Syncope Guidelines 2018

Reflex Syncope
Education and Life-style Measures (I)
Severe or Recurrent Form
severe = when very frequent syncope alters quality of life; when recurrent syncope without, or with a very short, prodrome exposes the patient to a risk of trauma;and when syncope occurs during a high-risk activity.
Fludrocortisone or Midodrine for low BP type.(IIb)
Counter-pressure Maneuver (IIa),
Tilt Training (IIb) for those with prodrome.
ILR guided management (I) for those with minimal or no prodrome.
Stop or Reduce hypotensive drugs (IIa)
Cardiac Pacing (IIa-IIb) for dominant cardioinhibitory and age>40.
IIa for spontaneous, IIb for tilt-induced.

Syncope due to Orthostatic Hypotension
Education and Life-style Measures (I)
Adequate Hydration and Salt Intake (I)
Discontinue or Reduce Vasoactive Drugs (IIa)
If symptoms persist
Compression Garments, Counter-pressure Maneuver, Head-up Tilt Sleeping, Midrodrine, Fludrocortisone (IIa)

Specific Therapy for Cardiac Syncope

	PACEMAKER for syncope with... Symptomatic sinus node dysfunction (I) Asymptomatic sinus node dysfunction (IIa) High grade AV block(I) Bifascicular block and +EPS for HV>70 or inducible AV block (I) Bifascicular block and +ILR (I)
	ICD for syncope with... VT and LVEF ≤35% (I) Prior MI and +EPS for VT (I) High-risks HCM (I) LQTs with adequate beta blockers (IIa) Spontaneous type I Brugada (IIa)
	Catheter ablation for syncope due to SVT or VT (I)

RE
CUR

Recurrent Syncope depends largely on MECHANISM rather than ETIOLOGY.
Pacemaker is the most effective therapy for syncope if the main mechanism is bradycardia.
Syncopal recurrences often decrease spontaneously after medical assessment, even in the absence of a specific therapy; in general, syncope recurs in <50% of patients within 1–2 years
Poor outcomes, including death, are related to the severity of the underlying disease rather than to syncope itself.

Driving Restriction

full details

The risk of syncope related car accident is less than 1%/year.
Generally, driving is allowed after "successful therapy is established" in most cases.
For single or mild reflex syncope, NO driving restriction unless syncope occurred during driving.
In a patient with syncope from cardiac arrhythmia or a patient who had ICD implanted, professinal driving is permanently restricted.