Elsevier

Heart Rhythm

Volume 14, Issue 8, August 2017, Pages e155-e217
Heart Rhythm

News From the Heart Rhythm Society
2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society

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Section snippets

ACC/AHA Task Force Members

Glenn N. Levine, MD, FACC, FAHA, Chair

Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect

Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair#

Sana M. Al-Khatib, MD, MHS, FACC, FAHA

Kim K. Birtcher, MS, PharmD, AACC

Biykem Bozkurt, MD, PhD, FACC, FAHA

Ralph G. Brindis, MD, MPH, MACC#

Joaquin E. Cigarroa, MD, FACC

Lesley H. Curtis, PhD, FAHA

Lee A. Fleisher, MD, FACC, FAHA

Federico Gentile, MD, FACC

Samuel Gidding, MD, FAHA

Mark A. Hlatky, MD, FACC

John Ikonomidis, MD, PhD, FAHA

José Joglar, MD, FACC, FAHA

Table of Contents

  • Preamble ....................................................................e156

  • 1.

    Introduction ...............................................................e159

    • 1.1.

      Methodology and Evidence Review .................e159

    • 1.2.

      Organization of the Writing Committee .............e159

    • 1.3.

      Document Review and Approval ........................e159

    • 1.4.

      Scope of the Guideline ........................................e159

  • 2.

    General Principles ......................................................e160

    • 2.1.

      Definitions: Terms and Classification

Preamble

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines (guidelines) with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each

Definitions: Terms and Classification

For the purpose of this guideline, definitions of syncope and relevant terms are provided in Table 3.

Epidemiology and Demographics

Syncope has many causes and clinical presentations; the incidence depends on the population being evaluated. Estimates of isolated or recurrent syncope may be inaccurate and underestimated because epidemiological data have not been collected in a consistent fashion or because a consistent definition has not been used. Interpretation of the symptoms varies among the patients, observers, and

Additional Evaluation and Diagnosis

The selection of a given diagnostic test, after the initial history, physical examination, and baseline ECG, is a clinical decision based on the patient’s clinical presentation, risk stratification, and a clear understanding of diagnostic and prognostic value of any further testing. A broad-based use of additional testing is costly and often ineffective. This section provides recommendations for the most appropriate use of additional testing for syncope evaluation. See Figure 3 for the

Management of Cardiovascular Conditions

The writing committee reviewed the evidence to support recommendations in the relevant ACC/AHA guidelines and affirms the ongoing validity of the related recommendations in the context of syncope, thus obviating the need to repeat existing guideline recommendations in the present guideline, except for the specific cardiac conditions in 4.2.4 Arrhythmogenic Right Ventricular Cardiomyopathy: Recommendations, 4.2.5 Cardiac Sarcoidosis: Recommendations, 4.3 Inheritable Arrhythmic Conditions:

Vasovagal Syncope: Recommendations

VVS is the most common cause of syncope and a frequent reason for ED visits.66 The underlying pathophysiology of VVS results from a reflex causing hypotension and bradycardia, triggered by prolonged standing or exposure to emotional stress, pain, or medical procedures.361, 362, 363, 364, 365 An episode of VVS is typically associated with a prodrome of diaphoresis, warmth, and pallor, with fatigue after the event. Given the benign nature of VVS and its frequent remissions, medical treatment is

Neurogenic Orthostatic Hypotension: Recommendations

OH involves excessive pooling of blood volume in the splanchnic and leg circulations. With standing, venous return to the heart drops, with a resultant decrease in cardiac output.31 Normally, the autonomic nervous system provides compensatory changes in vascular tone, heart rate, and cardiac contractility. In some individuals, this response may be defective or inadequate.31 In neurogenic OH, the vasoconstrictor mechanisms of vascular tone may be inadequate because of neurodegenerative

Orthostatic Intolerance

Orthostatic intolerance is a general term referring to frequent, recurrent, or persistent symptoms that develop upon standing (usually with a change in position from sitting or lying to an upright position) and are relieved by sitting or lying.38 Most commonly, the symptoms include lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue. These symptoms may be accompanied by hemodynamic disturbances, including blood pressure decrease,

Pseudosyncope: Recommendations

Psychogenic pseudosyncope is a syndrome of apparent loss of consciousness occurring in the absence of impaired cerebral perfusion or function. Psychogenic pseudosyncope is believed to be a conversion disorder—in essence, an external somatic manifestation or response to internal psychological stresses. It is an involuntary response and should not be confused with malingering or Munchausen syndrome. Psychogenic pseudosyncope and pseudoseizures may be the same condition. The clinical distinction

Uncommon Conditions Associated With Syncope

Syncope has been reported in many uncommon diseases, according to case reports. However, specific conditions may predispose the patient to various types of syncope. Table 9 provides a list of less common conditions associated with syncope. It is not intended as a reference for differential diagnosis or a complete synopsis of all conditions associated with syncope. Furthermore, it is not necessary to fully evaluate for all these causes when the etiology remains elusive. Most of these

Pediatric Syncope: Recommendations

Syncope is common in the pediatric population. By 18 years of age, it is estimated that 30% to 50% of children experience at least 1 fainting episode, and syncope accounts for 3% of all pediatric ED visits.617, 618, 619, 620, 621, 622 The incidence is higher in females and peaks between 15 to 19 years of age.617 Neurally mediated syncope accounts for 75% of pediatric syncope, followed by psychogenic or unexplained syncope in 8% to 15% of cases.623 Breath-holding spells are a form of

Impact of Syncope on Quality of Life

QoL is reduced with recurrent syncope,725, 726, 727, 728, 729, 730, 731, 732, 733 as demonstrated in studies that compared patients with and without syncope.727, 731 QoL associated with recurrent syncope was equivalent to severe rheumatoid arthritis and chronic low-back pain in an adult population.728 Similarly, pediatric patients with recurrent syncope reported worse QoL than individuals with diabetes mellitus and equivalent QoL to individuals with asthma, end-stage renal disease, and

Emerging Technology, Evidence Gaps, and Future Directions

The writing committee created a list of key areas in which knowledge gaps are present in the evaluation and management of patients presenting with syncope. These knowledge gaps present opportunities for future research to ultimately improve clinical outcomes and effectiveness of healthcare delivery.

Presidents and Staff

American College of Cardiology

Richard A. Chazal, MD, FACC, President

Shalom Jacobovitz, Chief Executive Officer

William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publishing

Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing

American College of Cardiology/American Heart Association

Katherine Sheehan, PhD, Director, Guideline Strategy and Operations

Lisa Bradfield, CAE, Director, Guideline Methodology and Policy

Abdul R.

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    Developed in collaboration with the American College of Emergency Physicians and Society for Academic Emergency Medicine.

    Endorsed by the Pediatric and Congenital Electrophysiology Society.

    This document was approved by the American College of Cardiology Clinical Policy Approval Committee on behalf of the Board of Trustees, the American Heart Association Science Advisory and Coordinating Committee, the American Heart Association Executive Committee, and the Heart Rhythm Society Board of Trustees in January 2017.

    The Heart Rhythm Society requests that this document be cited as follows: Shen W-K, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2017;14:e155–e217.

    This article has been copublished in Circulation and Journal of the American College of Cardiology.

    Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (professional.heart.org), and the Heart Rhythm Society (www.hrsonline.org). For copies of this document, please contact the Elsevier Inc. Reprint Department ([email protected]). Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the Heart Rhythm Society. Instructions for obtaining permission are located at https://www.elsevier.com/about/our-business/policies/copyright/permissions.

    Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.

    ACC/AHA Task Force on Clinical Practice Guidelines Liaison.

    ACC/AHA Representative.

    §

    HRS Representative.

    ACEP and SAEM Joint Representative.

    ACC/AHA Task Force on Performance Measures Liaison.

    #

    Former Task Force member; current member during the writing effort.

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