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European Heart Journal (2009) 30, 2631–2671

doi:10.1093/eurheartj/ehp298

ESC GUIDELINES

Guidelines for the diagnosis and management

of syncope (version 2009)

The Task Force for the Diagnosis and Management of Syncope of the

European Society of Cardiology (ESC)

Developed in collaboration with, European Heart Rhythm Association (EHRA) 1 ,

Heart Failure Association (HFA) 2 , and Heart Rhythm Society (HRS) 3

Endorsed by the following societies, European Society of Emergency Medicine (EuSEM) 4 , European Federation of

Internal Medicine (EFIM) 5 , European Union Geriatric Medicine Society (EUGMS) 6 , American Geriatrics Society

(AGS), European Neurological Society (ENS) 7 , European Federation of Autonomic Societies (EFAS) 8 , American

Autonomic Society (AAS) 9

Authors/Task Force Members, Angel Moya (Chairperson) (Spain) * , Richard Sutton (Co-Chairperson) (UK) * ,

Fabrizio Ammirati (Italy), Jean-Jacques Blanc (France), Michele Brignole 1 (Italy), Johannes B. Dahm (Germany),

Jean-Claude Deharo (France), Jacek Gajek (Poland), Knut Gjesdal 2 (Norway), Andrew Krahn 3 (Canada),

Martial Massin (Belgium), Mauro Pepi (Italy), Thomas Pezawas (Austria), Ricardo Ruiz Granell (Spain),

Francois Sarasin 4

(Italy), J. Gert van Dijk 7

(The Netherlands), Edmond P. Walma

(The Netherlands), Wouter Wieling (The Netherlands)

External Contributors, Haruhiko Abe (Japan), David G. Benditt (USA), Wyatt W. Decker (USA), Blair P. Grubb

(USA), Horacio Kaufmann 9 (USA), Carlos Morillo (Canada), Brian Olshansky (USA), Steve W. Parry (UK),

Robert Sheldon (Canada), Win K. Shen (USA)

ESC Committee for Practice Guidelines (CPG), Alec Vahanian (Chairperson) (France), Angelo Auricchio

(Switzerland), Jeroen Bax (The Netherlands), Claudio Ceconi (Italy), Veronica Dean (France), Gerasimos Filippatos

(Greece), Christian Funck-Brentano (France), Richard Hobbs (UK), Peter Kearney (Ireland), Theresa McDonagh

(UK), Keith McGregor (France), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Udo Sechtem (Germany),

Per Anton Sirnes (Norway), Michal Tendera (Poland), Panos Vardas (Greece), Petr Widimsky (Czech Republic)

Document Reviewers, Angelo Auricchio (CPG Review Coordinator) (Switzerland), Esmeray Acarturk (Turkey),

Felicita Andreotti (Italy), Riccardo Asteggiano (Italy), Urs Bauersfeld (Switzerland), Abdelouahab Bellou 4 (France),

Athanase Benetos 6 (France), Johan Brandt (Sweden), Mina K. Chung 3 (USA), Pietro Cortelli 8 (Italy),

Antoine Da Costa (France), Fabrice Extramiana (France), Jos ´ Ferro 7 (Portugal), Bulent Gorenek (Turkey),

Antti Hedman (Finland), Rafael Hirsch (Israel), Gabriela Kaliska (Slovak Republic), Rose Anne Kenny 6 (Ireland),

Keld Per Kjeldsen (Denmark), Rachel Lampert 3 (USA), Henning Mølgard (Denmark), Rain Paju (Estonia),

Aras Puodziukynas (Lithuania), Antonio Raviele (Italy), Pilar Roman 5

(Spain), Martin Scherer (Germany),

Ronald Schondorf 9

(Canada), Rosa Sicari (Italy), Peter Vanbrabant 4

(Belgium), Christian Wolpert 1

(Germany),

Jose Luis Zamorano (Spain)

The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines

* Corresponding authors: Angel Moya (Chairperson), Hospital Vall d’Hebron, P. Vall d’Hebron 119 – 129, 08035 Barcelona, Spain. Tel: þ 34 93 2746166, Fax: þ 34 93 2746002,

Email: amoya@comb.cat

Richard Sutton (UK) (Co-Chairperson), Imperial College, St Mary’s Hospital, Praed Street, London W2 1NY, UK. Tel: þ 44 20 79351011, Fax: þ 44 20 79356718, Email: r.sutton@

imperial.ac.uk

The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the

ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford

University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.

Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health

professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health

professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient’s

guardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

(Switzerland), Andrea Ungar 6

2632

ESC Guidelines

Table of Contents

2.2.9 Psychiatric evaluation . . . . . . . . . . . . . . . . . . . . 2653

2.2.10 Neurological evaluation . . . . . . . . . . . . . . . . . . . 2654

2.2.10.1 Clinical conditions . . . . . . . . . . . . . . . . . . . . 2654

2.2.10.2 Neurological tests . . . . . . . . . . . . . . . . . . . . 2655

Part 3. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2656

3.1 Treatment of reﬂex syncope and orthostatic

intolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2656

3.1.1 Reﬂex syncope . . . . . . . . . . . . . . . . . . . . . . . . 2657

3.1.1.1 Therapeutic options . . . . . . . . . . . . . . . . . . . 2657

3.1.1.2 Individual conditions . . . . . . . . . . . . . . . . . . . 2658

3.1.2 Orthostatic hypotension and orthostatic intolerance

syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . 2658

3.2 Cardiac arrhythmias as primary cause . . . . . . . . . . . . 2659

3.2.1 Sinus node dysfunction . . . . . . . . . . . . . . . . . . . 2659

3.2.2 Atrioventricular conduction system disease . . . . . . 2659

3.2.3 Paroxysmal supraventricular and ventricular

tachycardias . . . . . . . . . . . . . . . . . . . . . . . . . . 2659

3.2.4 Implanted device malfunction . . . . . . . . . . . . . . . 2660

3.3 Syncope secondary to structural cardiac or

cardiovascular disease . . . . . . . . . . . . . . . . . . . . . . 2660

3.4 Unexplained syncope in patients with high risk of

sudden cardiac death . . . . . . . . . . . . . . . . . . . . . . . 2661

3.4.1 Ischaemic and non-ischaemic cardiomyopathies . . . 2661

3.4.2 Hypertrophic cardiomyopathy . . . . . . . . . . . . . . 2661

3.4.3 Arrhythmogenic right ventricular cardiomyopathy/

dysplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2661

3.4.4 Patients with primary electrical diseases . . . . . . . . 2661

Part 4. Special issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2662

4.1 Syncope in the elderly . . . . . . . . . . . . . . . . . . . . . . 2662

4.2 Syncope in paediatric patients . . . . . . . . . . . . . . . . . 2663

4.3 Driving and syncope . . . . . . . . . . . . . . . . . . . . . . . 2663

Part 5. Organizational aspects . . . . . . . . . . . . . . . . . . . . . . 2664

5.1 Management of syncope in general practice . . . . . . . . 2664

5.2 Management of syncope in the Emergency Department 2664

5.3 Syncope (T-LOC) Management Unit . . . . . . . . . . . . 2664

5.3.1 Existing models of Syncope (T-LOC) Management

Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2665

5.3.2 Proposed model . . . . . . . . . . . . . . . . . . . . . . . 2665

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2666

Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . 2632

Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2633

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2634

Part 1. Deﬁnitions, classiﬁcation and pathophysiology,

epidemiology, prognosis, impact on quality of life, and

economic issues . . . . . . . . . . . . . . . . . . . . . . . . . . 2635

1.1 Deﬁnitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2635

1.2 Classiﬁcation and pathophysiology . . . . . . . . . . . . . . 2635

1.2.1 Placing syncope in the larger framework of transient

loss of consciousness (real or apparent) . . . . . . . . 2635

1.2.2 Classiﬁcation and pathophysiology of syncope . . . . 2636

1.2.2.1 Reﬂex syncope (neurally mediated syncope) . . . 2637

1.2.2.2 Orthostatic hypotension and orthostatic

intolerance syndromes . . . . . . . . . . . . . . . . . 2637

1.2.2.3 Cardiac syncope (cardiovascular) . . . . . . . . . . 2639

1.3 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2640

1.3.1 Prevalence of syncope in the general population. . . 2640

1.3.2 Referral from the general population to medical

settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2640

1.3.3 Prevalence of the causes of syncope . . . . . . . . . . 2641

1.4 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2641

1.4.1 Risk of death and life-threatening events . . . . . . . 2641

1.4.2 Recurrence of syncope and risk of physical injury . 2641

1.5 Impact on quality of life . . . . . . . . . . . . . . . . . . . . . 2641

1.6 Economic issues . . . . . . . . . . . . . . . . . . . . . . . . . . 2643

Part 2. Initial evaluation, diagnosis, and risk stratiﬁcation . . . . . 2644

2.1 Initial evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 2644

2.1.1 Diagnosis of syncope . . . . . . . . . . . . . . . . . . . . 2644

2.1.2 Aetiological diagnosis . . . . . . . . . . . . . . . . . . . . 2644

2.1.3 Risk stratiﬁcation . . . . . . . . . . . . . . . . . . . . . . . 2645

2.2 Diagnostic tests . . . . . . . . . . . . . . . . . . . . . . . . . . 2645

2.2.1 Carotid sinus massage . . . . . . . . . . . . . . . . . . . 2645

2.2.2 Orthostatic challenge . . . . . . . . . . . . . . . . . . . . 2647

2.2.2.1 Active standing . . . . . . . . . . . . . . . . . . . . . . 2647

2.2.2.2 Tilt testing . . . . . . . . . . . . . . . . . . . . . . . . . 2647

2.2.3 Electrocardiographic monitoring (non-invasive and

invasive) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2649

2.2.3.1 In-hospital monitoring . . . . . . . . . . . . . . . . . 2649

2.2.3.2 Holter monitoring . . . . . . . . . . . . . . . . . . . . 2649

2.2.3.3 Prospective external event recorders . . . . . . . 2649

2.2.3.4 External loop recorders . . . . . . . . . . . . . . . . 2649

2.2.3.5 Implantable loop recorders . . . . . . . . . . . . . . 2649

2.2.3.6 Remote (at home) telemetry . . . . . . . . . . . . . 2650

2.2.3.7 Classiﬁcation of electrocardiographic recordings 2650

2.2.3.8 Electrocardiographic monitoring in syncope—

where in the work-up? . . . . . . . . . . . . . . . . . 2650

2.2.4 Electrophysiological study . . . . . . . . . . . . . . . . . 2651

2.2.4.1 Suspected intermittent bradycardia . . . . . . . . . 2651

2.2.4.2 Syncope in patients with bundle branch block

(impending high degree atrioventricular block) . 2652

2.2.4.3 Suspected tachycardia . . . . . . . . . . . . . . . . . 2652

2.2.5 Adenosine triphosphate test . . . . . . . . . . . . . . . 2652

2.2.6 Echocardiography and other imaging techniques . . 2653

2.2.7 Exercise stress testing . . . . . . . . . . . . . . . . . . . . 2653

2.2.8 Cardiac catheterization . . . . . . . . . . . . . . . . . . . 2653

Abbreviations and acronyms

ANF

autonomic failure

ANS

autonomic nervous system

ARVC

arrhythmogenic right ventricular cardiomyopathy

ATP

adenosine triphosphate

atrioventricular

AVID

Antiarrhythmics vs. Implantable Deﬁbrillators

BBB

bundle branch block

blood pressure

b.p.m.

beats per minute

CAD

coronary artery disease

cardiac output

CPG

Committee for Practice Guidelines

CSH

carotid sinus hypersensitivity

CSM

carotid sinus massage

ESC Guidelines

2633

CSS carotid sinus syndrome

CSNRT corrected sinus node recovery time

CT computed tomography

DCM dilated cardiomyopathy

ECG electrocardiogram/electrocardiographic

ED Emergency Department

EEG electroencephalogram

EGSYS Evaluation of Guidelines in Syncope Study

EPS electrophysiological study

ESC European Society of Cardiology

FASS Falls and Syncope Service

FDA Food and Drug Administration

HF heart failure

HOCM hypertrophic obstructive cardiomyopathy

HR heart rate

HV His-ventricle

ICD implantable cardioverter deﬁbrillator

ILR implantable loop recorder

ISSUE International Study on Syncope of Unknown Etiology

LBBB left bundle branch block

LOC loss of consciousness

LVEF left ventricular ejection fraction

MRI magnetic resonance imaging

OH orthostatic hypotension

PCM physical counterpressure manoeuvre

PDA personal digital assistant

POTS postural orthostatic tachycardia syndrome

RBBB right bundle branch block

SCD sudden cardiac death

SCD-HeFT Sudden Cardiac Death in Heart Failure Trial

SNRT

sinus node recovery time

Documents can be found on the ESC Web Site (http://www

.escardio.org/guidelines).

In brief, experts in the ﬁeld are selected and undertake a com-

prehensive review of the published evidence for management and/

or prevention of a given condition. A critical evaluation of diagnos-

tic and therapeutic procedures is performed, including assessment

of the risk/beneﬁt ratio. Estimates of expected health outcomes for

larger societies are included, where data exist. The level of evi-

dence and the strength of recommendation of particular treatment

options are weighed and graded according to predeﬁned scales, as

outlined in Tables 1 and 2.

The experts of the writing panels have provided disclosure

statements of all relationships they may have which might be per-

ceived as real or potential sources of conﬂicts of interest. These

disclosure forms are kept on ﬁle at the European Heart House

Headquarters of the ESC. Any changes in conﬂict of interest that

arise during the writing period must be notiﬁed to the ESC. The

Task Force (TF) report was entirely supported ﬁnancially by the

ESC and was developed without any involvement of industry.

The ESC Committee for Practice Guidelines (CPG) supervises

and coordinates the preparation of new Guidelines and Expert

Consensus Documents produced by TF expert groups or consen-

sus panels. The Committee is also responsible for the endorse-

ment process of these Guidelines and Expert Consensus

Documents or statements. Once the document has been ﬁnalized

and approved by all the experts involved in the TF, it is submitted

to outside specialists for review. The document is revised, ﬁnally

approved by the CPG,and subsequently published.

After publication, dissemination of the message is of paramount

importance. Pocket-sized versions and personal digital assistant

(PDA)-downloadable versions are useful at the point of care.

Some surveys have shown that the intended end-users are some-

times not aware of the existence of the guidelines, or simply do

not translate them into practice; this is why implementation pro-

grammes for new guidelines form an important component of the

dissemination of knowledge. Meetings are organized by the ESC

and are directed towards its member national societies and key

opinion leaders in Europe. Implementation meetings can also be

undertaken at national levels, once the guidelines have been

endorsed by ESC member societies and translated into the national

language. Implementation programmes are needed because it has

been shown that the outcome of disease may be favourably inﬂu-

enced by thorough application of clinical recommendations.

Thus, the task of writing Guidelines or Expert Consensus Docu-

ments covers not only the integration of the most recent research,

but also the creation of educational tools and implementation pro-

grammes for the recommendations. The loop between clinical

research, the writing of guidelines, and implementing them into

clinical practice can then only be completed if surveys and regis-

tries are performed to verify that real-life daily practice is in

keeping with what is recommended in the guidelines. Such

surveys and registries also make it possible to evaluate the

impact of implementation of the guidelines on patient outcomes.

Guidelines and recommendations should help physicians to make

decisions in their clinical practice; however, the ultimate judgement

regarding the care of an individual patient must be made by the

physician in charge of that patient.

SVR

systemic vascular resistance

SVT

supraventricular tachycardia

TIA

transient ischaemic attack

Task Force

T-LOC

transient loss of consciousness

ventricular tachycardia

VVS

vasovagal syncope

Preamble

Guidelines and Expert Consensus Documents summarize and

evaluate all currently available evidence on a particular issue with

the aim of assisting physicians in selecting the best management

strategies for a typical patient, suffering from a given condition,

taking into account the impact on outcome, as well as the risk/

beneﬁt ratio of particular diagnostic or therapeutic means. Guide-

lines are no substitutes for textbooks. The legal implications of

medical guidelines have been previously discussed.

A great number of Guidelines and Expert Consensus Docu-

ments have been issued in recent years by the European Society

of Cardiology (ESC) as well as by other societies and organizations.

Because of the impact on clinical practice, quality criteria for the

development of guidelines have been established in order to

make all decisions transparent to the user. The recommendations

for formulating and issuing ESC Guidelines and Expert Consensus

2634

ESC Guidelines

Table 1 Classes of recommendations

Table 2 Levels of evidence

Introduction

great number of other specialists were involved, as either full

members, external contributors, or reviewers nominated by inter-

national societies of neurology, autonomic disease, internal medi-

cine, emergency medicine, geriatrics, and general medicine. In

total 76 specialists from different disciplines participated in this

project.

The most relevant changes are listed here:

The ﬁrst ESC Guidelines for the management of syncope, were

published in 2001, and reviewed in 2004. 1 In March 2008, the

CPG considered that there were enough new data to justify pro-

duction of new guidelines.

There are two main aspects of this document that differentiate it

from its predecessors.

The ﬁrst is to stress the concept that there are two distinct

reasons for evaluating patients with syncope: one is to identify

the precise cause in order to address an effective mechanism-

speciﬁc treatment; the other is to identify the speciﬁc risk to the

patient, which frequently depends on the underlying disease

rather than on the mechanism of syncope itself. The background

is provided for physicians to avoid confounding these two

concepts.

The second aspect is to produce a comprehensive document

which is addressed not only to cardiologists but to all physicians

who are interested in the ﬁeld. In order to achieve this aim a

† An update of the classiﬁcation of syncope in the larger frame-

work of transient loss of consciousness (T-LOC).

† New data on epidemiology.

† A new diagnostic approach focusing on risk stratiﬁcation of

sudden cardiac death (SCD) and cardiovascular events after

initial evaluation, including some recommendations for treat-

ment in patients with unexplained syncope at high risk.

† Emphasis on the increasing role of a diagnostic strategy based on

prolonged monitoring in contrast to the conventional strategy

based on laboratory testing.

† An update of evidence-based therapy.

ESC Guidelines

2635

The literature on syncope investigation and treatment is largely

composed of case series, cohort studies, or retrospective analyses

of already existing data. The impact of these approaches on guiding

therapy and reducing syncope recurrences is difﬁcult to discern

without randomization and blinding. Because of these issues, the

panel performed full reviews of the literature on diagnostic tests

but did not use predeﬁned criteria for selection of articles to be

reviewed. This TF recognizes that for some of the recommen-

dations related to diagnostic processes, controlled trials have

never been performed. Consequently, some of these recommen-

dations are based on brief observational studies, accepted clinical

practice, expert consensus and sometimes common sense. In

those cases, according to the current format of recommendations,

a level of evidence C is given.

Part 1. Deﬁnitions, classiﬁcation

and pathophysiology,

epidemiology, prognosis, impact

on quality of life, and economic

issues

1.1 Deﬁnitions

Syncope is a T-LOC due to transient global cerebral hypoperfusion

characterized by rapid onset, short duration, and spontaneous

complete recovery.

This deﬁnition of syncope differs from others by including the

cause of unconsciousness, i.e. transient global cerebral hypoperfu-

sion. Without that addition, the deﬁnition of syncope becomes

wide enough to include disorders such as epileptic seizures and

concussion. In fact, the deﬁnition then becomes that of T-LOC,a

term purposely meant to encompass all disorders characterized

by self-limited loss of consciousness (LOC), irrespective of mech-

anism (Figure 1). By distinguishing both T-LOC and syncope, the

present deﬁnition minimizes conceptual and diagnostic confusion.

In the past, papers often did not deﬁne syncope, or did so in differ-

ent ways. 2 Syncope was sometimes used for T-LOC, thus including

epileptic seizures and even stroke in ‘syncope’. This source of con-

fusion may still be found in the literature. 3,4

In some forms of syncope there may be a prodromal period in

which various symptoms (e.g. lightheadedness, nausea, sweating,

weakness, and visual disturbances) warn that syncope is imminent.

Often, however, LOC occurs without warning. An accurate esti-

mate of the duration of spontaneous episodes is rarely obtained.

Typical syncope is brief. Complete LOC in reﬂex syncope lasts

no longer than 20 s in duration. However, syncope may rarely

be longer, even as much as several minutes. 5 In such cases, the

differential diagnosis between syncope and other causes of LOC

can be difﬁcult. Recovery from syncope is usually accompanied

by almost immediate restoration of appropriate behaviour and

orientation. Retrograde amnesia, although believed to be uncom-

mon, may be more frequent than previously thought, particularly

in older individuals. Sometimes the post-recovery period may be

marked by fatigue. 5

Figure 1 Context of transient loss of consciousness (T-LOC).

SCD ¼ sudden cardiac death.

The adjective ‘pre-syncopal’ is used to indicate symptoms and

signs that occur before unconsciousness in syncope, so its

meaning is literal when used in this context and making it a

synonym of ‘warning’ and ‘prodromal’. The noun ‘pre-syncope’

or ‘near-syncope’ is used often to describe a state that resembles

the prodrome of syncope but which is not followed by LOC;

doubts remain as to whether the mechanisms involved are the

same as in syncope.

1.2 Classiﬁcation and

pathophysiology

1.2.1 Placing syncope in the larger

framework of transient loss of

consciousness (real or apparent)

The context of T-LOC is shown in Figure 1. Two decision trees

separating T-LOC from other conditions are whether conscious-

ness appears lost or not, and whether the four features deﬁning

the presentation of T-LOC (transient, with rapid onset, short dur-

ation, and spontaneous recovery) are present.

T-LOC is divided into traumatic and non-traumatic forms. Con-

cussion usually causes LOC; as the presence of a trauma is usually

clear, the risk of diagnostic confusion is limited.

Non-traumatic T-LOC is divided into syncope, epileptic sei-

zures, psychogenic pseudosyncope, and rare miscellaneous

causes. Psychogenic pseudosyncope is discussed elsewhere in

this document. Rare miscellaneous disorders include either those

that are rare (e.g. cataplexy) or those whose presentation

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