Practical Instructions for the 2018 ESC Syncope Guidelines
- Brignole M, Moya A, de Lange FJ, et al.
- Practical Instructions for the 2018 ESC Guidelines for the Diagnosis and Management of Syncope. Eur Heart J 2018;Mar 19:[Epub ahead of print].
The following are key points to remember from the Practical Instructions for the 2018 European Society of Cardiology (ESC) Guidelines for the Diagnosis and Management of Syncope:
- Reflex syncope is the most frequent cause of syncope in any setting and at all ages, with cardiac syncope as the second most common cause.
- Transient loss of consciousness is characterized by four specific characteristics: short duration, abnormal motor control, loss of responsiveness, and amnesia for the period of loss of consciousness.
- Carotid sinus massage (CSM) preferably is performed during continuous electrocardiogram (ECG) and noninvasive beat-to-beat blood pressure (BP) monitoring. Carotid sinus hypersensitivity is diagnosed when CSM elicits abnormal cardioinhibition (i.e., asystole ≥3 seconds) and/or vasodepression (i.e., a fall in systolic BP >50 mm Hg).
- It is recommended that the following method be adopted for tilt testing:
- Patients should be fasted for 2–4 hours before the test.
- Ensure a supine pre-tilt phase of ≥5 minutes when there is no venous cannulation, and of ≥20 minutes when there is venous cannulation.
- Tilt angle between 60 and 70 degrees.
- Passive phase of tilt of ≥20 minutes in duration and a maximum of 45 minutes.
- Use either sublingual nitroglycerin or intravenous isoproterenol for drug provocation if the passive phase is negative. The duration of the drug-challenge phase is 15–20 minutes.
- For nitroglycerin challenge, a fixed dose of 300–400 μg sublingually administered with the patient in the upright position.
- For isoproterenol challenge, an incremental infusion rate from 1 μg/min rising to 3 μg/min to increase average heart rate by about 20–25% over baseline.
- The test should be continued until complete loss of consciousness occurs or completion of the protocol.
- Tilt tables have only one specific requirement: the tilt-down time should be short (<15 seconds), as longer times increase the duration of precipitated asystole.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Sleep Apnea
Keywords: Arrhythmias, Cardiac, Amnesia, Blood Pressure, Carotid Sinus, Catheterization, Dizziness, Electrocardiography, Glottis, Heart Arrest, Hypotension, Hypotension, Orthostatic, Isoproterenol, Nitroglycerin, Orthostatic Intolerance, Postural Orthostatic Tachycardia Syndrome, Primary Prevention, Syncope, Syncope, Vasovagal, Tilt-Table Test, Tremor, Valsalva Maneuver
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