9/28/2017 2017 ACC/AHA/HRS Guideline for Patients With Syncope - American College of Cardiology

2017 ACC/AHA/HRS Guideline for Patients With Syncope

Mar 09, 2017   |  Thomas C. Crawford, MD, FACC

Authors: Shen WK, Sheldon RS, Benditt DG, et al.

Citation: 2017 ACC/AHA/HRS Guideline for the Evaluation

and Management of Patients With Syncope: A
Report of the American College of
Cardiology/American Heart Association Task Force
on Clinical Practice Guidelines, and the Heart
Rhythm Society. 2017;Mar 9:
[Epub ahead of print].

The following are key points to remember from the 2017 ACC/AHA/HRS Guideline
for the Evaluation and Management of Patients With Syncope:

1. A detailed history and physical examination should be performed in patients

with syncope (Class I).
2. In the initial evaluation of patients with syncope, a resting 12-lead
electrocardiogram (ECG) is useful (Class I). Evaluation of the cause and
assessment for the short- and long-term risk of syncope is recommended
(Class I).
3. Hospital evaluation and treatment is recommended for patients presenting
with syncope who have a serious medical condition potentially relevant to the
cause of syncope identi ed during initial evaluation (Class I).
4. Routine and comprehensive laboratory testing is not useful in the evaluation
of patients with syncope (Class III: No Bene t). Routine cardiac imaging is not
useful in the evaluation of patients with syncope unless cardiac etiology is
suspected based on an initial evaluation including history, physical
examination, or ECG (Class III: No Bene t). Carotid artery imaging is not
recommended in the routine evaluation of patients with syncope in the

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9/28/2017 2017 ACC/AHA/HRS Guideline for Patients With Syncope - American College of Cardiology

absence of focal neurologic ndings that support further evaluation (Class III:
No Bene t).
5. Vasovagal syncope is the most common cause of syncope. E ectiveness of
drug therapy is modest. Patient education on the diagnosis and prognosis is
recommended (Class I).
6. Dual-chamber pacing might be reasonable in a select population of patients
over 40 years of age with recurrent VVS and prolonged spontaneous pauses
(Class IIb). Beta-blockers are not bene cial in pediatric patients with VVS (Class
III: No Bene t).
7. Syncope suspected of orthostatic hypotension (OH) can be mediated by
neurogenic conditions, dehydration, or drugs. Fluid resuscitation by acute
water ingestion or intravenous infusion is recommended for occasional,
temporary relief in patients with neurogenic OH or dehydration (Class I).
Reducing or withdrawing medications that may cause hypotension can be
bene cial in selected patients with syncope (Class IIa).
8. In patients with syncope associated with bradycardia, tachycardia, or in the
presence of structural heart conditions, current guideline-directed
management and therapy (GDMT) is recommended (Class I).
9. Implantable cardioverter-de brillator (ICD) implantation is not recommended
in patients with Brugada ECG pattern and re ex-mediated syncope in the
absence of other risk factors (Class III: No Bene t).
10. Beta-blocker therapy, in the absence of contraindications, is indicated as a
rst-line therapy in patients with long QT syndrome (LQTS) and suspected
arrhythmic syncope (Class I). ICD implantation is reasonable in patients with
LQTS and suspected arrhythmic syncope on beta-blocker therapy or intolerant
to beta-blocker therapy (Class IIa).
11. Exercise restriction is recommended in patients with catecholaminergic
polymorphic ventricular tachycardia (CPVT) presenting with syncope suspected
of an arrhythmic etiology (Class I). Beta-blockers lacking intrinsic
sympathomimetic activity are recommended in patients with CPVT and stress-
induced syncope (Class I).
12. Electrophysiologic study is reasonable in selected patients with syncope
suspected of arrhythmic etiology (Class IIa).
13. Cardiovascular assessment by a care provider experienced in treating athletes
with syncope is recommended prior to resuming competitive sports (Class I).
Participation in competitive sports is not recommended for athletes with
syncope and phenotype-positive hypertrophic cardiomyopathy, CPVT, LQTS1,

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9/28/2017 2017 ACC/AHA/HRS Guideline for Patients With Syncope - American College of Cardiology

or arrhythmogenic right ventricular cardiomyopathy before evaluation by a

specialist (Class III: Harm).

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and
Pediatric Cardiology, Geriatric Cardiology, Heart Failure and Cardiomyopathies,
Noninvasive Imaging, Sports and Exercise Cardiology, Valvular Heart Disease,
Implantable Devices, Genetic Arrhythmic Conditions, SCD/Ventricular
Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart
Disease, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Imaging, CHD
& Pediatrics and Prevention, CHD & Pediatrics and Quality Improvement, Sports
& Exercise and Congenital Heart Disease & Pediatric Cardiology, Sports &
Exercise and ECG & Stress Testing, Sports & Exercise and Imaging

Keywords: Adrenergic beta-Antagonists, Arrhythmias, Cardiac, Athletes, Atrial Fibrillation,

Bradycardia, Brugada Syndrome, Cardiac Electrophysiology, Cardiomyopathy, Hypertrophic,
De brillators, Implantable, Electrophysiologic Techniques, Cardiac, Electrocardiography,
Electrophysiology, Hypotension, Hypotension, Orthostatic, Long QT Syndrome, Syncope,
Syncope, Vasovagal, Heart Defects, Congenital, Autonomic Nervous System Diseases,
Channelopathies, Diagnostic Imaging, Exercise Test, Genetic Diseases, Inborn, Geriatrics, Heart
Valve Diseases, Pediatrics, Pharmacology, Postural Orthostatic Tachycardia Syndrome,
Practice Guideline, Risk Assessment, Risk Factors, Tachycardia, Supraventricular, Tachycardia,
Ventricular, Tilt-Table Test

Suggested Materials
2017 Executive Summary
2017 Systematic Review
ACC Releases New Guidance For Syncope
2017 Slide Set
2017 CardioSmart Patient Resource
Arrhythmias and Clinical EP

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