A standardized guideline-based algorithm coupled with online decision-making tool: the new frontier for efficient management of syncope?

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Despite significant progress in the past three decades including the publication of guidelines, the development of several emergency room syncope decision rules and more generic risk scores, and the institution of formal dedicated syncope facilities, the management (diagnosis and therapy) of syncope is still largely unsatisfactory. A Position Paper commissioned by the Canadian Cardiovascular Society1 addresses the quality of evidence of the standardized methods of management of syncope proposed in recent years and gave pragmatic interpretation of strong vs. weak recommendations based on the GRADE system.2 In brief, there is little persuasive evidence that emergency room syncope rules and diagnostic syncope units provide efficient care and improved outcomes. While we congratulate the Canadian colleagues for their objective comprehensive evaluation, we think their conclusions reflect some major pitfalls that persist in the approach to patients with syncope: 1. Difficulty identifying patients at high risk (in particular those at short-term risk). This problem inevitably leads to an increase in the number of inappropriate hospitalizations, tests utilization, and eventually higher costs. 2. High rate of unexplained diagnosis. It seems that the most complex (i.e. with competing possible causes) and potentially severe syncope cases that require specialized treatment remain undiagnosed.3 Indeed, patients with unexplained syncope tend to be older and more frequently have structural heart disease or electrocardiographic abnormalities. Conversely, a diagnosis is more easily obtained in healthy young patients without structural heart disease, who are known to have a favourable outcome. The paradox is that the more we need a precise diagnosis, the more difficult it is to obtain one. 3. High rate of misdiagnosis. Typically patients are asymptomatic at the time of evaluation and the opportunity to capture a …