Materiały źródłowe

• #1 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  In the evaluation of patients with syncope, the critical first step is a detailed medical history. A diagnostic strategy based on initial evaluation is warranted. The importance of the initial evaluation goes well beyond its capability to make a diagnosis as it determines the most appropriate subsequent diagnostic pathways and risk evaluation. […] According to the Guidelines on Syncope of the European Society of Cardiology (ESC) the initial evaluation of a patient presenting with syncope consists of taking a careful history, and a physical examination, including orthostatic blood pressure measurements and standard electrocardiogram (ECG). […] Is loss of consciousness attributable to syncope or not? Differentiating true syncope from nonsyncopal conditions associated with real or apparent transient loss of consciousness is generally the first diagnostic challenge and influences the subsequent diagnostic strategy.

• #2 Vasovagal Episode – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK470277/

  A vasovagal episode or vasovagal syncope is the most common form of reflex syncope. Reflex syncope describes any form of syncopal episode caused by a failure in the autoregulation of blood pressure, and ultimately, a drop in cerebral perfusion pressure resulting in a transient loss of consciousness. […] This activity describes the risk factors, evaluation, and management of vasovagal episodes and highlights the role of the interprofessional team in enhancing care delivery for affected patients. […] Explain what evaluation should be done for patients that experience vasovagal episodes. […] Every patient with a complaint of syncope should have a complete history and physical exam, with attention to the presence or absence of pallor, cardiac abnormalities (murmurs, tachy/bradydysrhythmias, and irregular heartbeat), pulmonary abnormalities, and signs of trauma.

• #3 Clinical and Experimental Pediatrics

  https://www.e-cep.org/m/journal/view.php?number=20125555597

  Syncope is a heterogeneous syndrome with complex underlying mechanisms, hence, the spectrum of patients presenting with syncope is broad. The diagnosis of syncope begins with history taking, and an accurate diagnosis can be established through correct history taking and interpretation. […] An accurate diagnosis depends on correct history taking and its interpretation. An in-depth understanding of the symptoms of syncope in connection with its pathophysiology can lead to avoiding critical pitfalls in the diagnostic process of history taking. […] The initial evaluation of suspected syncope consists of a careful history taking, physical examination, and electrocardiography (ECG). […] A diagnosis using initial examination differs between expert (~85%) and nonexpert (60%70%) physicians owing to history taking as a main factor.

• #4 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  Accurate history taking alone is a key stage and often leads to the diagnosis or may suggest the strategy of evaluation. […] The absence of signs of suspected or overt heart disease virtually excludes a cardiac cause of syncope with the exception of syncope accompanied by palpitations which could be due to paroxysmal tachycardia (especially paroxysmal supraventricular tachycardia). Conversely, the presence of heart disease at the initial evaluation is a strong predictor of a cardiac cause of syncope, but its specificity is low as about half of patients with heart disease have a noncardiac cause of syncope. […] The classical vasovagal syncope is mediated by emotional or orthostatic stress and can be diagnosed by history taking. […] These forms are diagnosed by minor clinical criteria, exclusion of other causes for syncope (absence of structural heart disease) and positive response to tilt testing or carotid sinus massage.

• #5 Syncope: Evaluation and Differential Diagnosis | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/0301/p303.html

  A detailed history will suggest a diagnosis in up to 50% of patients and is the most important diagnostic tool in the evaluation of syncope. […] The history should focus on three key elements: (1) Is the loss of consciousness attributable to syncope? (2) Is there a history of cardiovascular disease? (3) Are there clinical features to suggest a specific cause of syncope? […] Routine laboratory studies have low diagnostic yield and should be ordered only if clinically indicated. […] ECG generally has a low diagnostic yield (approximately 3% to 5%) but is recommended for all patients with syncope. […] Continuous cardiac monitoring is the diagnostic standard to establish a correlation between symptoms and ECG findings. […] Provocative testing strategies include head-up tilt testing, exercise testing, and electrophysiologic studies.

• #6 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  Classical vasovagal syncope is diagnosed if precipitating events such as fear, severe pain, emotional distress, instrumentation or prolonged standing are associated with typical prodromal symptoms. […] Situational syncope is diagnosed if syncope occurs during or immediately after urination, defaecation, cough or swallowing. […] Orthostatic syncope is diagnosed when there is documentation of orthostatic hypotension (defined as a decrease in systolic blood pressure 20mmHg or a decrease of systolic blood pressure to 90mmHg) associated with syncope or presyncope. […] Arrhythmia-related syncope is diagnosed by ECG when there is sinus bradycardia 40beats/min or repetitive sinoatrial blocks or sinus pauses 3s in the absence of medications known to have negative chronotropic effect. […] The initial evaluation may lead to certain or suspected diagnosis or no diagnosis (here termed as unexplained syncope).

• #7 Syncope: an overview of diagnosis and treatment

  http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-04202011000100008

  In susceptible individuals vasovagal syncope may be triggered by prolonged periods of upright posture, relative dehydration, excessively warm closed-in environments, or extreme emotions. Warning symptoms may occur, and include feeling: hot or cold, sweaty, tachycardic, short of air, loss of hearing, nausea and change in breathing pattern. Physical findings often reported by bystanders in these cases include marked pallor, damp and cold (clammy) skin, and confusion. After the faint, if the patient is permitted to remain recumbent, recovery typically is very rapid, but a subsequent period of fatigue of variable duration is quite common.

• #8 Patient education: Syncope (fainting) (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/syncope-fainting-beyond-the-basics

  In most cases of vasovagal syncope, you have some warning that you are near fainting. These signs include dizziness, feeling hot or cold, nausea, pale skin, „tunnel-like” vision, disturbance of hearing, and profuse sweating. After the episode, symptoms may continue because of continued low blood pressure. Some people feel extremely tired afterward. In some cases, particularly in older people, the person may not remember having experienced any warning symptoms after they recover. […] SYNCOPE DIAGNOSIS […] There are three main ways to identify the causes of syncope: the medical history, the physical examination, and cardiac testing. A medical history and physical examination are recommended for anyone who has had syncope. Some people will also require cardiac testing. […] Medical history — Gathering as much information as possible about events that occurred before, during, and after a syncopal episode can be helpful in determining the possible cause of syncope.

• #9 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  In the evaluation of patients with syncope, the critical first step is a detailed medical history. A diagnostic strategy based on initial evaluation is warranted. The importance of the initial evaluation goes well beyond its capability to make a diagnosis as it determines the most appropriate subsequent diagnostic pathways and risk evaluation. […] According to the Guidelines on Syncope of the European Society of Cardiology (ESC) the initial evaluation of a patient presenting with syncope consists of taking a careful history, and a physical examination, including orthostatic blood pressure measurements and standard electrocardiogram (ECG). […] Is loss of consciousness attributable to syncope or not? Differentiating true syncope from nonsyncopal conditions associated with real or apparent transient loss of consciousness is generally the first diagnostic challenge and influences the subsequent diagnostic strategy.

• #10 Classification and diagnosis of syncope – MedCrave online

  https://medcraveonline.com/IJFCM/classification-and-diagnosis-of-syncope.html

  Syncope is defined as a transient loss of consciousness secondary to cerebral hypoperfusion, characterized by a short duration (usually less than one minute), rapid onset and spontaneous resolution. Adequate diagnosis and classification of syncope may help stratify the risk and define treatment options, leading to better outcomes. […] The first cause is vasovagal syncope is defined as a syncope secondary to an exaggerated parasympathetic response, usually leading to vagal symptoms prior or after the event. […] The most important diagnostic approach for syncope is performing a complete physical examination, in which the number, frequency and duration of the syncopal episodes is assessed. […] Finally, all patients with suspected or confirmed syncope should undergo an electrocardiogram, as a cost-effective screening exam for cardiac etiologies. […] Obtaining an accurate diagnosis of syncope is essential for the guidance of further treatment. Once a clear diagnosis is obtained, risk stratification is performed.

• #11 Patient education: Syncope (fainting) (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/syncope-fainting-beyond-the-basics

  In most cases of vasovagal syncope, you have some warning that you are near fainting. These signs include dizziness, feeling hot or cold, nausea, pale skin, „tunnel-like” vision, disturbance of hearing, and profuse sweating. After the episode, symptoms may continue because of continued low blood pressure. Some people feel extremely tired afterward. In some cases, particularly in older people, the person may not remember having experienced any warning symptoms after they recover. […] SYNCOPE DIAGNOSIS […] There are three main ways to identify the causes of syncope: the medical history, the physical examination, and cardiac testing. A medical history and physical examination are recommended for anyone who has had syncope. Some people will also require cardiac testing. […] Medical history — Gathering as much information as possible about events that occurred before, during, and after a syncopal episode can be helpful in determining the possible cause of syncope.

• #12 Pulsenotes | Vasovagal syncope

  https://app.pulsenotes.com/medicine/neurology/notes/vasovagal-syncope

  Vasovagal syncope is a form of reflex syncope more colloquially known as a common faint. […] The diagnosis of vasovagal syncope is usually based on the clinical assessment and exclusion of other causes. […] The diagnosis of vasovagal syncope requires a thorough history and clinical examination. […] During the actual event, hypotension and bradycardia are commonly observed that quickly improve. […] It is more difficult to make the diagnosis in the absence of a typical trigger, in elderly patients, or those with co-morbidities when a number of other causes could have potentially led to syncope. […] A witness account of the syncope can be really important, especially to exclude other potential causes of loss of consciousness including seizures. […] When the diagnosis is unclear or atypical, some confirmatory tests may be requested including the tilt-table test.

• #13 Syncope: an overview of diagnosis and treatment

  http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-04202011000100008

  In susceptible individuals vasovagal syncope may be triggered by prolonged periods of upright posture, relative dehydration, excessively warm closed-in environments, or extreme emotions. Warning symptoms may occur, and include feeling: hot or cold, sweaty, tachycardic, short of air, loss of hearing, nausea and change in breathing pattern. Physical findings often reported by bystanders in these cases include marked pallor, damp and cold (clammy) skin, and confusion. After the faint, if the patient is permitted to remain recumbent, recovery typically is very rapid, but a subsequent period of fatigue of variable duration is quite common.

• #14 Vasovagal Syncope | Cedars-Sinai

  https://www.cedars-sinai.org/health-library/diseases-and-conditions/v/vasovagal-syncope.html

  Vasovagal syncope is a condition that leads to fainting in some people. […] Your healthcare provider will review your medical history and do a physical exam. This will probably include measuring the blood pressure while lying down, seated, and then standing. Your healthcare provider will likely do an electrocardiogram (ECG) as well, to evaluate the hearts rhythm. For many children and young adults, this may be all that is needed. Usually, the healthcare provider can safely assume that the fainting is due to vasovagal syncope, and not some form of syncope that is more dangerous. […] Sometimes the healthcare provider needs to check for other possible causes for fainting. Because some causes of fainting are dangerous, the healthcare provider will want to rule out these other causes. Your healthcare provider might use tests, such as the following: Continuous portable ECG monitoring to further analyze heart rhythms, Echocardiogram to examine blood flow in the heart and heart motion, Exercise stress testing to see how your heart works during exercise, Blood work only if your healthcare provider is suspicious for an abnormality.

• #15 Syncope: Symptoms, Causes & Treatments

  https://my.clevelandclinic.org/health/diseases/17536-syncope

  Vasovagal syncope happens when you have a sudden drop in blood pressure, which causes a drop in blood flow to your brain. It often occurs after standing for a while or under emotional distress. Normally, when you stand up, gravity makes blood settle in the lower part of your body, below your diaphragm. When that happens, your heart and autonomic nervous system work to keep your blood pressure stable. […] In vasovagal syncope, your heart rate and blood pressure inappropriately decrease severely. This causes decreased blood flow to your brain and leads to passing out. Typically, vasovagal syncope is benign. […] If you have syncope, you should see a provider who can refer you to a syncope specialist for a complete evaluation. […] A syncope specialist will do a physical exam and a careful review of your medical history. Theyll ask you detailed questions about your symptoms and syncope episodes, including whether you have any symptoms before you faint and when and where you faint.

• #16 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Diagnosing vasovagal syncope often begins with a physical exam. During the physical exam, your healthcare professional listens to your heart and takes your blood pressure. Your healthcare professional may massage the main arteries in your neck to see if that causes you to feel faint. […] Your healthcare professional also may recommend several tests to rule out other possible causes of your fainting particularly heart-related conditions. These tests may include: […] Electrocardiogram. This test records the electrical signals your heart produces. It can detect irregular heart rhythms and other cardiac conditions. You may need to wear a portable monitor for at least a day or as long as a month. […] Echocardiogram. This test uses ultrasound imaging to view the heart and look for conditions such as valve problems that can cause fainting.

• #17 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Diagnosing vasovagal syncope often begins with a physical exam. During the physical exam, your healthcare professional listens to your heart and takes your blood pressure. Your healthcare professional may massage the main arteries in your neck to see if that causes you to feel faint. […] Your healthcare professional also may recommend several tests to rule out other possible causes of your fainting particularly heart-related conditions. These tests may include: […] Electrocardiogram. This test records the electrical signals your heart produces. It can detect irregular heart rhythms and other cardiac conditions. You may need to wear a portable monitor for at least a day or as long as a month. […] Echocardiogram. This test uses ultrasound imaging to view the heart and look for conditions such as valve problems that can cause fainting.

• #18

  https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/syncope/

  After a thorough history and physical exam, an electrocardiogram (ECG) should be obtained. Blood work should be obtained when metabolic diseases or anemia are suspected. Although the ECG is often normal on presentation, it is an essential part of the initial evaluation of syncope. […] Proper additional evaluations include: carotid sinus massage, echocardiogram, ECG monitoring (Holter, external or internal loop recorder), orthostatic challenge (tilt test), electrophysiological testing, stress testing, and cardiac catheterization. […] Carotid sinus massage (CSM) is indicated in patients older than 40 years with syncope of unknown etiology after initial evaluation. […] ECG monitoring is indicated in patients who have clinical or ECG findings suggestive of arrhythmic syncope and is diagnostic when a correlation between syncope and an arrhythmia is detected.

• #19 Brain MRI and EEG overemployment in patients with vasovagal syncope: results from a tertiary syncope unit | BMC Cardiovascular Disorders | Full Text

  https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-023-03615-y

  Based on our findings, performing MRI or EEG was common among VVS patients while it is not indicated in the majority of cases. This should be taken into consideration to prevent inappropriate MRI/EEG when there is a typical history compatible with VVS. […] Neurologic examination is not recommended as a routine diagnostic method in patients with syncope. The ESC guidelines published in 2018 recommend neurological evaluations in patients whose syncope is due to an autonomic disorder or in case of high epilepsy suspicion. […] However, brain MRI is recommended only in patients whose neurological examination shows evidence of parkinsonism, ataxia, or cognitive impairment (class of recommendation [CoR]: 1). In patients with syncope without suspicion of neurological causes, EEG, carotid ultrasound, and brain MRI are not indicated (CoR: 3).

• #20 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Diagnosing vasovagal syncope often begins with a physical exam. During the physical exam, your healthcare professional listens to your heart and takes your blood pressure. Your healthcare professional may massage the main arteries in your neck to see if that causes you to feel faint. […] Your healthcare professional also may recommend several tests to rule out other possible causes of your fainting particularly heart-related conditions. These tests may include: […] Electrocardiogram. This test records the electrical signals your heart produces. It can detect irregular heart rhythms and other cardiac conditions. You may need to wear a portable monitor for at least a day or as long as a month. […] Echocardiogram. This test uses ultrasound imaging to view the heart and look for conditions such as valve problems that can cause fainting.

• #21 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Diagnosing vasovagal syncope often begins with a physical exam. During the physical exam, your healthcare professional listens to your heart and takes your blood pressure. Your healthcare professional may massage the main arteries in your neck to see if that causes you to feel faint. […] Your healthcare professional also may recommend several tests to rule out other possible causes of your fainting particularly heart-related conditions. These tests may include: […] Electrocardiogram. This test records the electrical signals your heart produces. It can detect irregular heart rhythms and other cardiac conditions. You may need to wear a portable monitor for at least a day or as long as a month. […] Echocardiogram. This test uses ultrasound imaging to view the heart and look for conditions such as valve problems that can cause fainting.

• #22 Evaluation of Syncope | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0915/p640.html

  Syncope is classified as neurally mediated (i.e., carotid sinus hypersensitivity, situational, or vasovagal), cardiac, orthostatic, or neurogenic. […] Patients presenting with syncope (other than neurally mediated and orthostatic syncope) are at increased risk of death from any cause. […] All patients presenting with syncope require electrocardiography, orthostatic vital signs, and QT interval monitoring. […] Patients with neurally mediated or orthostatic syncope usually require no additional testing. […] In cases of unexplained syncope, further testing such as echocardiography, grade exercise testing, electrocardiographic monitoring, and electrophysiologic studies may be required. […] Vasovagal syncope may be diagnosed if there is a common precipitating factor with associated prodromal symptoms.

• #23 Syncope: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/811669-overview

  History and physical examination are the most specific and sensitive ways of evaluating syncope. […] No specific laboratory testing has sufficient power to be absolutely indicated for evaluation of syncope. […] A standard 12-lead ECG is a level A recommendation in the 2007 ACEP consensus guidelines for syncope. […] Other diagnostic tests and procedures include the following: Head-up tilt-table test: Useful for confirming autonomic dysfunction and can generally be safely arranged on an outpatient basis. […] Vasovagal syncope is the most common type in young adults but can occur at any age. […] Vasovagal syncope has a uniformly excellent prognosis. This condition does not increase the mortality, and recurrences are infrequent.

• #24 Vasovagal Episode – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK470277/

  Every person undergoing evaluation for syncope including presumed vasovagal syncope should have an ECG to look for evidence of underlying arrhythmogenic cardiac abnormalities, such as Wolff-Parkinson-White syndrome, prolonged QT syndrome, Brugada syndrome, or heart blocks. […] In healthy patients with a classic history of vasovagal syncope, a normal exam, and a normal ECG, no further testing is indicated, and laboratory testing is low yield. […] The diagnosis and management of vasovagal syncope is very difficult because the differential is enormous.

• #25 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Exercise stress test. This test studies heart rhythms during exercise. It’s usually conducted while you walk or jog on a treadmill. […] Blood tests. Your healthcare professional may look for conditions such as anemia that can cause or contribute to fainting spells. […] Tilt table test. If no heart conditions appear to cause your fainting, your healthcare professional may suggest that you undergo a tilt table test. During the test, you lie flat on your back on a table that changes positions, tilting you upward at various angles. A technician monitors your heart rhythms and blood pressure during the test to see if changing your posture affects them.

• #26 Vasovagal Syncope: Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/23325-vasovagal-syncope

  Vasovagal syncope happens when your nervous system overreacts and your blood pressure and heart rate drop suddenly, causing you to faint or pass out. A healthcare provider will ask questions about what might have caused you to faint. You should mention any recent changes in your health or unusual symptoms you’ve noticed, even if they don’t seem important. These can help your provider make an accurate diagnosis. A provider may also run the following tests, depending on the circumstances of your symptoms: Blood tests. These can detect several conditions that can cause fainting, like low iron in your blood (anemia). Electrocardiogram (EKG or ECG). This test measures electrical activity in your heart and may detect an abnormal heart rhythm. Echocardiogram. This test shows your heart’s structure. It can identify or rule out an issue that’s causing an abnormal heart rhythm. Electroencephalogram (EEG). This test measures electrical activity in your brain. This can help determine if you passed out because of a seizure. Tilt-table test. In this test, you lie on a table that a healthcare provider tilts upward. People with vasovagal syncope may pass out or start to pass out during this test. Hemodynamic test. This test uses a special type of X-ray (gamma camera) to detect an injected tracer. This shows how your blood circulates and any problems with that.

• #27 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  In the evaluation of patients with syncope, the critical first step is a detailed medical history. A diagnostic strategy based on initial evaluation is warranted. The importance of the initial evaluation goes well beyond its capability to make a diagnosis as it determines the most appropriate subsequent diagnostic pathways and risk evaluation. […] According to the Guidelines on Syncope of the European Society of Cardiology (ESC) the initial evaluation of a patient presenting with syncope consists of taking a careful history, and a physical examination, including orthostatic blood pressure measurements and standard electrocardiogram (ECG). […] Is loss of consciousness attributable to syncope or not? Differentiating true syncope from nonsyncopal conditions associated with real or apparent transient loss of consciousness is generally the first diagnostic challenge and influences the subsequent diagnostic strategy.

• #28 Clinical Presentation and Diagnosis of Vasovagal Syncope | SpringerLink

  https://link.springer.com/chapter/10.1007/978-3-319-09102-0_11

  Since the classic Lewis description of vasovagal syncope (VVS) in 1932, our knowledge on VVS has markedly improved, and we have learned that VVS may have different clinical presentations. The most relevant ones are typical VVS, sleep syncope, atypical VVS, and unexplained fall. […] Typical VVS can be diagnosed after the initial evaluation, when a transient loss of consciousness is triggered by emotional distress or orthostatic stress, in the presence of autonomic prodromes. An atypical VVS can be diagnosed in subjects with transient loss of consciousness not preceded by evident trigger, only when tilt test is positive, in the absence of any competing diagnosis. […] Many clinical features suggest that sleep syncope is a form of VVS. Very recent data show that an unexplained fall may be a clinical presentation of VVS.

• #29 Evaluation of Syncope | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0915/p640.html

  Documented or reproducible orthostatic hypotension in association with syncope is diagnostic for orthostatic syncope. […] Carotid sinus massage is useful for diagnosing carotid sinus hypersensitivity. […] Standardized testing (i.e., clinical evaluation, carotid sinus massage, ECG, and basic laboratory testing) has been shown to identify the etiology of syncope in 69 percent of patients. […] All patients presenting with syncope should have standard 12-lead ECG and QT interval monitoring. […] The routine use of a broad panel of laboratory tests is not recommended; tests should be ordered as clinically indicated by the history and physical examination. […] Electrocardiographic monitoring is indicated when there is a high pretest probability of identifying an arrhythmia associated with syncope.

• #30 Syncope Workup: Approach Considerations, Laboratory Studies, Imaging Studies

  https://emedicine.medscape.com/article/811669-workup

  The American College of Cardiology (ACC), American Heart Association (AHA), and the Heart Rhythm Society (HRS) recommend investigation and management in a hospital in the presence of a serious medical condition identified during the initial assessment of individuals presenting with syncope that may be relevant to its cause. […] They note that although targeted blood tests are reasonable for assessing selected patients with syncope identified from clinical evaluation, history and physical examination, and electrocardiographic (ECG) findings (class IIa), there’s no clarity regarding the utility of brain natriuretic peptide and high-sensitivity troponin levels in patients suspected of having a cardiac etiology of syncope (class IIb). Furthermore, there is no benefit to obtaining routine and comprehensive laboratory tests for evaluating patients with syncope (class III).

• #31 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Exercise stress test. This test studies heart rhythms during exercise. It’s usually conducted while you walk or jog on a treadmill. […] Blood tests. Your healthcare professional may look for conditions such as anemia that can cause or contribute to fainting spells. […] Tilt table test. If no heart conditions appear to cause your fainting, your healthcare professional may suggest that you undergo a tilt table test. During the test, you lie flat on your back on a table that changes positions, tilting you upward at various angles. A technician monitors your heart rhythms and blood pressure during the test to see if changing your posture affects them.

• #32 Vasovagal Syncope | Cedars-Sinai

  https://www.cedars-sinai.org/health-library/diseases-and-conditions/v/vasovagal-syncope.html

  If these tests are normal, you might need something called a tilt table test. For this test, you lie down on a padded table. Someone measures your heart rate and blood pressure while you are lying down and then tilted up for a period of time. Sometime medicine is also given to trigger a fainting response. If you have vasovagal syncope, you may faint during the upward tilt.

• #33 Vasovagal Syncope | Cedars-Sinai

  https://www.cedars-sinai.org/health-library/diseases-and-conditions/v/vasovagal-syncope.html

  If these tests are normal, you might need something called a tilt table test. For this test, you lie down on a padded table. Someone measures your heart rate and blood pressure while you are lying down and then tilted up for a period of time. Sometime medicine is also given to trigger a fainting response. If you have vasovagal syncope, you may faint during the upward tilt.

• #34 Pulsenotes | Vasovagal syncope

  https://app.pulsenotes.com/medicine/neurology/notes/vasovagal-syncope

  This test may be performed in patients with suspected vasovagal syncope or orthostatic syncope when the diagnosis is not clear. […] A positive test for vasovagal syncope is suggested by the development of syncope during the test with evidence of a cardioinhibitory and/or vasodepressor response that leads to hypotension.

• #35 Role of tilt-table testing in syncope diagnosis and management

  https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-13/role-of-tilt-table-testing-in-syncope-diagnosis-and-management

  Tilt-table testing (TTT) plays a major role during the evaluation of syncope patients, helps to differentiate syncope subtypes and to discriminate between syncope and other common conditions such as epilepsy, and could be useful in guiding treatment. […] The most common indication for TTT is to confirm a diagnosis of reflex syncope in patients in whom this diagnosis has been suspected but not confirmed by the initial evaluation. […] Compared with other diagnostic tests, TTT has one of the highest diagnostic yields if the result is abnormal, with the test being diagnostic in more than 50% of cases. […] However, this is the situation which exists in specialized syncope centres and units, where a diagnosis can be established in more than 50% of patients with a mean of three tests per patient.

• #36 Role of tilt-table testing in syncope diagnosis and management

  https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-13/role-of-tilt-table-testing-in-syncope-diagnosis-and-management

  Tilt-table testing (TTT) plays a major role during the evaluation of syncope patients, helps to differentiate syncope subtypes and to discriminate between syncope and other common conditions such as epilepsy, and could be useful in guiding treatment. […] The most common indication for TTT is to confirm a diagnosis of reflex syncope in patients in whom this diagnosis has been suspected but not confirmed by the initial evaluation. […] Compared with other diagnostic tests, TTT has one of the highest diagnostic yields if the result is abnormal, with the test being diagnostic in more than 50% of cases. […] However, this is the situation which exists in specialized syncope centres and units, where a diagnosis can be established in more than 50% of patients with a mean of three tests per patient.

• #37

  https://link.springer.com/article/10.1007/s10286-021-00809-2

  Vasovagal reflex syncope (VVS) is the most common cause of transient loss of consciousness (TLOC) in any setting and at any age. […] It is therefore key to efficiently diagnose VVS. […] The intermittent nature of VVS, with a normal cardiovascular function outside the episodes, prompted the use of the tilt-table test in the clinical setting to reproduce an episode, thus confirming the diagnosis, and its use has become widespread. […] While the use of the tilt-table test has contributed to the understanding of its pathophysiology, many ask whether the test is necessary for the diagnosis of VVS compared to a clinical diagnosis based on anamnesis and physical examination. […] No, a tilt-table test is not necessary to diagnose VVS. There are, however, some indications for its use in particular cases of suspected VVS.

• #38 Role of tilt-table testing in syncope diagnosis and management

  https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-13/role-of-tilt-table-testing-in-syncope-diagnosis-and-management

  Tilt-table testing (TTT) plays a major role during the evaluation of syncope patients, helps to differentiate syncope subtypes and to discriminate between syncope and other common conditions such as epilepsy, and could be useful in guiding treatment. […] The most common indication for TTT is to confirm a diagnosis of reflex syncope in patients in whom this diagnosis has been suspected but not confirmed by the initial evaluation. […] Compared with other diagnostic tests, TTT has one of the highest diagnostic yields if the result is abnormal, with the test being diagnostic in more than 50% of cases. […] However, this is the situation which exists in specialized syncope centres and units, where a diagnosis can be established in more than 50% of patients with a mean of three tests per patient.

• #39 Vasovagal Syncope: A Review of Current and Future Strategies – touchCARDIOLOGY

  https://touchcardio.com/syncope/journal-articles/vasovagal-syncope-a-review-of-current-and-future-strategies/

  A strong benefit of tilt table testing is the ability to clearly demonstrate the BP and heart rate changes in the patient on a beat-to-beat basis, correlating these changes with the patients own experience of clinical symptoms. […] As a result of the psychosocial impairment and distress caused by recurrent syncope, and the resultant loss of quality of life, an empathetic, holistic, patient-based approach is a core tenet of care. […] Comprehensive multidisciplinary rehabilitation programmes for recurrent VVS have shown significant improvements in health-related quality of life, fewer recurrent syncopal episodes, plus fewer medical consultations, hospitalizations and traumatic injuries, compared with standard care. […] Education about physical counter-manoeuvres, and exercise training.

• #40 Syncope Workup: Approach Considerations, Laboratory Studies, Imaging Studies

  https://emedicine.medscape.com/article/811669-workup

  Class IIa recommendations for tilt-table testing from the ACC/AHA/HRS guidelines include the following: In the setting of an unclear diagnosis after the initial evaluation, this test can be useful for patients with vasovagal syncope (VVS), as well as for individuals with syncope and suspected delayed orthostatic hypotension. […] However, the ACC/AHA/HRS does not recommend tilt-table testing for prediction of a response to medical therapy for VVS (class III).

• #41 Vasovagal Syncope: A Review of Current and Future Strategies – touchCARDIOLOGY

  https://touchcardio.com/syncope/journal-articles/vasovagal-syncope-a-review-of-current-and-future-strategies/

  Tilt table tests are valuable for confirming the diagnosis. […] However, a recent meta-analysis showed a discriminatory ability to detect VVS, with an odds ratio of 12.5 compared with asymptomatic individuals. […] Recent European Society of Cardiology (ESC) guidelines recommend the use of tilt table testing in VVS (Class 2A) for: confirming a diagnosis of reflex syncope (as well as other orthostatic intolerance syndromes) when suspected, but not confirmed; educating and empowering the patient to recognize symptoms and appreciate the effects of counter pressure manoeuvres; and to recognize a hypotensive susceptibility in individuals with unexplained syncope, albeit acknowledging that this may not explain the full mechanism of syncope and thus not make a full diagnosis. […] Implantable loop recorders (ILRs) are indicated when structural heart disease is excluded and another diagnosis is uncertain from the initial evaluation, with or without tilt testing.

• #42 Syncope: an overview of diagnosis and treatment

  http://www.scielo.edu.uy/scielo.php?script=sci_arttext&pid=S1688-04202011000100008

  Syncope is a syndrome in which a relatively sudden-onset, brief loss of consciousness results from a temporary self-terminating period of total cerebral hypoperfusion. In itself, syncope is not a complete diagnosis. Identifying the cause is important, since syncope may be a marker of increased mortality risk in some cases, but even more often may lead to physical injury resulting from falls or accidents, diminished quality-of-life, and possible restriction from employment or avocation. The goal should be to determine the cause of syncope with sufficient confidence to provide a reasonable assessment of prognosis, recurrence risk, and treatment options. The initial step is always the documentation of a comprehensive and detailed medical history. […] Typically, the diagnosis is made from the medical history alone and no testing is needed. However, if the medical history does not provide sufficient basis to make the diagnosis, head-up tilt-table testing (HUT) may be helpful to support a diagnosis of vasovagal syncope. Such testing, in the absence of pharmacological provocation, has a specificity of approximately 90%. HUT is not known to be useful in the other neurally-mediated reflex faints.

• #43 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Diagnosing vasovagal syncope often begins with a physical exam. During the physical exam, your healthcare professional listens to your heart and takes your blood pressure. Your healthcare professional may massage the main arteries in your neck to see if that causes you to feel faint. […] Your healthcare professional also may recommend several tests to rule out other possible causes of your fainting particularly heart-related conditions. These tests may include: […] Electrocardiogram. This test records the electrical signals your heart produces. It can detect irregular heart rhythms and other cardiac conditions. You may need to wear a portable monitor for at least a day or as long as a month. […] Echocardiogram. This test uses ultrasound imaging to view the heart and look for conditions such as valve problems that can cause fainting.

• #44 Syncope Workup: Approach Considerations, Laboratory Studies, Imaging Studies

  https://emedicine.medscape.com/article/811669-workup

  In the setting of a suspected cardiovascular origin of syncope or presyncope (on the basis of history, physical examination, and ECG findings), an appropriate initial imaging evaluation is resting transthoracic echocardiography (TTE). […] The American College of Cardiology (ACC), American Heart Association (AHA), and the Heart Rhythm Society (HRS) indicate no benefit to obtaining routine cardiac imaging in evaluating patients with syncope unless there is suspicion of a cardiac origin from findings on an initial assessment, including the patient’s history, physical examination, or electrocardiogram (class III). […] If a clinical suspicion of structural heart disease exists, transthoracic echocardiography can be useful in selected patients with syncope. […] The tilt-table test may be indicated when the initial evaluation doesn’t provide a clear, highly likely, or potential diagnosis, but does raise the suspicion of reflex syncope, orthostatic hypotension, postural orthostatic tachycardia syndrome, or psychogenic pseudosyncope.

• #45

  https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/syncope/

  The tilt table test is a simple test that moves a patient from a supine to an upright position using a tilt table. It is used to examine autonomic neural regulation of cardiovascular orthostatic responses. […] Evaluation with echocardiography is a class IIa recommendation from the American College of Cardiology/American Heart Association if there is clinical suspicion of structural heart disease and it is of no benefit unless cardiac etiology is suspected. […] Electrophysiology testing has a low yield in patients with normal ECG, no evidence of structural heart disease, and ejection fraction 40%.

• #46 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Diagnosing vasovagal syncope often begins with a physical exam. During the physical exam, your healthcare professional listens to your heart and takes your blood pressure. Your healthcare professional may massage the main arteries in your neck to see if that causes you to feel faint. […] Your healthcare professional also may recommend several tests to rule out other possible causes of your fainting particularly heart-related conditions. These tests may include: […] Electrocardiogram. This test records the electrical signals your heart produces. It can detect irregular heart rhythms and other cardiac conditions. You may need to wear a portable monitor for at least a day or as long as a month. […] Echocardiogram. This test uses ultrasound imaging to view the heart and look for conditions such as valve problems that can cause fainting.

• #47 Neurocardiogenic Syncope Symptoms & Treatment | Baptist Health

  https://www.baptisthealth.com/care-services/conditions-treatments/neurocardiogenic-syncope

  Holter monitor: This portable EKG device continuously records the hearts rhythms and is worn for 24 to 48 hours during normal activity. […] Tilt table test: For a tilt table test, the patient lies flat on a table. After 15 minutes, the table is quickly tilted to raise the body to a head-up position simulating a change in position from lying to standing. A patients heart rate and blood pressure are monitored for 45 minutes to 1 hour while upright, allowing the physician to evaluate the bodys cardiovascular response to the change in position.

• #48 Neurocardiogenic Syncope Symptoms & Treatment | Baptist Health

  https://www.baptisthealth.com/care-services/conditions-treatments/neurocardiogenic-syncope

  Diagnosing neurocardiogenic syncope involves ruling out other, particularly heart-related or neurological, causes of fainting. Tests may include: […] Echocardiogram: This ultrasound exam uses soundwaves to take moving pictures of the hearts chambers and valves. […] Electrocardiogram (EKG): This test measures the electrical activity of the heart and can help determine if parts of the heart are enlarged, overworked or damaged. The hearts electrical currents are detected by 12 to 15 electrodes that are attached to the arms, legs and chest via sticky tape. […] Electrophysiology study: This test records the hearts electrical activities and pathways. It can help find whats causing heart rhythm problems and identify the best treatment. […] Event monitor: This portable EKG device records the heart rate when a button is pressed. It can be worn for weeks or until symptoms occur.

• #49 Vasovagal Syncope: A Review of Current and Future Strategies – touchCARDIOLOGY

  https://touchcardio.com/syncope/journal-articles/vasovagal-syncope-a-review-of-current-and-future-strategies/

  Tilt table tests are valuable for confirming the diagnosis. […] However, a recent meta-analysis showed a discriminatory ability to detect VVS, with an odds ratio of 12.5 compared with asymptomatic individuals. […] Recent European Society of Cardiology (ESC) guidelines recommend the use of tilt table testing in VVS (Class 2A) for: confirming a diagnosis of reflex syncope (as well as other orthostatic intolerance syndromes) when suspected, but not confirmed; educating and empowering the patient to recognize symptoms and appreciate the effects of counter pressure manoeuvres; and to recognize a hypotensive susceptibility in individuals with unexplained syncope, albeit acknowledging that this may not explain the full mechanism of syncope and thus not make a full diagnosis. […] Implantable loop recorders (ILRs) are indicated when structural heart disease is excluded and another diagnosis is uncertain from the initial evaluation, with or without tilt testing.

• #50 Vasovagal Syncope: Symptoms, Diagnosis, Treatments – SelfDecode Health

  https://health.selfdecode.com/blog/vasovagal-syncope/

  Vasovagal syncope is usually not serious, but it can signal a potentially dangerous medical condition. […] Common vasovagal syncope is diagnosed if the fainting event is associated with emotional distress, such as fear or pain. Prolonged standing can also cause fainting. […] Usually, syncope is diagnosed based on the patients fainting episode, medical history, physical examination, and blood tests. […] The tilt table test is used to replicate and document fainting symptoms. Patients are usually strapped to a tilt table, then suspended upright while medical data is collected. […] An implantable loop recorder can be surgically implanted under the skin to track heartbeat patterns. The recorder detects any abnormal heart rhythms during fainting events. […] The treadmill test is the newest method to diagnose syncope. Patients start walking at 1.7 mph at a flat incline. Speed and incline increase every 3 minutes and it ends after 30 minutes. After a 1-minute rest, the patient is administered nitroglycerin and medical data is collected. […] Vasovagal syncope is commonly misdiagnosed as an epileptic seizure due to occasional involuntary movements (myoclonic jerks) after fainting. However, fainting does not show the same responses as a seizure on different diagnostic tools (ECG, EEG, etc.).

• #51 Vasovagal syncope – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/diagnosis-treatment/drc-20350531

  Exercise stress test. This test studies heart rhythms during exercise. It’s usually conducted while you walk or jog on a treadmill. […] Blood tests. Your healthcare professional may look for conditions such as anemia that can cause or contribute to fainting spells. […] Tilt table test. If no heart conditions appear to cause your fainting, your healthcare professional may suggest that you undergo a tilt table test. During the test, you lie flat on your back on a table that changes positions, tilting you upward at various angles. A technician monitors your heart rhythms and blood pressure during the test to see if changing your posture affects them.

• #52 Patient education: Syncope (fainting) (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/syncope-fainting-beyond-the-basics

  Electrophysiology study — An electrophysiology study (EPS) may be performed if you have heart disease or if a rhythm problem is suspected. […] Exercise testing — In some people, especially those with a history of syncope during exertion, an exercise test is useful. […] Electroencephalogram — An electroencephalogram (EEG) is used to diagnose seizures, but may be part of the evaluation of unexplained „collapse” events.

• #53 Patient education: Syncope (fainting) (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/syncope-fainting-beyond-the-basics

  Electrophysiology study — An electrophysiology study (EPS) may be performed if you have heart disease or if a rhythm problem is suspected. […] Exercise testing — In some people, especially those with a history of syncope during exertion, an exercise test is useful. […] Electroencephalogram — An electroencephalogram (EEG) is used to diagnose seizures, but may be part of the evaluation of unexplained „collapse” events.

• #54 Evaluation of Syncope | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0915/p640.html

  Tilt-table testing is useful to confirm the diagnosis of suspected neurally mediated syncope in the absence of structural heart disease or ischemia. […] The American Heart Association/American College of Cardiology Foundation (AHA/ACCF) indications for electrophysiology include CAD and syncope, CAD with an ejection fraction less than 35 percent, and possibly nonischemic dilated cardiomyopathy.

• #55 Vasovagal Syncope: Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/23325-vasovagal-syncope

  Vasovagal syncope happens when your nervous system overreacts and your blood pressure and heart rate drop suddenly, causing you to faint or pass out. A healthcare provider will ask questions about what might have caused you to faint. You should mention any recent changes in your health or unusual symptoms you’ve noticed, even if they don’t seem important. These can help your provider make an accurate diagnosis. A provider may also run the following tests, depending on the circumstances of your symptoms: Blood tests. These can detect several conditions that can cause fainting, like low iron in your blood (anemia). Electrocardiogram (EKG or ECG). This test measures electrical activity in your heart and may detect an abnormal heart rhythm. Echocardiogram. This test shows your heart’s structure. It can identify or rule out an issue that’s causing an abnormal heart rhythm. Electroencephalogram (EEG). This test measures electrical activity in your brain. This can help determine if you passed out because of a seizure. Tilt-table test. In this test, you lie on a table that a healthcare provider tilts upward. People with vasovagal syncope may pass out or start to pass out during this test. Hemodynamic test. This test uses a special type of X-ray (gamma camera) to detect an injected tracer. This shows how your blood circulates and any problems with that.

• #56 Patient education: Syncope (fainting) (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/syncope-fainting-beyond-the-basics

  Electrophysiology study — An electrophysiology study (EPS) may be performed if you have heart disease or if a rhythm problem is suspected. […] Exercise testing — In some people, especially those with a history of syncope during exertion, an exercise test is useful. […] Electroencephalogram — An electroencephalogram (EEG) is used to diagnose seizures, but may be part of the evaluation of unexplained „collapse” events.

• #57 Brain MRI and EEG overemployment in patients with vasovagal syncope: results from a tertiary syncope unit | BMC Cardiovascular Disorders | Full Text

  https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-023-03615-y

  Based on our findings, performing MRI or EEG was common among VVS patients while it is not indicated in the majority of cases. This should be taken into consideration to prevent inappropriate MRI/EEG when there is a typical history compatible with VVS. […] Neurologic examination is not recommended as a routine diagnostic method in patients with syncope. The ESC guidelines published in 2018 recommend neurological evaluations in patients whose syncope is due to an autonomic disorder or in case of high epilepsy suspicion. […] However, brain MRI is recommended only in patients whose neurological examination shows evidence of parkinsonism, ataxia, or cognitive impairment (class of recommendation [CoR]: 1). In patients with syncope without suspicion of neurological causes, EEG, carotid ultrasound, and brain MRI are not indicated (CoR: 3).

• #58 Syncope: Evaluation and Differential Diagnosis | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/0301/p303.html

  Cranial or cardiac imaging, carotid ultrasonography, electroencephalography, and cardiac enzyme testing are rarely helpful in determining the cause of syncope and should not be ordered routinely. […] The treatment of syncope is directed at the underlying cause. […] Treatment of neurally mediated syncope includes reassurance, education, and physical therapy. […] Treatment of orthostatic hypotension includes education and lifestyle modifications, such as slowly transitioning from a supine or sitting position to standing and increasing fluid and sodium intake. […] Management of cardiac syncope is directed at the underlying etiology.

• #59 Brain MRI and EEG overemployment in patients with vasovagal syncope: results from a tertiary syncope unit | BMC Cardiovascular Disorders | Full Text

  https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-023-03615-y

  While about half of the patients diagnosed with VVS underwent EEG or MRI, the factors associated with this were head trauma, referring by the neurologist, headaches, and typical seizure presentations such as tongue bite, urinary incontinence, and tonic-clonic movements. Clinicians should follow the guidelines and avoid administrating brain MRI or EEG in case of history and physical examination consistent with VVS, as they have no place in the routine evaluation of these patients.

• #60 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  In the evaluation of patients with syncope, the critical first step is a detailed medical history. A diagnostic strategy based on initial evaluation is warranted. The importance of the initial evaluation goes well beyond its capability to make a diagnosis as it determines the most appropriate subsequent diagnostic pathways and risk evaluation. […] According to the Guidelines on Syncope of the European Society of Cardiology (ESC) the initial evaluation of a patient presenting with syncope consists of taking a careful history, and a physical examination, including orthostatic blood pressure measurements and standard electrocardiogram (ECG). […] Is loss of consciousness attributable to syncope or not? Differentiating true syncope from nonsyncopal conditions associated with real or apparent transient loss of consciousness is generally the first diagnostic challenge and influences the subsequent diagnostic strategy.

• #61 Evaluation of Syncope | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0915/p640.html

  Syncope is classified as neurally mediated (i.e., carotid sinus hypersensitivity, situational, or vasovagal), cardiac, orthostatic, or neurogenic. […] Patients presenting with syncope (other than neurally mediated and orthostatic syncope) are at increased risk of death from any cause. […] All patients presenting with syncope require electrocardiography, orthostatic vital signs, and QT interval monitoring. […] Patients with neurally mediated or orthostatic syncope usually require no additional testing. […] In cases of unexplained syncope, further testing such as echocardiography, grade exercise testing, electrocardiographic monitoring, and electrophysiologic studies may be required. […] Vasovagal syncope may be diagnosed if there is a common precipitating factor with associated prodromal symptoms.

• #62 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  Classical vasovagal syncope is diagnosed if precipitating events such as fear, severe pain, emotional distress, instrumentation or prolonged standing are associated with typical prodromal symptoms. […] Situational syncope is diagnosed if syncope occurs during or immediately after urination, defaecation, cough or swallowing. […] Orthostatic syncope is diagnosed when there is documentation of orthostatic hypotension (defined as a decrease in systolic blood pressure 20mmHg or a decrease of systolic blood pressure to 90mmHg) associated with syncope or presyncope. […] Arrhythmia-related syncope is diagnosed by ECG when there is sinus bradycardia 40beats/min or repetitive sinoatrial blocks or sinus pauses 3s in the absence of medications known to have negative chronotropic effect. […] The initial evaluation may lead to certain or suspected diagnosis or no diagnosis (here termed as unexplained syncope).

• #63 Clinical Presentation and Diagnosis of Vasovagal Syncope | SpringerLink

  https://link.springer.com/chapter/10.1007/978-3-319-09102-0_11

  Since the classic Lewis description of vasovagal syncope (VVS) in 1932, our knowledge on VVS has markedly improved, and we have learned that VVS may have different clinical presentations. The most relevant ones are typical VVS, sleep syncope, atypical VVS, and unexplained fall. […] Typical VVS can be diagnosed after the initial evaluation, when a transient loss of consciousness is triggered by emotional distress or orthostatic stress, in the presence of autonomic prodromes. An atypical VVS can be diagnosed in subjects with transient loss of consciousness not preceded by evident trigger, only when tilt test is positive, in the absence of any competing diagnosis. […] Many clinical features suggest that sleep syncope is a form of VVS. Very recent data show that an unexplained fall may be a clinical presentation of VVS.

• #64 Frontiers | Differential Diagnosis Between Psychogenic Pseudosyncope and Vasovagal Syncope in Children: A Quantitative Scoring Model Based on Clinical Manifestations

  https://www.frontiersin.org/journals/cardiovascular-medicine/articles/10.3389/fcvm.2022.839183/full

  Differential Diagnosis Between Psychogenic Pseudosyncope and Vasovagal Syncope in Children: A Quantitative Scoring Model Based on Clinical Manifestations […] The study was designed to explore a clinical manifestation-based quantitative scoring model to assist the differentiation between psychogenic pseudosyncope (PPS) and vasovagal syncope (VVS) in children. […] The diagnostic criteria of VVS are: (1) occurring primarily in older children and adolescents; (2) often accompanied by precipitating factors such as long periods of uprightness, mental tension, and sultry environment; (3) a clear history or aura of syncope; (4) a positive HUTT test; and (5) exclusion of other diseases such as cardiogenic, cerebrovascular or metabolic diseases. […] At present, there has not been any acknowledged clinical manifestation-based systematic procedure to differentiate PPS and VVS in children. […] Therefore, a simple, efficient, and rapid measure for the differentiation between PPS and VVS based on clinical manifestations is urgently needed. […] The scoring model for the preliminary discrimination between PPS and VVS by four variables (daily frequency of attacks, upright posture, DLOC, and BMI) was established through binary logistic regression. […] When the total score of the child was ≥5 points, the sensitivity and specificity for the possible differentiation of PPS from VVS were 92.0% and 90.7%, respectively. […] In the external validation, the sensitivity of the scoring model is not as high as that of the training set in our study. […] By this scoring model, a rapid preliminary judgment between PPS and VVS can be made just through a simple inquiry of medical history and basic measurement of height and weight, which is highly practical and easy to be popularized. […] This study developed a clinical manifestation-based scoring model to differentiate PPS from VVS, assisting in making a quick initial differential diagnosis.

• #65 Clinical Presentation and Diagnosis of Vasovagal Syncope | SpringerLink

  https://link.springer.com/chapter/10.1007/978-3-319-09102-0_11

  Since the classic Lewis description of vasovagal syncope (VVS) in 1932, our knowledge on VVS has markedly improved, and we have learned that VVS may have different clinical presentations. The most relevant ones are typical VVS, sleep syncope, atypical VVS, and unexplained fall. […] Typical VVS can be diagnosed after the initial evaluation, when a transient loss of consciousness is triggered by emotional distress or orthostatic stress, in the presence of autonomic prodromes. An atypical VVS can be diagnosed in subjects with transient loss of consciousness not preceded by evident trigger, only when tilt test is positive, in the absence of any competing diagnosis. […] Many clinical features suggest that sleep syncope is a form of VVS. Very recent data show that an unexplained fall may be a clinical presentation of VVS.

• #66 Syncope: Evaluation and Differential Diagnosis | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/0301/p303.html

  Syncope is classified as neurally mediated, cardiac, and orthostatic hypotension. […] A standardized approach to syncope evaluation reduces hospital admissions and medical costs, and increases diagnostic accuracy. […] The initial assessment for all patients presenting with syncope includes a detailed history, physical examination, and electrocardiography. […] Several comparable clinical decision rules can be used to assess the short-term risk of death and the need for hospital admission. […] High-risk patients with cardiovascular or structural heart disease, history concerning for arrhythmia, abnormal electrocardiographic findings, or severe comorbidities should be admitted to the hospital for further evaluation. […] In cases of unexplained syncope, provocative testing and prolonged electrocardiographic monitoring strategies can be diagnostic.

• #67 Syncope – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/syncope/

  Syncope is a sudden, transient loss of consciousness, which is thought to be secondary to cerebral hypoperfusion. The diagnostic approach is focused on determining if loss of consciousness was due to syncope (ruling out differential diagnoses), ruling out immediately life-threatening causes of syncope, and determining the risk of serious adverse events from syncope, which further guide management and disposition. This involves obtaining a detailed history and performing a physical examination, including orthostatic vital sign measurements and an initial ECG. Further diagnostics should be guided by clinical suspicion of the underlying disease. […] The following categories are consistent with nomenclature and classification used in the 2017 American Heart Association (AHA) syncope guidelines.

• #68 Frontiers | Differential Diagnosis Between Psychogenic Pseudosyncope and Vasovagal Syncope in Children: A Quantitative Scoring Model Based on Clinical Manifestations

  https://www.frontiersin.org/journals/cardiovascular-medicine/articles/10.3389/fcvm.2022.839183/full

  Differential Diagnosis Between Psychogenic Pseudosyncope and Vasovagal Syncope in Children: A Quantitative Scoring Model Based on Clinical Manifestations […] The study was designed to explore a clinical manifestation-based quantitative scoring model to assist the differentiation between psychogenic pseudosyncope (PPS) and vasovagal syncope (VVS) in children. […] The diagnostic criteria of VVS are: (1) occurring primarily in older children and adolescents; (2) often accompanied by precipitating factors such as long periods of uprightness, mental tension, and sultry environment; (3) a clear history or aura of syncope; (4) a positive HUTT test; and (5) exclusion of other diseases such as cardiogenic, cerebrovascular or metabolic diseases. […] At present, there has not been any acknowledged clinical manifestation-based systematic procedure to differentiate PPS and VVS in children. […] Therefore, a simple, efficient, and rapid measure for the differentiation between PPS and VVS based on clinical manifestations is urgently needed. […] The scoring model for the preliminary discrimination between PPS and VVS by four variables (daily frequency of attacks, upright posture, DLOC, and BMI) was established through binary logistic regression. […] When the total score of the child was ≥5 points, the sensitivity and specificity for the possible differentiation of PPS from VVS were 92.0% and 90.7%, respectively. […] In the external validation, the sensitivity of the scoring model is not as high as that of the training set in our study. […] By this scoring model, a rapid preliminary judgment between PPS and VVS can be made just through a simple inquiry of medical history and basic measurement of height and weight, which is highly practical and easy to be popularized. […] This study developed a clinical manifestation-based scoring model to differentiate PPS from VVS, assisting in making a quick initial differential diagnosis.

• #69

  https://www.nytimes.com/interactive/2018/05/04/magazine/netflix-diagnosis-series-matts-fainting-spells.html

  Fainting, or what is known medically as syncope, is a transient loss of consciousness caused by reduced blood flow to the brain, usually from a heart that isn’t beating well enough to get the blood where it needs to go. […] Vasovagal syncope (VVS), the most common form of nerve-induced fainting, occurs when the heart gets an unneeded signal to slow down. […] The classic story for cardiac syncope is a middle-aged man who suddenly finds himself on the ground with no preceding symptoms and no awareness of the fall. […] Vasovagal syncope usually has a very different story. Patients with this type of syncope are frequently young and describe feeling lightheaded or faint before losing consciousness. […] This young man had elements of a classic story of vasovagal syncope: Each instance was preceded by a feeling of faintness, nausea and a cold sweat. […] Because the young man’s story didn’t fit the classic picture of VVS, the doctors caring for him in the hospital wanted to make certain his heart was not involved. […] The cardiologist still felt confident that this was vasovagal syncope.

• #70 Vasovagal Syncope: Symptoms, Causes, and Treatments

  https://www.verywellhealth.com/vasovagal-cardioneurogenic-syncope-1746389

  The results of these tests help your provider rule out other, sometimes more serious causes of fainting: Orthostatic hypotension, a condition where your blood pressure falls when you stand up, making you feel dizzy or lightheaded, Postural orthostatic tachycardia syndrome (POTS), a condition when an exaggerated increase in your heart rate when you stand up can make you feel lightheaded and have heart palpitations (irregular beats), Low red blood cell count (anemia), Seizures, Heart conditions or problems, Diabetes if blood sugar levels are too high or too low, Conditions that affect your brain, like a transient ischemic attack, Lung problems resulting in a lack of oxygen (hypoxia), Breathing too fast or too hard (hyperventilation), such as when you’re scared or anxious, Certain medications and substances.

• #71 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  Patients who seek medical advice after having experienced a vasovagal faint require reassurance and education regarding the nature of the disease and the avoidance of triggering events. […] Nonpharmacological physical treatments are emerging as a new front line treatment of vasovagal syncope. […] Many drugs have been used in the treatment of vasovagal syncope. […] The role of cardiac pacing for vasovagal syncope is not yet established. […] Cardiac pacing appears to be beneficial in the carotid sinus syndrome and, although only one relatively small randomised controlled trial has been undertaken, pacing is acknowledged to be the treatment of choice when bradycardia has been documented.

• #72 Syncope: Evaluation and Differential Diagnosis | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/0301/p303.html

  Syncope is classified as neurally mediated, cardiac, and orthostatic hypotension. […] A standardized approach to syncope evaluation reduces hospital admissions and medical costs, and increases diagnostic accuracy. […] The initial assessment for all patients presenting with syncope includes a detailed history, physical examination, and electrocardiography. […] Several comparable clinical decision rules can be used to assess the short-term risk of death and the need for hospital admission. […] High-risk patients with cardiovascular or structural heart disease, history concerning for arrhythmia, abnormal electrocardiographic findings, or severe comorbidities should be admitted to the hospital for further evaluation. […] In cases of unexplained syncope, provocative testing and prolonged electrocardiographic monitoring strategies can be diagnostic.

• #73 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  Patients who seek medical advice after having experienced a vasovagal faint require reassurance and education regarding the nature of the disease and the avoidance of triggering events. […] Nonpharmacological physical treatments are emerging as a new front line treatment of vasovagal syncope. […] Many drugs have been used in the treatment of vasovagal syncope. […] The role of cardiac pacing for vasovagal syncope is not yet established. […] Cardiac pacing appears to be beneficial in the carotid sinus syndrome and, although only one relatively small randomised controlled trial has been undertaken, pacing is acknowledged to be the treatment of choice when bradycardia has been documented.

• #74 What can I do when first-line measures are not enough for vasovagal syncope? | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/85/12/920

  Confirming the diagnosis of vasovagal syncope with tilt-table testing may reassure the patient. It can also help the patient learn to identify the symptoms associated with a vasovagal episode, which in turn may encourage timely use of physical counter-pressure maneuvers at the onset. […] In patients who continue to have syncopal episodes despite adequate use of first-line measures, medical therapy can be considered. Unfortunately, evidence supporting drug therapy for recurrent syncope is limited. Options include midodrine (class IIa), fludrocortisone (class IIb), beta-blockers (class IIb), and selective serotonin reuptake inhibitors (class IIb).

• #75 Syncope | Doctor

  https://patient.info/doctor/syncope

  Adults with clear vasovagal features should not be routinely referred, even if there is brief associated limb jerking. […] Referral is indicated if there is any suggestion of a serious underlying cause or if the episodes of syncope are frequent, have implications for driving, cause injuries or cannot be controlled by simple avoidance of precipitating factors. […] The gold standard for the diagnosis of cardiac syncope is when a correlation between the symptoms and a documented arrhythmia is recorded. […] If the cause still remains unclear then repeat evaluation, including neurological investigations, and possible admission to hospital may be required.

• #76 Syncope: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/811669-overview

  History and physical examination are the most specific and sensitive ways of evaluating syncope. […] No specific laboratory testing has sufficient power to be absolutely indicated for evaluation of syncope. […] A standard 12-lead ECG is a level A recommendation in the 2007 ACEP consensus guidelines for syncope. […] Other diagnostic tests and procedures include the following: Head-up tilt-table test: Useful for confirming autonomic dysfunction and can generally be safely arranged on an outpatient basis. […] Vasovagal syncope is the most common type in young adults but can occur at any age. […] Vasovagal syncope has a uniformly excellent prognosis. This condition does not increase the mortality, and recurrences are infrequent.

• #77 Vasovagal syncope – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/symptoms-causes/syc-20350527

  Vasovagal syncope is usually harmless and requires no treatment. But it’s possible that you may injure yourself during a vasovagal syncope episode. Your healthcare professional may recommend tests to rule out more-serious causes of fainting, such as heart conditions. […] Fainting can be a sign of a more serious condition, such as a heart or brain condition. You may want to consult your healthcare professional after a fainting spell, especially if you’ve never had one before. […] During a vasovagal syncope episode, your heart rate slows, and the blood vessels in your legs widen. This allows blood to pool in your legs, which lowers your blood pressure. The drop in blood pressure and slowed heart rate quickly reduce blood flow to your brain, and you faint.

• #78 Diagnosis and treatment of syncope

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1861366/

  Patients who seek medical advice after having experienced a vasovagal faint require reassurance and education regarding the nature of the disease and the avoidance of triggering events. […] Nonpharmacological physical treatments are emerging as a new front line treatment of vasovagal syncope. […] Many drugs have been used in the treatment of vasovagal syncope. […] The role of cardiac pacing for vasovagal syncope is not yet established. […] Cardiac pacing appears to be beneficial in the carotid sinus syndrome and, although only one relatively small randomised controlled trial has been undertaken, pacing is acknowledged to be the treatment of choice when bradycardia has been documented.

• #79 Vasovagal Syncope: Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/23325-vasovagal-syncope

  Most people who have vasovagal syncope will recover on their own. For others, treatment may include: IV fluids. These are especially helpful if you’re dehydrated. Trigger education and avoidance. Knowing what causes vasovagal syncope can help you avoid that trigger or at least be ready for it. You may be able to avoid passing out entirely. Medications. Some medications for heart rhythm disorders or blood pressure may help. These include fludrocortisone and midodrine. Compression stockings. Waist-high stockings (medical grade) work best. If you find these too uncomfortable, you can wear compression clothing made for athletes. Counter-pressure maneuvers. These include crossing your legs and squeezing your leg muscles tightly for several seconds, as well as interlocking your fists and pulling your arms apart. These maneuvers can help increase your blood pressure and prevent you from fainting. Pacing devices. In rare cases, you may need a pacemaker or another device that can help you avoid passing out because of pauses in your heartbeat. Catheter ablation. Healthcare providers are using cardioneuroablation to treat rare cases. This targets nerves in your heart. […] If you pass out, you should receive emergency medical care right away. Serious or life-threatening conditions can cause vasovagal syncope. A healthcare provider should examine you right away to determine if a more severe condition caused you to faint.

• #80 Syncope: Evaluation and Differential Diagnosis | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/0301/p303.html

  Cranial or cardiac imaging, carotid ultrasonography, electroencephalography, and cardiac enzyme testing are rarely helpful in determining the cause of syncope and should not be ordered routinely. […] The treatment of syncope is directed at the underlying cause. […] Treatment of neurally mediated syncope includes reassurance, education, and physical therapy. […] Treatment of orthostatic hypotension includes education and lifestyle modifications, such as slowly transitioning from a supine or sitting position to standing and increasing fluid and sodium intake. […] Management of cardiac syncope is directed at the underlying etiology.

• #81 Vasovagal Syncope: A Review of Current and Future Strategies – touchCARDIOLOGY

  https://touchcardio.com/syncope/journal-articles/vasovagal-syncope-a-review-of-current-and-future-strategies/

  A strong benefit of tilt table testing is the ability to clearly demonstrate the BP and heart rate changes in the patient on a beat-to-beat basis, correlating these changes with the patients own experience of clinical symptoms. […] As a result of the psychosocial impairment and distress caused by recurrent syncope, and the resultant loss of quality of life, an empathetic, holistic, patient-based approach is a core tenet of care. […] Comprehensive multidisciplinary rehabilitation programmes for recurrent VVS have shown significant improvements in health-related quality of life, fewer recurrent syncopal episodes, plus fewer medical consultations, hospitalizations and traumatic injuries, compared with standard care. […] Education about physical counter-manoeuvres, and exercise training.

• #82 Vasovagal syncope – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/symptoms-causes/syc-20350527

  Vasovagal syncope is usually harmless and requires no treatment. But it’s possible that you may injure yourself during a vasovagal syncope episode. Your healthcare professional may recommend tests to rule out more-serious causes of fainting, such as heart conditions. […] Fainting can be a sign of a more serious condition, such as a heart or brain condition. You may want to consult your healthcare professional after a fainting spell, especially if you’ve never had one before. […] During a vasovagal syncope episode, your heart rate slows, and the blood vessels in your legs widen. This allows blood to pool in your legs, which lowers your blood pressure. The drop in blood pressure and slowed heart rate quickly reduce blood flow to your brain, and you faint.

• #83 Reflex syncope in adults and adolescents: Clinical presentation and diagnostic evaluation – UpToDate

  https://www.uptodate.com/contents/reflex-syncope-in-adults-and-adolescents-clinical-presentation-and-diagnostic-evaluation

  Vasovagal syncope is the most common cause of syncope in patients of all ages, and its diagnosis may usually be made by taking a careful history detailing the features of symptomatic events and identifying well-known triggers; however, a classic history is not always present, especially in older individuals. […] The diagnosis can also be supported by a characteristic response to upright tilt table testing, during which the patient’s premonitory symptoms and signs (ie, hot/cold, sweaty, pale) and syncope may be reproduced. […] The clinical presentation and diagnostic evaluation of patients with vasovagal syncope and situational reflex syncope will be reviewed here.

• #84 Role of tilt-table testing in syncope diagnosis and management

  https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-13/role-of-tilt-table-testing-in-syncope-diagnosis-and-management

  Tilt-table testing (TTT) plays a major role during the evaluation of syncope patients, helps to differentiate syncope subtypes and to discriminate between syncope and other common conditions such as epilepsy, and could be useful in guiding treatment. […] The most common indication for TTT is to confirm a diagnosis of reflex syncope in patients in whom this diagnosis has been suspected but not confirmed by the initial evaluation. […] Compared with other diagnostic tests, TTT has one of the highest diagnostic yields if the result is abnormal, with the test being diagnostic in more than 50% of cases. […] However, this is the situation which exists in specialized syncope centres and units, where a diagnosis can be established in more than 50% of patients with a mean of three tests per patient.

• #85 Vasovagal Episode – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK470277/

  Every person undergoing evaluation for syncope including presumed vasovagal syncope should have an ECG to look for evidence of underlying arrhythmogenic cardiac abnormalities, such as Wolff-Parkinson-White syndrome, prolonged QT syndrome, Brugada syndrome, or heart blocks. […] In healthy patients with a classic history of vasovagal syncope, a normal exam, and a normal ECG, no further testing is indicated, and laboratory testing is low yield. […] The diagnosis and management of vasovagal syncope is very difficult because the differential is enormous.

• #86 Vasovagal Syncope: A Review of Current and Future Strategies – touchCARDIOLOGY

  https://touchcardio.com/syncope/journal-articles/vasovagal-syncope-a-review-of-current-and-future-strategies/

  A strong benefit of tilt table testing is the ability to clearly demonstrate the BP and heart rate changes in the patient on a beat-to-beat basis, correlating these changes with the patients own experience of clinical symptoms. […] As a result of the psychosocial impairment and distress caused by recurrent syncope, and the resultant loss of quality of life, an empathetic, holistic, patient-based approach is a core tenet of care. […] Comprehensive multidisciplinary rehabilitation programmes for recurrent VVS have shown significant improvements in health-related quality of life, fewer recurrent syncopal episodes, plus fewer medical consultations, hospitalizations and traumatic injuries, compared with standard care. […] Education about physical counter-manoeuvres, and exercise training.

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