Fear of ventricular tachycardia in Syncope: Clinical reasoning versus reflex alarmism

Despite widespread concern, ventricular tachycardia (VT) is rarely the actual cause of syncope, even in patients with structural heart disease. Indeed sustained VT occurs, it typically results in cardiac arrest rather than transient loss of consciousness, with the exception of torsades de pointes. On the other hand when syncope is arrhythmic, it is more commonly due to atrioventricular (AV) block or sinus node dysfunction, age-related conditions due to conduction system fibrosis. We argue that current guideline-based risk stratification may overestimate arrhythmic and sudden death risk in patients with syncope. A more physiologically grounded, recurrence-based approach is needed to avoid reflex alarmism, unnecessary hospitalization and patient distress. Our focus should be clear: the goal is not to predict mortality from any cause but to identify the rare but genuine arrhythmic syncope.