CardioPulse The European Society of Cardiology Guidelines for the diagnosis and management of syncope reviewed by Angel Moya , MD , FESC , Chair of the Guideline Taskforce with

The European Society of Cardiology (ESC) published its first guidelines on syncope in 2001 and these were updated in 2004 by the same taskforce. The 2009 Guidelines contain many aspects that were not in previous versions and . 60% of the taskforce members are new. Defining syncope in the context of other disorders that present with transient loss of consciousness is the first new aspect of the guidelines. The aim was to differentiate syncope from other clinical pictures characterized by loss of consciousness. In the past, there had been some confusion both in clinical practice and in some published papers in which epilepsy or psychogenic syncope had been described as syncope. So, the guidelines clearly set out what is syncope and what is not syncope, in the context of loss of consciousness. Secondly, the guidelines contain new data on epidemiology, including a picture of the distribution and aetiology of syncope by age. The fact that young people have more frequent episodes was known, but today there is very detailed information about the aetiology of neurally mediated benign syncope in young persons and orthostatic hypotension in older persons. New data are also presented on syncope in different clinical settings. For example, although syncope occurs frequently, ,50% of the patients seek medical attention. Publications from a variety of countries also reveal that syncope represents 1% of all attendances in the emergency department. And epidemiological data show that syncope affects quality of life and that treating these patients has an important economic impact. The inclusion of new epidemiological data will help cardiologists to treat patients, says Dr Angel Moya, Chair of the guideline taskforce and Director of the Arrhythmia Unit, Serveis de Cardiologia, Vall d’Hebron University Hospital in Barcelona, Spain. ‘They will be more aware about what to do with these patients and will be able to recognise those patients in different clinical settings’. A new diagnostic strategy that includes risk stratification is a third new aspect in the guidelines. Previous guidelines stressed the importance of diagnostic tests following the initial evaluation. But the 2009 guidelines say that if the aetiology has not been determined after the initial evaluation, then cardiologists should stratify the risk of having a cardiac event or sudden cardiac death. This will determine the treatment strategy. Patients at high risk should be immediately admitted to hospital for monitoring and treatment, whereas patients at low risk can be followed as outpatients. Fourthly, the guidelines discuss the role of prolonged monitoring in the diagnosis of patients who are at low risk but have frequent syncope and in whom there is no diagnosis. Prolonged monitoring, which is primarily done with implanted devices, determines the diagnosis in 50% of these patients. Prolonged monitoring was mentioned in the former ESC guidelines, but today there are data to confirm that this type of strategy should be used more frequently and probably earlier in the diagnosis flow chart. New data on non-pharmacological treatment, such as counterpressure manoeuvres, in patients with neurally mediated syncope is a fifth addition. Dr Moya says: ‘That can be cheap and easy to apply in patients with benign syncope in whom drugs are not useful and who don’t need anything else but counselling and to apply these simple measures’. The 2009 guidelines also contain, for the first time, 10 CME questions. The taskforce members were charged with writing a document of no more than 35 000 words and containing no more than 200 references. Given the bulk of knowledge on syncope, summarizing