Canadian Cardiovascular Society (CCS) Clinical Practice Update
The Canadian Cardiovascular Society (CCS) published their first guideline document on the
assessment and management of syncope, compiling international guidelines with a focus on the
Canadian perspective. We highlighted the Top 10 Clinical Practice Tips:
1. The initial ED evaluation for syncope – consisting of history, physical exam and 12-lead ECG – should be used to risk stratify patients
2. Risk stratification can be used to guide ED disposition
a. Low-risk: Refer outpatient with timely access to community services
b. Intermediate-risk: Consider urgent cardiology assessment (potentially urgent outpatient
cardiology referral)
c. High risk: admit for inpatient evaluation
* While some countries suggest syncope units, Canada advises against these syncope monitoring units as they have weak evidence of benefit yet substantially increase healthcare costs
3. Targeted investigations based on clinical suspicion are recommended, as broad investigations are
ineffective and costly
4. Tilt-table testing can be considered if there is diagnostic uncertainty or non-hemodynamic collapses,
such as distinguishing convulsive syncope from epilepsy
5. The role of invasive electrophysiological studies (EPS) is limited and reserved for suspicion of
arrhythmic causes with abnormal ECG or structural heart disease
6. Education is the mainstay in managing vasovagal syncope (VVS), but pharmacotherapy is indicated if
recurrent and refractory
a. Fludrocortisone (0.2 mg/d) or midodrine (5-15 mg) are acceptable first-line options
b. Beta-blockers can be used in patients over 42 years, especially those with other indications
for beta-blockers
c. Combination therapy may be used in refractory VVS
7. Pacing for refractory VVS is controversial and only used as a last line option in patients over 40 years
with highly symptomatic recurrent VVS, and documented asystole or tilt-test induced asystole/
bradycardia. Pacemaker decision requires cardiologist/electrophysiologist consultation.
8. The risk of syncope while driving in patients with VVS is <1% per year. Physicians are strongly advised to understand the local regulations. In general, no driving restrictions are required, unless patients have high risk features or lack prodrome, in which 30 days of restrictions might be reasonable.
9. Non-pharmacological intervention for orthostatic hypotension (OH) focuses on education, hydration
and medication review. Compression garments and head-up tilt sleeping can be recommended in
patients with persistent symptoms.
10. Acceptable first-line pharmacotherapy in patients with OH include midodrine and fludrocortisone