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CardioLogIQ
2018

ESC 2018 Guidelines — Syncope

2018 ESC Guidelines for the diagnosis and management of syncope

The 2018 guideline separates the initial evaluation from everything that follows, and most questions are really asking which stage you are at. History, examination, electrocardiogram and orthostatic measurements settle a large share of cases; the further tests exist for the cases they do not settle.

Pacing is the sharpest examinable line. A device is indicated for a documented cardioinhibitory mechanism, not for a positive tilt test, not for a purely vasodepressor response, and not where recordings from spontaneous episodes show sinus rhythm throughout. A reversible cause — a rate-limiting drug, an electrolyte disturbance — is corrected before any device is considered.

Reflex syncope is managed with explanation, reassurance and counterpressure manoeuvres as the first step, with drug therapy reserved and beta-blockers explicitly not indicated. Orthostatic hypotension has its own graded measures, including non-pharmacological ones that are easy to overlook. Emergency department risk stratification and the role of the implantable loop recorder complete the topic.

What is in the bank

133 active questions. Class and level follow the recommendation each question is built from.

Class of recommendation

Class I
65
Class IIa
42
Class IIb
22
Class III
4

Level of evidence

Level A
8
Level B
58
Level C
67

Sample questions

Syncope · 2018Class IIILevel A
A 42-year-old woman has recurrent brief episodes of loss of consciousness triggered by prolonged standing, each preceded by nausea, pallor and light-headedness building over half a minute, with rapid full recovery afterwards. Her examination, electrocardiogram, echocardiogram and supine and standing blood pressures are all normal, and she takes no medication, so this is classical vasovagal syncope. She has not yet been given any structured advice about her condition. A colleague suggests starting propranolol, reasoning that blunting the sympathetic surge should interrupt the reflex before it reaches the stage that causes bradycardia and vasodilatation. What should be done?
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