Consider European Guidelines for Syncope

Abstract

Regrettably the authors have made several mistakes relating to the European guidelines for the diagnosis and management of syncope (1), which suggest that the reported results (many additional diagnostic procedures, low diagnostic yield) were achieved by using guideline conform treatment. They claim that the recommended basic diagnostic criteria for the emergency department were carried out for nearly all patients with syncope. Basic diagnostic procedures include a careful medical history, physical examination including blood pressure and pulse measurements taken in a supine position and for a minimum of 3 minutes while standing up (“orthostatic testing”), and a 12-lead ECG. Orthostatic testing was used in only 14.5% of cases. A careful history would have prompted for characteristics preceding the syncope—such as vegetative signs (sweating, sensation of warmth) or circumstances that might act as triggers, such as standing in warm rooms—which reliably enable the conclusion of a vasovagal mechanism. The guidelines include this type of “signposting” information from the medical history, enabling a diagnosis of vasovagal syncope often even without further tests. Taking a thorough history would certainly have diagnosed more than just 10.4% of cases of vasovagal syncope. Furthermore, specific additional diagnostic tests that are indicated in suspected vasovagal syncope without confirmatory basic diagnostic criteria (tilt table test, carotid sinus massage) were not carried out at all (or not mentioned in the article). They would probably have helped clarify further cases of syncope. The European guidelines list only three categories of syncope: vasovagal syncope (referred to as reflex syncope), orthostatic hypotension, and cardiac syncope. Guldner and colleagues refer to these guidelines, but, without offering any further explanation, they describe two further categories: neurological syncope and psychogenic syncope. This will inevitably cause confusion in those who believe themselves on safe ground, in firm knowledge of the guidelines. Perhaps the authors meant epileptic, cataplectic, or dissociative (psychogenic) attacks. These are, however, by definition not the same as syncope.