[Significance of diagnostic methods in the work-up of syncope]

After the initial evaluation including detailed history, physical examination, electrocardiogram, and orthostatic blood pressure measurements, risk stratification should follow, if the cause of syncope is still unclear in order to define the acuteness and extensiveness of the further diagnostic evaluation. The documentation of arrhythmia during syncope is the gold standard for diagnosis of arrhythmic syncope. The implantable loop recorder should be integrated early in the diagnostic work-up. In patients >40 years with otherwise unexplained syncope, carotid sinus massage is recommended. In suspected reflex-mediated syncope, the tilt test is able to confirm the diagnosis and gives information about the underlying pathomechanisms, while electrophysiological studies have still a proven indication in patients with previous myocardial infarction and preserved left ventricular function. The adenosine triphophate test has no clinical relevance in the diagnostics of syncope. Echocardiography plays an important role in the risk stratification by diagnosing structural cardiac disease. In patients experiencing syncope associated with exertion, exercise stress testing is indicated. Finally, a coronary angiogram should be performed, if ischemia triggered syncope is suspected. A routinely performed neurological evaluation is not recommended.