Figure 2
Title. Schematic practical decision pathway for the management of vasovagal syncope according to age
Caption. Both the European and U.S. guidelines recommend pacemaker implantation for patients with recurrent vasovagal syncope older than age 40 years and evidence of symptomatic spontaneous asystole for at least 3 s, or asymptomatic spontaneous asystole for at least 6 s on implantable loop recordings (ILR)*. However, spontaneous asystole in patients with reflex syncope received a slightly different class of recommendation in the U.S. guidelines (Class IIb) when compared with the European guidelines (Class IIa). The European guidelines also provide Class IIb recommendations for pacing in patients older than age 40 years with head-up tilt table (HUTT)-induced asystolic response for at least 3 s without direct parallel U.S**. recommendations. In selected cases, cardioneuroablation (CNA) may be used in patients aged <40 years. However, guidelines do not give any recommendations due to the lack of sufficient evidence from studies in this population. Please see text for details. Yellow, orange, and red boxes indicate our suggestions is useful (class I), is recommended (class IIa), may be considered (class IIb), respectively. CNA, cardioneuroablation; DDD-CLS, dual-chamber closed loop stimulation; DDD-RDR, dual-chamber rate drop response.