syncope statement: background

2. Syncope Statement: Background

3. Syncope Statement: Points for reconsideration

4. Syncope Statement: The goal

5. Syncope Statement: Up for debate

6. Syncope Statement: Rebuttal

7. Syncope Statement: Rebuttal No gold standard/consensus on definition Main goal of evaluation in first-time syncope is to rule out dangerous causes Some treatment options addressed; primarily defibrillators for people with structural heart disease

8. Syncope Statement: Evaluation, not treatment "Most people would say for one episode or even three episodes over 20 years, that you're probably not going to treat that patient, but you will provide them with education, pay attention to symptoms, increase your volume status, pay attention to situations where you could . . . precipitate an episode."

9. Syncope Statement: Rebuttal, cont'd Studies omitted if they dealt primarily with multiple episodes of neurocardiogenic syncope/syndrome No one is opposed to multidisciplinary guidelines

10. Syncope Statement: Unpublished concerns The context: Scientific statement published in Circulation and the Journal of the American College of Cardiology (JACC); in response, Benditt et al sent an extensive letter, but it was never published "When should a letter to the editor really be published? . . . Some of the issues that have been raised may be very important but will never really go to press."

11. Physicians rely heavily on professional organizations to publish guidance documents There will always be differences of opinion, but concerns should be aired In the case of syncope letter: Circulation refused to publish; JACC has accepted an abbreviated letter Syncope Statement: Unpublished concerns

12. Syncope Statement: Persistent issues "It's not easy to get differences of opinion published, even when they're reasoned." Statement does not clearly state at outset that focus is on single episode. We agree: primary purpose of an evaluation ought to be for assessing prognosis Beyond syncope statement: if there are differences of opinion with this, there may be differences of opinion never aired for other documents

13. In defense of the statement There's room for a reasoned response; but it's up to organizations to set policies We all agree, we need to figure out what's wrong with patients If heart tests are normal, we know what diagnosis is going to be

14. "The issue for me is not perhaps what was written but what was missing." Definition of syncope should be up front Need to differentiate between syncope and transient loss of consciousness as a starting point, otherwise diagnoses get missed Syncope Statement: Persistent issues

15. Syncope Statement: A philosophic change "This might seem semantic, but I think it's more than that. I think it's a fundamental philosophic change in diagnostic attitude. . . . I want doctors seeing a patient who's had a fall or apparent blackout to really move to a broader picture."

16. Syncope diagnosis: Start broad Single vs multiple episodes can be difficult to prove, so strategies need to be addressed: loop recorders may be undervalued Start with a "broad radar" ESC syncope guidelines useful and should have been referenced in statement

17. In defense of the statement Exclusion of ESC syncope guidelines an oversight Statement does discuss strategies in patients with multiple episodes Differential diagnoses discussed, including seizures, psychiatric problems, etc

18. Syncope Statement: Utility disputed "The paper . . . has the basic problem of not going through the evaluation in terms of what are the most likely events, what are the concerning events that we need to eliminate up front. At the end of the day, it doesn't provide the reader with something that they can actually use at home and improve the efficiency of the diagnosis. But what it does do, fortunately, is bring loss-of-consciousness events up higher on our radar screen."

19. Syncope Statement: Utility disputed "There's a lot of people—people I haven't seen for 15 years—who have called me up and said, this is really helpful." May need to agree to disagree over helpfulness, efficiency of the statement

20. Syncope Statement: A role for tilt table testing? TTT is a subsidiary test with diagnostic value in patients with suspected but uncertain vasovagal syncope Problems of false negatives and false positives: test not perfect, but may be of some help Possible role in treatment as a "training" tool

21. Syncope: More general guidance needed? Should we be looking into developing more general, multidisciplinary guidelines? Readership may not distinguish between statements and guidelines Physicians can tweak statements in practice, but legal community sees them as definitive

22. Syncope Statement: Conclusions "Discourse, and controversy, and disagreements are good. . . . I'm glad that you brought it up."

23. Syncope Statement: Conclusions "It's easy to take potshots at things that are on the table. If everybody sort of stood back and never stuck their necks out to put a written document out for us, it would be very unfortunate. . . . Even if we disagree with part or all or whatever, it takes time, effort, courage, and dedication to do that, and that is a crucial part of advancement of medical care."