Unanswered Questions

Abstract

What is necessary? What is superfluous? One in three persons will experience syncope. Other causes of brief loss of consciousness need to be differentiated: brain stem ischemia, epileptic seizures, metabolic causes, dissociative attacks (1). Drop attacks are not a type of syncope either. In English speaking countries, the established term is “transient loss of consciousness.” In neurogenic syncope, distinction is made between neurocardiogenic syncope, orthostatic hypotension, and postural orthostatic tachycardia syndrome (2). Further differentiation is needed for cardiogenic syncope and hyperventilation syncope. The uncritical classification of causes of syncope into “neurological syncope” and “psychogenic syncope” is unsatisfactory for neurologists as well as being erroneous (3). We refer to “cardiogenic”, not “cardiological,” syncope. Terms such as “psychogenic” are of no help. We should demand complete clarity about which terms to use, which enables a diagnostic classification that is based on pathophysiology. Basic diagnostic criteria include a medical history and third-party medical history, physical examination, a 12-lead ECG, and a Schellong test. Simply measuring blood pressure in a supine and standing position is the most helpful test, but in the study it was conducted least often, at 14.5%. The statement “the recommended basic diagnostic criteria for the ED [emergency department] were carried out for nearly all patients” lacks a foundation. Further to a detailed medical history, these simple examination techniques often lead the way. Superfluous diagnostic tests, such as computed tomography scanning (29%) can be omitted altogether. Pathological findings on apparatus-based diagnostic evaluation do not explain the syncope or the occurrence of “end points that appeared within 30 days.” The authors speculate that more usage of the orthostatic test would be possible only in a specialized “syncope unit.” By contrast, teaching students about the autonomic nervous system during their university course seems rather more promising.