Stepwise Evaluation of Unexplained Syncope in a Large Ambulatory Population
Open accessAbstract
Background: Up to 60% of syncopal episodes remain unexplained. We report the results of a standardized, stepwise evaluation of patients referred to an ambulatory clinic for unexplained syncope. Methods and Results: We studied 939 consecutive patients referred for unexplained syncope, who underwent a standardized evaluation, including history, physical examination, electrocardiogram, head‐up tilt testing (HUTT), carotid sinus massage (CSM) and hyperventilation testing (HYV). Echocardiogram and stress test were performed when underlying heart disease was initially suspected. Electrophysiological study (EPS) and implantable loop recorder (ILR) were used only in patients with underlying structural heart disease or major unexplained syncope. We identified a cause of syncope in 66% of patients, including 27% vasovagal, 14% psychogenic, 6% arrhythmias, and 6% hypotension. Noninvasive testing identified 92% and invasive testing an additional 8% of the causes. HUTT yielded 38%, CSM 28%, HYV 49%, EPS 22%, and ILR 56% of diagnoses. On average, patients with arrhythmic causes were older, had a lower functional capacity, longer P‐wave duration, and presented with fewer prodromes than patients with vasovagal or psychogenic syncope. Conclusions: A standardized stepwise evaluation emphasizing noninvasive tests yielded 2/3 of causes in patients referred to an ambulatory clinic for unexplained syncope. Neurally mediated and psychogenic mechanisms were behind >50% of episodes, while cardiac arrhythmias were uncommon. Sudden syncope, particularly in older patients with functional limitations or a prolonged P‐wave, suggests an arrhythmic cause.
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Patients with psychogenic pseudosyncope are often young females.
“Patients with psychogenic pseudosyncope are often young females with a higher prevalence of preexisting VVS or a history of physical and/or sexual abuse (229,525).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [525]
Episodes of psychogenic pseudosyncope are frequent.
“The apparent duration of loss of consciousness is often long (5 to 20 minutes), and episodes are frequent (525).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [525]
The Distribution of Causes of Syncope reports a 14% prevalence of psychogenic pseudosyncope, but prevalence is not the frequency of episodes in affected patients. Clinical Characteristics and Causes of Syncope gives a mean number of episodes for the entire study population, not for patients with psychogenic pseudosyncope. Searches for recurrent or frequent psychogenic episodes found no subtype-specific evidence. (LLM, conf=0.76)
Experimental — accuracy not yet measuredPatients with psychogenic pseudosyncope have a higher prevalence of preexisting VVS or a history of physical and/or sexual abuse.
“Patients with psychogenic pseudosyncope are often young females with a higher prevalence of preexisting VVS or a history of physical and/or sexual abuse (229,525).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [525]
The Distribution of Causes of Syncope section describes patients with psychogenic pseudosyncope as rather young and female, but does not discuss preexisting vasovagal syncope or a history of physical or sexual abuse. The Clinical Characteristics and Causes of Syncope section lists vasovagal syncope and psychogenic pseudosyncope as separate diagnoses; searches for prior vasovagal syncope and abuse found no passage supporting the attributed claim. Page numbers were not available in our copy. (LLM, conf=0.72)
Experimental — accuracy not yet measuredThe apparent duration of loss of consciousness in psychogenic pseudosyncope is often 5 to 20 minutes.
“The apparent duration of loss of consciousness is often long (5 to 20 minutes), and episodes are frequent (525).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [525]
The Patient Population and Methods section discusses the duration of prodromes and recovery symptoms, not the duration of apparent loss of consciousness. The Distribution of Causes of Syncope section reports psychogenic pseudosyncope diagnoses but gives no episode duration. Searches for the 5–20-minute range and for prolonged episodes found no supporting passage in our copy. (LLM, conf=0.75)
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Cites
Cost implications of testing strategy in patients with syncope
Krahn, A. D., Klein, G. J., Yee, R., Hoch, J. S., & Skanes, A. C. (2003) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(03)00659-4 · Cited by 170 · see citing works
Management of syncope referred urgently to general hospitals with and without syncope units
Brignole, M. (2003) · Europace · doi:10.1016/s1099-5129(03)00047-3 · Cited by 118 · see citing works
Does the use of a syncope diagnostic protocol improve the investigation and management of syncope?
Farwell, D. J., & Sulke, A. N. (2004) · Heart · doi:10.1136/heart.90.1.52 · Cited by 109 · see citing works
Flagged first, then by citations
Research works printed but not linked: 8
- Sarasin FP, Louis-Simonet M, Carballo D, Slama S, Rajeswaran A, Metzger JT, Lovis C, et al. Prospective evaluation of patients with syncope: A population-based study. Am J Med 2001; 111:177- 184.
- Graf D, Schlaepfer J, Gollut E, van Melle G, Mischler C, Fromer M, Kappenberger L, et al. Predictive models of syncope causes in an outpatient clinic. Int J Cardiol 2008; 123:249-256.
- Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ, Bloch Thomsen PE, van Dijk JG, et al., on behalf of the Task Force on Syncope, European Society of Cardiology). Guidelines on manage- ment (diagnosis and treatment) of syncope: Update 2004. Europace 2004; 6:467-537.
- Brignole M, Menozzi C, Bartoletti A, Giada F, Lagi A, Ungar A, Ponassi I, et al. A new management of syncope: Prospective sys- tematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J 2006; 27:76-82.
- Alboni P, Brignole M, Menozzi C, Raviele A, Del Rosso A, Dinelli M, Bettiol K, et al. Clinical spectrum of neurally mediated reflex syncopes. Europace 2004; 6:55-62.
- Sheldon R, Rose S, Connolly S, Ritchie D, Koshman ML, Frenneaux M. Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur Heart J 2006; 27:344-350.
- Linzer M, Felder A, Hackel A, Perry AJ, Varia I, Melville ML, Krishnan KR. Psychiatric syncope: A new look at an old disease. Psychosomatics 1990; 31:181-188.
- Benbadis SR, Chichkova R. Psychogenic pseudosyncope: An un- derestimated and provable diagnosis. Epilepsy Behav 2006; 9:106- 110.
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2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
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., et al. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.03.004 · Cited by 484 · see citing works
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
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., et al. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.03.003 · Cited by 327 · see citing works
Locati, E. T., Moya, A., Oliveira, M., Tanner, H., Willems, R., Lunati, M., & Brignole, M. (2016) · Europace · doi:10.1093/europace/euv311 · Cited by 95 · see citing works
Psychogenic pseudosyncope: diagnosis and management
Raj, V., Rowe, A. A., Fleisch, S. B., Paranjape, S. Y., Arain, A. M., & Nicolson, S. E. (2014) · Autonomic Neuroscience · doi:10.1016/j.autneu.2014.05.003 · Cited by 69 · see citing works
- Authors
- IGLESIAS, J. F., GRAF, D., FORCLAZ, A., SCHLAEPFER, J., FROMER, M., & PRUVOT, E.
- Affiliations
- Centre Hospitalier Universitaire Vaudois (CH)
- Corresponding author
- PRUVOT, ETIENNE
- Venue
- Pacing and Clinical Electrophysiology
- Publisher
- Wiley
- Published
- 2009-02-23
- Volume
- 32
- Issue
- s1
- Pages
- S202-6
- ISSN
- 0147-8389 (ISSN-L)
- 1540-8159
- OpenAlex
- W2138804049
- Cited by
- 37
- References
- 3
- Citations by year
- 2025: 1 · 2024: 1 · 2023: 1 · 2022: 1 · 2021: 1 · 2020: 2 · 2019: 3 · 2018: 3 · 2017: 6 · 2016: 5 · 2015: 2 · 2014: 3 · 2013: 4 · 2012: 4
- FWCI
- 1.34
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Pacing and Clinical Electrophysiology (publishedVersion)
- PubMed (publishedVersion)
- SERVAL (Université de Lausanne) (publishedVersion, other-oa)
- IRIS (submittedVersion)
- SERVAL (Université de Lausanne) (submittedVersion, other-oa)
- 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
- unexplained syncope, vasovagal syncope, psychogenic syncope, cardiac arrhythmias, head-up tilt, carotid sinus massage, implantable loop recorder, non-invasive diagnosis, P-wave duration
- MeSH terms
- Female, Humans, Male, Middle Aged, Sensitivity and Specificity, Switzerland, Syncope, Reproducibility of Results, Causality, Incidence, Monitoring, Ambulatory
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