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.