CORRESPONDENCE: LETTER TO THE EDITOR
The ACCF/AHA Scientific Statement on Syncope Needs Rethinking
David G. Benditt, MD, FACC, FRCP(C), FHRS*,
Brian Olshansky, MD, FACC,
Wouter Wieling, MD, PhD on behalf of the Ad Hoc Syncope Consortium
* University of Minnesota, Medicine, Cardiac Arrhythmia Center, 420 Delaware Street SE, MMC 508, Minneapolis, Minnesota 55455 (Email: bendi001{at}umn.edu).
On behalf of a multidisciplinary international consortium of more than 60 physicians experienced in caring for patients with episodic transient loss of consciousness, including syncope, we write as an Ad Hoc Syncope Consortium to highlight a number of concerns regarding the recently published American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Scientific Statement on the Evaluation of Syncope ("Statement") (1). The Statement was intended to provide guidance for physicians. However, in our opinion it does not sufficiently address a number of long-standing clinical misconceptions regarding the evaluation of individuals who have seemingly suffered a transient loss of consciousness (TLOC) episode. We raise these issues here, not simply to highlight certain differences of opinion with the Statement, but, more importantly, to encourage physicians to take a broader perspective in evaluation and treatment of TLOC patients than is offered by the Statement, and to encourage professional societies to work in concert to develop multidisciplinary clinical practice guidelines.
Space limitation permits our pointing out only a few of the more important concerns that we have with the Statement. First, it is crucial for readers of the Statement to be able to put "syncope" within the larger context of the many conditions that can cause real or apparent TLOC. The Statement fails to consider this key step. The Statement would be improved if it clearly distinguished "syncope" (i.e., TLOC due to transient inadequate cerebral perfusion) from the broader problem of TLOC, and thereby clarify from the beginning what is, and what is not, syncope. Thus, for example, it is important that the clinician be advised both why and how to differentiate syncope from nonsyncope conditions such as epilepsy, concussion, or psychogenic pseudo-syncope. To be fair to the Statement’s authors, failure to highlight these same key points (2) is commonly found in other current prominent medical writings (3,4).
Second, the Statement states that the primary "purpose of the (syncope) evaluation" is "to determine whether the patient is at increased risk for death." Certainly mortality risk assessment is an important concern, and must be a consideration in the overall evaluation of TLOC patients. However, a more comprehensive perspective is needed; most syncope patients have disabling conditions that require attention but are not life-threatening. These patients may indeed feel better knowing that they are not at high-risk of death; nevertheless, they still want and need their symptoms addressed and recurrences prevented. A revised ACCF/AHA Syncope Statement could emphasize a broad fundamental goal for the TLOC/syncope evaluation, namely the importance of establishing the diagnosis underlying the patient’s symptoms with sufficient confidence to assess prognosis and recommend a sensible and, it is hoped, effective treatment strategy.
Third, we are concerned that a large body of medical evidence underlying recent evolution of thought regarding the optimal approach to TLOC/syncope management was overlooked. At its outset, the Statement offers "to summarize the data that direct the evaluation of ... syncope." However, recent relevant literature is not cited; consequently, the reader is not provided immediate access to up-to-date sources. In this regard, though it is true that many published trials focus on treatment, the evaluation and treatment processes cannot be readily divorced. The treatment trials provide readers crucial insight into the appropriate evaluation process. Consequently, although we acknowledge that the Statement may have had constraints placed on it with respect to length, it would have been a stronger document had it provided a more comprehensive assessment of important recent literature. For example, the European Society of Cardiology Syncope Guidelines (5,6) and findings from a number of important published controlled trials would be of value to readers. Additionally, among missing references are the two major North American pacing trials targeting syncope patients (VPS [Vasovagal Pacing Study]-1, VPS-2), an important beta-blocker trial (POST [Prevention of Syncope Trial]), the only North American trial assessing syncope management units (SEEDS [Syncope Evaluation in Emergency Department Study]), and more than half-a-dozen European trials assessing various aspects of syncope evaluation (references provided on request). Furthermore, among studies cited in the Statement, 3 implantable cardioverter-defibrillator (ICD) trials and one drug trial did not focus primarily on a "syncope" population per se; only a single non-ICD trial that did enroll syncope patients was included.
As a group representing many of the medical disciplines concerned with the evaluation and treatment of TLOC/syncope patients (cardiovascular medicine, emergency medicine, geriatrics, neuroscience, and pediatrics), the Ad Hoc Syncope Consortium recommends, and would be pleased to participate in, a prompt and careful review and revision of the current Syncope Statement. Ultimately, our goal and that of the Syncope Statement’s authorship is undoubtedly the same: to provide clinicians with an ACCF/AHA document that incorporates an up-to-date, evidence-based, multidisciplinary viewpoint on TLOC/syncope management.
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Footnotes
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Please note: portions of this letter have been previously published on theheart.org (http://www.theheart.org/article/724541.do).
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References
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1. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF scientific statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke; the quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation in collaboration with the Heart Rhythm Society J Am Coll Cardiol 2006;47:473-484.[Free Full Text]2. Thijs RD, Benditt DG, Mathias CJ, et al. Unconscious confusionA literature search for definitions of syncope and related disorders. Clin Autonom Res 2005;15:35-39.[CrossRef][Web of Science][Medline] 3. Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope N Engl J Med 2002;347:878-885.[Abstract/Free Full Text] 4. Chen-Scarabelli C, Scarabelli TM. Neurocardiogenic syncope BMJ 2004;329:336-341.[Free Full Text] 5. Brignole M, Alboni P, Benditt DG, et al. Guidelines on management (diagnosis and treatment) of syncope Eur Heart J 2001;22:1256-1306.[Abstract/Free Full Text] 6. Brignole M, Alboni P, Benditt DG, et al. Guidelines on management (diagnosis and treatment) of syncope—update 2004 Europace 2004;6:467-537.[Free Full Text]
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