[Treatment of arrhythmias and syncope in the elderly with heart failure]

A review of the huge literature on syncope and arrhythmias has been conducted with special regard to older subjects with heart failure. All the available data show that aging is a risk factor for syncope spells and that the risk is almost doubled in patients with heart failure. In older patients as well, syncope may be classified as non-cardiac, cardiac and unknown in origin and in the aging cardiac syncope has been clearly demonstrated to have a worse prognosis. Syncope, whatever the mechanism involved in, may hardly impair the quality of life. The diagnostic algorithm in spells of unknown origin is extensively discussed and the troubling problem related to vasovagal (and carotid sinus hypersensitivity) syncope and to iatrogenic episodes (very frequent in patients often treated with multiple drugs acting on pressure regulation) is highlighted. A review of the management options is performed with special emphasis on the difficulties due to the scarce relevance of the older groups in clinical trials regarding the treatment strategies of syncope and arrhythmias. Finally, the authors suggest a brief decision-making protocol extrapolated by their experience to manage these difficult clinical conditions.