This international consensus statement was written by experts in the field who were chosen by the Heart Rhythm Society, in collaboration with representatives from the American Autonomic Society (AAS), the American College of Cardiology (ACC), the American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), the European Heart Rhythm Association (EHRA), the Pediatric and Congenital Electrophysiology Society (PACES), and the Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE)-Latin American Society of Cardiac Pacing and Electrophysiology. This document is intended to help front-line cardiologists, arrhythmia specialists, and other health care professionals interested in the care of patients who present with presumed postural tachycardia syndrome (POTS), inappropriate sinus tachycardia (IST), and vasovagal syncope (VVS). It is not intended to be a comprehensive narrative review, as excellent reviews, chapters, and entire volumes have appeared recently.1–3 This document has 3 objectives: (1) establish working criteria for the diagnosis of POTS, IST, and VVS; (2) provide guidance and recommendations on their assessment and management; and (3) identify key areas in which knowledge is lacking, to highlight opportunities for future collaborative research efforts. To maintain this pragmatic focus, we excluded several related topics, including a detailed approach to syncope and other syndromes of transient loss of consciousness, the impact of syncope on other disorders, most orthostatic hypotension syndromes, the effects of the autonomic system on arrhythmias, the use of syncope scores or syncope units, and recommendations on training programs and staffing criteria. A number of sections contain very brief reviews, given that the material has recently been covered elsewhere. We refer readers to the excellent European Society of Cardiology guidelines2 and related recent reviews.1,4 The writing group aimed to provide a succinct, evidence-based document at a uniform level, rather than a comprehensive narrative review. As much as possible, we made recommendations based on published evidence. There was a wide range in terms of the level of evidence available, and we included the highest-level evidence for each section. Inevitably, this led to heterogeneity in the level of evidence included. Each section, indeed the entire document, is a compromise among clinical need, succinctness, clarity, and level of evidence. The specific wording of definitions, recommendations, and the choice of references were the result of prolonged debate, consensus-seeking, and repeated votes. Each section was drafted by compact writing groups with 3–5 members who completed the first versions and developed preliminary recommendations. The group assignments were based on individual interests and expertise. The recommendations and text underwent iterative revisions to resolve differences, increase clarity, and align the document format with that recommended by the American College of Cardiology.5 All members of the writing group and peer reviewers provided disclosure statements of all relationships that might present real or perceived conflicts of interest, as shown in the Appendices. The recommendations and definitions in this document are based on the consensus of the full writing group following the Heart Rhythm Society’s process for establishing consensus-based guidance for clinical care. To identify consensus, we conducted surveys of the entire writing group, using a predefined threshold for agreement as a vote of >75% on each recommendation. An initial failure to reach consensus was resolved by subsequent discussion and re-voting. The final minimum consensus was 76% and the mean was 94%. The consensus recommendations in this document use the commonly used class I, IIa, IIb, and III classifications and the corresponding language according to the most recent statement of the American College of Cardiology.6 Class I is a strong recommendation, denoting benefit greatly exceeding risk. Class IIa is a somewhat weaker recommendation, denoting benefit probably exceeding risk, and class IIb denotes benefit equivalent or possibly exceeding risk. Class III is a recommendation against a specific treatment, because either there is no net benefit or there is net harm. Level A denotes the highest level of evidence, usually from multiple clinical trials with or without registries. Level B evidence is of a moderate level, either from randomized trials (B–R) or well-executed nonrandomized trials (B-NR). Level C evidence is from weaker studies with significant limitations, and level E is simply a consensus opinion in the absence of credible published evidence. When considering the guidance provided in this document, it is important to remember that there are no absolutes with regard to many clinical situations. The writing group was struck by the large number of issues lacking high-level evidence. To this end, the document provides evidence-informed recommendations, striking a balance between the need for recommendations and the availability of evidence. Health care providers and patients need to jointly make the final decision regarding care in light of their individual circumstances.
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Jul 3, 2015
Mei Gong + 1
Open Access