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Cited by 155Cardiovascular Syncope and Autonomic DisordersHeart Rate Variability and Autonomic ControlCardiac electrophysiology and arrhythmias

2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary

Open access
Shen, Win-Kuang, Sheldon, Robert S., Benditt, David G., Cohen, Mitchell I., Forman, Daniel E., Goldberger, Zachary D., Grubb, Blair P., Hamdan, Mohamed H. +8 more·2017·Journal of the American College of Cardiology
DOI 10.1016/j.jacc.2017.03.002
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AI snapshot

Written from the paper’s full text.

TL;DR

This executive summary of the 2017 ACC/AHA/HRS guideline provides contemporary, accessible guidance on the evaluation and management of adult and pediatric patients with suspected syncope, developed from an evidence review and an independent systematic review on pacing for reflex-mediated syncope. It defines syncope as a symptom with different causes across populations and settings, and identifies key knowledge gaps to guide future research.

Key findings

  • Studies report syncope prevalence rates as high as 41%, with recurrent syncope in 13.5%; in 1,925 randomly selected Olmsted County residents (median age 62 years, all >45 years), 364 reported a lifetime episode, giving an estimated prevalence of 19%, with higher prevalence in females (22% versus 15%, p<0.001).
  • Incidence follows a trimodal distribution in both sexes, with first episodes common around 20, 60, or 80 years of age; reflex syncope was most common (21%), followed by cardiac syncope (9%) and orthostatic hypotension (9%), with cause unknown in 37%.
  • The National Hospital Ambulatory Medical Care Survey reported 6.7 million syncope episodes in the emergency department (0.77% of all ED patients); among patients >80 years, 58% were admitted to hospital.
  • Quality of life with recurrent syncope was equivalent to severe rheumatoid arthritis and chronic low-back pain in adults; pediatric patients with recurrent syncope reported worse QoL than individuals with diabetes mellitus and equivalent QoL to those with asthma, end-stage renal disease, and structural heart disease.

Methods

  • Evidence review conducted July to October 2015 using MEDLINE (PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases, with additional relevant studies published through October 2016 considered; finalized evidence tables are in the Online Data Supplement.
  • An independent evidence review committee performed a systematic review of clinical questions, published as "Pacing as a Treatment for Reflex-Mediated (Vasovagal, Situational, or Carotid Sinus Hypersensitivity) Syncope"; recommendations based on it are marked "SR."
  • Writing committee composed of cardiologists, electrophysiologists, an emergency physician, and a pediatric cardiologist, with representatives from ACC, AHA, HRS, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine; recommendations use Class of Recommendation and Level of Evidence grading.

Limitations

  • The guideline states that referral recommendations to specialists (e.g., autonomic neurology, adult congenital heart disease, older populations, athletes) were made as Class IIa "because of the paucity of outcome data."
  • Evidence for treatment of most types of situational syncope is "limited mainly to case reports, small case series, and small observational studies"; for POTS, "there is little evidence that the syncope is due to POTS."
  • Driving suggestions are "based on expert opinion and supported by limited data"; the document also lists extensive evidence gaps (Section 12) including needs for prospectively validated risk scores, RCTs, and standardized registries.
  • Evident from the text: this is an executive summary that "contains limited information," with readers directed to the full-text guideline for additional detail; the recommendation tables themselves are not reproduced in the provided text.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.jacc.2017.03.002

Cites

Statistics

Nothing to recompute.

Claims the paper makes

0 of 22 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    Quality of life associated with recurrent syncope was equivalent to severe rheumatoid arthritis and chronic low-back pain in an adult population.

    “QoL associated with recurrent syncope was equivalent to severe rheumatoid arthritis and chronic low-back pain in an adult population (400).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [400] Linzer, 1991, Impairment of physical and psychosocial function in recurrent syncope, J Clin Epidemiol source

      Not checked in the free run.

  • Findingcitation

    Quality of life is reduced with recurrent syncope, as demonstrated in studies that compared patients with and without syncope.

    “QoL is reduced with recurrent syncope (397–405), as demonstrated in studies that compared patients with and without syncope (399,405).”
    Quote in the paperNot a substantial claim0 of 9 sources checked
    • cites [397] Anderson, 2012, The effect of paediatric syncope on health-related quality of life, Cardiol Young source

      Not checked in the free run.

    • cites [398] Barón-Esquivias, 2005, Short-term evolution of vasovagal syncope: influence on the quality of life, Int J Cardiol source

      Not checked in the free run.

    • cites [399] Giada, 2005, Psychiatric profile, quality of life and risk of syncopal recurrence in patients with tilt-induced vasovagal syncope, Europace source

      Not checked in the free run.

    • cites [400] Linzer, 1991, Impairment of physical and psychosocial function in recurrent syncope, J Clin Epidemiol source

      Not checked in the free run.

    • cites [401] Romme, 2010, Prospective evaluation of non-pharmacological treatment in vasovagal syncope, Europace source

      Not checked in the free run.

    • cites [402] Rose, 2009, The development and preliminary validation of a scale measuring the impact of syncope on quality of life, Europace source

      Not checked in the free run.

    • cites [403] Santhouse, 2007, A comparison of self-reported quality of life between patients with epilepsy and neurocardiogenic syncope, Epilepsia source

      Not checked in the free run.

    • cites [404] van Dijk, 2006, Clinical factors associated with quality of life in patients with transient loss of consciousness, J Cardiovasc Electrophysiol source

      Not checked in the free run.

    • cites [405] van, 2007, Quality of life within one year following presentation after transient loss of consciousness, Am J Cardiol source

      Not checked in the free run.

  • Interpretationreasoning

    Treatment of most types of situational syncope relies heavily on avoidance or elimination of a triggering event.

    “Treatment of most types of situational syncope relies heavily on avoidance or elimination of a triggering event.”
    Quote in the paperSubstantial claim
  • Premisecitation

    Evidence for treatment of situational syncope is limited mainly to case reports, small case series, and small observational studies.

    “Evidence for treatment is limited mainly to case reports, small case series, and small observational studies (280,282–285).”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [280] Allan, 2004, Abnormalities of sympathetic and parasympathetic autonomic function in subjects with defaecation syncope, Europace source

      Not checked in the free run.

    • cites [282] Bonekat, 1987, Smoking and cough syncope: follow-up in 45 cases, Int J Addict source

      Not checked in the free run.

    • cites [283] Dicpinigaitis, 2014, Cough syncope, Respir Med source

      Not checked in the free run.

    • cites [284] Garg, 2014, Swallow syncope: clinical presentation, diagnostic criteria, and therapeutic options, Saudi J Gastroenterol source

      Not checked in the free run.

    • cites [285] Kapoor, 1985, Micturition syncope. A reappraisal, JAMA source

      Not checked in the free run.

  • May combine two claims. 8
  • Classified as probably not a substantial claim. 20

  • May combine two claims.

    Findingcitation

    Pediatric patients with recurrent syncope reported worse quality of life than individuals with diabetes mellitus and equivalent quality of life to individuals with asthma, end-stage renal disease, and structural heart disease.

    “Similarly, pediatric patients with recurrent syncope reported worse QoL than individuals with diabetes mellitus and equivalent QoL to individuals with asthma, end-stage renal disease, and structural heart disease (397).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [397] Anderson, 2012, The effect of paediatric syncope on health-related quality of life, Cardiol Young source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation
    § Appendix 3

    When developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data.

    “When developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data (4–7).”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [4] ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. American College of Cardiology and American Heart Association, 2010. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf. Accessed January 23, 2015.

      Not checked in the free run.

    • cites [5] Halperin, 2016, Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines, J Am Coll Cardiol source

      Not checked in the free run.

    • cites [6] Jacobs, 2013, ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, J Am Coll Cardiol source

      Not checked in the free run.

    • cites [7] Jacobs, 2014, The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, J Am Coll Cardiol source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given
    § Appendix 3

    The ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence.

    “The ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given
    § Appendix 3

    The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds.

    “The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given
    § Appendix 3

    Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice.

    “Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given
    § Appendix 3

    The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts.

    “The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Although potential causes of syncope are multiple, a treatment decision is usually fairly straightforward for patients with cardiac causes of syncope or orthostatic causes.

    “Although potential causes of syncope are multiple, a treatment decision is usually fairly straightforward for patients with cardiac causes of syncope or orthostatic causes.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    In developing this guideline, the writing committee reviewed the evidence to support recommendations in the relevant ACC/AHA guidelines noted in Table 2 and affirms the ongoing validity of the related recommendations in the context of syncope, thus obviating the need to repeat existing guideline recommendations in the present guideline when applicable or when appropriate.

    “In developing this guideline, the writing committee reviewed the evidence to support recommendations in the relevant ACC/AHA guidelines noted in Table 2 (in the full-text guideline) and affirms the ongoing validity of the related recommendations in the context of syncope, thus obviating the need to repeat existing guideline recommendations in the present guideline when applicable or when appropri”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    This document was reviewed by 2 official reviewers each nominated by the ACC, AHA, and HRS; 1 reviewer each from the American Academy of Neurology, American College of Emergency Physicians and Society for Academic Emergency Medicine, and Pediatric and Congenital Electrophysiology Society; a lay/patient representative; and 25 individual content reviewers.

    “This document was reviewed by 2 official reviewers each nominated by the ACC, AHA, and HRS; 1 reviewer each from the American Academy of Neurology, American College of Emergency Physicians and Society for Academic Emergency Medicine, and Pediatric and Congenital Electrophysiology Society; a lay/patient representative; and 25 individual content reviewers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § 7 Orthostatic Intolerance

    Although syncope occurs in patients with POTS, it is relatively infrequent, and there is little evidence that the syncope is due to POTS.

    “Although syncope occurs in patients with POTS, it is relatively infrequent, and there is little evidence that the syncope is due to POTS (9,10).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [9] Shen, 2017, 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology Foundation, /American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society, J Am Coll Cardiol source

      Not checked in the free run.

    • cites [10] Varosy, 2017, J Am Coll Cardiol source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Most suggestions for private drivers are based on expert opinion and supported by limited data.

    “Most suggestions are based on expert opinion and supported by limited data.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    An independent ERC was commissioned to perform a systematic review of clinical questions, the results of which were considered by the writing committee for incorporation into this guideline.

    “An independent ERC was commissioned to perform a systematic review of clinical questions, the results of which were considered by the writing committee for incorporation into this guideline.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisereasoning

    The nature of syncope as a symptom required the writing committee to consider numerous conditions for which it can be a symptom, and the guideline addresses syncope only as a presenting symptom as much as possible.

    “The nature of syncope as a symptom required that the writing committee consider numerous conditions for which it can be a symptom, and as much as possible, we have addressed the involvement of syncope only as a presenting symptom.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Additional relevant studies published through October 2016, during the guideline writing process, were also considered by the writing committee, and added to the evidence tables when appropriate.

    “Additional relevant studies published through October 2016, during the guideline writing process, were also considered by the writing committee, and added to the evidence tables when appropriate.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    This document was approved for publication by the governing bodies of the ACC, AHA, and HRS and endorsed by the American College of Emergency Physicians, Society for Academic Emergency Medicine, and the Pediatric and Congenital Electrophysiology Society.

    “This document was approved for publication by the governing bodies of the ACC, AHA, and HRS and endorsed by the American College of Emergency Physicians, Society for Academic Emergency Medicine, and the Pediatric and Congenital Electrophysiology Society.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Appendix 3

    An independent evidence review committee (ERC) is commissioned when there are 1 or more questions deemed of utmost clinical importance that merit formal systematic review.

    “An independent evidence review committee (ERC) is commissioned when there are 1 or more questions deemed of utmost clinical importance that merit formal systematic review.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Treatment remains challenging in patients who have recurrences despite conservative therapy.

    “Treatment remains challenging in patients who have recurrences despite conservative therapy.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The writing committee included representatives from the ACC, AHA, Heart Rhythm Society (HRS), American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine.

    “The writing committee included representatives from the ACC, AHA, Heart Rhythm Society (HRS), American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Appendix 3

    Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion.

    “Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The writing committee was composed of clinicians with expertise in caring for patients with syncope, including cardiologists, electrophysiologists, an emergency physician, and a pediatric cardiologist.

    “The writing committee was composed of clinicians with expertise in caring for patients with syncope, including cardiologists, electrophysiologists, an emergency physician, and a pediatric cardiologist.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Reported incidence and prevalence of syncope vary significantly because of several confounders: variable definitions for syncope versus transient loss of consciousness, different populations, different clinical settings, and different study methodologies.

    “Reported incidence and prevalence of syncope vary significantly because of several confounders: variable definitions for syncope versus transient loss of consciousness, different populations, different clinical settings, and different study methodologies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    An initial extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted from July to October 2015.

    “An initial extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted from July to October 2015.”
    Quote in the paperNot a substantial claim
22 of 22

  • The paper relies on this without support.

    There is a plausible association of syncope and sudden cardiac death (SCD) in selected populations.

    “Because of the plausible association of syncope and sudden cardiac death (SCD) in selected populations, this document discusses risk stratification and prevention of SCD when appropriate.”

  • The paper relies on this without support.

    Vasovagal syncope (VVS) is the most common cause of syncope in the general population.

    “VVS is the most common cause of syncope in the general population.”

  • The paper relies on this without support.

    High healthcare costs are associated with the evaluation and management of syncope.

    “High healthcare costs are associated with the evaluation and management of syncope.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Syncope is not a predominant feature of POTS; only about 20-30% of patients pass out, usually due to vasovagal syncope.

    “Syncope is not a predominant feature of POTS (only ~20-30% actually pass out, and this is usually thought to be due to vasovagal syncope)”

    From Postural tachycardia syndrome – Diagnosis, physiology, and prognosis (2018) · cites this paper as Shen et al., 2017

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • HRS consensus statement is cited as the full-text guideline

    Minor

    The text directs readers to the Heart Rhythm Society consensus statement as reference 9, but reference 9 is the full-text syncope guideline. The Heart Rhythm Society consensus statement is listed as reference 12.

1 of 1

The citation lists haven’t been fetched yet

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Research works printed but not linked: 52

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Authors
Shen, W.-K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P., Hamdan, M. H., Krahn, A. D., Link, M. S., Olshansky, B., Raj, S. R., Sandhu, R. K., Sorajja, D., Sun, B. C., & Yancy, C. W.
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
2017-08
Volume
70
Issue
5
Pages
620-663
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/j.jacc.2017.03.002
OpenAlex
W3015148905
Cited by
155
References
422
Citations by year
2026: 6 · 2025: 10 · 2024: 9 · 2023: 12 · 2022: 15 · 2021: 22 · 2020: 27 · 2019: 22 · 2018: 19 · 2017: 12 · 2014: 1
FWCI
22.42
Type
journal article
Language
en
Update notices
erratum (2017-10-17)
Open access
Licence
Locations
Journal of the American College of Cardiology (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
Keywords
syncope, syncope evaluation, syncope management, cardiovascular risk stratification, syncope etiology

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