2017 ACC/AHA/HRS Guideline for Patients With Syncope

Shen WK, Sheldon RS, Benditt DG, et al.
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. J Am Coll Cardiol 2017;Mar 9:[Epub ahead of print].

The following are key points to remember from the 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope:

  1. A detailed history and physical examination should be performed in patients with syncope (Class I).
  2. In the initial evaluation of patients with syncope, a resting 12-lead electrocardiogram (ECG) is useful (Class I). Evaluation of the cause and assessment for the short- and long-term risk of syncope is recommended (Class I).
  3. Hospital evaluation and treatment is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation (Class I).
  4. Routine and comprehensive laboratory testing is not useful in the evaluation of patients with syncope (Class III: No Benefit). Routine cardiac imaging is not useful in the evaluation of patients with syncope unless cardiac etiology is suspected based on an initial evaluation including history, physical examination, or ECG (Class III: No Benefit). Carotid artery imaging is not recommended in the routine evaluation of patients with syncope in the absence of focal neurologic findings that support further evaluation (Class III: No Benefit).
  5. Vasovagal syncope is the most common cause of syncope. Effectiveness of drug therapy is modest. Patient education on the diagnosis and prognosis is recommended (Class I).
  6. Dual-chamber pacing might be reasonable in a select population of patients over 40 years of age with recurrent VVS and prolonged spontaneous pauses (Class IIb). Beta-blockers are not beneficial in pediatric patients with VVS (Class III: No Benefit).
  7. Syncope suspected of orthostatic hypotension (OH) can be mediated by neurogenic conditions, dehydration, or drugs. Fluid resuscitation by acute water ingestion or intravenous infusion is recommended for occasional, temporary relief in patients with neurogenic OH or dehydration (Class I). Reducing or withdrawing medications that may cause hypotension can be beneficial in selected patients with syncope (Class IIa).
  8. In patients with syncope associated with bradycardia, tachycardia, or in the presence of structural heart conditions, current guideline-directed management and therapy (GDMT) is recommended (Class I).
  9. Implantable cardioverter-defibrillator (ICD) implantation is not recommended in patients with Brugada ECG pattern and reflex-mediated syncope in the absence of other risk factors (Class III: No Benefit).
  10. Beta-blocker therapy, in the absence of contraindications, is indicated as a first-line therapy in patients with long QT syndrome (LQTS) and suspected arrhythmic syncope (Class I). ICD implantation is reasonable in patients with LQTS and suspected arrhythmic syncope on beta-blocker therapy or intolerant to beta-blocker therapy (Class IIa).
  11. Exercise restriction is recommended in patients with catecholaminergic polymorphic ventricular tachycardia (CPVT) presenting with syncope suspected of an arrhythmic etiology (Class I). Beta-blockers lacking intrinsic sympathomimetic activity are recommended in patients with CPVT and stress-induced syncope (Class I).
  12. Electrophysiologic study is reasonable in selected patients with syncope suspected of arrhythmic etiology (Class IIa).
  13. Cardiovascular assessment by a care provider experienced in treating athletes with syncope is recommended prior to resuming competitive sports (Class I). Participation in competitive sports is not recommended for athletes with syncope and phenotype-positive hypertrophic cardiomyopathy, CPVT, LQTS1, or arrhythmogenic right ventricular cardiomyopathy before evaluation by a specialist (Class III: Harm).

Keywords: Adrenergic beta-Antagonists, Arrhythmias, Cardiac, Athletes, Atrial Fibrillation, Bradycardia, Brugada Syndrome, Cardiac Electrophysiology, Cardiomyopathy, Hypertrophic, Defibrillators, Implantable, Electrophysiologic Techniques, Cardiac, Electrocardiography, Electrophysiology, Hypotension, Hypotension, Orthostatic, Long QT Syndrome, Syncope, Syncope, Vasovagal, Heart Defects, Congenital, Autonomic Nervous System Diseases, Channelopathies, Diagnostic Imaging, Exercise Test, Genetic Diseases, Inborn, Geriatrics, Heart Valve Diseases, Pediatrics, Pharmacology, Postural Orthostatic Tachycardia Syndrome, Practice Guideline, Risk Assessment, Risk Factors, Tachycardia, Supraventricular, Tachycardia, Ventricular, Tilt-Table Test

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