AHA ACC Syncope 2017

Shen W-K, et al 2017 ACC/AHA/HRS Syncope Guideline 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 Developed in Collaboration With the American College of Emergency Physicians and Society for Academic Emergency Medicine Endorsed by the Pediatric and Congenital Electrophysiology Society WRITING COMMITTEE MEMBERS* Downloaded from http://circ.ahajournals.org/ by guest on April 16, 2017 Win-Kuang Shen, MD, FACC, FAHA, FHRS, Chair† Robert S Sheldon, MD, PhD, FHRS, Vice Chair David G Benditt, MD, FACC, FHRS*‡ Mark S Link, MD, FACC‡ Mitchell I Cohen, MD, FACC, FHRS‡ Brian Olshansky, MD, FACC, FAHA, FHRS*‡ Daniel E Forman, MD, FACC, FAHA‡ Satish R Raj, MD, MSc, FACC, FHRS*§ Zachary D Goldberger, MD, MS, FACC, FAHA, FHRS‡ Roopinder Kaur Sandhu, MD, MPH‡ Blair P Grubb, MD, FACC§ Dan Sorajja, MD‡ Mohamed H Hamdan, MD, MBA, FACC, FHRS*‡ Benjamin C Sun, MD, MPP, FACEP║ Andrew D Krahn, MD, FHRS*§ Clyde W Yancy, MD, MSc, FACC, FAHA‡¶ ACC/AHA TASK FORCE MEMBERS Glenn N Levine, MD, FACC, FAHA, Chair Patrick T O’Gara, MD, FACC, FAHA, Chair-Elect Jonathan L Halperin, MD, FACC, FAHA, Immediate Past Chair# Sana M Al-Khatib, MD, MHS, FACC, FAHA Federico Gentile, MD, FACC Kim K Birtcher, MS, PharmD, AACC Samuel Gidding, MD, FAHA Biykem Bozkurt, MD, PhD, FACC, FAHA Mark A Hlatky, MD, FACC Ralph G Brindis, MD, MPH, MACC# John Ikonomidis, MD, PhD, FAHA Joaquin E Cigarroa, MD, FACC José Joglar, MD, FACC, FAHA Lesley H Curtis, PhD, FAHA Susan J Pressler, PhD, RN, FAHA Lee A Fleisher, MD, FACC, FAHA Duminda N Wijeysundera, MD, PhD *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix for detailed information †ACC/AHA Task Force on Clinical Practice Guidelines Liaison ‡ACC/AHA Representative §HRS Representative ║ACEP and SAEM Joint Representative ¶ACC/AHA Task Force on Performance Measures Liaison #Former Task Force member; current member during the writing effort This document was approved by the American College of Cardiology Clinical Policy Approval Committee on behalf of the Board of Trustees, the American Heart Association Science Advisory and Coordinating Committee, the American Heart Association Executive Committee, and the Heart Rhythm Society Board of Trustees in January 2017 The online Comprehensive RWI Data Supplement table is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000499/-/DC1 The online Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000499/-/DC2 © 2017 by the American College of Cardiology Foundation, American Heart Association, Inc., and Heart Rhythm Society Shen W-K, et al 2017 ACC/AHA/HRS Syncope Guideline The American Heart Association requests that this document be cited as follows: Shen W-K, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW 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 Circulation 2017;:– DOI: 10.1161/CIR.0000000000000499 This article has been copublished in the Journal of the American College of Cardiology and Heart Rhythm Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (professional.heart.org), and the Heart Rhythm Society (www.hrsonline.org) A copy of the document is available at http://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations For more on AHA statements and guidelines development, visit http://professional.heart.org/statements Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.” Downloaded from http://circ.ahajournals.org/ by guest on April 16, 2017 Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp A link to the “Copyright Permissions Request Form” appears on the right side of the page (Circulation 2017;000:e000–e000 DOI: 10.1161/CIR.0000000000000499.) © 2017 by the American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society Circulation is available at http://circ.ahajournals.org © 2017 by the American College of Cardiology Foundation, American Heart Association, Inc., and Heart Rhythm Society Shen W-K, et al 2017 ACC/AHA/HRS Syncope Guideline Table of Contents Downloaded from http://circ.ahajournals.org/ by guest on April 16, 2017 Preamble Introduction 1.1 Methodology and Evidence Review 1.2 Organization of the Writing Committee 1.3 Document Review and Approval 1.4 Scope of the Guideline General Principles 11 2.1 Definitions: Terms and Classification 11 2.2 Epidemiology and Demographics 12 2.3 Initial Evaluation of Patients With Syncope 13 History and Physical Examination: Recommendation 14 Electrocardiography: Recommendation 15 Risk Assessment: Recommendations 16 Disposition After Initial Evaluation: Recommendations 19 Additional Evaluation and Diagnosis 21 3.1 Blood Testing: Recommendations 22 3.2 Cardiovascular Testing 23 Cardiac Imaging: Recommendations 24 Stress Testing: Recommendation 25 Cardiac Monitoring: Recommendations 25 In-Hospital Telemetry: Recommendation 28 Electrophysiological Study: Recommendations 29 Tilt-Table Testing: Recommendations 30 3.3 Neurological Testing 32 Autonomic Evaluation: Recommendation 32 Neurological and Imaging Diagnostics: Recommendations 33 Management of Cardiovascular Conditions 34 4.1 Arrhythmic Conditions 34 Bradycardia: Recommendation 35 Supraventricular Tachycardia: Recommendation 35 Ventricular Arrhythmia: Recommendation 36 4.2 Structural Conditions 36 Ischemic and Nonischemic Cardiomyopathy: Recommendation 37 Valvular Heart Disease: Recommendation 37 Hypertrophic Cardiomyopathy: Recommendation 37 Arrhythmogenic Right Ventricular Cardiomyopathy: Recommendation 38 Cardiac Sarcoidosis: Recommendations 38 4.3 Inheritable Arrhythmic Conditions 39 Brugada Syndrome: Recommendations 39 Short-QT Syndrome: Recommendation 40 Long-QT Syndrome: Recommendations 41 Catecholaminergic Polymorphic Ventricular Tachycardia: Recommendations 42 Early Repolarization Pattern: Recommendations 43 Reflex Conditions 44 5.1 Vasovagal Syncope: Recommendations 44 5.2 Pacemakers in Vasovagal Syncope: Recommendation 46 5.3 Carotid Sinus Syndrome: Recommendations 47 5.4 Other Reflex Conditions 48 Orthostatic Hypotension 48 6.1 Neurogenic Orthostatic Hypotension: Recommendations 48 © 2017 by the American College of Cardiology Foundation, American Heart Association, Inc., and Heart Rhythm Society Shen W-K, et al 2017 ACC/AHA/HRS Syncope Guideline Downloaded from http://circ.ahajournals.org/ by guest on April 16, 2017 6.2 Dehydration and Drugs: Recommendations 50 Orthostatic Intolerance 52 Pseudosyncope: Recommendations 53 Uncommon Conditions Associated With Syncope 54 10 Age, Lifestyle, and Special Populations 56 10.1 Pediatric Syncope: Recommendations 56 10.2 Adult Congenital Heart Disease: Recommendations 59 10.3 Geriatric Patients: Recommendations 60 10.4 Driving and Syncope: Recommendation 61 10.5 Athletes: Recommendations 63 11 Quality of Life and Healthcare Cost of Syncope 65 11.1 Impact of Syncope on Quality of Life 65 11.2 Healthcare Costs Associated With Syncope 65 12 Emerging Technology, Evidence Gaps, and Future Directions 66 12.1 Definition, Classification, and Epidemiology 66 12.2 Risk Stratification and Clinical Outcomes 66 12.3 Evaluation and Diagnosis 67 12.4 Management of Specific Conditions 67 12.5 Special Populations 68 Appendix Author Relationships With Industry and Other Entities (Relevant) 70 Appendix Reviewer Relationships With Industry and Other Entities (Comprehensive) 74 Appendix Abbreviations 81 References 82 © 2017 by the American College of Cardiology Foundation, American Heart Association, Inc., and Heart Rhythm Society Shen W-K, et al 2017 ACC/AHA/HRS Syncope Guideline Preamble 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 Downloaded from http://circ.ahajournals.org/ by guest on April 16, 2017 Intended Use 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 Clinical Implementation 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 Methodology and Modernization 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 Medicine (1,2) and on the basis of internal reevaluation Similarly, the presentation and delivery of guidelines are reevaluated 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 and affirms the ongoing validity of the related recommendations in the context of syncope, thus obviating the need to repeat existing guideline © 2017 by the American College of Cardiology Foundation, American Heart Association, Inc., and Heart Rhythm Society Shen W-K, et al 2017 ACC/AHA/HRS Syncope Guideline recommendations in the present guideline when applicable or when appropriate Table also contains a list of other statements that may be of interest to the reader Table Relevant ACC/AHA Guidelines Organization Publication Year (Reference) ACC/AHA/HRS AHA/ACC ACCF/AHA/HRS ACC/AHA/ESC 2015 (10) 2014 (11) 2012 (12) 2006 (13)* ACC/AHA ACC/AHA/ACP/ AATS/PCNA/SCAI/STS AHA/ACC/HRS AHA/ACC ACC/AHA ACC/AHA ACC/AHA ACC/AHA ACC/AHA 2012 and 2014 (14,15) 2014 (16) 2014 (17) 2013 (18) 2013 (19)* 2011 (20) 2010 (21) 2008 (22)* AHA 2016 (23) HRS 2015 (24) ESC PACES/HRS 2015 and 2013 (25,26) 2014 (27) HRS/ACC/AHA 2014 (28) EHRA/HRS/APHRS 2014 (29) HRS/EHRA/APHRS 2013 (25) ESC 2009 (30) Title ACC/AHA guideline policy relevant to the management of syncope Supraventricular tachycardia Valvular heart disease Device-based therapies for cardiac rhythm abnormalities Ventricular arrhythmias and sudden cardiac death Other ACC/AHA guidelines of interest Hypertension* Stable ischemic heart disease Downloaded from http://circ.ahajournals.org/ by guest on April 16, 2017 Atrial fibrillation Non–ST-elevation acute coronary syndromes Assessment of cardiovascular risk Heart failure Hypertrophic cardiomyopathy Assessment of cardiovascular risk in asymptomatic adults Adult congenital heart disease Other related references Scientific statement on electrocardiographic early repolarization Expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death Expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease Expert consensus statement on the use of implantable cardioverter-defibrillator therapy in patients who are not included or not well represented in clinical trials Expert consensus statement on ventricular arrhythmias Expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes Guidelines for the diagnosis and management of syncope *Revisions to the current documents are being prepared, with publication expected in 2017 AATS indicates American Association for Thoracic Surgery; 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 © 2017 by the American College of Cardiology Foundation, American Heart Association, Inc., and Heart Rhythm Society 10 ... Relevant ACC /AHA Guidelines Organization Publication Year (Reference) ACC /AHA/ HRS AHA/ ACC ACCF /AHA/ HRS ACC /AHA/ ESC 2015 (10) 2014 (11) 2012 (12) 2006 (13)* ACC /AHA ACC /AHA/ ACP/ AATS/PCNA/SCAI/STS AHA/ ACC/ HRS... AATS/PCNA/SCAI/STS AHA/ ACC/ HRS AHA/ ACC ACC /AHA ACC /AHA ACC /AHA ACC /AHA ACC /AHA 2012 and 2014 (14,15) 2014 (16) 2014 (17) 2013 (18) 2013 (19)* 2011 (20) 2010 (21) 2008 (22)* AHA 2016 (23) HRS 2015... Inc., and Heart Rhythm Society 11 Shen W-K, et al 2017 ACC /AHA/ HRS Syncope Guideline Reflex (neurally mediated) syncope • Vasovagal syncope (VVS) Syncope due to a reflex that causes vasodilation,