2017 Consensus Guidelines on the Approach to Syncope in Adults and Children

Key Recommendations

1). Initial evaluation

  • Conduct physical exam, history (with careful attention to factors in Tables 1 & 2) and resting electrocardiogram (ECG) to identify a possible cause (see Tables 2 & 3).

2). Disposition from the emergency department (ED)

  • Hospital admission is recommended for patients with serious medical conditions that might be relevant to the identified cause of syncope.
  • For admitted patients with syncope suspected to be of cardiac etiology, admit to a telemetry unit for continuous cardiac monitoring.
  • Patients with presumptive reflex-mediated syncope (i.e., situational syncope) may be managed as outpatients if they do not have serious medical conditions.
  • ED observation units are appropriate for patients at intermediate risk who have an unclear cause of syncope.

3). Testing

  • Only if the initial clinical evaluation does not reveal an etiology, targeted blood tests may be reasonable (e.g., CBCD, CMP, cardiac enzymes).
  • For selected patients with syncope suspected to be due to cardiovascular causes, certain tests may be useful, including the following:
    • For structural heart disease: transthoracic echocardiography
    • For cardiac etiology: cardiac computed tomography or magnetic resonance imaging
    • For syncope during exertion: echocardiogram and exercise stress testing
    • For arrhythmia: electrophysiologic studies

4) DMV Reporting

  • All cases of syncope requiring hospitalization should be reported to the DMV as they constitute an example of a “lapse in consciousness.”


Table 1:  Risk Factors for Syncope Requiring Hospitalization

Male sex

Older age (>60 y)

No prodrome

Palpitations preceding loss of consciousness

Exertional syncope


Structural heart disease

Heart failure

Cerebrovascular disease

Family history of Sudden Cardiac Death

Diabetes mellitus



Table 2:  Physical Examination or Laboratory Investigation

Abnormal ECG (e.g., pathologic Q waves, non-sinus rhythm or AV block)

Evidence of bleeding

Persistent abnormal vital signs (especially SBP<90 and HR<50 or >140)

Elevated troponin I or troponin T


Table 3:  Examples of Serious Medical Conditions That Might Warrant Consideration of Further Evaluation and Therapy in a Hospital Setting


Cardiac Arrhythmic Conditions

  • Sustained or symptomatic Ventricular tachycardia
  • Symptomatic conduction system disease or Mobitz II or third-degree heart block
  • Symptomatic bradycardia or sinus pauses not related to neurally mediated syncope
  • Symptomatic Supraventricular tachycardia
  • Pacemaker/ICD malfunction
  • Inheritable cardiovascular conditions predisposing to arrhythmias


Cardiac or Vascular Nonarrhythmic Conditions

  • Cardiac ischemia
  • Severe aortic stenosis
  • Cardiac tamponade
  • Hypertrophic cardiomyopathy
  • Severe prosthetic valve dysfunction
  • Pulmonary embolism
  • Aortic dissection
  • Acute Heart failure
  • Moderate-to-severe Left Ventricular dysfunction


Noncardiac Conditions

  • Severe anemia/gastrointestinal bleeding
  • Major traumatic injury due to syncope
  • Persistent vital sign abnormalities (especially SBP<90 and HR<50 or >140)

Shen W-K et al. ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation 2017 March 9

Read all articles in Cardiovascular diseases, Emergency Procedures, Medical General, Oncology, Respiratory diseases, Traumatology
Tags: Aortic dissection, aortic stenosis, AV block, cancer, Cardiac ischemia, cardiac syncope, Cardiac tamponade, diabetes mellitus, GI bleed, heart block, Heart failure, HPC updates, Hypertrophic cardiomyopathy, pulmonary embolism, Severe prosthetic valve dysfunction, syncope, trauma

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