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Key differences between USA and European syncope guidelines
Published on January 31, 2021 37 min
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I'm Brian Olshansky, Professor Emeritus at the University of Iowa in Iowa City. I'm an adjunct professor at Des Moines University, and an electrophysiologist in practice in Waterloo, Iowa, and Mason City, Iowa. Today, we're going to discuss guidelines to manage syncope. We're going to discuss the United States and European guidelines, how they are similar and how they differ.
In 2017, the American College of Cardiology, American Heart Association, and Heart Rhythm Society teamed up to create a guideline to manage and evaluate patients with syncope. This was also developed with collaboration from the American College of Emergency Physicians and the Society for Academic Emergency Medicine. It was also endorsed by the Pediatric and Congenital Electrophysiology Society. I was one of the writing members in this group to create this guideline.
In 2018, the European Society of Cardiology created a guideline for the diagnosis and management of syncope. This was developed with special contribution from European Heart Rhythm Association, and was endorsed by a variety of organizations, including the European Academy of Neurology, European Federation of Autonomic Sciences, the European Federation of Internal Medicine and other groups. The individuals that were involved with creating this guideline were generally different, but importantly, looking at the same information in terms of evaluation and management of syncope.
Syncope is a big problem and a difficult one at that. Part of the problem is that the symptom can be hard to understand, and can be due to a variety of different causes. Therefore the management is complex, confusing, and often challenging. This is a common medical problem that almost all physicians have to address at some point in their career, since the problem itself is so common and some would even say 30-40 percent of individuals at some point in their life will pass out. The goals of the management are to try to find the cause. But it's more than just that because knowing the cause will not necessarily prevent recurrent episodes, and will not necessarily prevent the risks associated with syncope. Because syncope, in some cases, is associated with sudden death or even total mortality. Part of the problem in this regard is to make sure that the evaluation is properly targeted, so that it is not inappropriate and extraordinarily expensive. What often happens throughout the world is that patients who have had syncope get admitted to the hospital, and have a very involved and expensive evaluation which often leads nowhere. So it's important to properly evaluate the individual, and this is what the guidelines address. It's important to prevent recurrence and ultimately debilitation related to recurrent episodes of syncope, but at the same time minimize hospitalization unless it's absolutely necessary, and ultimately reduce the risk of dying. In many ways, the American College of Cardiology/American Heart Association and European Society of Cardiology guidelines concur. However, there are differences and this is interesting because both groups looked at the same data, but didn't necessarily come to the same conclusion. The question then arises: how can we make sense of these recommendations despite varying interpretation? What is the appropriate way to evaluate the patient and manage the patient who has syncope?