13. Consider video recording (at home or in hospital) of TLOC suspected to be of non-syncopal nature. Treatment 14. To all patients with reflex syncope and OH, explain the diagnosis, reassure, explain the risk of recurrence, and give advice on how to avoid triggers and situations. These measures are the cornerstone of treatment and have a high impact in reducing the recurrence of syncope. 15. In patients with severe forms of reflex syncope, select one or more of the following additional specific treatments according to the clinical features: Midodrine or fludrocortisone in young patients with low BP phenotype. Counter-pressure manoeuvres (including tilt training if needed) in young patients with prodromes. ILR-guided management strategy in selected patients without or with short prodromes. Discontinuation/reduction of hypotensive therapy targeting a systolic BP of 140 mmHg in old hypertensive patients. Pacemaker implantation in old patients with dominant cardioinhibitory forms. 16. In patients with OH, select one or more of the following additional specific treatments according to clinical severity: Education regarding lifestyle manoeuvres. Adequate hydration and salt intake. Discontinuation/reduction of hypotensive therapy. Counter-pressure manoeuvres. Abdominal binders and/or support stockings. Head-up tilt sleeping. Midodrine or fludrocortisone. 17. Ensure that all patients with cardiac syncope receive the specific therapy of the culprit arrhythmia and/or of the underlying disease. 18. Balance the benefits and harm of ICD implantation in patients with unexplained syncope at high risk of SCD (e.g. those affected by left ventricle systolic dysfunction, HCM, ARVC, or inheritable arrhythmogenic disorders). In this situation, unexplained syncope is defined as syncope that does not meet any class I diagnostic criterion defined in the tables of recommendations of the 2018 ESC Guidelines on syncope and is considered a suspected arrhythmic syncope. 19. Re-evaluate the diagnostic process and consider alternative therapies if the above rules fail or are not applicable to an individual patient. Bear in mind that Guidelines are only advisory. Even though they are based on the best available scientific evidence, treatment should be tailored to an individual patient’s need. 11 Gaps in evidence and areas for future research Clinicians responsible for managing patients with TLOC must frequently make treatment decisions without adequate evidence or a consensus of expert opinion. The following is a short list of selected, common issues that deserve to be addressed in future clinical research. Diagnosis: the gap between the best available scientific evidence and the need for the dissemination of these concepts into clinical practice There is wide variation in the practice of syncope evaluation, and wide variation in the adoption of recommendations from published guidelines. The absence of a systematic approach to TLOC incurs higher health and social care costs, unnecessary hospitalizations and diagnostic procedures, prolongation of hospital stays, lower diagnostic rates, and higher rates of misdiagnoses and symptom recurrence. Therefore, there is a need for: 1) Large clinical studies that assess the diagnostic yield and compliance of a guideline-based standardized systematic approach Despite the recommendation from the ESC Guidelines on syncope, syncope units are not widely established in clinical practice. Barriers to establishing a syncope unit include lack of resources, lack of trained dedicated staff, and complex presentations to multiple settings, necessitating involvement from multiple disciplines. The evidence for the usefulness of syncope units is controversial. Downloaded from academic.oup.com/eurheartj/article/39/21/1883/4939241 by guest on 07 October 2026