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Syncope shares many clinical features with other disorders; it therefore presents in many differential diagnoses. This group of disorders is labelled TLOC.

TLOC is defined as a state of real or apparent LOC with loss of awareness, characterized by amnesia for the period of unconsciousness, abnormal motor control, loss of responsiveness, and a short duration.

The two main groups of TLOC are ‘TLOC due to head trauma’ and ‘non-traumatic TLOC’ ( Figure 2 ). Traumatic TLOC will not be considered further in this document, so TLOC will be used to mean non-traumatic TLOC.

Figure 2
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Syncope in the context of transient loss of consciousness. Non-traumatic transient loss of consciousness is classified into one of four groupings: syncope, epileptic seizures, psychogenic transient loss of consciousness, and a miscellaneous group of rare causes. This order represents their rate of occurrence. Combinations occur; e.g. non-traumatic transient loss of consciousness causes can cause falls with concussion, in which case transient loss of consciousness is both traumatic and non-traumatic. TIA = transient ischaemic attack; TLOC = transient loss of consciousness.

Figure 2
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Syncope in the context of transient loss of consciousness. Non-traumatic transient loss of consciousness is classified into one of four groupings: syncope, epileptic seizures, psychogenic transient loss of consciousness, and a miscellaneous group of rare causes. This order represents their rate of occurrence. Combinations occur; e.g. non-traumatic transient loss of consciousness causes can cause falls with concussion, in which case transient loss of consciousness is both traumatic and non-traumatic. TIA = transient ischaemic attack; TLOC = transient loss of consciousness.

The clinical features characterizing TLOC are usually derived from history taking from patients and eyewitnesses. Specific characteristics that aid diagnosis are outlined in section 3 of the Web Practical Instructions .

TLOC groups are defined using pathophysiology: the qualifying criterion for syncope is cerebral hypoperfusion; for epileptic seizures, it is abnormal excessive brain activity; and for psychogenic TLOC it is the psychological process of conversion. The syncope definition rests on pathophysiology because no set of clinical features encompasses all forms of syncope while also excluding all epileptic seizures and psychogenic TLOC events.

The adjective presyncope is used to indicate symptoms and signs that occur before unconsciousness in syncope. Note that the noun presyncope is often used to describe a state that resembles the prodrome of syncope, but which is not followed by LOC.

Implantable cardioverter defibrillator indications in patients with unexplained syncope and left ventricular systolic dysfunction

ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association; SCD = sudden cardiac death.

a

Unexplained syncope is defined as syncope that does not meet a class I diagnostic criterion defined in the tables of recommendations in section 4. In the presence of clinical features described in this section, unexplained syncope is considered a risk factor for ventricular tachyarrhythmias.

b
c

Implantable cardioverter defibrillator indications in patients with unexplained syncope and left ventricular systolic dysfunction

ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association; SCD = sudden cardiac death.

a
b
c

Unexplained syncope is an independent predictor for SCD and appropriate ICD discharge. In a systematic review, the average hazard ratio of unexplained syncope (irrespective of definition) was 2.68 (95% CI 0.97–4.38). 361 In the largest multicentre study to date (>3600 patients with HCM), syncope was an independent predictor of the composite of SCD and ICD discharge (hazard ratio 2.05, 95% CI 1.48–2.82). 350 A prophylactic ICD is appropriate in individuals with other features indicative of a high risk of SCD that are used to estimate the 5-year risk of SCD using the HCM Risk-SCD model 245 ; they include: age, family history of SCD, maximum left ventricular wall thickness, left atrial diameter, and non-sustained VT.

Implantable cardioverter defibrillator indications in patients with unexplained syncope and hypertrophic cardiomyopathy

ESC = European Society of Cardiology; HCM = hypertrophic cardiomyopathy; ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; SCD = sudden cardiac death.

a

Unexplained syncope is defined as syncope that does not meet the class I diagnostic criterion defined in the tables of recommendations in section 4. In the presence of clinical features described in this section, unexplained syncope is considered a risk factor for ventricular tachyarrhythmias.

b
c
d

A web-based calculator of the HCM risk score can be found at: http://www.doc2do.com/hcm/webHCM.html . It can also be found in the ESC Pocket Guidelines App found in all app stores.

Implantable cardioverter defibrillator indications in patients with unexplained syncope and hypertrophic cardiomyopathy

ESC = European Society of Cardiology; HCM = hypertrophic cardiomyopathy; ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; SCD = sudden cardiac death.

a
b
c
d

Although limited and diverse, current data suggest that unexplained syncope is a marker of arrhythmic risk in patients with ARVC. 46 , 351 , 362 , 363 The decision to implant an ICD should take into account the other known risk factors for arrhythmic events 46 : frequent non-sustained VT, family history of premature sudden death, extensive right ventricular disease, marked QRS prolongation, late gadolinium enhancement on magnetic resonance imaging (MRI) (including left ventricular involvement), left ventricular dysfunction, and VT induction during EPS. 46

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