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.............................. 13. Supplementary Data and Web Practical Instructions

Supplementary Data with additional Web Tables complementing the full text, and an additional Web Practical Instructions document— with a glossary containing definitions of syncope and related concepts with tracings, videos, flow charts, and checklists—are available on the European Heart Journal website and via the ESC Website at www. escardio.org/guidelines. 14 Appendix

ESC Committee for Practice Guidelines (CPG): Stephan Windecker (Chairperson) (Switzerland), Victor Aboyans (France), Stefan Agewall (Norway), Emanuele Barbato (Italy), He ́ctor Bueno (Spain), Antonio Coca (Spain), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Veronica Dean (France), Victoria Delgado (The Netherlands), Donna Fitzsimons (UK), Oliver Gaemperli (Switzerland), Gerhard Hindricks (Germany), Bernard Iung (France), Peter Ju ̈ni (Canada), Hugo Albert Katus (Germany), Juhani

Treatment of reflex syncope

Explanation of the diagnosis, provision of reassurance, and explanation of the risk of recurrence and the avoidance of triggers and situations are indicated in all patients. Supplementary Data Table 10 I B Beta-adrenergic blocking drugs are not indicated.279,280 III A Cardiac pacing is not indicated in the absence of a documented cardioinhibitory reflex.299,300 III B

Treatment of OH

Explanation of the diagnosis, provision of reassurance, and explanation of the risk of recurrence and the avoidance of triggers and situations are indicated in all patients. I C Adequate hydration and salt intake are indicated.310,311 I C

Treatment of syncope due to cardiac arrhythmias

Cardiac pacing is indicated when there is an established relationship between syncope and symptomatic bradycardia.200,210–212,255,334–338,341 I B

Cardiac pacing is indicated in patients with intermittent/paroxysmal intrinsic third- or second-degree AV block (including AF with slow ventricular conduction), although there is no documentation of a correlation between symptoms and ECG. I C

Cardiac pacing is not indicated in patients when there are reversible causes for bradycardia. III C Cardiac pacing is indicated in patients with syncope, BBB, and a positive EPS or ILR-documented AV block.188,217 I B

Catheter ablation is indicated in patients with syncope due to SVT or VT in order to prevent syncope recurrence. I C An ICD is indicated in patients with syncope due to VT and ejection fraction <_35%.46 I A An ICD is indicated in patients with syncope and previous myocardial infarction who have VT induced during EPS.218 I C

ICD indications in patients with unexplained syncope and left ventricular systolic dysfunction

ICD therapy is recommended to reduce SCD in patients with symptomatic heart failure (NYHA class II–III) and LVEF <_35% after >_3 months of optimal medical therapy, who are expected to survive for >_1 year with good functional status.46 systolic dysfunction I A

Syncope in patients with comorbidity and frailty

A multifactorial evaluation and intervention is recommended in older patients because more than one possible cause for syncope and unexplained fall may be present.33,372–374,376–380 I B

Neurological evaluation

Neurological evaluation is indicated when syncope is suspected to be epilepsy or due to autonomic failure to evaluate the underlying disease. I C

AF = atrial fibrillation; AV = atrioventricular; BBB = bundle branch block; BP = blood pressure; b.p.m. = beats per minute; CSM = carotid sinus massage; CSS = carotid sinus syndrome; ECG = electrocardiogram; ED = emergency department; EPS = electrophysiological study; ESC = European Society of Cardiology; HR = heart rate; ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association; OH = orthostatic hypotension; SCD = sudden cardiac death; SVT = supraventricular tachycardia; VA = ventricular arrhythmia; VT = ventricular tachycardia; VVS = vasovagal syncope. Downloaded from academic.oup.com/eurheartj/article/39/21/1883/4939241 by guest on 07 October 2026