Transient Loss of Consciousness Resulting in Syncope: Review of International Clinical Practice Guidelines

Background: Syncope is a symptom characterised by transient loss of consciousness due to global cerebral hypoperfusion. 30-50% of children and adolescents experience a faint. Syncope results in 1-3% of all visits to the Paediatric Emergency Department. While benign pathology dominates, recurrent events, ancillary injuries or anxiety around sinister pathology can bias clinical judgement. Resulting heterogeneity in clinical care drives wasteful investigations or referrals to oversubscribed services. Here we review state-of-the-art International Clinical Practice Guidelines (CPG) which may be used to reduce disease burden.

Methods: Structured review of Cochrane, Pubmed and Web of Science databases performed using search terms: (“Clinical Practice Guideline” AND “Paediatric” (OR “Pediatric”) AND “Syncope”), (“Patient Algorithm” OR “Diagnostic Algorithm” AND “Paediatric” AND “Syncope”).

Results: Our search generated 126 articles, with further review yielding five CPG’s: European Society of Cardiology²⁰¹⁸, American Heart Association²⁰¹⁷, Canadian Cardiovascular Society/Pediatric Cardiology Association²⁰¹⁷, NICE²⁰¹¹, Chinese Pediatric Cardiology Society²⁰¹⁸. Guidelines used “Class I Evidence” or “Strong Recommendation” to support the role of the following: History (peri-event features), Physical Examination plus Family History (Epilepsy, premature cardiac death in 1^st/2^nd degree relative <40yrs). All but one endorsed ECG as a necessary diagnostic test. In the absence of positive findings, no further investigation is required. While presence of symptoms related to exertion should receive diagnostic work-up with referral to specialist services e.g. syncope unit, cardiology. Reassurance, education/ lifestyle measures remain the cornerstone of clinical management. Guidelines expanded on this to include medication use for refractory cases, maintaining psychological wellbeing and autonomic function training.

Discussion: Adherence to evidence-based guidelines ensures clinically appropriate management of syncope, whilst reducing wasteful investigations or referrals. Although all guidelines reviewed agree on history and examination, specific differences around ECG use, or non-pharmacological treatment exist.