Syncope in the elderly

Syncope is defined as a self-limited loss of consciousness, usually combined with falling due to the inability to maintain postural tone. The underlying mechanism is a transient global cerebral hypoperfusion. The aetiology essentially includes cardiac disorders (structured heart disease or arrhythmias), neurally-mediated reflex syndromes, orthostatic hypotension and carotid sinus syndrome. History and physical examination will lead to the diagnosis in up to 50%. The most important step is to differentiate patients with heart disease from others, since the mortality of these patients is doubled. Echocardiography, Holter-monitoring and electrophysiological study are useful to approach this population. In patients with suspected neurally-mediated syncope (vasovagal syncope) tilt testing is indicated. Treatment depends on the aetiology. The diagnostic work-up and the therapeutic approach of patients with syncope are outlined. For patients with vasovagal syncope conventional therapeutic strategies include an increased salt/fluid intake, moderate exercise training, tilt-sleeping or tilt-training. Beta-blockers failed to show efficacy in a number of randomised trials. Recently, pacemaker implantation in selected patients with recurrent vasovagal syncopical episodes showed a significant increase in syncope-free survival, compared to no therapy and compared to beta-blocker therapy. In contrast to the increased mortality risk for patients with cardiac syncope, patients with vasovagal syncope have a benign prognosis.