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CRC
Press
Syncope
From
Etiopathogenesis
to
New
Therapeutic
Options
Edited
by
Tolga
Aksu
and
Carlos
A
.
Morillo
Syncope
Syncope is a common condition related to transient loss of consciousness due to global cerebral
hypoperfusion and caused by a variety of etiologies. Although it is self‑limited, and usually
benign, syncope can be the harbinger of life‑threatening heart rhythm problems due to cardiac
conditions. A multidisciplinary approach is practical for its evaluation and treatment, requir‑
ing the expertise of cardiologists, neurologists, emergency medicine specialists, and other clini‑
cians. This book provides a detailed review of etiopathogenesis and a state‑of‑the‑art update on
therapeutic options offering recommendations based on the guidelines and experience of experts
while discussing procedures and tests with their indications, methodology, interpretation, and
limitations.
Key Features:
◾
Discusses new diagnostic tools, and therapeutic modalities including video monitoring.
◾
Provides up‑to‑date recommendations regarding the indications for and appropriate interpreta‑
tion of noninvasive and invasive cardiac testing, for cardiologists and internists.
◾
Places particular emphasis on diagnosing and treating reex and arrhythmic syncope.
Syncope
From Etiopathogenesis to
New Therapeutic Options
Edited by
Tolga Aksu, MD, FESC, FEHRA
and
Carlos A. Morillo, MD, FRCPC, FACC, FHRS, FESC
Designed cover image: ww w.shutterstock.com/image‑photo/arm‑supports‑heart‑concept‑design‑657615100
First ed ition published 2025
by CRC Press
2385 NW Executive Center Drive, Suite 320, Boca Raton FL 33431
and by CRC Press
4 Park Square, Milton Pa rk, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2025 selection and editoria l matter, Tolga Aksu and Carlos A. Moril lo individua l chapters, the contributors
is book contains information obtained from authentic and highly regarded sources. While all reasonable eorts have been made
to publish reliable data and information, neither the author(s) nor the publisher can accept any legal responsibility or liabi lity for
any errors or omissions that may be made. e publishers wish to make clear t hat any v iews or opinions expressed in t his book by
indiv idual editors, authors, or contributors are personal to them and do not necessarily reect the views/opinions of the publishers.
e information or g uida nce contained in this book is intended for use by medica l, scientic, or healthcare professionals a nd is
provided strictly as a supplement to the medical or ot her professional’s own judgment, their knowledge of the patient ’s medica l
history, releva nt manu facturer’s instr uctions, and the appropriate best pract ice gu idelines. Because of the rapid advances in medical
science, a ny information or advice on dosages, procedu res, or diagnos es should be independently veried. e reader i s strongly urge d
to consu lt the relevant national drug formulary a nd the drug companies’ and dev ice or material manufacturers’ printed instructions,
and thei r websites, before ad minister ing or utilizing a ny of the drugs, device s, or materials mentioned in this book. is bo ok does not
indicate whether a particular treatment is appropriate or suitable for a particular individua l. Ultimately, it is the sole responsibility of
the medical professiona l to make his or her own professional judgments, so as to advise and treat patients appropriately. e authors
and publishers have also attempted to trace the copy right holders of all material reproduced in this publication and apologize to
copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged,
please write and let us know so we may rectify in any fut ure repr int.
Except as permit ted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmit ted, or ut ilized in any
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For permission to photocopy or u se material electronically from this work, access ww w.copyr ight.com or contact the Copyright
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please contact mpkbookspermissions@tandf.co.uk
Trademark notice: Product or corporate names may be trademark s or registered trademarks and are used only for identication a nd
explanation without intent to in fri nge.
Library of Congress Cataloging‑in‑Publication Data
Names: A ksu, Tolga, editor. | Morillo, Ca rlos A., editor.
Title: Syncope : from etiopathogenesis to new therapeutic options / edited by Tolga Aksu and Carlos A. Mori llo.
Other titles: Sy ncope (Aksu)
Description: Fi rst edition. | Boca Raton : CRC Press, 2025. | Includes bibliographical references and index. | Summary: “Syncope is a
common cond ition related to transient loss of consciousness due to global cerebral hypoperfusion and caused by a variet y of aetiolo‑
gies. A lthough it is self‑lim ited, a nd usually benign, syncope can be the ha rbinger of life‑threatening heart rhythm problems due to
cardiac condit ions. A multidiscipl inary approach is prac tical for its evaluation and treatment, requi ring the expertise of cardiolog ists,
neurologists, emergenc y medicine specialists, and ot her cli nicians. is book provides a detailed review of etiopathogenesis and a
state‑of the ar t update on therapeutic options oering recommendat ions ba sed on the guidelines and experience of experts while
discussing procedures and tests with their indications, methodology, interpretation, and limitations”— Provided by publisher.
Identiers: LCCN 2024 022076 (print) | LCC N 2024 022077 (ebook) | ISBN 9781032542348 (hbk) |
ISBN 9781032542331 (pbk) | ISBN 9781003415855 (ebk)
Subjects: MESH: Syncope—physiopathology | Syncope—therapy
Classicat ion: LCC RB150.S9 (print) | LCC RB150.S9 (ebook) | NLM WB 182 | DDC 616/.047—dc23/eng/20240705
LC record available at https://lccn.loc.gov/2024022076
LC ebook record available at ht tps://lccn.loc.gov/2024 022077
ISBN: 9781032542348 (hbk)
ISBN: 9781032542331 (pbk)
ISBN: 9781003 415855 (ebk)
DOI: 10.1201/97810 03 415 855
Typeset in Palatino
by codeMantra
Dedicated to our children who bear the burden of accompanying us through this
indefatigable journey toward the pursuit of knowledge and silently accept and support
our endless hours of dedication to incomprehensible projects to their innocent minds.
T.A. and C.A.M.
https://t.me/med1917
vii
Contents
Preface .............................................................................. ix
Acknowledgment
....................................................................x
About the Editors
................................................................... xi
Contributors
........................................................................xii
1. Syncope: Denition, Terminology and Classication ....................................1
John A. Paydar, Liane A. Arcinas, Carlos A. Morillo,
Robert S. Sheldon, and Satish R. Raj
2. Epidemiology and Economics of Syncope ............................................10
Dana Shiffer and Raffaello Furlan
3. Etiopathogenesis of Syncope ........................................................ 18
Lina E. Lombo and Juan Camilo Guzmán
4. Initial Evaluation and Risk Stratication in Syncope ...................................23
Robert S. Sheldon, Liane A. Arcinas, Frederik de Lange, and Roopinder Sandhu
5. Diagnostic Tests in Syncope ........................................................32
5A. Diagnostic Tests in Syncope: Tilt‑Table Testing, Autonomic Tests,
and Electrophysiological Study
.....................................................32
Wayne O. Adkisson and David G. Benditt
5B. Diag nostic Tests in Syncope: ECG, Prolonged Ambulatory Monitori ng,
and Exercise Stress Testing
.........................................................43
Matthew T. Bennett and Andrew D. Krahn
6. Reex Syncope ....................................................................52
6A. Reex Syncope: Vasovagal Syncope ..................................................52
William H. Parker, Mark W. Chapleau, and Brian Olshansky
6B. Reex Syncope: Ot her Causes of Reex Syncope ......................................65
Piotr Kulakowski
7. Adenosine‑Sensitive Syncope: Diagnosis and Management .............................72
Régis Guieu, Michele Brignole, and Jean Claude Deharo
8. Disorders of Orthostatic Intolerance: Orthostatic Hypotension and
Postural Orthostatic Tachycardia Syndrome ..........................................79
Jacquie R. Baker and Satish R. Raj
9. Cardiac Syncope ..................................................................91
Angel Moya‑Mitjans and Jaume Francisco‑Pascual
10. Syncope in Children ..............................................................100
Khalil Kanjwal, Wasim Rashid, and Blair P. Grubb
https://t.me/med1917
viii
11. Pseudosyncope and Ictal Syncope: Diagnosis and Management ........................116
Leonardo Calò, Marco Rebecchi, Pietro Desimone, DomenicoGiamundo,
Ermenegildo De Ruvo, and Antonella Sette
12. Other Neurological Conditions (Sleep Disorders, Autonomic Failure, and
Structural Brain Lesions)
..........................................................124
Ann‑Kathrin Kahle, Katharina Scherschel, Fares‑Alexander Alken, and Christian Meyer
13. Management of Reex Syncope ....................................................135
13A. Management of Reex Syncope: Non‑Pharmacological and Pharmacological ............135
Giulia Rivasi and Artur Fedorowski
13B. Management of Reex Syncope: Cardioneuroablation ................................142
Tolga Aksu, Jeanne M. Du‑Fay‑de‑Lavallaz, Asad Khan, and Henry Huang
13C. Management of Reex Syncope: Cardiac Pacing in Reex Syncope .....................149
Michael Liu, Dan Sorajja, and Win‑Kuang Shen
14. The Legal Aspects of Syncope .....................................................161
Frederik J. de Lange and Robert S. Sheldon
15. Syncope and Falls in Older Adults ..................................................168
Desmond O’Donnell and Rose Anne Kenny
Index
...............................................................................177
https://t.me/med1917
ix
Preface
“Syncope may arise due to a diseased condition of the heart itself. It usually occurs due to ‘dys‑
crasia,’ which is the unhealthy temperament of a person, or due to an inammation or due to a
tumour or due to ‘erysipelas,’ which is any disease that reddens the skins with diffuse purulent
inammations of internal organs, but also due to a sympathetic affection of the heart…” Galen. In
Hippocratis de victus acutorum commentaria iv. In Kuhn CG, ed. Opera Omnia. Volume 15. Lipsiae:
Libraria Car. Cnoblochii 1828: 600, 722, 775.
Fainting and transient loss of consciousness (TLOC) have fascinated physicians for centuries
since the reportedly initial descriptions from Hippocrates. Galen, who was likely one of the
most prolic authors on this topic, would be spellbound by the incredible advances over the past
40
years. The introduction of the head‑up tilt‑table test in 1986 by Kenny, Sutton, and collaborators
provided a simple test that opened our minds to the diagnosis and understanding of the most
frequent cause of syncope, namely, reex “vasovagal” syncope. Almost 40
years after the introduc‑
tion of this test that triggered an array of pathophysiologic and clinical trial studies from yoga to
cardioneuroablation have forever changed our perception of the “common faint.” Another trans‑
formational advance in our understanding and detection of this random event known as syncope
is the development of the implantable loop recorded in the early 1990s by the Klein Group at the
University of Western Ontario, in London, Canada. Capturing the ECG evidence during the actual
episode of TLOC provided new insights and novel treatments for patients with recurrent syncope
of unknown etiology.
Syncope, a symptom that can be due to many etiologies and a potential harbinger of sudden
death, continues to be a challenge for the everyday physician who confronts these cases. In this
comprehensive syncope textbook authored by world‑renowned authorities in the eld, we provide
an updated pragmatic review of the state‑of‑the‑art advances in the diagnosis, etiology, risk strati‑
cation, and management of syncope in the 21st century.
We anticipate that readers will nd this textbook useful in the management of patients with
syncope and will be provided with a widespread approach for the patient with syncope. We hope
this textbook will also stimulate the upcoming generations of researchers in this eld.
We would like to thank all the authors who have contributed chapters to this book and thank
the publishers for all their assistance and patience at every stage of the publication. We would like
to particularly thank Himani Dwivedi, Shivangi Pramanik, and Lavanya Sharma for their tireless
efforts, for their constant reminders, and for putting up with us through the editorial process.
https://t.me/med1917
x
Acknowledgment
We would like to acknowledge our mentors, colleagues, trainees, and patients who have been the
source of knowledge and inspiration.
https://t.me/med1917
xi
About the Editors
Tolga Aksu, MD, FESC, FEHRA is a professor of cardiology. Currently, he is a member of the
Department of Cardiology and Director of Clinical Electrophysiology at the Yeditepe University
Hospital in Turkey. Dr.Aksu is clinically interested in invasive electrophysiology, device implanta‑
tion, and catheter ablation therapies. Special interest areas include atrial brillation and cardio‑
neuroablation, and he has been a pioneer and advocate in this eld. Dr.Aksu has published more
than 130 international scientic publications. He is an associate editor of Journal of Electrocardiology
and SoMe Editor of JICE. He is also a member of the editorial board of World Journal of Cardiology,
Medicine Journal, Journal of Atrial Fibrillation, and Journal of Cardiac Arrhythmias.
Carlos A. Morillo, MD, FRCPC, FACC, FHRS, FESC is a cardiac electrophysiologist, who served
in the Chief Division of Cardiology (2015–2022) at the Libin Cardiovascular Institute, University
of Calgary, Calgary, Alberta, Canada, and is currently on academic sabbatical leave at the
Molecular and Novel Arrhythmia Mechanisms group at the Centro Nacional de Investigaciones
Cardiovasculares (CNIC) in Madrid, Spain. He has been involved in syncope research since1986
and has extensively investigated the mechanisms of neurally mediated syncope, and he has par‑
ticipated and led several landmark clinical trials related to the diagnosis and management of vaso‑
vagal syncope including the VPS, POST, and SPAIN trials. Prof. Morillo has published over 350
peer‑reviewed articles and has also participated in several syncope guidelines from the ESC, ACC,
AHA, HRS, and Canadian Society of Cardiology. Prof. Morillo’s key research areas are related to
the development of clinical trials in the areas of syncope, cardiac arrhythmias, AF ablation, screen‑
ing and detection of AF in varied populations, and treatment of Chagas disease.
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