2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope
2017; Elsevier BV; Volume: 14; Issue: 8 Linguagem: Inglês
10.1016/j.hrthm.2017.03.004
ISSN1556-3871
AutoresWin-Kuang Shen, Robert S. Sheldon, David G. Benditt, Mitchell I. Cohen, Daniel E. Forman, Zachary D. Goldberger, Blair P. Grubb, Mohamed H. Hamdan, Andrew D. Krahn, Mark S. Link, Brian Olshansky, Satish R. Raj, Roopinder K. Sandhu, Dan Sorajja, Benjamin Sun, Clyde W. Yancy,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoGlenn N. Levine, MD, FACC, FAHA, Chair Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair #Former Task Force member; current member during the writing effort. Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, MS, PharmD, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC #Former Task Force member; current member during the writing effort. Joaquin E. Cigarroa, MD, FACC Lesley H. Curtis, PhD, FAHA Lee A. Fleisher, MD, FACC, FAHA Federico Gentile, MD, FACC Samuel Gidding, MD, FAHA Mark A. Hlatky, MD, FACC John Ikonomidis, MD, PhD, FAHA José Joglar, MD, FACC, FAHA Susan J. Pressler, PhD, RN, FAHA Duminda N. Wijeysundera, MD, PhD Preamble ....................................................................e1561.Introduction ...............................................................e1591.1.Methodology and Evidence Review .................e1591.2.Organization of the Writing Committee .............e1591.3.Document Review and Approval ........................e1591.4.Scope of the Guideline ........................................e1592.General Principles ......................................................e1602.1.Definitions: Terms and Classification ................e1602.2.Epidemiology and Demographics ......................e1602.3.Initial Evaluation of Patients With Syncope..........e1622.3.1.History and Physical Examination: Recommendation ........................................e1622.3.2.Electrocardiography: Recommendation..............e1632.3.3.Risk Assessment: Recommendations ..........e1632.3.4.Disposition After Initial Evaluation: Recommendations .....................................e1653.Additional Evaluation and Diagnosis ......................e1673.1.Blood Testing: Recommendations ..................e1673.2.Cardiovascular Testing: Recommendations .....e1683.2.1.Cardiac Imaging: Recommendations .........e1683.2.2.Stress Testing: Recommendation .............e1693.2.3.Cardiac Monitoring: Recommendations......e1693.2.4.In-Hospital Telemetry: Recommendation ......e1713.2.5.Electrophysiological Study: Recommendations .......................................e1713.2.6.Tilt-Table Testing: Recommendations.......e1723.3.Neurological Testing: Recommendations ........e1733.3.1.Autonomic Evaluation: Recommendation.........e1733.3.2.Neurological and Imaging Diagnostics: Recommendations .....................................e1744.Management of Cardiovascular Conditions ............e1754.1.Arrhythmic Conditions: Recommendations .....e1754.1.1.Bradycardia: Recommendation .................e1754.1.2.Supraventricular Tachycardia: Recommendations ...................................e1754.1.3.Ventricular Arrhythmia: Recommendation...e1764.2.Structural Conditions: Recommendations .......e1764.2.1.Ischemic and Nonischemic Cardiomyopathy: Recommendation ..........e1764.2.2.Valvular Heart Disease: Recommendation........e1764.2.3.Hypertrophic Cardiomyopathy: Recommendation .....................................e1774.2.4.Arrhythmogenic Right Ventricular Cardiomyopathy: Recommendations .........e1774.2.5.Cardiac Sarcoidosis: Recommendations.....e1774.3.Inheritable Arrhythmic Conditions: Recommendations ........................................e1784.3.1.Brugada Syndrome: Recommendations......e1784.3.2.Short-QT Syndrome: Recommendation.......e1794.3.3.Long-QT Syndrome: Recommendations...........e1794.3.4.Catecholaminergic Polymorphic Ventricular Tachycardia: Recommendations...............e1804.3.5.Early Repolarization Pattern: Recommendations............................................e1805.Reflex Conditions: Recommendations ...................e1815.1.Vasovagal Syncope: Recommendations ...........e1815.2.Pacemakers in Vasovagal Syncope: Recommendation .........................................e1825.3.Carotid Sinus Syndrome: Recommendations .......e1835.4.Other Reflex Conditions ..............................e1836.Orthostatic Hypotension: Recommendations .......e1836.1.Neurogenic Orthostatic Hypotension: Recommendations .......................................e1836.2.Dehydration and Drugs: Recommendations.......e1857.Orthostatic Intolerance .........................................e1868.Pseudosyncope: Recommendations .....................e1869.Uncommon Conditions Associated With Syncope ....e18710.Age, Lifestyle, and Special Populations: Recommendations ...............................................e18810.1.Pediatric Syncope: Recommendations ........e18810.2.Adult Congenital Heart Disease: Recommendations .....................................e19010.3.Geriatric Patients: Recommendations ........e19110.4.Driving and Syncope: Recommendation ......e19210.5.Athletes: Recommendations ......................e19311.Quality of Life and Healthcare Cost of Syncope .....e19411.1.Impact of Syncope on Quality of Life .........e19411.2.Healthcare Costs Associated With Syncope .....e19412.Emerging Technology, Evidence Gaps, and Future Directions ...............................................................e19412.1.Definition, Classification, and Epidemiology...e19412.2.Risk Stratification and Clinical Outcomes ....e19412.3.Evaluation and Diagnosis ............................e19512.4.Management of Specific Conditions ............e19512.5.Special Populations ....................................e195References ..............................................................e196Appendix 1.Author Relationships With Industry and Other Entities (Relevant) ......................................e210Appendix 2.Reviewer Relationships With Industry and Other Entities (Comprehensive) ............................e212Appendix 3.Abbreviations ......................................................e217 Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines (guidelines) with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. 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. Guidelines are official policy of the ACC and AHA. Practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations may have a global impact. Although guidelines may be used to inform regulatory or payer decisions, their intent is to improve patients’ quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment. Guideline-recommended management is effective only when followed by healthcare providers and patients. Adherence to recommendations can be enhanced by shared decision making between healthcare providers and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities. The ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations including the Institute of Medicine1Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine (U.S.) Clinical Practice Guidelines We Can Trust. National Academies Press, Washington, DC2011Google Scholar, 2Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of Medicine (U.S.) Finding What Works in Health Care: Standards for Systematic Reviews. National Academies Press, Washington, DC2011Google Scholar and on the basis of internal re-evaluation. Similarly, the presentation and delivery of guidelines are re-evaluated and modified on the basis of evolving technologies and other factors to facilitate optimal dissemination of information at the point of care to healthcare professionals. Given time constraints of busy healthcare providers and the need to limit text, the current guideline format delineates that each recommendation be supported by limited text (ideally, 75 years is used to define older populations or older adults in this document, unless otherwise specified. If a study has defined older adults by a different age cutoff, the relevant age is noted in those specific cases. Finally, the guideline addresses the management of syncope with the patient as a focus, rather than larger aspects of health services, such as syncope management units. The goals of the present guideline are:•To define syncope as a symptom, with different causes, in different populations and circumstances.•To provide guidance and recommendations on the evaluation and management of patients with suspected syncope in the context of different clinical settings, specific causes, or selected circumstances.•To identify key areas in which knowledge is lacking, to foster future collaborative research opportunities and efforts. 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. Table 2 also contains a list of other statements that may be of interest to the reader.Table 2Relevant ACC/AHA GuidelinesTitleOrganizationPublication Year (Reference)ACC/AHA guideline policy relevant to the management of syncopeSupraventricular tachycardiaACC/AHA/HRS201510Page R.L. Joglar J.A. Caldwell M.A. et al.2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2016; 67: e27-e115Crossref PubMed Google ScholarValvular heart diseaseAHA/ACC201411Nishimura R.A. Otto C.M. Bonow R.O. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2438-2488Crossref PubMed Scopus (742) Google ScholarDevice-based therapies for cardiac rhythm abnormalitiesACCF/AHA/HRS201212Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al.2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2013; 61: e6-e75PubMed Google ScholarVentricular arrhythmias and sudden cardiac deathACC/AHA/ESC200613Zipes D.P. Camm A.J. Borggrefe M. et al.ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death).J Am Coll Cardiol. 2006; 48: e247-e346Crossref PubMed Scopus (772) Google Scholar,∗Revisions to the current documents are being prepared, with publication expected in 2017.Other ACC/AHA guidelines of interestHypertension∗Revisions to the current documents are being prepared, with publication expected in 2017.ACC/AHA---Stable ischemic heart diseaseACC/AHA/ACP/AATS/PCNA/SCAI/STS2012 and 201414Fihn S.D. Blankenship J.C. Alexander K.P. et al.2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2014; 64: 1929-1949Crossref PubMed Scopus (165) Google Scholar, 15Fihn S.D. Gardin J.M. 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Alpert J.S. et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2014; 64: e1-e76Crossref PubMed Scopus (1372) Google ScholarNon–ST-elevation acute coronary syndromesAHA/ACC201417Amsterdam E.A. Wenger N.K. Brindis R.G. et al.2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 64: e139-e228Crossref PubMed Scopus (707) Google ScholarAssessment of cardiovascular riskACC/AHA201318Goff Jr., D.C. Lloyd-Jones D.M. Bennett G. et al.2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2935-2959Crossref PubMed Scopus (732) Google ScholarHeart failureACC/AHA201319Yancy C.W. Jessup M. Bozkurt B. et al.2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 62: e147-e239Crossref PubMed Scopus (2105) Google Scholar,∗Revisions to the current documents are being prepared, with publication expected in 2017.Hypertrophic cardiomyopathyACC/AHA201120Gersh B.J. Maron B.J. Bonow R.O. et al.2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2011; 58: e212-e260Crossref PubMed Scopus (392) Google ScholarAssessment of cardiovascular risk in asymptomatic adultsACC/AHA201021Greenland P. Alpert J.S. Beller G.A. et al.2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2010; 56: e50-e103Crossref PubMed Scopus (779) Google ScholarAdult congenital heart diseaseACC/AHA200822Warnes C.A. Williams R.G. Bashore T.M. et al.ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in collaboration with the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular A
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