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; Lippincott Williams & Wilkins; Volume: 136; Issue: 5 Linguagem: Inglês
10.1161/cir.0000000000000499
ISSN1524-4539
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
ResumoHomeCirculationVol. 136, No. 52017 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 Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUB2017 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 Win-Kuang Shen, MD, FACC, FAHA, FHRS, Chair, Robert S. Sheldon, MD, PhD, FHRS, Vice Chair, David G. Benditt, MD, FACC, FHRS, Mitchell I. Cohen, MD, FACC, FHRS, Daniel E. Forman, MD, FACC, FAHA, Zachary D. Goldberger, MD, MS, FACC, FAHA, FHRS, Blair P. Grubb, MD, FACC, Mohamed H. Hamdan, MD, MBA, FACC, FHRS, Andrew D. Krahn, MD, FHRS, Mark S. Link, MD, FACC, Brian Olshansky, MD, FACC, FAHA, FHRS, Satish R. Raj, MD, MSc, FACC, FHRS, Roopinder Kaur Sandhu, MD, MPH, Dan Sorajja, MD, Benjamin C. Sun, MD, MPP, FACEP and Clyde W. Yancy, MD, MSc, FACC, FAHA Win-Kuang ShenWin-Kuang Shen *, †, ‡, §, ‖, ¶ , Robert S. SheldonRobert S. Sheldon , David G. BendittDavid G. Benditt *, †, ‡, §, ‖, ¶ , Mitchell I. CohenMitchell I. Cohen *, †, ‡, §, ‖, ¶ , Daniel E. FormanDaniel E. Forman *, †, ‡, §, ‖, ¶ , Zachary D. GoldbergerZachary D. Goldberger *, †, ‡, §, ‖, ¶ , Blair P. GrubbBlair P. Grubb *, †, ‡, §, ‖, ¶ , Mohamed H. HamdanMohamed H. Hamdan *, †, ‡, §, ‖, ¶ , Andrew D. KrahnAndrew D. Krahn *, †, ‡, §, ‖, ¶ , Mark S. LinkMark S. Link *, †, ‡, §, ‖, ¶ , Brian OlshanskyBrian Olshansky *, †, ‡, §, ‖, ¶ , Satish R. RajSatish R. Raj *, †, ‡, §, ‖, ¶ , Roopinder Kaur SandhuRoopinder Kaur Sandhu *, †, ‡, §, ‖, ¶ , Dan SorajjaDan Sorajja *, †, ‡, §, ‖, ¶ , Benjamin C. SunBenjamin C. Sun *, †, ‡, §, ‖, ¶ and Clyde W. YancyClyde W. Yancy *, †, ‡, §, ‖, ¶ Originally published9 Mar 2017https://doi.org/10.1161/CIR.0000000000000499Circulation. 2017;136:e60–e122is corrected byCorrection to: 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 SocietyOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2017: Previous Version 1 Table of ContentsPreamblee 611. Introduction e641.1. Methodology and Evidence Review e641.2. Organization of the Writing Committee e641.3. Document Review and Approval e641.4. Scope of the Guideline e642. General Principles e672.1. Definitions: Terms and Classification e672.2. Epidemiology and Demographics e672.3. Initial Evaluation of Patients with Syncope: Recommendations e672.3.1. History and Physical Examination: Recommendation e682.3.2. Electrocardiography: Recommendation e682.3.3. Risk Assessment: Recommendations e682.3.4. Disposition After Initial Evaluation: Recommendations e693. Additional Evaluation and Diagnosis e703.1. Blood Testing: Recommendations e703.2. Cardiovascular Testing: Recommendations e713.2.1. Cardiac Imaging: Recommendations e713.2.2. Stress Testing: Recommendation e723.2.3. Cardiac Monitoring: Recommendations e723.2.4. In-Hospital Telemetry: Recommendation e733.2.5. Electrophysiological Study: Recommendations e743.2.6. Tilt-Table Testing: Recommendations e753.3. Neurological Testing: Recommendations e763.3.1. Autonomic Evaluation: Recommendation e763.3.2. Neurological and Imaging Diagnostics: Recommendations e764. Management of Cardiovascular Conditions e784.1. Arrhythmic Conditions: Recommendations e794.1.1. Bradycardia: Recommendation e794.1.2. Supraventricular Tachycardia: Recommendations e794.1.3. Ventricular Arrhythmia: Recommendation e804.2. Structural Conditions: Recommendations e804.2.1. Ischemic and Nonischemic Cardiomyopathy: Recommendation e804.2.2. Valvular Heart Disease: Recommendation e804.2.3. Hypertrophic Cardiomyopathy: Recommendation e804.2.4. Arrhythmogenic Right Ventricular Cardiomyopathy: Recommendations e814.2.5. Cardiac Sarcoidosis: Recommendations e814.3. Inheritable Arrhythmic Conditions: Recommendations e814.3.1. Brugada Syndrome: Recommendations e814.3.2. Short-QT Syndrome: Recommendation e824.3.3. Long-QT Syndrome: Recommendations e824.3.4. Catecholaminergic Polymorphic Ventricular Tachycardia: Recommendations e834.3.5. Early Repolarization Pattern: Recommendations e845. Reflex Conditions: Recommendations e845.1. Vasovagal Syncope: Recommendations e845.2. Pacemakers in Vasovagal Syncope: Recommendation e855.3. Carotid Sinus Syndrome: Recommendations e865.4. Other Reflex Conditions e866. Orthostatic Hypotension: Recommendations e866.1. Neurogenic Orthostatic Hypotension: Recommendations e866.2. Dehydration and Drugs: Recommendations e887. Orthostatic Intolerance e888. Pseudosyncope: Recommendations e889. Uncommon Conditions Associated with Syncope e8910. Age, Lifestyle, and Special Populations: Recommendations e8910.1. Pediatric Syncope: Recommendations e8910.2. Adult Congenital Heart Disease: Recommendations e9110.3. Geriatric Patients: Recommendations e9210.4. Driving and Syncope: Recommendation e9210.5. Athletes: Recommendations e9311. Quality of Life and Healthcare Cost of Syncope e9411.1. Impact of Syncope on Quality of Life e9411.2. Healthcare Costs Associated with Syncope e9412. Emerging Technology, Evidence Gaps, and Future Directions e9612.1. Definition, Classification, and Epidemiology e9612.2. Risk Stratification and Clinical Outcomes e9712.3. Evaluation and Diagnosis e9712.4. Management of Specific Conditions e9812.5. Special Populations e98Referencese 99Appendix 1. Author Relationships with Industry and Other Entities (Relevant) e115Appendix 2. Reviewer Relationships with Industry and Other Entities (Comprehensive) e117Appendix 3. Abbreviationse 122PreambleSince 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.Intended UsePractice 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.Clinical ImplementationGuideline-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.Methodology and ModernizationThe 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 Medicine1,2 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 2. Relevant ACC/AHA GuidelinesTitleOrganizationPublication Year (Reference)ACC/AHA guideline policy relevant to the management of syncope Supraventricular tachycardiaACC/AHA/HRS201510 Valvular heart diseaseAHA/ACC201411 Device-based therapies for cardiac rhythm abnormalitiesACCF/AHA/HRS201212 Ventricular arrhythmias and sudden cardiac deathACC/AHA/ESC200613*Other ACC/AHA guidelines of interest Hypertension*ACC/AHA– Stable ischemic heart diseaseACC/AHA/ACP/AATS/PCNA/SCAI/STS2012 and 201414,15 Atrial fibrillationAHA/ACC/HRS201416 Non–ST-elevation acute coronary syndromesAHA/ACC201417 Assessment of cardiovascular riskACC/AHA201318 Heart failureACC/AHA201319* Hypertrophic cardiomyopathyACC/AHA201120 Assessment of cardiovascular risk in asymptomatic adultsACC/AHA201021 Adult congenital heart diseaseACC/AHA200822*Other related references Scientific statement on electrocardiographic early repolarizationAHA201623 Expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncopeHRS201524 Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac deathESC2015 and 201325,26 Expert consensus statement on the recognition and management of arrhythmias in adult congenital heart diseasePACES/HRS201427 Expert consensus statement on the use of implantable cardioverter-defibrillator therapy in patients who are not included or not well represented in clinical trialsHRS/ACC/AHA201428 Expert consensus statement on ventricular arrhythmiasEHRA/HRS/APHRS201429 Expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromesHRS/EHRA/APHRS201325 Guidelines for the diagnosis and management of syncopeESC200930*Revisions to the current documents are being prepared, with publication expected in 2017.AATS indicates American Association for Thoracic Surgeons; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; ACP, American College of Physicians; AHA, American Heart Association; APHRS, Asia Pacific Heart Rhythm Society; EHRA, European Heart Rhythm Association; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; PACES, Pediatric and Congenital Electrophysiology Society; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; and STS, Society of Thoracic Surgery.2. General Principles2.1. Definitions: Terms and ClassificationFor the purpose of this guideline, definitions of syncope and relevant terms are provided in Table 3.Table 3. Relevant Terms and Definitions*TermDefinition/Comments and ReferencesSyncopeA symptom that presents with an abrupt, transient, complete loss of consciousness, associated with inability to maintain postural tone, with rapid and spontaneous recovery. The presumed mechanism is cerebral hypoperfusion.24,30 There should not be clinical features of other nonsyncope causes of loss of consciousness, such as seizure, antecedent head trauma, or apparent loss of consciousness (ie, pseudosyncope).24,30Loss of consciousnessA cognitive state in which one lacks awareness of oneself and one's situation, with an inability to respond to stimuli.Transient loss of consciousnessSelf-limited loss of consciousness30 can be divided into syncope and nonsyncope conditions. Nonsyncope conditions include but are not limited to seizures, hypoglycemia, metabolic conditions, drug or alcohol intoxication, and concussion due to head trauma. The underlying mechanism of syncope is presumed to be cerebral hypoperfusion, whereas nonsyncope conditions are attributed to different mechanisms.Presyncope (near-syncope)The symptoms before syncope. These symptoms could include extreme lightheadedness; visual sensations, such as "tunnel vision" or "graying out"; and variable degrees of altered consciousness without complete loss of consciousness. Presyncope could progress to syncope, or it could abort without syncope.Unexplained syncope (syncope of undetermined etiology)Syncope for which a cause is undetermined after an initial evaluation that is deemed appropriate by the experienced healthcare provider. The initial evaluation includes but is not limited to a thorough history, physical examination, and ECG.Orthostatic intoleranceA syndrome consisting of a constellation of symptoms that include frequent, recurrent, or persistent lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue upon standing. These symptoms can occur with or without orthostatic tachycardia, OH, or syncope.24 Individuals with orthostatic intolerance have ≥1 of these symptoms associated with reduced ability to maintain upright posture.Orthostatic tachycardiaA sustained increase in heart rate of ≥30 bpm within 10 min of moving from a recumbent to a quiet (nonexertional) standing position (or ≥40 bpm in individuals 12–19 y of age).24,30,31Orthostatic hypotension (OH)A drop in systolic BP of ≥20 mm Hg or diastolic BP of ≥10 mm Hg with assumption of an upright posture.31 Initial (immediate) OHA transient BP decrease within 15 s after standing, with presyncope or syncope.31,32 Classic OHA sustained reduction of systolic BP of ≥20 mm Hg or diastolic BP of ≥10 mm Hg within 3 min of assuming upright posture.31 Delayed OHA sustained reduction of systolic BP of ≥20 mm Hg (or 30 mm Hg in patients with supine hypertension) or diastolic BP of ≥10 mm Hg that takes >3 min of upright posture to develop. The fall in BP is usually gradual until reaching the threshold.31 Neurogenic OHA subtype of OH that is due to dysfunction of the autonomic nervous system and not solely due to environmental triggers (eg, dehydration or drugs).33,34 Neurogenic OH is due to lesions involving the central or peripheral autonomic nerves.Cardiac (cardiovascular) syncopeSyncope caused by bradycardia, tachycardia, or hypotension due to low cardiac index, blood flow obstruction, vasodilatation, or acute vascular dissection.35,36Noncardiac syncopeSyncope due to noncardiac causes, which include reflex syncope, OH, volume depletion, dehydration, and blood loss.35Reflex (neurally mediated) syncopeSyncope due to a reflex that causes vasodilation, bradycardia, or both.24,30,31 Vasovagal syncope (VVS)The most common form of reflex syncope mediated by the vasovagal reflex. VVS: 1) may occur with upright posture (standing or seated or with exposure to emotional stress, pain, or medical settings; 2) typically is characterized by diaphoresis, warmth, nausea, and pallor; 3) is associated with vasodepressor hypotension and/or inappropriate bradycardia; and 4) is often followed by fatigue. Typical features may be absent in older patients.24 VVS is often preceded by identifiable triggers and/or by a characteristic prodrome. The diagnosis is made primarily on the basis of a thorough history, physical examination, and eyewitness observation, if available. Carotid sinus syndromeReflex syncope associated with carotid sinus hypersensitivity.30 Carotid sinus hypersensitivity is present when a pause ≥3 s and/or a decrease of systolic pressure ≥50 mm Hg occurs upon stimulation of the carotid sinus. It occurs more frequently in older patients. Carotid sinus hypersensitivity can be associated with varying degrees of symptoms. Carotid sinus syndrome is defined when syncope occurs in the presence of carotid sinus hypersensitivity. Situational syncopeReflex syncope associated with a specific action, such as coughing, laughing, swallowing, micturition, or defecation. These syncope events are closely associated with specific physical functions.Postural (orthostatic) tachycardia syndrome (POTS)A clinical syndrome usually characterized by all of the following: 1) frequent symptoms that occur with standing (eg, lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue); and 2) an increase in heart rate of ≥30 bpm during a positional change from supine to standing (or ≥40 bpm in those 12–19 y of age); and 3) the absence of OH (>20 mm Hg reduction in systolic BP). Symptoms associated with POTS include those that occur with standing (eg, lightheadedness, palpitations); those not associated with particular postures (eg, bloating, nausea, diarrhea, abdominal pain); and those that are systemic (eg, fatigue, sleep disturbance, migraine headaches).37 The standing heart rate is often >120 bpm.31,38–42Psychogenic pseudosyncopeA syndrome of apparent but not true loss of consciousness that may occur in the absence of identifiable cardiac, reflex, neurological, or metabolic causes.30*These definitions are derived from previously published definitions from scientific investigations, guidelines, expert consensus statements, and Webster dictionary after obtaining consensus from the WC.BP indicates blood pressure; ECG, electrocardiogram; OH, orthostatic hypotension; POTS, postural tachycardia syndrome; and VVS, vasovagal syncope.Table 4. Historical Characteristics Associated with Increased Probability of Cardiac and Noncardiac Causes of Syncope60,67–75More Often Associated With Cardiac Causes of Syncope Older age (>60 y) Male sex Presence of known ischemic heart disease, structural heart disease, previous arrhythmias, or reduced ventricular function Brief prodrome, such as palpitations, or sudden loss of consciousness without prodrome Syncope during exertion Syncope in the supine position Low number of syncope episodes (1 or 2) Abnormal cardiac examination Family history of inheritable conditions or premature SCD (<50 y of age) Presence of known congenital heart diseaseMore Often Associated With Noncardiac Causes of Syncope Younger age No known cardiac disease Syncope only in the standing position Positional change from supine or sitting to standing Presence of prodrome: nausea, vomiting, feeling warmth Presence of specific triggers: dehydration, pain, distressful stimulus, medical environment Situational triggers: cough, laugh, micturition, defecation, deglutition Frequent recurrence and prolonged history of syncope with similar characteristicsSCD indicates sudden cardiac death.2.2. Epidemiology and DemographicsSyncope has many causes and clinical presentations; the incidence depends on the population being evaluated. Estimates of isolated or recurrent syncope may be inaccurate and underestimated because epidemiological data have not been collected in a consistent fashion or because a consistent definition has not been used. I
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