Syncope

Abstract

Syncope is quite common in older patients, with a 10% prevalence and a 33% 2-year recurrence rate. Syncope-associated morbidity is also common in older patients, ranging from loss of confidence or depressive symptoms due to fear of falling, to fractures and consequent disability and institutionalization. Moreover, advanced age is associated with significant short- and long-term mortality after syncope. Neurally mediated (51%) and orthostatic syncope (12%) are the two most common forms of syncope in the elderly. Indeed, those older than 75 years have orthostatic hypotension in 30.5% of cases, a finding that confirms the clinical relevance of systematically measuring blood pressure in the supine and upright position in this age group. A standardized approach, based on initial evaluation (clinical history, physical examination, 12-lead ECG), followed by neuroautonomic assessment (tilt testing, carotid sinus massage), can obtain a definite diagnosis in more than 90% of older patients with syncope. Given the high rate of carotid sinus syndrome in the elderly, the European Society of Cardiology (ESC) guidelines for the diagnosis and management of syncope suggest carotid sinus massage as part of the initial evaluation. The diagnostic work-up can be completed by advanced tools, such as the implantable loop recorder, useful in making diagnosis when syncope is not so frequent to be detected by standard monitoring methods. The device can also be indicated at an early stage in low-risk patients with recurrent or unexplained syncope. For a comprehensive management of patients with syncope from risk stratification to diagnosis, treatment and follow-up, the ESC guidelines also suggest the implementation of functional and multidisciplinary Syncope Units, which may be successful in reducing inappropriate tests and hospitalization rates.